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Managing Psychological Issues Inclusive of Terminal Restlessness

Palliative Care (PC) is a multidisciplinary team approach that deals with patients and their families under conditions of life-threatening illness aimed at improving their quality of life. Palliative care is performed when the curative treatment is no longer working, that is, when it does not have the expected effect of curing or reducing the tumor (O'Connor, Tan and Lau, 2016). Palliative care can be performed at the patient's home, at a hospital or health facility, or at a hospice. Palliative care cannot be regarded as a kind of alternative option with the possibility of radical treatment, but all hope remains for palliative care when radical clinical methods have ceased to effectively influence progressive diseases. Its main objective is to improve the patient's quality of life at the end of life. Clinical practical guideline are documents that aim to ensure the best possible health care given and the resources available in the Unified Health System (Stoodley, 2017). They can be used as educational materials for health professionals, administrative assistance for managers, regulation of assistance conduct before the Judiciary (O’Connor and Meageen, 2020). The main aim of these guidelines is to establish the criteria for the diagnosis of a disease or health problem; the recommended treatment, with medications and other appropriate products when it fits; the recommended dosages; the mechanisms of clinical control; and monitoring and verification of therapeutic results. It includes recommendations for conducts, drugs or products for the different evolutionary stages of the disease or health problem, as well as those indicated in cases loss of effectiveness and the appearance of intolerance or relevant adverse reaction, caused by the medicine, product or procedure of first choice. The main aim of this report is to analyze what kind of palliative care was provided to patient and what are the important care points are neglected by the staff (Anon., 2016).

As per this case, Frank who is a sixty-year old male has experience seizure while at work. He has undergone neurological assessment. He is losing his control over walking properly, passing urine, and faucal continence. Further he is reluctant in taking medicine properly. Frank was diagnosed with Glioblastoma Multiforme (GBM), which is the most frequent brain tumor in humans is an inevitably lethal and incurable form of cancer, whose incidence is constantly and worryingly increasing (Bozkurt, 2014). It is a highly aggressive and malignant form of brain tumor that can grow rapidly and infiltrate large areas of brain tissue. Moreover, he is facing terminal restlessness which is usually a visible manifestation the culmination of multiorgan failure associated with other irreversible factors. Despite this in clinical practice terminal agitation is often not recognized as a sign that the patient is in an immediate terminal phase. In fact, the unrest it can only be safely classified as a posteriori terminal (Levett-Jones, 2018).

The main concerns of patients are their loved ones, the fear of not being themselves, the physical consequences of the disease, their finances and their mental capacities. Patients cared for by their partner, affected in their physical autonomy, with a low level of education and experiencing financial difficulties, are the most at risk of poor quality of life. Whatever the therapeutic choice made, patients with a brain tumor should have access to palliative care from the moment of diagnosis in order to improve their own quality of life as well as that of their loved ones. Which is in this case Frank was immediately shifted to Palliative care unit where his initial assessment was performed and brief history was also taken.

In this case care is provided by the team. On arrival, he was welcomed and directed to his RN who performed several assessments. The first thing which is analyzed the falls risk and pain assessment. His current health status was noted such as modified Karnowski score and RUG-ADL. Other assessments are also performed which are linked with the problem which Frank has faced related to seizure. Another important aspect here was the proper pain assessment. The patient may experience physical pain, altered body image (e.g. related to the disease itself or to the treatments), since the activities of daily take effort and time, psychological and moral consequences illness, dependence on others, vulnerability, fatigue, real or imaginary marginalization, of the questioning of the meaning of one's life, of fear and of the suffering of those around him. The teams in charge offer patient time for discussion to assess and integrate the situation by discussing the lived reality, the loss of autonomy, the preferences of each other, the alternatives, results and prognosis. In this case, the diagnosis was made clinically through the obtaining a detailed history and a general physical examination, with emphasis on the neurological and psychiatric. Often, the assistance of an eyewitness is important for the crisis to be described in detail. So, a discussion was also made with her wife. They also took history and one good thing which Frank openly tell that his father had GBM, restlessness, and he wish to live a quality life and not like his father who died of this disease (Bennette, 2016).

Other aspects which are negative in this care and was not provided include; OT home assessment, physiotherapist assessment, nutrition and diet review, and pastoral care was made. These guidelines make it possible to collate the patient's wishes on the type and level of care he would like for himself and the choice of the person who could represent him and participate in the decisions. They often remain vague and / or not very applicable depending on the situation, which could rarely be foreseen, which does not favor decision-making processes. In the process of obtaining consent at a meeting with family members, it is necessary to explain the main points, including talk about the patient's current condition, prognosis, etiology of resistant symptoms. In addition, it is necessary to explain why there is reason to believe that adequate relief of symptoms cannot be achieved with standard therapies, to present the risks and benefits of palliative sedation, and to describe in detail the sedation process with predetermined goals of this process.

The teams are therefore responsible for getting patients to develop a care plan. The Advance care planning, or anticipatory care project, aims to build a personalized frame of reference for making care-related decisions, based on the objectives prioritized by the patient. This also protects the patient in the event of incompetence to determine. As hospitalization affects the quality of life, home maintenance can be favored by oncological treatments when they are desired and possible. In this case patient was of 60 years of age, whose average survival is five months, treatments reduce the risk of hospitalization for a quarter of the time remaining to live, with a respective adjusted Hazard Ratio of 0.31 (CI 95 %: 0.23-0.42) for temozolomide, 0.49 (95% CI: 0.42-0.58) for radiotherapy and 0.83 (95% CI: 0.69-0, 99) for surgery. For patients and their loved ones have enormous, often unmet needs. Coordination of both ambulatory and hospital services, aids and care is essential, basic palliative care being the responsibility and competence of everyone. The objective is to support / train relatives in their role of caregiver, to help them renegotiate relationships and responsibilities, to prevent / manage crisis situations (behavioral disorders, epilepsy, degradations, etc.) and finally to know what to expect when the patient is living his last days and tackle the aftermath. In palliative care it is also important for a nurse to identify whether the patient having any serious spiritual crisis, identify patient’s distress, hopelessness, meaninglessness and also the hope and purpose. Provide the patients compassionate care and also empowering the patient for determining their inner resources of acceptance and healing. Nurse is required to understand why the patient is hopeless about his health and future and why he has no hope in value of life and loss of a person. In this case as the patient suffered from the seizure and he is also facing restlessness issue might be there are changes he has some spiritual issues.

There was no delirium screening performed which is very important for this case. It is important to monitor delirium, because it is underdiagnosed. and have implications for important prognoses for the patient. Given the high prevalence of delirium in an intensive care setting current guidelines recommend the daily assessment of delirium and a multidisciplinary approach (H, 2018). Monitoring of delirium in the ICU is important not to only as an indicator of organ dysfunction, but also to prevent accidental injuries. Thus, promotes the reduction of adverse effects and allows the establishment of preventive and therapeutic measures to provide adequate rehabilitation and, potentially, decrease losses related to quality of life. The ability to accurately assess delirium is a key component of any systematic strategy adopted to prevent or treat it. It's important to highlight that although there is evidence that an intervention multifactorial design reduces the duration of delirium, the capitalization and mortality, there is no scientific evidence that demonstrates that a systematic assessment of delirium, by itself, improve the results. The delirium is thus an important issue, as regards the safety of critically ill patients. The reduction in occurrence of delirium in the ICU should be considered a quality indicator and a target to be pursued, representing improving the care delivery process to the patient (Boettger et al., 2018).

Palliative care is represented by medical, physical, psychological, spiritual and social interventions that are mainly aimed at maintaining the functions of patients during the time of the disease, while maintaining an acceptable quality of life and ensuring a dignified death (Anon., 2018). It is very important to carry out a balanced assessment that includes the possible toxicity of the treatment-survival obtained versus the preference of the patients and quality of life derived from the reintervention, bearing in mind that the treatment of these patients is palliative. Adequate practice of its application does not lead to a decrease in life expectancy. In this case, there is a need of more discussion with the patient and his representatives and then after performing several test decisions made by the multidisciplinary medical team. With regard to the degree of sedation required, the patient's consciousness should be lowered to the level required to relieve suffering. This principle helps determine when to start the procedure.

References for Palliative Care for Asylum Seekers

Anon., 2016. Nursing Midway Board of Australia. [Online]
Available at: https://www.nursingmidwiferyboard.gov.au/news/newsletters/december-2016.aspx

Anon., 2018. Palliative Care Australia, s.l.: National Palliative Care Standards (5th Ed.).

Bennette, S. R. C. G. L., 2016. Investigating the impact of headaches on quality of life of patient with glioblastoma multiforme, s.l.: BMJ Open.

Levett-Jones, T., 2018. Learning to Think Like a Nurse. Pearson.

'Connor, M., Tan, H. and Lau, R., 2016. Outcomes from applying a Palliative Care Satisfaction Survey Instrument in Victoria, Australia. Progress in Palliative Care, 24(2), pp.93-97

Boettger, S., Meyer, R., Richter, A., Fernandez, S., Rudiger, A., Schubert, M., Jenewein, J. and Nuñez, D., 2018. Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): Symptom profile and utility of individual items in the identification of delirium dependent on the level of sedation. Palliative and Supportive Care, 17(1), pp.74-81.

Bozkurt, F., 2014. Mathematical Modeling and Stability Analysis of the Brain Tumor Glioblastoma Multiforme (GBM). International Journal of Modeling and Optimization, 4(4), pp.257-262.Case Medical Research, 2019. Post-stroke Delirium Screening.

O’Connor, M. and Meageen, S., 2020. Palliative care for asylum seekers living in the community in Australia. Progress in Palliative Care, pp.1-4.

H, J., 2018. Screening for delirium with the Intensive Care Delirium Screening Checklist (ICDSC): a re-evaluation of the threshold for delirium. Swiss Medical Weekly, 148(1112).

Stoodley, N., 2017. RCPCH clinical guideline, stroke in childhood: an evidence-based guideline for diagnosis, management, and rehabilitation. Clinical Radiology, 72, p.S25.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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