12. Nursing in palliative cares

"You have to give life to the hours, not hours to life."

A patient at-terminalidad is one patient who suffers from an irreversible disease without the possibility of active treatment with prognosis no more than 6 months. This situation has a great impact on the patient and family and the multidisciplinary team.

These patients have symptoms highly variable among which are:

• Pain
• Insomnia
• Nausea and vomiting
• Anorexia
• Change in bowel habits, constipation
• Dyspnoea
• Alterations in the oral mucosa

A patient at-terminalidad passes through 5 stages that were described by Dra. Kubler-Ross:

1. Denial (rejection of truth): denial is a unconscious defense mechanism that has the patient to attempt to reduce the sources of anxiety.
2. Anger and rage (recognition of truth): initial denial gives way to feelings of anger and rage: the patient becomes intolerant, irascible, and unjustly accused at the others of the situation you have.
3. Denial (commitment to truth): the patient tries to extend its life or eliminate discomfort or pain that the disease generates. Follow strictly the prescribed treatment and demands radical solutions.
4. Depression (depression): the patient is aware that the disease continues to progress and progressive weakness. Feel a sense of loss, is a depressive reaction associated with events that are going to be developing in the near future. Physical deterioration is usually the main cause of depression.
5. Acceptance (reconciliation with the truth): if the patient has been able to live and express their feelings properly supported, can enter the final stage of acceptance and resignation; assumes that its end is mint and there is no solution. It's important to respect the patient's wishes.

The overall goals of palliative care are:

• Perform proper care of the physical, psychological, social and spiritual.
• Helping the family by providing resources necessary for the patient's environment and family is appropriate to the situation.
• Respect the daily routine of the patient and family, providing adequate guidelines and commensurate with their way of life.
• Detect the information and support needs (both patient and family).
• Identify the primary caregiver and provide information on the process evaluation.
• Educate family on therapeutic aspects, nutritional information and communication with the patient and emotional care.

At this stage of life, there are patients who choose to die at home (instead of dying in the hospital). There, as in all decisions, there are advantages and disadvantages, which are:

• Dying at home:
• Advantages:
• The patient is surrounded by family, friends and personal items.
• It's in a familiar environment in which there are no rules.
• Disadvantages:
• Family claudication (tiredness, exhaustion)
• The patient receives basic care
• You cannot administer certain treatments
• Create family conflicts
• Dying in hospital:
• Advantages:
• Professional rotation
• Professional experts care
• Required very specific treatment
• Very specific necessary treatments
• Disadvantages:
• Surrounded by other patients and health professionals
• Unknown Environment
• Inflexible rules

In my opinion, when a patient reaches this stage, the nurse should prioritize their care, as it is a fatal situation in the patient and also he feels that he is dying, so confused his feelings. You should try to make reality all his wishes.

Bibliography

• AECC. Asociación española contra el cáncer. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: https://www.aecc.es/SOBREELCANCER/CUIDADOSPALIATIVOS/Paginas/Objetivosdeloscuidadospaliativos.aspx
• Bermejo J. C; Díaz-Albo, E. Sánchez, E. manual básico para la atención integral en cuidados paliativos.  Madrid: Cáritas España; 2011.
• Lefrançois, G. R. El ciclo de la vida (6ª edición). Madrid: Thomson; 2005.