Concept Analysis

Palliative Care: Concept Analysis

            Concept analysis is an integral element of knowledge development in nursing. Nursing concepts are the basic building blocks of all nursing theories. Concept analysis involves the assessment of the specific meanings, principles, features and applications of nursing theories and models. Nursing concepts are always changing contextually and in their application. Therefore, the ongoing analysis of the different concepts is crucial to promoting research and evidence-based practice in various clinical settings. Palliative care is an important concept in long-term care settings. Its key meanings and application are grounded in Kolcaba’s Comfort Theory. The analysis of the meanings, features and application of the palliative care concept is critical to the delivery of holistic nursing care.

Definition of Palliative Care

            A review of the different definitions of palliative care is needed to understand clearly the meaning of the concept. The WHO defines palliative care as the actions and processes for managing pain and suffering to improve the quality of life of patients and families with life-threatening illnesses (Guo, Jacelon, & Marquard, 2012, p. 2). The AAHPM defines palliative care as the comprehensive and interdisciplinary process of providing specialized care with the goal of managing suffering and promoting the quality of life of patients and families with life-threatening illnesses. Hogston and Marjoram (2011) define palliative care as the process of delivering holistic care to the patients dealing with advanced and progressive illnesses.

Literature Review

            Each concept in nursing is communicated through a set of words and or phrases that capture its unique meaning. The use of inconsistent words and phrases when defining a concept makes the concept complex and challenging to interpret and apply. When two nurses define and interpret the same concept differently, then its operationalization becomes difficult.

Therefore, the identification of the standard words and phrases used commonly to define palliative care is crucial to the proper understanding of the concept. This literature review will focus on identifying the key terms used to describe palliative care, the attributes of palliative care and the theoretical underpinnings of the concept.

Palliative Care: Key Terms and Phrases

            Wu and Volker (2012) studied the main theoretical concepts relevant to palliative care nursing. The researchers assessed the relevance of the Humanistic Theory to palliative care. The researchers concluded that the keywords and phrases used to describe palliative care include call-and-response, uniqueness, otherness, being and doing with patient and end-of-life. These words and phrases demonstrate that palliative care involves patient-centered responses intended to support patients and families dealing with unique and complex end-of-life needs.  Being and doing with the patient is an integral part of the therapeutic use of the self.

            Hui et al. (2014) conducted a systematic review to investigate the meanings of the key terms used in palliative care and develop a standard definition of the concept. The study revealed that the key terms were actively dying, end-of-life, terminally-ill and transition of care. The main terms relating to the end-of-life were terminal illnesses, life-threatening diseases and progressive decline. On the other hand, the main terms relating to the transition of care were acute to hospice care and curative to palliative care. Therefore, palliative care involves interventions to help patients manage and cope with life-threatening and progressive diseases. Hui (2014) analyzed the use of the term, supportive care, in nursing research and clinical settings. The study revealed that supportive care is used to describe the actions focused on managing symptoms, improving the quality of life and caring for the patients receiving treatment for diseases in advanced stages. Palliative care is an integral part of supportive care. It is classified as secondary supportive care and is directed towards patients with complex healthcare problems that cannot be managed solely by the patient’s primary care physician.  The physician engages the palliative care team to deliver holistic care.  

Palliative Care: Attributes

            Guo, Jacelon, and Marquard (2012) studied the changes in the meaning of the concept of palliative care.  The study revealed that the most recent definitions of palliative care share several attributes. These are the medical specialty, relieving pain and other distressing symptoms, wholesome care, patient and family-centeredness, interdisciplinary teamwork, therapeutic communication, trust and safety. Granda-Cameron and Houldin (2012) examined the characteristics of a good death in terminally-ill patients.  The researchers concluded that the main attributes of good death are the effective management of pain and symptoms, awareness of death, dignity in dying, family’s presence and supportive and therapeutic communication.

Palliative Care: Theoretical Underpinnings

            The review of the key terms and attributes of palliative care shows that palliative care should focus on giving the patient maximum comfort. This level of comfort is attained when the patient is relieved from all the distressing conditions. The appropriate theoretical framework for palliative care should provide a model for interpreting how terminally ill patients experience comfort. Coelho, Parola, Escobar-Bravo, and Apóstolo (2016), conducted a phenomenological study to investigate the experiences of comfort and discomfort by the patients at palliative care centers. The researchers found that individualized care, control of symptoms, therapeutic relationships and hope were crucial to the attainment of comfort. The Theory of Comfort provides a clear description of the different forms of comfort and the contexts in which they occur. Trotte and Caldas (2015) conducted a study to investigate whether applying the Comfort Theory in caring for Heart Failure patients in a palliative care unit led to improved comfort and quality of life. Twenty subjects participated in the study and were evaluated using the end-of-life comfort questionnaire and NOC comfort scale. The study concluded that the application of the Comfort Theory led to improved comfort through enhanced therapeutic communication, decrease death anxiety and increased hope.

Defining the Attributes

            The definition and discussion of some of the key attributes of palliative care supports the complete understanding of the concept. First, palliative care is a wholesome or holistic practice that focuses not only on relieving the individual’s pain and suffering but the whole being. It ensures the patient’s comfort in the physical, psycho-spiritual, environmental and social contexts (Coelho, Parola, Escobar-Bravo, & Apóstolo, 2016, p. 3).  Secondly, palliative care is patient and family-centered. Patients with terminal and advanced stage diseases have complex and unique health care needs associated with the diminishing functional mobility, declined response to treatment and the awareness of impending death. The identification and response to each patient’s needs are crucial. The patient’s family members are an important source of physical, emotional, psychological and financial support. Therefore, palliative care teams must engage the family in developing the patient’s care plans and coping strategies (Wu, & Volker, 2012). Thirdly, palliative care involves therapeutic communication. The palliative care team(s) cannot attain the desired patient outcomes without developing trust and confidence with the patient. Both the verbal and nonverbal communications are crucial to the effective sharing of information, decision making and implementation of care plans.

Antecedents and Consequences

            One antecedent of palliative care is the terminal illness. Palliative care is primarily intended for patients with conditions that cannot be cured. The focus of treatment shifts from curative interventions to relieving the distressing symptoms when a patient is diagnosed with a terminal illness (Guo, Jacelon, & Marquard, 2012, p. 2). For example, it is useless to apply curative interventions for a patient diagnosed with Stage IV breast cancer. The care plan for such a patient should focus on interventions to ease her pain and suffering as she awaits death. On the other hand, one key outcome of palliative care is the improvement in the patient’s quality of life. Terminally-ill patients suffer physical, emotional and psychological distress due to factors such as the incapacitating effects of the illness, perceived helplessness, hopelessness, anxiety and fear (p. 4). These factors lead to poor quality of life for the patient. The implementation of effective palliative care interventions relieves the patient’s suffering in the physical, psycho-spiritual, social and environmental contexts leading to the overall improvement in the quality of life.

Empirical Referents

            The two key empirical referents of palliative care are the alleviation of pain and other distressing symptoms and dying with dignity. First, terminally-ill patients who receive holistic palliative care enjoy an improved quality of life when their distressing symptoms are managed effectively. The patients attain significant physical, psychological, emotional and spiritual peace towards the end of their life.  Secondly, palliative care patients die with dignity because their rights and needs are protected and promoted (Granda-Cameron & Houldin, 2012). The patient’s privacy, autonomy, values and beliefs regarding dying guide the applied interventions. Therefore, when the palliative care patient dies, he will pass on peacefully with his dignity and personal wishes honored.

Constructing Cases

Model Case

            Mrs. Johnson is a 64-year-old patient with stage IV breast cancer. She experiences frequent episodes of severe pain that continue sometimes for several hours.  She appears increasingly withdrawn and prefers to stay in her room most of the time. Her family lives far away and cannot visit regularly. Recently, the patient disclosed to her nurse that she no longer enjoys life and did not see the need to continue living. This case illustrates that the patient has prolonged physiological discomfort and difficulty coping with the life-threatening illness. Therefore, palliative care is necessary.

Borderline Case

            Simon has been hospitalized for the past one week and is receiving chemotherapy for the treatment of Stage III prostate cancer. The patient feels tired, suffers periodic back and joint pains and has difficulty sleeping. He is keen to undergo treatment. However, he is anxious about how long he will be staying at the hospital. Simon’s children visit him often. He enjoys time with the children and can be found playing and laughing with them. This case shows that Simon is suffering some of the physiological and psychological effects of a potentially life-threatening illness. However, he can still enjoy interactions with his family and participate in various activities.

Contrary Case

            John, a traffic police, has been hospitalized for the past 3 days following a motorcycle accident. He suffered a concussion and fractures in one of his legs. He is keenly watching a basketball match on T.V and cheering his team. John is upbeat about being discharged by the end of the week and looks forward to returning to work in a few weeks.  This case has no attributes of palliative care.  

Applications of Palliative Care

            Concept analysis guides the identification of a theoretical framework that is most suited for the concept of interest. Kolcaba’s Comfort Theory provides a comprehensive and consistent model for accessing the needs of terminally-ill patients and designing interventions to promote the physiological, psychological, spiritual and emotional comfort of patients and their families (Trotte & Caldas, 2015). The Comfort Theory defines the scope of palliative care by describing the types and contexts of comfort that the patient should experience. 

Conclusion

            The analysis of the palliative care concept, its theoretical underpinning and application illustrate that the holistic care for terminally-ill patients should respond not only to the physiological distress of patients and their families but also their psychological, emotional and spiritual distress.  Holistic palliative care should lead to improved quality of life and dignity for the dying patients.  The values, attitudes, beliefs and actions by the palliative care nurse have a significant impact on the way the patient lives until he dies, the way the patient dies and the memories of the patient’s last days for the family.