Palliative Care within the Acute Care Setting

Palliative Care within the Acute Care Setting Palliative Care during End-of-life: An Annotated Bibliography Waldrop and Kirkendall (2009) surveyed employees from a 120-bed suburban nonprofit nursing home to explore how their staff recognized a dying patient and identified standards of care which would be put into place once palliative care has been initiated. Using a qualitative method to gather data, 42 employees were interviewed which included nurses, chaplains, social workers, nursing assistants, housekeepers, and administrators to provide multiple perspectives on the dying experience. The survey was done in the form of a 30-minute interview in a quiet location of the nursing home away from the nursing unit (Waldrop Kirkensall, 2009). An affiliated research assistant or investigator whom has had training in conducting interviews and qualitative data analysis conducted it. They asked the employees open-ended and objective questions about frequency and standards of care for dying patients and their families. All interviews were audio taped, transcribed by a professional transcriptionist, and labeled with a letter number combination (e.g., N[urse]-1). The transcripts were entered into Atlas ti software for data organization and management(Waldrop Kirkensall, 2009). The survey identified physical, behavioral, and social factors as the three main indicators of impending death. Physical indicators included altered breathing patterns (including apnea), anorexia, or increase in pain; behavioral indicators included mood changes and diminished activity level and social indicators sometimes included withdrawal from interaction with staff or family (Waldrop Kirkendall, 2009). During the survey the staff explained that Comfort care is initiated when patients began to exhibit these signs. At this nursing home standard order sets were not used and comfort care measures were described as being very patient individualized and holistic. Comfort care includes an interrelationship of symptom management, family care, interpersonal relationships, and interdisciplinary cooperation in which each member of the healthcare team participates in the care of the patient, according to their scope of practice (Waldrop Kirkendall, 2009). The survey revealed that health care employees deliver comfort care in different ways and it identified the need for more comparison studies in other nursing homes to explore standards of care in other facilities because this was just one study of one nursing home. By further comparing nursing homes which use different models of care comfort care standards and or improvements can be made. This survey was conducted in a nursing home setting but its results reflect on hospital end-of-life care. At the present time the standard of care for dying patients in a hospital setting consists of pre-printed order sets which are not individualized to the specific needs of the patient. This study promotes use of the holistic, individualized care approach to ensure a more satisfying and comforting dying experience. Level of evidence: VI Single descriptive qualitative/physiologic study Jarabek, B.R., Cha, S.S., Ruegg, S.R., Moynihan, T.J., McDonald, F.S. (2008). Use of a palliative care order set to improve resident comfort with symptom management in palliative care. Palliative Medicine, 22, 343-349. Jarabek, Cha, Ruegg, Moynihan, McDonald, (2008) began a study within the Internal Medicine Residency Program at Mayo Clinic in Rochester, Minnesota hypothesized that standard palliative order sets within a hospital setting would enhance physician comfort with managing 4 aspects of end-of-life care: pain, secretions, agitation, and dyspnea. A 5-question, pre-intervention web-based survey regarding physician comfort in diverse aspects of palliative care was given to 144 internal medicine resident physicians before the release of the palliative order set, which would later be used within the hospital. Each question included a 5-item Likert response scale, ranging from 1, very comfortable to 5, very uncomfortable(Larabek et al., 2008). Three months later an educational email was sent to all house staff and faculty addressing end-of life-care along with the initiation of the order set, which consisted of physical ailment provisions. Another 3 months was spent allowing staff to use and or work with the order sets at which point a post-intervention survey was performed. Results of the post-intervention survey were that 88% had utilized the palliative order sets and 63% stated that they felt increasingly comfortable with palliative care (Jarabek et al., 2008). There was an overall 10% increase in resident comfort regarding the 4 aspects of palliative care with the initiation of order sets, but no change in social or communication-related comfort (Jarabek et al., 2008). The survey concluded that palliative order sets can increase physician comfort in providing care to patients during end-of-life, but it also revealed that the order sets do not address the psychosocial needs of the patient when providing comfort care. Although physicians find comfort in having order sets as guidelines for end-of-life care, they are only guidelines and open communication needs to be initiated between the health care team and the patient to ensure all the comfort care needs of the patient and family are met in a holistic way so that they may have a peaceful dying experience. Level of evidence: Teno, J.M., Clarridge, B.R., Casey, V., Welch, L.C., Wetle, T., Shield, R., Mor, V. (2004). Family perspectives on end-of-life care at the last place of care. Journal of the American Medical Association, 291(1), 88-93. Teno, clarridge, casey, welchl wetle,shield, mor (2004) evaluated 1578 adult patients with different, chronic illnesses end of life experiences by surveying the decedents loved ones and determining whether their perspectives on quality end-of-life care were influenced by the environment where the patient spent their last 48 hours of life. A survey was devised from a conceptual model for patient-focused, family-centered medical care and the calculation of scores and psychometrics of the measures were taken from an online tool formulated by Brown University. Within 9 to 15 months from the time of death a close family member or informant whom was listed on the death certificate was surveyed and was asked about the quality of care their loved one received during their last 48 hours of life. Five different domains were used in the survey, including whether healthcare workers provided patient physical comfort and emotional support, supported collaborative decision-making with the physician , treated the patient with respect, attended to family needs, and provided coordinated care with other healthcare workers or facilities (Teno., et al. 2004). Teno et al. (2004) concluded that 69% of the decedents site of death and last place to receive care was in a hospital or nursing home setting, 31% home, 36% without nursing service, 12% home nursing, and 52% home hospice. The survey showed that family perceptions of the quality of care were different according to where their loved one last received care. Families of patients who were in nursing homes or had home health had a higher rate of unmet needs for pain (Teno., et al. 2004). Over half of the families in hospital or nursing home settings reported unmet emotional needs. In addition, 70% of families receiving home health care reported inadequate emotional support in comparison to 35% in families who utilized home hospice care. Patient and family respect was also a concern to families and varied in different settings. Only 68% of nursing home residents families felt they had been treated with respect and consideration compared to the 96% of families receiving hospice care (Teno et al., 2004). Survey participants felt that physical symptom management was adequately managed so it was comparably equal throughout all patient settings. Although families did not experience a difference in pain or dyspnea management in comparison to other nursing services families who used hospice services overall, 71% reported excellent care (Teno et al., 2004). Kolcaba, K.Y., Steiner, R. (2004). Efficacy of hand massage for enhancing the comfort of hospice patients. Journal of Hospice and Palliative Nursing, 6(2), 91-102. Kolcaba, Dowd, Steiner, and Mitzel (2004) identified the need for comforting interventions for patients at end of life that are simple, easy to learn and administer, and require minimal effort on behalf of the patient. Bilateral hand massage is a good intervention because it is noninvasive, easy to do, does not take long, and relies on caring/healing touch( Kolcaba., et al. 2004). The purpose of their study was to determine empirically if a bilateral hand massage provided to patients near end of life twice per week for 3 weeks was associated with higher levels of comfort and less symptom distress. 31 adult hospice patients from 2 hospice agencies participated in the study. Each patient was English-speaking and expected to remain alert and oriented for the duration of the trial, 13 months. Data collectors who were unknown to the patients called the homes of the patients, explained the study, and then scheduled an appointment for a research visit. Data was collected at the patients homes and at the hospice centers(Kolcaba., et al. 2004). After informed consent, participants were randomly divided into the treatment group (with 16 patients) and the comparison group (with 15 patients). All participants were asked to complete a modified General Comfort Questionnaire (GCQ), tailored for end-of-life patients, once a week for 3 weeks. After completing the questionnaire each week, the treatment group then received the hand massage intervention twice a week for 3 weeks. The comparison group received the intervention once at the end of the study period. The study concluded no significant difference between the treatment and comparison groups in regard to enhanced comfort or decreased symptom distress over time (Kolcaba et al., 2004). However, comfort did increase some in the treatment group even as the patient approached death. The study also revealed that the hand massage seemed to allow more time for therapeutic or face to face communication allowing the patients to talk about how they feel and their feelings on transitioning to death, and patients receiving the intervention reported it to be a personalized experience something they could engage in that feels good, and family members were appreciative of the care and attention their loved one was getting (Kolcaba et al., 2004). Because this intervention is easy to learn and requires minimal time for the caregiver to do and minimal effort for the patient it is an excellent intervention that can even be taught to the family. This study identifies interventions that can be used withi n the hospital setting and any other setting to enhance comfort during end-of-life. Nurses and family members can use this intervention to increase communication by using caring touch, which provide psychosocial care and therefore holistic comfort for the patient. Bakitas, M., Lyons, K. D., Hegel, M. T., Balan, S., Brokaw, F. C., Seville, J., Hull, J. G., Li, Z., Tosteson, T. D., Byock, I. R., Ahles, T. A., (2009). Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer. The Journal of the American Medical Association. 302 (7): 741-749. Bakitas, Lyons, Hegel, Balan, Brokaw, Seville, hull, Li, Tosteson, Byock, Ahles, (2009) using project ENABLE combined with a nurse-led intervention with ongoing assessment, coaching, symptom management, crisis prevetion, and timely referral to palliative care and hospices hypothesize that patients newly diagnosed with advanced cancer if exposed to this intervention right away would become informed, active participants in their care, and would experience an improved quality of life, mood, and have better symptom relief. The study protocol and data and safety monitoring board plan were approved by the institutional review boards of the Norris Cotton Cancer Center and Dartmouth College in Lebanon, New Hampshire, and the Veterans Administration (VA) medical center in White River Junction, Vermont. All patient and caregiver participants signed a document confirming their informed consent.(Bakitas., et al (2009). Participants completed baseline questionnaires when they were enrolled and th en completed a follow-up one month later. Using a stratified randomization scheme patients and their caregivers were randomly assigned to the interventions or usual care group. One of 2 advanced practice nurses with palliative care experience conducted 4 structured educational problem solving sessions first one lasting 41 minutes and sessions 2 through 4 approx 30 minutes each and at least monthly telephone follow-up sessions until the participant died or the study ended (Bakitas., et al.2009) The advanced practice nurse began all contacts with an initial assessment by administering the Distress Thermometer, an 11-point rating scale recommended by the National Comprehensive Cancer Network guidelines. It identifies sources of distress in the 5 areas of practical problems physical problems, family problems, spiritual, emotional problems or religious concerns. If distress intensity was higher than 3, the advanced practice nurses then identifies the sources of distress and checks to see if the participant would like to problem/solve to take care of their issue. The nurse then covers the assigned module for that session. The participants clinical teams are responsible for all medical decisions and inpatient care management, however the advanced practice nurse was readily available by telephone for the participants and they could also facilitate ancillary resources. The participants also were able to participate in group shared medical appointments (SMAs), which are led by certified palliative care physicians. The usual care participants were allowed to use all oncology and supportive services without restriction. Follow-up questionnaires were mailed every 3 months until the patient died or study completion in December 31, 2007. Quality of Life was measured with a 46-item tool called the Functional Assessment of Chronic Illness Therapy for Palliative Care. It measures the participants physical, social, emotional, and functional well being along with the concerns of a person whom has a life-threatening illness. Of 1222 screened, 681 were eligible and were approached and 322 were enrolled (47% participation rate). There were a total of 134 participants in the usual care group and 145 participants in the intervention group. A systematic review of specialized palliative care identified 22 trials (16 from the United States) between 1984-2007 with a median sample size of 204, half exclusively with cancer patients. There was lack of evidence due to contamination, adherence, and recruitment etc. The trial addressed these issues and contributed to the increasing evidence that palliative care may improve quality of life and mood at the end of life. In our study, intervention participants higher quality of life and lower depressed mood may be attributed to improved psychosocial and emotional well being. Mood is a determinant of the experience of quality of life and suffering despite a mounting burden of physical symptoms(Bakitas., et al. 2009). However, while patients in the intervention group had improvement in these outcomes, we conservatively planned our original target trial enrollment of 400 based on a significance level of .01. Statistical inferences based on this stringent critical value would lead to the conclusion that there were no statistically significant differences between groups in quality of life or mood(Bakitas., et al. 2009). The study concluded that compared with participants receiving usual oncology care those receiving a nurse-led, palliative care-focused interventions that takes care of the patient holistically provided at the same time with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital (Bakitas., et al. 2009). Level of evidence- Summary The research presented reveals while palliative care order sets provide a helpful guideline or tool which reassures health care providers in giving consistent good quality care, patients care needs should be assessed and individualized orders and interventions should be implemented to ensure a peaceful and comforting dying experience. Hospice care settings have been shown to provide excellent holistic care for dying patients and they have also been shown to show compassion to the family as well. The comfort interventions from these facilities can be modified for application in the hospital for use in the acute care setting. Holistic comfort care interventions include hand massage, music therapy, or the utilization of a visual analog scale the faces to measure comfort. These are some of the ways hospitals can utilize the findings from this research into daily practice to ensure quality holistic patient comfort is achieved and ultimately a peaceful death.

Forbidden Love Essay

â€Å"There is a charm about the forbidden that makes it unspeakably desirable† quote by Mark Twain. Michael Ondaatje feels similarly in his poem â€Å"The Cinnamon Peeler† because he longs to be with his beloved but this is not possible. We infer that Ondaatje is in a lower caste than his love because he hypothetically states â€Å"If I were a cinnamon peeler†¦Ã¢â‚¬  (1). The idea of them being together is what sets off this love poem. He goes on a type of role-playing game in which he and his wife are such passionate lovers that their desire leaves a scent that others can notice. In this dramatic monologue, Ondaatje explores the theme of bold love with his wife. He wishes to be free with his lover, having his ideal marriage. It was not possible for them to be together before marriage because everyone would smell the cinnamon scent off of her, â€Å"You will be known among strangers as the cinnamon peeler’s wife† (17-18). The speaker gets carried away and seduced by the idea of forbidden love. The author reveals the true situation when explaining that he could never look at her before marriage because of her brother’s and mother. The speaker longs for his beloved but knows they can never be together. Individuality and male dominance are also prominent themes in this poem. Individuality is expressed through the speaker’s description of their relationship. Their need to sneak around with each other causes them to go against their familial and cultural values which grant them independence. There is clear evidence of a male dominated society. The cinnamon peelers wife, lime burner daughter, and grass cutter wife are great examples of where a woman is defined by either her father or husband. Every woman in this poem has been directly referred to through the men in their lives. The male dominant theme is seen in every aspect of the poem, from the leaving of bark dust on pillows to â€Å"my fingers floating over you† (7-8). The female character questions his commitment to her; since they cannot be together all the time she wonders if he is faithful to her. Then she realizes â€Å"what good is it to be the lime burner’s daughter left with no trace as if not spoken to in the act of love† (37-40). She knows that this erotic love is something that only they share. When one first reads Ondaatje’s â€Å"The Cinnamon Peeler,† it is clear that the poem is about sex, specifically, the speaker’s sexual desire for his wife. The speaker and his wife are therefore marked physically by the scent of his occupation. This cinnamon scent takes on very sexual overtones as the poem progresses and shape the way the poem is interpreted. Smell is the sense most closely tied to memory – and Ondaatje is is using it to evoke both an imagined future. Cinnamon is a very strong scent, while grass and lime are less erotic. He uses olfactory imagery to manifest the theme of possessiveness, â€Å"You will be known among strangers as the cinnamon peeler’s wife† (17). Symbolism is also apparent. Cinnamon is very luxurious, connotes passion, and is very economically beneficial in Ondaatje’s home town of Sri Lanka. The cinnamon peeler in some cases throughout the poem uses the cinnamon smell as a metaphor for his sexual desire. Ondaatje uses the mark of the cinnamon peelers profession to create intense imagery. The strong use of the cinnamon smell to display the women’s sexuality allows Ondaatje to provoke intense images of lust and sexuality. The poem allows the reader to imagine all the ideas because Ondaatje describes the concepts well, through metaphor. The stories and situations are very simple, easy to quickly imagine and the emotion are very basic. The imagery is enforced by the way the poem applies to the senses. The poem talks about touch and smell which aids the imagination visualize the poem. The cinnamon peeler displays his ownership of his wife in the poem on many occasions, especially in the second stanza of the poem, â€Å"[y]our breasts and shoulders would reek† (5). He declares that wherever she went, everyone would know that she was his. Even â€Å"[t]he blind would stumble certain of whom they approached† (8-9). This imagery allows the reader to picture the speaker’s wife walking through the streets as she left a trail of the cinnamon scent. This poem serves as a dramatic monologue because it has a silent audience, there is no dialogue, and can be described as a character study. Because â€Å"The Cinnamon Peeler† is one person’s speech, and provides no analysis, it places emphasis on the speaker’s thoughts and emotions and allows the audience to create their own interpretation. â€Å"The Cinnamon Peeler† is very sensual, focused on emotional and both physical and psychological experiences of the speaker. Such poems reveal not the poet’s own thoughts but the mind of the character, whose personality is revealed quite quickly; thus distinguishing it as a dramatic monologue. The entire poem is simply the speaker’s perspective, not once do we enter the thoughts of the female character, and that is also an element for this type of poetic genre. Ondaatje wisely chose this form, allowing the audience to go deeply into the speaker’s thoughts and visions and feelings. One is left to wonder how his beloved feels. We only get a short part of her side in the last few lines â€Å"I am the cinnamon peeler’s wife. Smell me† (45-46). The cinnamon smell, and its constant use, can be interpreted more closely to his passion for her, his lust for her. At the end of the poem, she touches him finally and embraces the scent. This only strengthens their connection. Situations similar to the speakers are ongoing today. The caste system is still relevant in many cultures, where one is unable to marry, or even associate with someone in a lower division. Rarely is this tradition broken, this is because those of different birth circumstances are inherently unequal and are avoided.

Mentoring & Coaching Essay

Analyse and evaluate the use of Mentoring and/or coaching to support both your own and others,’ development of professional skills and knowledge. In ancient Greek mythology Mentor was the friend of Odysseus and tutor to his son. His name is well-known for a faithful and wise adviser. Today on the athletic field and in corporate offices a mentor or coach can help elevate performance. (http://heartlandbusinessexchange.com/MentorCoach.aspx) There are many definitions for coaching and mentoring. The commonality we can find in these hundreds of definitions of Coaching and Mentoring is that they both aim to support the Coached / Mentees (people that are in a relation with a Coach/Mentor) developing themselves in order to reach specific goals. Coaching is collaborative inquiry into the technical aspects of any activity, most often of work, as well as support for development and performance improvement. Of course, coaching applies to relationships in every setting. Mentoring provides a unique growth-oriented relationship which is the necessary context for risk taking, deep sharing, insights, and growth. Mentoring requires commitment and freely choosing to be held accountable for living out one’s intentions. It also includes coaching, but adds a wide range of strategies for discovering, supporting, and challenging personal, spiritual, and/or professional growth Both coaching and mentoring must be non evaluative, positive, and nonjudgmental if the process is to be authentic and genuine and the results are to be discovery, learning, growth, and improvement. Mentoring and coaching are an investment in another person’s success, you may have experienced this kind of empowering support from parents, a pastor, a teacher, an athletic coach, a friend, perhaps even a boss or your spouse. Often, people like these care so much about you that they will go the â€Å"extra mile† and do all they can to help you succeed. We might call this f orm of support â€Å"intuitive† mentoring or coaching because it is well meaning folks, doing the best they can, based on common sense and what they feel is best. www.businessmentorcenter.com A mentor can enter into a truly collaborative, trusting, positive, and support relationship . He can make you feel comfortable and make a person see the benefits of an open sharing of his feelings and dreams for his life, help to  learn to see oneself more objectively and how to gain the personal insights one needs to succeed, assess one’s natural tendencies and gifts and how their interactions may create internal confusion and dissatisfaction. It helps a person to set goals and develop plans and the self discipline to achieve his goals and more over he helps to solve and understand the problems and conflicts one confronts and move on. Coaching and Mentoring are then aimed to promote the development of an individual in order to be successful in the fulfilment of their tasks (at school, at work or in their personal lives), reinforc ing and strengthening their competencies and self-confidence. Coaching and Mentoring are to be considered as the two extreme of the line. Between these two extremes exists many different and flexible possibilities for support, using Mentoring and Coaching as appropriate to the situation.

What Is an Independent Variable

An independent variable is a variable that doesnt depend on another variable and isnt changed by any factors an experimenter is trying to measure. Its the variable that is controlled or changed in a scientific experiment to test its effect on the dependent variable. The independent variable is denoted by the letter x in an experiment or graph. Independent Variable Example For example, a scientist is testing the effect of light and dark on the behavior of moths by turning a light on and off. The independent variable is the amount of light and the moths reaction is the dependent variable. For another example, say you are measuring whether amount of sleep affects test scores. The hours of sleep would be the independent variable while the test scores would be dependent variable.A change in the independent variable directly causes a change in the dependent variable. If you have a hypothesis written such that youre looking at whether x affects y, the x is always the independent variable and the y is the dependent variable. Graphing the Independent Variable If the dependent and independent variables are plotted on a graph, the x-axis would be the independent variable and the y-axis would be the dependent variable. You can remember this using the DRY MIX acronym, where DRY means dependent or responsive variable is on the y-axis, while MIX means the manipulated or independent variable is on the x-axis More About Variables The independent variable is only one of the variables in an experiment. Learn about other variables and how they are used to design an experiment. What Is a Variable in Science?What Is a Dependent Variable?What Is a Control Group?What Is an Experimental Group?