*Holistic/Palliative Management of Patient's Health Care and Home Situation in a Depressed… DOI: http://dx.doi.org/10.5772/intechopen.92736*

Quality Forum (NQF) jointly formulated the concept of palliative care so as to separate it from other types of care [14]. And so they came up with eight domains of palliative care: 'structure and processes of care; physical aspects of care; psychosocial and psychiatric aspects of care; social aspect of care; spiritual, religious, and existential aspects of care; cultural aspects of care; care of the imminently dying patient and ethical and legal aspect of care' [14].

Palliative care is often misidentified as being the same as care given to the patient approaching death where no cure is expected to be achieved [15]. It is focused on the relief of distress during the advancement of patient's illness. Even though hospice and palliative care is extensively used in the western world, many patients are seen to register in hospice very close to death, which limits the advantage these services would have obtained.

Rosser and Walsh cited WHO's principles of palliative care as follows:


*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

**2.1 Principles of a holistic approach**

**3. Palliative care and its principles**

distressing clinical complications' [12].

symptoms [5].

• All people have natural healing powers;

• The patient is a person, not just a disease;

• Suitable healing therapy needs a team approach;

• Patient and health care professionals are collaborators in the healing process;

The World Health Assembly approved the resolution to integrate hospice and palliative care services into national health services [11]. The body recognises these important health services as an important component of health systems worldwide and therefore calls on national authorities to make sure they be given the awareness they deserve. This is the first time that the World Health Assembly has considered a declaration on palliative care. It endorses that all countries need to take palliative care seriously [11]. The main recommendations to all member states of WHO as seen in the resolution are to integrate palliative care into health care systems, to make sure that palliative care is incorporated into the introductory and continuing education and training for all health care personnel and to make sure that appropriate medica-

Many individuals, organisations and bodies including the WHO have suggested different definitions of palliative care. WHO revised the meaning of palliative care to be 'an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual' [12]. WHO further listed the following features of palliative care: 'provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten nor postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patients illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; will enhance quality of life, and may also absolutely influence the progression of illness; is applicable early in the course of illness, in conjunction with other treatments that are aimed to prolong life, such as chemotherapy or radiation therapy, and includes those examinations needed to better understand and manage

Boltz defined palliative care 'as expert curative care of patients with severe disorders, and it emphases providing patients with relief from symptoms, discomfort and worry of serious illness, irrespective of the diagnosis' [13]. She further explained that the word 'palliative' has its origin in the Latin word meaning to 'cloak or cover'. And upheld that, Viewpoint of how cancer, which is one of the terminal diseases is observed and not properly diagnosed, is suitable description because most cancers progress without warning signs for an extensive period before the individual tries to seek help. The National Consensus Project (NCP) and National

tions, as well as strong pain medications, are accessible to patients [11].

• Treatment comprises fixing the cause of the illness, not just reliving the

**252**


These principles according to Rosser and Walsh focus on a whole, humanistic method of caring for the total being during the course of their illness, instead of concentrating on the ailment or situation [5]. Palliative care answers to the altering wishes of the patient and family, identifying that the illness development and the related involvements are distinctive to each individual. Rosser and Walsh opined that palliative care is seen as supportive care [5]. They see it as care delivered to patients, friends and family during the course of their illness; this includes the period before diagnosis has been made, as soon as patients start undergoing series of examinations, treatment and home care. The purpose of supportive care is to assist the patients and their families to be able to handle their illness and management at home.

Becker also penned principles that are relevant to providing palliative care. These include the following:

• Follow-up of all patients diagnosed with terminal illness at any stage of the disease


These principles will put humanity back into the care offered by nurses. After physicians, nurses are the most important members of the palliative care team in the sense that they spend 24 hours with the patients and should be able to display the principles [16]. Skill is an important characteristic for ensuring quality, safety and cost-effective health care. The term competence according to the Royal College of Nursing "(RCN) comprises the skills, knowledge, practices, qualities and manners essential for an individual" so as to execute the work successfully [16]. A nurse is said to be competent when she has the skills and talents vital for lawful, safe and effective professional practice without direct guidance [17]. Competence can be said to be basic features of persons that result in effective performance. They can be described as a mixture of knowledge, skills, purposes and personal character traits. It can also be seen as the way someone behaves or acts.

Areas of competency include verbal message, written communication, enquiring skills and team skills [17]. Nurses are expected to communicate efficiently, generating talking and listening skills. Nurses should be able to use their knowledge and skills to promote open and honest communication skills to support open and honest interaction that recognises the needs of patients, and also creates a satisfying association in which they are able to apply counselling skills and initiate follow-up programmes to help them to adjust to their illness and care. Their knowledge and skill will also ascertain that patients obtain full evidence-based nursing care. They understand and identify the impact of terminal disease when dealing with clinical or home situation, so that they can be able to assess the outcome of care and give appropriate intervention. Competence also includes the ability of the nurses to use the e11 function health patterns to assess the patient. Gordon Morgan, according to Doenges and Moorhouse, devised 11 functional health patterns to be used by nurses in nursing process to provide more comprehensive nursing assessment of the patient. This will help the nurses to give holistic care to patients [18].

The model of palliative care put together by the Canadian Hospice and Palliative Care Association (CHPCA) [19] is the model that is used to guide this chapter. This model is effective because it was developed to plan, evaluate and develop educational programmes [19]. In adopting this model, the paper considered the prominent position of the hospital management, without which it would be impossible to develop a programme for home care. The key role played by nurses as members of the palliative care team begins as soon as diagnosis is confirmed by the physician. Based on gaps identified after confirmation of diagnosis, the model provides guidance in tracking and tracing each patient, and planning home care. Communicating the true position of diagnoses at this stage is very important as it will help to reduce anxiety—after which, follow-up and home care measures will then be put in place.

Two fundamental elements in the framework as utilised are the 'square of care' and the 'square of organization'. As set out in the model [19], the 'square of care' has six components and the 'square of organization' has six stages that are relevant to palliative care integration. The composition of the conceptual framework is shown in **Figure 2** covers all phases of a palliative care programme, service or group. The patient and family are at the middle of the joint square, and their needs decide the concerns to be covered, the care necessary and the purposes and means to deliver care [20].

**255**

• assessment

**Figure 2.**

• information sharing

• decision-making

• care delivery and

• care planning

• planning

• operation

*Holistic/Palliative Management of Patient's Health Care and Home Situation in a Depressed…*

The Square of Care refers to the six important phases during the process of rendering care to patients and family. The phases of square of care include:

• confirmation, and demonstration that they relate to the concerns (or areas)

that patients and families usually encounter.

*Square of care and organisation (Source: adopted from CHPCA).*

• quality improvement communication/marketing

• governance and administration

• collection and use of data.

Square of organisation also has six stages, which comprise:

*DOI: http://dx.doi.org/10.5772/intechopen.92736*

*Holistic/Palliative Management of Patient's Health Care and Home Situation in a Depressed… DOI: http://dx.doi.org/10.5772/intechopen.92736*

#### **Figure 2.**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

These principles will put humanity back into the care offered by nurses. After physicians, nurses are the most important members of the palliative care team in the sense that they spend 24 hours with the patients and should be able to display the principles [16]. Skill is an important characteristic for ensuring quality, safety and cost-effective health care. The term competence according to the Royal College of Nursing "(RCN) comprises the skills, knowledge, practices, qualities and manners essential for an individual" so as to execute the work successfully [16]. A nurse is said to be competent when she has the skills and talents vital for lawful, safe and effective professional practice without direct guidance [17]. Competence can be said to be basic features of persons that result in effective performance. They can be described as a mixture of knowledge, skills, purposes and personal character traits.

Areas of competency include verbal message, written communication, enquiring skills and team skills [17]. Nurses are expected to communicate efficiently, generating talking and listening skills. Nurses should be able to use their knowledge and skills to promote open and honest communication skills to support open and honest interaction that recognises the needs of patients, and also creates a satisfying association in which they are able to apply counselling skills and initiate follow-up programmes to help them to adjust to their illness and care. Their knowledge and skill will also ascertain that patients obtain full evidence-based nursing care. They understand and identify the impact of terminal disease when dealing with clinical or home situation, so that they can be able to assess the outcome of care and give appropriate intervention. Competence also includes the ability of the nurses to use the e11 function health patterns to assess the patient. Gordon Morgan, according to Doenges and Moorhouse, devised 11 functional health patterns to be used by nurses in nursing process to provide more comprehensive nursing assessment of the

• Competence at putting patients at ease

It can also be seen as the way someone behaves or acts.

patient. This will help the nurses to give holistic care to patients [18].

The model of palliative care put together by the Canadian Hospice and Palliative Care Association (CHPCA) [19] is the model that is used to guide this chapter. This model is effective because it was developed to plan, evaluate and develop educational programmes [19]. In adopting this model, the paper considered the prominent position of the hospital management, without which it would be impossible to develop a programme for home care. The key role played by nurses as members of the palliative care team begins as soon as diagnosis is confirmed by the physician. Based on gaps identified after confirmation of diagnosis, the model provides guidance in tracking and tracing each patient, and planning home care. Communicating the true position of diagnoses at this stage is very important as it will help to reduce anxiety—after which, follow-up and home care measures will

Two fundamental elements in the framework as utilised are the 'square of care' and the 'square of organization'. As set out in the model [19], the 'square of care' has six components and the 'square of organization' has six stages that are relevant to palliative care integration. The composition of the conceptual framework is shown in **Figure 2** covers all phases of a palliative care programme, service or group. The patient and family are at the middle of the joint square, and their needs decide the concerns to be covered, the care necessary and the purposes and means to deliver

• Listening and attention skills

• Questioning techniques [16].

**254**

care [20].

then be put in place.

*Square of care and organisation (Source: adopted from CHPCA).*

The Square of Care refers to the six important phases during the process of rendering care to patients and family. The phases of square of care include:


Square of organisation also has six stages, which comprise:


The main concepts of the model are the standards and regulatory beliefs that were established and decided upon through a national consensus-based practice [20].

There should be plans for both the health care professional and patients/families to manage physical and psychosocial suffering and to get ready for the likelihood of advanced disease. This aspect of palliative care involves ways to provide physical and emotional care that will help patients to get through treatments. It enhances patients' compliance with disease management, helps them accept changes in care and prepares patients and their families for the tasks ahead if the disease eventually does not lead to a cure.

#### **3.1 Application of the model**

Based on the model of palliative care as developed by CHPCA, the model takes into consideration the prominent position of the hospital management without which it will be impossible to develop any programme of such magnitude [19, 20]. This is because, a lot of things will be considered, especially, developing human resources example training of palliative care nurses, setting up palliative care team, providing other means of integrating palliative care into daily care of patients. Again, patients and families should also be seen at the centre of developing this programme as compliance is the key to success of any programme.

A nurse as an important member of palliative care team has an important role to play as soon as a patient is indicated for home care. Based on the gaps identified, after confirmation of diagnosis, tools that are going to be adapted will be used to track each patient; communication of the true position of diagnoses at this level is very important as this will help to reduce anxiety and follow-up measures will then be put in place. Studies conducted by Temel et al. indicate that patients who had palliative care integrated into normal treatment had a better outcome even when they were diagnosed at the advanced stage of the disease than patients who managed with only normal treatments [21].

## **4. The relevance of spirituality in health care**

Spirituality is a part of holistic care for clients and families. Patients getting palliative care benefit much from the special care that is devoted to physical, personal and social needs [22]. Spiritual care is seen as very significant for a lot of terminally ill patients, but professionals have trouble determining what such care they could embrace. From the viewpoints of the patients/clients at the end of life, their family caregivers and health care workers, the main aims are: to search the notion of spirituality and the meaning of this term; to discover beliefs, understandings and prospects with respect to spirituality, spiritual needs, pain or distress and spiritual care and, eventually, to see how spiritual care can best be provided for patients at home in a depressed economy.

Spirituality and health is an increasing new area of health care; the first textbook on spirituality and health was published by Oxford University Press [23]. Puchalski et al. established that patients would like their spirituality to be addressed in their health care. As the trends and research developed, ethical queries began to come up as to the definition of spirituality within medical care, its role in patient care and the implementation of spiritual care in the clinical setting.

Rosser and Walsh are of the opinion that spirituality takes account of an individual's beliefs, values, identity, a sense of meaning and purpose [5]. Some people see religion as being a component of spirituality. Wright and Neuberger designate spirituality to be pertained to how we see ourselves in the pattern of

**257**

*Holistic/Palliative Management of Patient's Health Care and Home Situation in a Depressed…*

things, how we relate to other human beings and the wider world and how we ascertain meaning, purpose and association in life [24]. By its very nature, spirituality is often subjective, absolute and personal. In addition to the suggested principles for health care professionals to take care of the whole person, together with the patient's spirituality, studies have established that patients appreciate a more whole-person emphasis on care and value health care professional's probe

Spirituality according to some schools of thought covers the confidence in self and others and this may include a belief in a divine being or higher authority [26].

If patients' needs could be recognised early and their care adequately planned to include (but not limiting to) follow-up of all patients diagnosed with terminal illness through telephone calls, home visiting, advanced care planning, assessment and treatment of physical, psychosocial and spiritual aspect of patient's needs, etc., there will be better outcome when the condition reaches advanced stage. Some may reason that because spirituality is so personal, it has no relationship in health care but when the perception of total pain is looked into, it is obvious that spiritual care

Economic depression is a period of time of economic slowdown presenting low output, not having enough funds and unemployment. It is considered by its length, abnormal upsurges in unemployment, falls in the obtainability of adequate health

The major causes of economic depression in any given economy (lessons from

• High inflation, a general rise in price of goods and services—leading to low

great depressions, 1981, 1991, 2008 economic recession) may include:

• Accumulation of debt servicing especially foreign debt.

The RCN also describes the following as factors of spirituality:

*DOI: http://dx.doi.org/10.5772/intechopen.92736*

into their spiritual beliefs [25].

• hope

• trust

• love

• strength

• forgiveness

• relationships

• self-expression [26].

is a vital element of care [5].

purchasing power.

**5. The impact of economic depression on health**

services, shrinking output and investment, etc.

**5.1 General causes of economic depression**

• creativity

*Holistic/Palliative Management of Patient's Health Care and Home Situation in a Depressed… DOI: http://dx.doi.org/10.5772/intechopen.92736*

things, how we relate to other human beings and the wider world and how we ascertain meaning, purpose and association in life [24]. By its very nature, spirituality is often subjective, absolute and personal. In addition to the suggested principles for health care professionals to take care of the whole person, together with the patient's spirituality, studies have established that patients appreciate a more whole-person emphasis on care and value health care professional's probe into their spiritual beliefs [25].

Spirituality according to some schools of thought covers the confidence in self and others and this may include a belief in a divine being or higher authority [26]. The RCN also describes the following as factors of spirituality:

• hope

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

programme as compliance is the key to success of any programme.

does not lead to a cure.

**3.1 Application of the model**

aged with only normal treatments [21].

home in a depressed economy.

**4. The relevance of spirituality in health care**

the implementation of spiritual care in the clinical setting.

The main concepts of the model are the standards and regulatory beliefs that were

There should be plans for both the health care professional and patients/families to manage physical and psychosocial suffering and to get ready for the likelihood of advanced disease. This aspect of palliative care involves ways to provide physical and emotional care that will help patients to get through treatments. It enhances patients' compliance with disease management, helps them accept changes in care and prepares patients and their families for the tasks ahead if the disease eventually

Based on the model of palliative care as developed by CHPCA, the model takes into consideration the prominent position of the hospital management without which it will be impossible to develop any programme of such magnitude [19, 20]. This is because, a lot of things will be considered, especially, developing human resources example training of palliative care nurses, setting up palliative care team, providing other means of integrating palliative care into daily care of patients. Again, patients and families should also be seen at the centre of developing this

A nurse as an important member of palliative care team has an important role to play as soon as a patient is indicated for home care. Based on the gaps identified, after confirmation of diagnosis, tools that are going to be adapted will be used to track each patient; communication of the true position of diagnoses at this level is very important as this will help to reduce anxiety and follow-up measures will then be put in place. Studies conducted by Temel et al. indicate that patients who had palliative care integrated into normal treatment had a better outcome even when they were diagnosed at the advanced stage of the disease than patients who man-

Spirituality is a part of holistic care for clients and families. Patients getting palliative care benefit much from the special care that is devoted to physical, personal and social needs [22]. Spiritual care is seen as very significant for a lot of terminally ill patients, but professionals have trouble determining what such care they could embrace. From the viewpoints of the patients/clients at the end of life, their family caregivers and health care workers, the main aims are: to search the notion of spirituality and the meaning of this term; to discover beliefs, understandings and prospects with respect to spirituality, spiritual needs, pain or distress and spiritual care and, eventually, to see how spiritual care can best be provided for patients at

Spirituality and health is an increasing new area of health care; the first textbook on spirituality and health was published by Oxford University Press [23]. Puchalski et al. established that patients would like their spirituality to be addressed in their health care. As the trends and research developed, ethical queries began to come up as to the definition of spirituality within medical care, its role in patient care and

Rosser and Walsh are of the opinion that spirituality takes account of an individual's beliefs, values, identity, a sense of meaning and purpose [5]. Some people see religion as being a component of spirituality. Wright and Neuberger designate spirituality to be pertained to how we see ourselves in the pattern of

established and decided upon through a national consensus-based practice [20].

**256**


If patients' needs could be recognised early and their care adequately planned to include (but not limiting to) follow-up of all patients diagnosed with terminal illness through telephone calls, home visiting, advanced care planning, assessment and treatment of physical, psychosocial and spiritual aspect of patient's needs, etc., there will be better outcome when the condition reaches advanced stage. Some may reason that because spirituality is so personal, it has no relationship in health care but when the perception of total pain is looked into, it is obvious that spiritual care is a vital element of care [5].
