Managing symptoms is core business for palliative care. Nurses have a role to play in helping to achieve the best symptom control and optimum quality of life for patients.
Working with patients often on a daily basis, nurses are best placed to assess and monitor pain and symptoms and advocate for patients in regards to their care and management. Many services use pain assessment tools or the SAS (Symptom Assessment Scale) in their practice which facilitates tracking of symptoms from the patients’ perspective.
It is also important to recognise that not all symptoms will be physical, but could be psychological, social or spiritual, or have psychological, social or spiritual components. In many cases a mix of pharmacological and non-pharmacological approaches are available to support symptom management. For a person with palliative care needs common symptoms include: [1,2]
- Constipation: the inability to defaecate in line with what is normal for the person is very common in palliative care. This can lead to additional symptoms including pain, faecal incontinence, and agitation. Although multiple factors can be involved the use of opioids is a common cause of constipation.
- Breathing difficulties: Breathlessness can be frightening for the person and carers. Providing reassurance is part of care. Assessment for possible treatable causes such as infection or airway obstruction is important. Non-pharmacological approaches such as increasing air flow around the person with a fan or open window or repositioning the person are also well recognised interventions that can help.
- Delirium: Confusion or lack of attention and awareness can develop quickly or over many days. In the person with palliative care needs delirium may not be reversible. Following assessment non-pharmacological approaches including attention to comfort and limiting excessive noise and other stimuli may help.
- Fatigue: Persistent tiredness which not relieved by sleep or rest is very common amongst palliative care patients. It is causes significant distress and regular assessment to distinguish from depression or other conditions is important. A number of treatments are available, including non-pharmacological and attention should be given to identify reversible factors.
- Nausea and Vomiting: Occurring in 50-70% of people with advanced cancer, nausea is the most debilitating of these two symptoms. Assessment to determine the cause is important. Many of the known causes are reversible or readily managed using non-pharmacological and/or pharmacological approaches.
- Pain: A common symptom in palliative care, pain can be related to the disease or the treatment. Assessment and treatment are essential and there are both pharmacological and non-pharmacological approaches available. Opioids are the mainstay of management for moderate to severe pain. In the terminal phase transition from oral to the parenteral route is common.
To learn more about the latest evidence relevant to management of palliative care symptoms, including assessment and treatment, visit the CareSearch Clinical Evidence pages on Patient Care and Conditions, and relevant sections in the GP Hub. There you will also find information on the use of complementary medicines.
Clinical Assessment
The clinical assessment of a patient needs to be impeccable, comprehensive, systematic and ongoing; however barriers to this often exist, such as lack of time and training. [3] As with the principles of person centred care in dementia, assessment needs to be tailored and individualised to the patient.
A structured approach to assessment often involves using clinical assessment tools which should be used appropriately and with caution, and not as a substitute for a comprehensive, holistic assessment. [3] Tools should also be reliable and valid, and not adapted to meet local needs unless they are re-validated within that population or setting. [4]
Clinical Decision Making
When making clinical judgements, nurses draw from many sources including their formal nursing education and/or from their experience gained over time in practice. [5] Clinical decision making can be defined as choosing between alternatives, a skill that improves as nurses gain experience, both as a nurse and in a specific specialty. [6]
Clinical decision making requires good quality judgment including critical thinking. [7] An earlier definition of critical thinking in nursing is: '…..Critical thinkers in nursing practice the cognitive skills of analysing, applying standards, discriminating, information seeking, logical reasoning, predicting and transforming knowledge' [8 p357] It has also been highlighted that reflection on practice can be as a result of a breakdown in clinical judgement. [9]