The purpose of this assessment is to examine your ability to complete an assessment of palliative care patient using the validated assessment tools discussed in Themes 2, 3, 4 and 5 and to demonstrate the integration of theory, into the context of your clinical practice. Confidentiality must be maintained in this assessment.
You need to support your discussion with references to current literature in order to demonstrate clinical reasoning and evidence based practice.
It is important to obtain patient consent and maintain patient confidentiality. In your written submission you must provide a script of approximately 50–75 words of what you said to the patient when asking for consent. You must also state that the patient gave consent.
Assessment:
• Introduce a palliative care patient from your clinical setting and provide a detailed description of the individual’s clinical presentation and significant history (200 words).
Joe is a 87-year-old lady who resides at a local Residential Aged Care Facility (RACF). Penny is a Muslim lady from Syria and has strong religious beliefs, including family commitment. She is at the end stage of her life.
Joe was diagnosed 10 years ago with Alzheimer’s disease. Two years ago a lump was observed on her left breast. This was diagnosed as breast cancer. Due to her age and health status, no active treatment was commenced. The lump has just recently developed into a fungating wound which requires management.
Prior to her admission to the facility Penny was cared for at home by her granddaughter, Margaret, and her two brothers who have recently arrived from her native country to be with her and to offer support to the family until they family was unable to cope at home but still offer to visit Joe in the nursing home and support Joe spiritually. More recently due to her wandering and intrusive behaviours Joe has been cared for in a Dementia specific unit. Joe is widowed and. Margaret visits frequently, is Joe’s next of kin and holds Enduring Power of Attorney for Joe’s health decisions. Margaret has noticed a visible decline Joe over the last 2 months and now she is refusing to take food and only minimal fluids. She is becoming weaker and no longer is at risk of wandering, has become increasingly confused, lost weight and spends her days nursed in bed or in a comfort chair.
At family conference Joe’s doctor has advised her family that she is now requiring palliative care and active medical interventions would be ceased and interventions will be more focused on keeping her comfortable and pain free. The doctor states he will instruct that she be commenced on an End of Life Pathway.

• Choose and give rationale to an assessment tool that has been taken from those suggested in the subject content and could be utilised to assess this specific condition or history (500 words).
• Describe the extent to which factors such as the individual’s ethnicity, culture, gender, spiritual values, sexuality, age, disability, economic and social factors, may have impacted on their condition and your assessment (500 words).
• Appraise the consultation and referral pathways available to the nurse, as a member of the multi-disciplinary team, to optimise outcomes and facilitate a person centred care approach (300 words).
• Utilise the theory provided throughout this unit and your clinical assessment finding, to develop an evidence based management plan for this client (500 words)(refer to theme 2,3,4,5)
• Reflect on any communication barriers and how these were overcome or could have been resolved (500 words).

Appendices – must be uploaded with your assessment but are not included in the word count:
• Script- detailing consent
• Completed (de-identified) assessment tool.

References

1 Milligan, S. P. (2018). Chapter 1: Who is the palliative care patient. In C. Walshe, N. Preston, B. Johnston (Eds.), Palliative care nursing: Principles and evidence for practice (3rd ed., pp.5-21). Oxford University Press.

Rogers, I. R., & Lukin, B. (2015). Applying palliative care principles and practice to emergency medicine. Emergency Medicine Australasia, 27(6), 612–615. https://doi.org/10.1111/1742-6723.12494
1.5 Prince-Paul, M., & Daly, B. J. (2019). Chapter 70: Ethical considerations in palliative care. In B. R. Ferrell, & J. A. Paice (Eds.), Oxford Handbook of palliative nursing (5th ed.). Oxford University Press
Stiles, E. (2013). Providing artificial nutrition and hydration in palliative care. Nursing Standard, 27(20), 35–42. https://doi.org/10.7748/ns2013.01.27.20.35.c9501
Shibata, B. (2017). An Ethical Analysis of Euthanasia and Physician-Assisted Suicide: Rejecting Euthanasia and Accepting Physician-Assisted Suicide with Palliative Care. Journal of Legal Medicine, 37(1–2), 155–166. https://doi.org/10.1080/01947648.2017.1303354

2.4 Lane, H., & Philip, J. (2015). Managing expectations: Providing palliative care in aged care facilities. Australasian Journal on Ageing, 34(2), 76–81. https://doi.org/10.1111/ajag.12085
2.5 Bloomer, M. J., Endacott, R., O’Connor, M., & Cross, W. (2013). The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study. Palliative Medicine, 27(8), 757–764. https://doi.org/10.1177/0269216313477176
2.6 Jansson, M., Dixon, K., & Hatcher, D. (2017). The palliative care experiences of adults living in regional and remote areas of Australia: A literature review. Contemporary Nurse, 53(1), 94–104. https://doi.org/10.1080/10376178.2016.1268063
2.7 Broom, A., Good, P., Kirby, E., & Lwin, Z. (2013). Negotiating palliative care in the context of culturally and linguistically diverse patients. Internal Medicine Journal, 43(9), 1043–1046. https://doi.org/10.1111/imj.12244
2.9 Mcgee, P., & Johnson M. R. D. (2014). Developing cultural competence in palliative care. British Journal of Community Nursing, 19(2), 91–93. https://doi.org/10.12968/bjcn.2014.19.2.91
Advance Care Planning Australia. (2021). Advance care planning. Austin Health. https://www.advancecareplanning.org.au/individuals/what-is-advance-care-planning
McCaffrey, N., Bradley, S., Ratcliffe, J., & Currow, D. C. (2016). What Aspects of Quality of Life Are Important From Palliative Care Patients’ Perspectives? A Systematic Review of Qualitative Research. Journal of Pain and Symptom Management, 52(2), 318-328.e5. https://doi.org/10.1016/j.jpainsymman.2016.02.012
3.2 Blumstein, B. (2015). Neuropathic Pain Management: A Reference for the Clinical Nurse. MEDSURG Nursing, 24(6), 381–438.
Cousins, M. J., & Gallagher, R. M. (2015). Chapter 2: Assessment of pain. In Fast facts: Chronic pain and cancer pain (4th ed., pp. 29-44). Health Press Limited.
Kwon, J. H. (2014). Overcoming Barriers in Cancer Pain Management. Journal of Clinical Oncology, 32(16), 1727–1733. https://doi.org/10.1200/jco.2013.52.4827
Nunn, C. (2014). It’s not just about pain: Symptom management in palliative care. Nurse Prescribing, 12(7), 338–344. https://doi.org/10.12968/npre.2014.12.7.338
Keall, R., Clayton, J. M., & Butow, P. (2014). How do Australian palliative care nurses address existential and spiritual concerns? Facilitators, barriers and strategies. Journal of Clinical Nursing, 23(21–22), 3197–3205. https://doi.org/10.1111/jocn.12566
Patient Care Outcomes Collaboration (PCOC). (2020). Assessment forms. University of Wollongong. https://www.uow.edu.au/ahsri/pcoc/palliative-care/assessment-forms/#d.en.111571
Donnelly, M., & Martin, D. (2016). History taking and physical assessment in holistic palliative care. British Journal of Nursing, 25(22),1250–1255. https://doi.org/10.12968/bjon.2016.25.22.1250
Schroeder, K., & Lorenz, K. (2018). Nursing and the Future of Palliative Care. Asia-Pacific Journal of Oncology Nursing, 5(1), 4–8. https://doi.org/10.4103/apjon.apjon_43_17
Chidiac, C. (2018). The evidence of early specialist palliative care on patient and caregiver outcomes. International Journal of Palliative Nursing, 24(5), 230–237. https://doi.org/10.12968/ijpn.2018.24.5.230
Hawley, P. (2014). The Bow Tie Model of 21st Century Palliative Care. Journal of Pain and Symptom Management, 47(1), 2–5. https://doi.org/10.1016/j.jpainsymman.2013.10.009
Luckett, T., Phillips, J., Agar, M., Virdun, C., Green, A., & Davidson, P. M. (2014). Elements of effective palliative care models: a rapid review. BMC Health Services Research, 14(1), 1-22. https://doi.org/10.1186/1472-6963-14-136
Dalkin, S. M., Jones, D., Lhussier, M., & Cunningham, B. (2012). Understanding integrated care pathways in palliative care using realist evaluation: a mixed-methods study protocol: Table 1. BMJ Open, 2(4), 1-6. https://doi.org/10.1136/bmjopen-2012-001533
Palliative Care Australia. (2018b). Palliative care service development guidelines. https://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/02/PalliativeCare-Service-Delivery-2018_web2.pdf

Palliative Care Australia. (2018c). Paediatric Addendum – Palliative Care Service Development Guidelines. https://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/12/PalliativeCare-Paediatricaddendum-2018_web.pdf

Svarosky, T. (2013). Having Difficult Conversations: The Advanced Practitioner’s Role. Journal of the Advanced Practitioner in Oncology, 4(1), 47-52. https://doi.org/10.6004/jadpro.2013.4.1.5
Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard (Royal College of Nursing (Great Britain) : 1987), 29(14), 53–59. https://doi.org/10.7748/ns.29.14.53.e9355
Kirby, E., Broom, A., & Good, P. (2014). The role and significance of nurses in managing transitions to palliative care: a qualitative study. BMJ Open, 4(9), e006026. https://doi.org/10.1136/bmjopen-2014-006026
5.4 Fringer, A., Hechinger, M., & Schnepp, W. (2018). Transitions as experienced by persons in palliative care circumstances and their families – a qualitative meta-synthesis. BMC Palliative Care, 17(1), 22. https://doi.org/10.1186/s12904-018-0275-7
Mehta, D. H., Perez, G. K., Traeger, L., Park, E. R., Goldman, R. E., Haime, V., Chittenden, E. H., Denninger, J. W., & Jackson, V. A. (2016). Building Resiliency in a Palliative Care Team: A Pilot Study. Journal of Pain and Symptom Management, 51(3), 604–608. https://doi.org/10.1016/j.jpainsymman.2015.10.013
Smit, C. (2017). Making Self-Care a Priority: Caring for the Carer. Whitireia Nursing & Health Journal, 24, 29–35.
Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the meaning and practice of self-care among palliative care nurses and doctors: a qualitative study. BMC Palliative Care, 17(1), 1-12. https://doi.org/10.1186/s12904-018-0318-0
Queensland University of Technology (QUT). (2021b). Topic 3: Caring for children with life-limiting illnesses. https://pcc4u.org.au/learning/topics/topic3/
ReachOut Australia. (2021). Developing a self-care plan. https://schools.au.reachout.com/articles/developing-a-self-care-plan
Royal Australasian College of Physicians. (2015). Pomegranate Health. Ep1: Recognising Death. https://www.racp.edu.au/pomegranate/View/episode-1-recognising-death

Case Analysis: Palliative Care

Student’s Name

Institutional Affiliations

Case Analysis: Palliative Care

Description of a Palliative Care Patient

Joe is an 87-year-old lady who resides at a local Residential Aged Care Facility (RACF). Penny is a Muslim lady from Syria and has strong religious beliefs, including family commitment. She is at the end stage of her life. Joe was diagnosed 10 years ago with Alzheimer’s disease. Two years ago, a lump was observed on her left breast. This was diagnosed as breast cancer. Due to her age and health status, no active treatment was commenced. The lump has just recently developed into a fungating wound which requires management. Prior to her admission to the facility, Penny was cared for at home by her granddaughter, Margaret, and her two brothers who have recently arrived from her native country to be with her and to offer support to the family until the family was unable to cope at home but still offer to visit Joe in the nursing home and support Joe spiritually. More recently due to her wandering and intrusive behaviours, Joe has been cared for in a Dementia specific unit. Joe is widowed and Margaret, who visits frequently, is Joe’s next of kin and holds Enduring Power of Attorney for Joe’s health decisions. Margaret has noticed a visible decline in Joe over the last 2 months and now she is refusing to take food and only minimal fluids. She is becoming weaker and no longer is at risk of wandering, has become increasingly confused, lost weight, and spends her days nursed in bed or in a comfort chair.
At the family conference, Joe’s doctor has advised her family that she is now requiring palliative care and active medical interventions would be ceased and interventions will be more focused on keeping her comfortable and pain-free. The doctor states he will instruct that she be commenced on an End-of-Life Pathway.

Assessment Tool

It is important to assess Joe’s palliative care needs before making a conclusion as to whether she requires hospice care or not. A script detaining the consent that was obtained from the patient is shown in Appendix 1. The most appropriate assessment tool to be used to examine Joe is the Palliative Performance Scale (PPS) (Wilner & Arnold, 2021). The rationale for choosing PPS is that it will enable the healthcare provider to assess the functional performance of the patient and determine her progression towards end-of-life. PPS is appropriate for cancer patients who are receiving outpatient services or those in ambulatory settings. Using the tool, the healthcare provider will be able to understand the patient’s needs and decide the types of interventions that Joe requires when commenced on an End-of-Life Pathway (Wilner & Arnold, 2021; Patient Care Outcomes Collaboration (PCOC). (2020). According to Stone et al. (2021), clinicians normally use the PPS as a reference tool for deciding the most appropriate time to discuss goals of care with terminally ill patients and their families. Scores that are less than 70% indicate that the patient should be commenced on an End-of-Life Pathway. Such patients are less likely to survive for more than 6 months. However, it is important to prepare family members for any eventualities by informing them that they should not be surprised if their relative lives longer than 6 months.

The PPS uses five domains organized into five columns. There are 10 categories per domain. The domains, which are observer-rated, include ambulation, activity & evidence of disease, self-care, intake, and conscious level. The poorest functional status is denoted by a score of 10% (totally bed-bound, unable to do any activity, mouth care only, and drowsy or in a coma). Conversely, the best functional status is denoted by a score of 100% (full ambulation, normal activity and work with no evidence of disease, able to take care of themselves, normal intake of food, and full conscious level) (Stone et al., 2021). Appendix 2 shows the completed PPS for Joe.

Joe’s assessment on the PPS tool has generated a score of 20% (totally bed-bound, unable to do any activity with evidence of extensive disease, total care, minimal to sips, and full or drowsy with confusion. Joe has significantly reduced ambulation and diminished self-care. Joe is unable to walk and she cannot perform any activities, including self-care, on her own. Due to profound weakness, she spends her days nursed in bed or in a comfort chair. There is evidence of extensive disease as the lump in her breast has just recently developed into a fungating wound which requires management. She also presents with behavioral issues due to the effects of Alzheimer’s disease. Joe is refusing to take food and only consumes minimal fluids. She has become increasingly confused. A PPS score of 20% indicates that Joe has poor functional status and is less likely to survive for more than 6 months. She should be commenced on an End-of-Life Pathway immediately.

Effects of Factors on the Patient’s Condition

Healthcare providers offer holistic care to patients by making appropriate cultural, religious, physical, and socioeconomic considerations. Notably, Joe’s ethnicity, culture, gender, spiritual values, sexuality, age, disability, economic and social factors impacted her condition and the clinician’s assessment in various ways. For example, her ethnic and spiritual values could make her believe that Allah will heal her from her current condition (Keall et al., 2014). Joe is a Muslim lady from Syria who has strong religious beliefs, including family commitment. Besides, Joe’s culture in relation to her beliefs about health, illness, and treatment could have an influence on the assessment process and on her reaction regarding the clinician’s final decision. She could either accept or refuse to commence an end-of-life pathway based on her cultural beliefs (Broom et al., 2013s). As Mcgee and Johnson (2014) point out, it is imperative that the clinician assesses the patient’s ethnic, religious, and cultural beliefs because it does not necessarily mean that they will always follow the customs followed by members of their ethnicities, religions, and cultures. During the assessment, the clinician had the opportunity to ask the patient about what she would want the provider to know about her and how best she would want the provider to care for her including spiritual concerns that she might have wanted the healthcare provider to consider.

Joe’s gender, sexuality, age, language, disability status, and socioeconomic factors influenced the approaches taken by the clinician during the assessment. For example, the clinician considered her gender and sexuality, when identifying the best questions to ask to be able to complete the PPS scale. Additionally, her advanced age influenced the healthcare provider to consider her perceptions and to conduct an age-appropriate assessment. Joe has diminished self-care due to the weakness caused by her condition. Although she is not disabled, the physical challenges caused by her health problems have been considered and recorded during the assessment. Language is an important component of Joe’s culture which has affected how the clinician has communicated with her. Essentially, the clinician has used simple language and has expressed issues clearly to enhance understanding (Svarosky, 2013; Bramhall, 2014). Economic, as well, as social or environmental factors have affected the way the clinician interacted with Joe during the assessment by considering the fact that she is totally bed-bound and requires total care from Margaret, her next of kin. The clinician needs to find out whether Joe is enrolled in any health insurance program and whether she is comfortable with the social support she is getting from people around her.

Consultation and Referral Pathways Available to the Nurse

Effective care of palliative patients requires the involvement of members of multidisciplinary teams. Therefore, the nurse caring for Joe needs to consult members of multidisciplinary teams who will work together to ensure that her healthcare needs are effectively addressed. Furthermore, the nurse should select referral pathways based on Joe’s specific health needs (Nunn, 2014; Dalkin et al., 2012). The specific areas in which the nurse need consultations include pain management, psychological care, feeding, self-care, physical activity, and movement. According to McCaffrey et al. (2016), uncontrolled pain is associated with emotional, psychosocial, and physical effects on the health and wellbeing of palliative care patients. These effects negatively affect their quality of life (QOL). From the PPS Assessment results, it is evident that Joe has issues with feeding, self-care, activity, ambulation, and consciousness. The consultations made by the nurse should target these specific areas.

Appropriate choice of referral pathways will optimize outcomes and facilitate a person-centered care approach for Joe. The nurse needs to consult other healthcare specialists regarding the best way to address her health needs. The referral pathways to follow should include a physician, particularly an oncologist, who will conduct a physical assessment and recommend the best pain-management medications for her (Chidiac, 2018; Donnelly & Martin, 2016). The nurse should also refer the patient to a mental health provider who will conduct psychological and emotional assessments before identifying the most appropriate interventions to address the identified issues (McCaffrey et al., 2016). Including a nutritionist in the referral pathway will help to improve Joe’s feeding behavior and hydration issues (Stiles, 2013). Additionally, including a physiotherapist in the referral pathway will help to address activity-related issues. Although full recovery from current health problems might not be possible, it is important to note that such referrals will have positive impacts on Joe’s overall quality of life. The nurse should make such referrals in an organized and well-coordinated manner to ensure that necessary assistance is offered in a manner that will generate maximum benefits for the patient.

Theory Application and an Evidence-Based Management Plan

Joe’s management plan should be guided by appropriate palliative care theory and must be guided by research-based evidence. The theory that has been chosen for her scenario is the Bow Tie Model. According to Hawley (2014), the Bow Tie Model helps the clinician to develop a plan that integrates both care and treatment approaches into the management plan for a patient right from the time of diagnosis. The goal is to help the patient and his or her family to hope for the best while at the same time preparing for the worst. Figure 1 is a diagrammatic representation of the Bow Tie Model of Care.

Figure 1: The Bow Tie Model

The Bow Tie concepts are applicable to Joe’s scenario during assessment and management as a special patient population to improve the quality of life, provide holistic care, and engage in effective communication that enhances the achievement of positive health outcomes. As presented in figure 1, concepts on the left side of the diagram comprise disease management whereas those towards the right signify palliative care (Hawley, 2014). In palliative care, it is important to note that possible outcomes are survival and death. The Bow Tie Model includes survivorship as a possible outcome and a crucial component of palliative care.

When applying the model to develop an evidence-based management plan for Joe, the clinician includes aspects of care that will address the patient’s health needs. For instance, the clinician begins by implementing interventions that will lead to symptom management and provide supportive care (Nunn, 2014). During symptom management and care provision, the nurse must keep reminding the patient, her caregiver, and family members of the possible outcomes including survival or death (Hawley, 2014).

The healthcare provider should use the Bow Tie Model to identify specific areas in the patient’s journey when it is appropriate to implement supportive care and palliative care interventions. For example, guided by the contents of the model, the nurse should list and discuss with the patient the available management and care options. The nurse must consider the factors within the setting and of the patient’s immediate environment (Hawley, 2014; Advance Care Planning Australia, 2021). Informing the patient about available treatment options when preparing a disease management plan is an approach that is supported by research-based evidence (McCaffrey et al., 2016). Additionally, the nurse should be guided by the model to use simple language that can easily be understood by the patient when developing the management plan.

Notably, palliative care, as a crucial component of the Bow Tie model comprises important aspects of care that the nurse must include in the treatment plan. These include psychological interventions, social support, pain management interventions, advance care planning, respiratory therapy, spiritual care, and physiotherapy (McCaffrey et al., 2016; Stiles, 2013). The management plan must also include a list of members of the multidisciplinary team that will work together in the hospice facility to ensure improved quality of life outcomes for Joe (Hawley, 2014). Guided by the principles and assumptions of the Bow Tie Model, the nurse should develop a plan that targets cure and control as management components of the plan and those that target hospice support and survivorship as components of palliative care components of the plan.

Communication Barriers and Resolution Strategies

Communication barriers can hinder the creation of strong therapeutic relationships with patients thereby preventing the realization of the desired quality outcomes when working with palliative care patients. Therefore, clinicians who are working with these patients and their caregivers must possess effective communication skills and be able to identify communication barriers that might have negative impacts on the healthcare delivery process (Bramhall, 2014). Besides, the nurse should be in a position to select and implement appropriate resolution strategies to address those communication barriers.

The nurse experience four types of communication barriers when working with Joe. One of these barriers was emotional distress experienced by both Joe and Margaret, her next of kin. Both Joe and Margaret appeared to be psychologically disturbed and could not comfortably discuss issues related to Joe’s illness with the nurse. They looked helpless and seemed to have lost hope. To overcome this barrier, the nurse informed Joe and Margaret that death is not the only outcome of end-of-life care (Kwon, 2014). They were informed that although assessment results had shown that the patient cannot survive for more than six months, they should not be surprised to see her survive past the said period.

Joe’s drowsiness and unconsciousness acted as a communication barrier. These patient issues prevented her from responding effectively to some of the nurse’s questions. According to Fringer et al. (2018), circumstances faced by palliative care patients and their families, as well as the changing conditions of the patient, can interfere with communication thereby preventing effective care transition. Therefore, identifying and addressing these circumstances can enhance the achievement of the desired outcomes. The nurse addressed this barrier by using Margaret, Joe’s next of kin, to facilitate effective communication with her.

Language and religious beliefs were some of the factors that affected effective communication between the Nurse and Joe. Joe is a Muslim lady from Syria and has strong religious beliefs, including family commitment. Since the nurse is a Christian, she at times attempted to ask questions that could best be addressed by a Christian. Additionally, at some point during the conversation, Joe kept asking the nurse to simplify her statement. Conflicting religious beliefs and the use of complex language can undermine therapeutic relationships when communicating with palliative care patients and their family members (Fringer et al., 2018). The nurse addressed these barriers by considering Joe’s religious background and using simple language as they progressed through their therapeutic relationship.

Nurses must recognize that compassionate communication is the foundation of effective palliative nursing care. Breaking news about a terminal illness to the patient and his or her relatives is one of the difficult conversations experienced by palliative care nurses (Svarosky, 2013). Therefore, nurses with effective communication skills can engage in compassionate communication with patients and their families during palliative care nursing thereby strengthening therapeutic relationships.

 

 

 

 

 

 

 

References

Advance Care Planning Australia. (2021). Advance care planning. Austin Health. https://www.advancecareplanning.org.au/individuals/what-is-advance-care-planning

Bramhall, E. (2014). Effective communication skills in nursing practice. Nursing Standard (Royal College of Nursing (Great Britain): 1987), 29(14), 53–59. https://doi.org/10.7748/ns.29.14.53.e9355.

Broom, A., Good, P., Kirby, E., & Lwin, Z. (2013). Negotiating palliative care in the context of culturally and linguistically diverse patients. Internal Medicine Journal, 43(9), 1043–1046. https://doi.org/10.1111/imj.12244

Chidiac, C. (2018). The evidence of early specialist palliative care on patient and caregiver outcomes. International Journal of Palliative Nursing, 24(5), 230–237. https://doi.org/10.12968/ijpn.2018.24.5.230.

Dalkin, S. M., Jones, D., Lhussier, M., & Cunningham, B. (2012). Understanding integrated care pathways in palliative care using realist evaluation: a mixed-methods study protocol: Table 1. BMJ Open, 2(4), 1-6. https://doi.org/10.1136/bmjopen-2012-001533

Donnelly, M., & Martin, D. (2016). History taking and physical assessment in holistic palliative care. British Journal of Nursing, 25(22),1250–1255. https://doi.org/10.12968/bjon.2016.25.22.1250.

Fringer, A., Hechinger, M., & Schnepp, W. (2018). Transitions as experienced by persons in palliative care circumstances and their families – a qualitative meta-synthesis. BMC Palliative Care, 17(1), 22. https://doi.org/10.1186/s12904-018-0275-7.

Hawley, P. (2014). The Bow Tie Model of 21st century palliative care. Journal of Pain and Symptom Management, 47(1), 2–5. https://doi.org/10.1016/j.jpainsymman.2013.10.009.

Keall, R., Clayton, J. M., & Butow, P. (2014). How do Australian palliative care nurses address existential and spiritual concerns? Facilitators, barriers and strategies. Journal of Clinical Nursing, 23(21–22), 3197–3205. https://doi.org/10.1111/jocn.12566.

Kwon, J. H. (2014). Overcoming barriers in cancer pain management. Journal of Clinical Oncology, 32(16), 1727–1733. https://doi.org/10.1200/jco.2013.52.4827.

McCaffrey, N., Bradley, S., Ratcliffe, J., & Currow, D. C. (2016). What aspects of quality of life are important from palliative care patients’ perspectives? A systematic review of qualitative research. Journal of Pain and Symptom Management, 52(2), 318-328.e5. https://doi.org/10.1016/j.jpainsymman.2016.02.012.

Mcgee, P., & Johnson M. R. D. (2014). Developing cultural competence in palliative care. British Journal of Community Nursing, 19(2), 91–93. https://doi.org/10.12968/bjcn.2014.19.2.91

Nunn, C. (2014). It’s not just about pain: Symptom management in palliative care. Nurse Prescribing, 12(7), 338–344. https://doi.org/10.12968/npre.2014.12.7.338.

Patient Care Outcomes Collaboration (PCOC). (2020). Assessment forms. University of Wollongong. https://www.uow.edu.au/ahsri/pcoc/palliative-care/assessment-forms/#d.en.111571.

Stiles, E. (2013). Providing artificial nutrition and hydration in palliative care. Nursing Standard, 27(20), 35–42. https://doi.org/10.7748/ns2013.01.27.20.35.c9501

Stone, P., Vickerstaff, V., Kalpakidou, A., Todd, C., Griffiths, J., & Keeley, V. (2021). Prognostic tools or clinical predictions: Which are better in palliative care? PLoS ONE 16(4): e0249763. https://doi.org/10.1371/journal.pone.0249763

Svarosky, T. (2013). Having difficult conversations: the advanced practitioner’s role. Journal of the Advanced Practitioner in Oncology, 4(1), 47-52. https://doi.org/10.6004/jadpro.2013.4.1.5.

Wilner, L. S.,  & Arnold, R. (2021). The Palliative Performance Scale (PPS). https://www.mypcnow.org/fast-fact/the-palliative-performance-scale-pps/