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Palliative Care for Nursing Home Residents

The vast majority of people who have access to specialist palliative care services in Ireland have a diagnosis of cancer. However, increasingly services are expanding their remit to include people with non-malignant end-of-life care. A small study undertaken in one Dublin region identifies that inequities exist relative to the delivery of specialist palliative care in nursing homes . Nursing homes involved in the provision of end-of-life care encounter substantial challenges, such as issues regarding reimbursement, training, staff shortages, and high staff turnover. These points must be addressed if efforts to incorporate palliative care are to prove fruitful. International literature suggests that the provision of palliative care improves the quality of life for older people . Resources may act as a barrier to the expansion of palliative care both from the perspective of nursing home managers and specialist palliative care professionals. Therefore service providers need to consider and agree realistic responses.

Different Types of Palliative Care

Greater attention is now being given within the field of palliative care to the needs of older people with chronic degenerative illnesses . Kristiansen et al asserts that, to understand the potential contribution of palliative care in conditions other than cancer, service providers must be able to distinguish between the different types of palliative care. Specialist palliative care services are necessary for a minority of people with advanced incurable illness and those facing death. These services may be provided directly by specialists in palliative care or indirectly through advising the primary care providers. Palliative interventions are described as non-curative measures, implemented by staff in disciplines other than palliative care, which aim to control symptoms and improve quality of life. These interventions may include palliative radiotherapy, surgical procedures and anaesthetic techniques for pain relief . The palliative care approach aims to improve the quality of life of individuals facing life threatening illnesses by the prevention and relief of suffering through early identification, assessment and treatment of pain and other problems, including physical, psychosocial and spiritual . This approach facilitates the identification of the wishes of the patient and the family about care throughout the period of declining health and especially during end-of-life care.

Recommended structure of palliative care services

The report of the National Advisory Committee on Palliative Care (2001) for the Department of Health and Children recommends that health services should be sufficiently flexible to allow movement of patients (residents) from one setting to another, depending on their clinical needs and personal preference. The report recommends that palliative care services be structured in three levels of ascending specialisation. These levels refer to the expertise of the staff providing the service:

  • Level 1 - Palliative Care Approach: Palliative care principles should be appropriately applied by all health care professionals.
  • Level 2 - General Palliative Care: At an intermediate level, a proportion of patients and families will benefit form the expertise of health professionals who, although not engaged in full-time palliative care, have had some additional training and experience in palliative care.
  • Level 3 - Specialist Palliative Care: Specialist palliative care services are those services whose core activity is limited to the provision of palliative care.

The NACPC's report also asserts that good palliative care should be available to all who need it, when they need it and where they need it. Clearly, a palliative care approach would benefit the majority of nursing home residents; however, there are some who will require specialist palliative care. It is important then, that service providers endeavour to provide a palliative approach to all residents. Thus, very good basic care must be available to all residents; there must be sufficient numbers of staff who have appropriate training and support, and service providers must know when and in what circumstances the services of specialist palliative care providers are required. Education and empowerment require specialist support and expertise . Palliative care has the potential to offer the highest quality of life possible to nursing home residents, encompassing as it does their physical, psychological, social and also spiritual needs. The focus of hospice and palliative care is to relieve suffering and improve the quality of living and dying. This approach is appropriate for any patient and/or family living with a life-threatening illness, due to any diagnosis, with any prognosis and regardless of age. The palliative approach to care may complement and enhance acute treatment and long-term care, or it may become the total focus of care. Blending nursing care with meaningful activities as appropriate, the approach promotes peaceful and relaxing end-of-life experiences for older adults. Sensory-based practices, like placement in comfortable armchairs, soothing music and gentle massage, emphasise comfort and pleasure.

Need for Palliative Care Services Set to Increase

The need for palliative care services is expected to increase in Ireland over the coming years. In particular, efforts to address the needs of older people are growing due to the changing demographic profile of the older person population. The Regional Populations Projections (2006 - 2021) indicate that the number of people over sixty-five will increase during the period in every region in Ireland, while the number of people aged eighty and over is predicted to increase by two-thirds generally and up to 90% in the Dublin region. These changes will impact on current and future health and social care. However, there is limited evidence as to the effect this will have. There are particular implications for staff working in nursing homes and residential care institutions, because the majority of older people with progressive and incurable conditions will spend their final days, weeks or even years in these settings. It is imperative that this population is enabled to live as well as possible until they die. Therefore, appropriate levels of training and education need to be available. Little research has been undertaken in Ireland to highlight the palliative needs of older people, or indeed to find out if they actually want or require palliative care services. Thus, qualitative and quantitative evidence is crucial. Clinical studies looking at the outcomes of care delivery, staffing issues, communications and quality assurance are necessary to guide and support changes in care planning. Evidence regarding management structures, education needs assessment and evaluation of training programs is equally important. Such studies need to be carried out at a national level so that palliative care may be incorporated appropriately.

The ultimate aim of a palliative approach to care in nursing homes is to improve residents' quality of life by providing care that meets the current and anticipated need of each resident. This includes supporting the social and emotional perspective of each individual; enhancing opportunities for family involvement and strengthening staff morale, relative to caring for those with life-threatening illness and ensuring good end-of-life care. Specialist palliative care service providers have a responsibility to make information available relative to their structure, operating procedures and means of contact. They must engage in ongoing education and training accredited by a recognised authority. Without appropriate evidence, changes in practice may fail; therefore research is crucial.

This article has been contributed by Noreen Holland, who is a committee member of the Nursing Advisory Forum of the Irish Association for Palliative Care and nurse tutor on palliative care at Our Lady's Hospice, Harold's Cross, Dublin.

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    Ling, J., (2005) Palliative Care in Irish nursing homes: the work of community nurse specialists. International Journal of Palliative Nursing. 11: (7) 314-21.
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