Palliative Care for Patients with Cancer

Nongluck Ananta-ard, RN, PCN, PhD

Department of Nursing, king Chulalongkorn Memorial Hospital, Bangkok, Thailand


SYNOPSIS

The early palliative care refers to comprehensive cancer care by multidisciplinary team approach during cancer treatment in order to improve quality of life for advanced cancer patients. It is introduced to cancer patients earlier than the usual palliative care measures. Unfortunately, current evidences have reported that people with hematologic malignancies tend to unmet palliative care needs compared to patients with solid tumors. However, based on our experience early integration of palliative care into routine hematologic malignancy care along with their treatment trajectory may possible for achievement of outcomes.

Hematology unit of the King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand, is a medical training center for a specialty of hematologic diseases, and also provides both services and research to improve the effectiveness of treatments. There is a large number of patients receiving treatment as inpatients and outpatients including the patients who are in palliative care stage. Unlike solid tumors, the prognosis of hematologic malignancies is quite difficulty to proceed concerning types of disease, dose of chemotherapy, new optional treatments and supportive care by administering blood transfusion in particular end of life stage. Although, the palliative care center of the hospital provides specialized palliative care for both inpatients and outpatients, an integration of early palliative care for the patients are difficult in routine practice. This is the reason why the palliative care nurse (PCN) navigator is setting up.  Here, we would like to share experiences in the context of nurse-led early palliative care for people with hematologic malignancies. 

From 2018, the hematologists who focus not only on treatments, but also disease in order to improve patient outcomes. A PCN navigator is considered as indispensable part of a team to deliver medical services in which the early palliative care has been initiated. Our team administer the early palliative care for patients having following inclusion criteria as follow: (1) incurable disease, (2) at risk of adverse outcomes from receiving intensive treatment, (3) high symptoms burden, (4) significant psychological distress, (5) psychosocial needs, and (6) transition to end of life phase. 

The PCN has coordinated with multidisciplinary team to provide symptom management and psychosocial support. Our team has provided palliative education and created emotional and spiritual support for patients, their families, and nurses. Also, the team has consulted with specialist from a palliative care team to help foster patents, their families and caregivers according to their individual needs. Additionally, the PCN has a proactive approach to facilitate an advance care plan, and prepare them for the end-of-life. 

In the past year, we provided early access to 68 patients. Thirty-eight patients needed early palliative care at outpatient hematological clinic while 30 patients required the service at inpatient ward. The most frequent entities were acute myeloid leukemia (39%), aggressive lymphoma (28%) and multiple myeloma (19%) respectively.

Regarding the record, 55 out of 68 patients passed away and it revealed that 80% of patients died in hospital (26 patients died in the KCMH, 15 patients died in their primary hospitals),18.2% died peaceful at home, and 1.8% died in unknown places in succession. 

The Distress score was a wide range between 2-10 on the distress thermometer (performing a rating score 0-10 at the first visit and along with their treatment trajectory). Fatigue and pain were the most common symptom distress meanwhile sadness was considered as the common emotional problems. Evidently, deep Breathing exercise is viewed as the best way to reduce the extreme fatigue. Regarding psychological distress, 25% patients suffered from a level of moderate and severe of mental issues. Then, the care team notified the relevant physicians and spiritual leaders such as monks to help them. In what way, it is beneficial in terms of emotional and spiritual supports.

Out of the total of 55, decreased patients, 26 were consulted with palliative care specialist team of the hospital for preparing patients and their families for the end-of-life issues. Ten patients needed spiritual care from monks, and 3 patients required art therapists for supportive care. 

Based upon our experiences, a nurse-led early palliative care for people with hematological malignancies with a multidisciplinary team should be presented as soon as possible. The model of a palliative care nurse navigator for this specialized population is taking into consideration and it will be established in practical ways based on context and clinical practice. The needs for conducting effectiveness research to test a nurse-led early palliative care for this specific population is significant for benefits for these patients in relation to better quality of life.


CHULABHORN HOSPITAL’S PALLIATIVE CARE MODEL

Thitaree Boonchaue

Chulabhorn Hospital (Chulabhorn Royal Academy), Bangkok, Thailand


SYNOPSIS

Chulabhorn Oncology Medical Centre, Chulabhorn Hospital, which is a part of the Chulabhorn Royal Academy under supervision of the Prime Minister’s Office, is a 100-bed hospital specialising in cancer treatment and care. Due to the imperative of palliative care in cancer treatment, the palliative care team at Chulabhorn Hospital was established in 2014. This multidisciplinary team is composed of medical doctors from various specialities, nurses and practical nurses, psychologists, physiotherapists, nutritionists, pharmacists and social workers.

The palliative care path way of the Chulabhorn Hospital is developed and implemented to provide a clear and practical process of holistic care. The palliative care team looks after the patients with collaboration of their primary doctors when: 1) The patient’s distress score is four or more 2) the patient is diagnosed with end stage cancer 3) the patient and care taker need home visit 4) there is any issue that the primary doctors would like the team to support. The team is continuously taking care of the patients and families until the end of life and after the patient died with bereavement care for the families and care givers. Moreover, the integrative care such as Chinese traditional medicine, group activities and religious spiritual support is also provided.


THAI NURSES’ PALLIATIVE CARE COMPETENCIES AT A GLANCE

Assistant Professor Tiraporn Junda, RN., Ph.D.

Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand


SYNOPSIS

Currently, palliative care is now classified as one of the significant cares in health care system worldwide. With an aging population and modern technology, people with chronic illnesses are rising dramatically as well as patients at the end of life stages. There are estimates about 20 million worldwide who need palliative cares. Thailand also similarly faces this dilemma. Thai Ministry of Public Health reported that in 2015 there was about 163,860 elderly with bedridden had been taking care at home, and about 41,557 were at their end of life. 

In the past 20 years, palliative care services were limited to cancer patients and Thai health care teams were struggling with palliative care services due to many factors such as limited resources, negative attitude of the health care team, or no supporting system. At that time there was no palliative care standard or system to guide the Thai health care system. And definitely few preparations for palliative care personnel mostly focus on nurses and some family doctor teams. However, there was not enough staff who run palliative care services with the rising palliative population who in need of palliative care. Since 2015, the Thai government had launched the policy require that all hospitals at all levels have had to have palliative care service and real operation. From the previous study of following up the services in the central area in 2017 founded that to provide good quality of palliative care, the nurse is one of the key personals. There were eminent that most quality nurses had been trained about palliative care at least 10 days to 4 months. However, there were a lot of nurses who provided services by heart or volunteering without any former training, but they seem to be quality nurses, too because there past care experiences, but some nurses felt unsure whether their care was good enough due to their few background knowledge of palliative care. In addition, based on the analysis of Thai nursing curriculum also confirmed the dilemma of few preparations of the palliative topics about 1-2 hour at most. The previous study confirmed that with lack of knowledge or preparation about palliative care, most novice nurses about palliative care felt uncomfortable and unsure how to provide quality of palliative cares. 

With the missing part of palliative care teaching course, Thai Nursing Council palliative care consortium suggested about cores requirement of palliative care in nursing. Based on Bloom and colleagues’ competency model, palliative care competency consist of knowledge about palliative care, good attitude about the care, and confident in skills how to giving care (K = Knowledge, A = Attitude, P = Practice). And in 2015, Thai Nursing Council announced their mandate cores palliative care competencies at three levels; A, basic postgraduate; B, advanced post graduated; and C, specialist post graduated. Which mandated that all nurses after graduated must receive basic palliative care training at least 3 days. The required competencies were at beginner level with six core competencies included 1) providing care for patients and family, 2) Pain management, relieving suffering symptoms and promote comfort, 3) Caring at near death, 4) Grief, loss, and bereavement care, 5) Communication and 6) Ethic and legal care. The advanced post graduated is a 10 days training aimed at nurses who will be in a palliative care team who work in the ward or call palliative care ward nurse (PCWN). Their required seven core competencies which add collaboration with the team to the beginner level competencies. And specialist post graduated level with 2 – 4 months training or short course program consists of 9 competencies which adding 1) religion, spiritual, and cultural care, and 2) teaching and education. 

Since then many nurses had been trained and ongoing. In Thailand, there are about 11,035 hospitals under the Ministry of Health regulation not include university hospitals and private hospitals. Thai Nursing Council expected that about one nurse per hospital should get training each year and expected about 12,000 -15,000 nurses will get training per year. The total number of Thai nurses in 2017 was about 108,293. However, up until now, there had been no report on the outcome of palliative care training as a whole, due to lack of standard measurement. Each training centre has their own evaluation form and mostly evaluate the course, not on trainees’ competencies. In addition, there are few follow-up evaluations after training when trainees go back to work and give palliative care services. Thus, we cannot conclude that after training, whether nurses will improve palliative care knowledge, attitude, and their skills of care which reflect 6-9 core competencies or not. 

Some measurement had been developed to assess nurses palliative care core competencies based on different theory or analysis. For example, Slatten and colleague developed new measurement, the nurses’ core competence in palliative care (NCPC) for Norwegian Nurses based on 5 domains of Becker. Montagnini and colleagues used the ethics committee of the society of critical care medicine recommendation for the end of life care in ICU to create the assessment of self-perceived end-of-life care competencies of ICU providers.  For Desbiens and Fillion developed the palliative care nursing self-competence scale (PCNSC) based on Bandura’s social cognitive theory or self-efficacy was in the context of measurement. The issue the gap of previous self-efficacy measurement was lacking of important dimensions of palliative care; spirituality, team collaboration, and professional development. They rigorously developed new measurement with three phrases and ended of 10 dimensions with 50 questions. For some papers separately measure knowledge, attitude, and skills with different measurement. Thus how to evaluate nurses’ palliative care core competencies can be differently chosen. 

For this report after exploring each measurement, the PCNSC by Desbiens and Fillion was quite fit with Thai nine core competencies and it was also used in Vietnam. After getting permission from the original authors we got the PCNSC Thai version from another researcher who translated and conducted research with Thai nurses in central of Thailand. Then PCNSC was evaluated by our research team comparing with Thai Nursing Council core competencies and found that some items needed and we generated our new items with nine competencies. We also kept all original 50 items. Thus 15 new items were added to fit with Thai context. This measurement is now being tested with nurses in 5 parts of Thailand. 

References

  1. Bureau of Policy and Strategy, Ministry of Public Health. Public Health Statistics A.D. 2015.  

    Bangkok : Samcharoen Panich (Bangkok);2016. (in Thai)

  1. Montagnini M, Smith H, & Balistrieri T. Assessment of Self-Perceived End-of-Life Care 

    Competencies of Intensive Care Unit Providers. Journal of Palliative Medicine; 2012;15(1):  

    29-36.

  1. Desbiens J, Fillion L. Development of the Palliative Care Nursing Self-competence Scale. 

    Journal of Hospice & Palliative Nursing; 2011;13(4):230-41.

Event Hours(1)

  • Lotus 5-6.

    03:00 pm – 04:30 pm

    Speakers:
    1. Dr. Nongluck Ananta-ard (CU)
    2. Mrs. Thitaree Boonchaue (CRA)
    3. Miss. Thochaporn Tesasil (SI)
    4. Asst. Prof. Dr. Tiraporn Junda (Rama)

    Moderator:
    Miss Kingtip Tamthong (CU)