Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube...
Transcript of Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube...
![Page 1: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/1.jpg)
Palliation and Living Well –
Not a Contradiction
Living Well with Dementia
Conference
Alzheimer’s Australia August 22 2016, Sydney
Frank Brennan
Palliative Care Consultant
![Page 2: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/2.jpg)
• What is Palliative Care ?
• What is its role in dementia ?
• What are the needs of the person, their families
and carers ?
![Page 3: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/3.jpg)
• Hope and Dignity
• The importance of living well with an
illness
• Care of the dying person and care of the
grieving
![Page 4: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/4.jpg)
What is Palliative Care ?
![Page 5: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/5.jpg)
Bruce Dawe, the Queensland poet, wrote :
White -Water Rafting and Palliative Care
for my late wife, Gloria
If I had understood (when down the river
you and I went swirling in that boat)
that there were those who knew the ways of water
and how to use the oars to keep afloat
– I might have been less deafened by the worry,
less stunned by thoughts of what lay up ahead
(the rocks, the darkness threatening to capsize daily),
if I had only realised instead
that help was all around me for the asking
– I never asked, and therefore never knew
that such additional comfort could have helped me
in turn to be more help in comforting you.
I’d have found it easier then to simply hold you
instead of bobbing to and fro so much,
for it was you who seemed to be more tranquil
and I whom death was reaching out to touch.
If only I had had sufficient knowledge
in that white-water rafting I’d have learned
that there were those around us (with life jackets)
to whom I might have, in that turmoil, turned.
Instead, because I had not thought of rivers,
or rocks, or rapids, and gave way to fears
that seeking help might make a man less manly
and liable to betray himself with tears,
I was less useful then, as twilight deepened,
than I might well have been, had I but known:
however wild the waves that roll around us
– no one needs to live (or die) alone …
![Page 6: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/6.jpg)
WHO definition (2002)
Palliative Care is an approach which improves the quality of life of patients and their families facing 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.
![Page 7: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/7.jpg)
“The doctor told us that the only thing
left for mum was palliative care.”
![Page 8: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/8.jpg)
Sense that all options must be explored
and exhausted before palliative care
should be involved.
![Page 9: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/9.jpg)
Setting up a contrast
between “Hope” and
“Hopelessness”.
You have crossed the
border into another
country.
![Page 10: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/10.jpg)
Modern view of Palliative Medicine
A. Early involvement : “There is wide
recognition that the principles of
palliative care should be applied as early
as possible in the course of any chronic,
ultimately fatal illness.”
![Page 11: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/11.jpg)
B. The concept of concurrent care
: that active care and palliative
care can and should occur
concurrently.
![Page 12: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/12.jpg)
C. That the introduction of a
palliative approach at the “death
–bed” is a set of missed
opportunities.
![Page 13: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/13.jpg)
Benefits of early involvement–
- reinforcement of idea of comfort.
- that symptom control is impeccable
throughout.
- establishing a rapport/trust
- demystifying analgesia (opioids)
- introducing idea of Community Pall Care
- helps avoid sense of abandonment
![Page 14: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/14.jpg)
D. That the palliative approach
involves more than simply pain relief.
![Page 15: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/15.jpg)
Palliative Care is more than caring for the
dying.
How then can a palliative approach
allow people to live better ?
![Page 16: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/16.jpg)
Dementia
• Patients
• Caregivers
• Family
• Health professionals
![Page 17: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/17.jpg)
Needs of the patient
• Physical
• Practical
• Emotional
• Spiritual
![Page 18: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/18.jpg)
Gradual change in memory and
ability to cope with daily activities
![Page 19: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/19.jpg)
Over time there will be
physical changes also.
![Page 20: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/20.jpg)
Speech
![Page 21: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/21.jpg)
Swallowing
![Page 22: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/22.jpg)
Appetite
![Page 23: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/23.jpg)
Walking around
![Page 24: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/24.jpg)
Continence
![Page 25: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/25.jpg)
We need to be very conscious
that each change is a loss and
source of grief for the patient and the family.
![Page 26: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/26.jpg)
These practical changes
are felt emotionally.
![Page 27: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/27.jpg)
Case
An 89 y.o. woman
Alzheimer’s Disease diagnosed 8 years ago.
![Page 28: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/28.jpg)
At the beginning
she was independent.
![Page 29: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/29.jpg)
Over time
things became more difficult.
![Page 30: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/30.jpg)
• She struggled managing.
• She began to lose interest in things
around her.
• Her family did their best to help.
![Page 31: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/31.jpg)
Eventually, after much deliberation, she was
admitted to a Nursing Home.
She settled in.
![Page 32: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/32.jpg)
It is 8 years after her diagnosis.
![Page 33: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/33.jpg)
• She now needs assistance with all her
daily activities.
• She wants to spend more time in bed.
• Recurrent episodes of aspiration
pneumonia
• Several hospital admissions - treated with
IV antibiotics, fluids, oxygen
![Page 34: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/34.jpg)
Speech Pathology review –
moderate difficulty with swallowing
consistent with her level of dementia.
![Page 35: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/35.jpg)
• Family worried about her “starving to
death”
• Should a feeding tube be inserted ?
![Page 36: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/36.jpg)
Is there a reversible cause for her poor
intake – oral thrush, depression, poor
dentition ?
![Page 37: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/37.jpg)
For patients with End stage Dementia
there is no evidence that artificial
nutrition/hydration prolongs life
or relieves suffering.
![Page 38: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/38.jpg)
Loss of appetite is a natural part of the
dying process.
![Page 39: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/39.jpg)
Symptoms of thirst can be relieved with
meticulous oral hygiene, sips of water,
Aquaspray, artificial saliva
![Page 40: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/40.jpg)
Nasogastric tube feeding does not decrease the risk of aspiration pneumonia,
Some studies actually show an increase.
![Page 41: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/41.jpg)
PEG tube insertion and maintenance have
complications.
Patients can suffer aspiration due to lying
too flat during feeding, bolus feeding and an
inability to swallow normal mouth and throat
secretions.
![Page 42: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/42.jpg)
If she has further episodes of pneumonia
and recognising that this will keep
happening
it may be best to stop treating her with
antibiotics and
simply try to get her comfortable and allow
the natural process of dying to take place.
![Page 43: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/43.jpg)
The ‘living well” in this whole process of
change upon change
requires a meticulous attention to detail.
![Page 44: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/44.jpg)
1. Communication
![Page 45: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/45.jpg)
2. Symptom control
![Page 46: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/46.jpg)
Pain and dementia
![Page 47: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/47.jpg)
Several studies highlight the poor
recognition and treatment of pain
in Nursing Homes.
Corbett et al 2012; McAuliffe et al 2009.
![Page 48: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/48.jpg)
Geriatric patients with hip fractures receive
inadequate pain control, especially if
suffering from cognitive impairment.
Feldt KS et al. J Am Ger Soc (1998) 46: 1079-1085;
Morrison R et al JPSM (2000) 19:240-248.
![Page 49: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/49.jpg)
People with end stage dementia receive less
medications for pain than patients without
dementia.
Australian Pain Society, 2005.
![Page 50: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/50.jpg)
Cognitive impairment and communication
difficulties contribute to pain being
unrecognised.
Morrison, Siu, 2000
![Page 51: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/51.jpg)
Why is pain assessment difficult ?
Short term memory loss –taking history of pain or medication effect is difficult or impossible.
![Page 52: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/52.jpg)
May be very difficult for the patient
to show where it hurts or
describe how much it hurts.
![Page 53: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/53.jpg)
Distress may be caused by many things
and can be due to the Dementia itself
![Page 54: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/54.jpg)
What can help : cause
• Overview of the medical problems – could
they relate to pain ?
• For example if known hip arthritis, this may
relate to resident screaming when legs are
moved.
• Peptic ulcer disease or reflux may relate to
discomfort when eating or after meals.
![Page 55: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/55.jpg)
Always look for pressure areas/ulcers
![Page 56: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/56.jpg)
What can help : severity
• Does it wake them up ?
• Do they grimace with only light touch or being
disturbed by noise ?
• Do they cry out ?
• Depressed mood, sleep disturbance, decreased
appetite, behavioural disturbance
![Page 57: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/57.jpg)
What can help : localisation and
radiation
• Person may be able to point
• Skin sensitive to touch in painful areas
• Not moving a limb
• Not able to weight bear
![Page 58: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/58.jpg)
Painful pressure sores
• Treat any reversible cause
• Topical morphine gel 0.1 % ; excellent
results
![Page 59: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/59.jpg)
Shingles
• Commence antiviral medication urgently
• Analgesia is vital – early use of anti-
neuropathic pain agents
![Page 60: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/60.jpg)
Pain etiquette
• ENQUIRE REGULARLY
• RESPOND COMPASSIONATELY
• TREAT COMPETENTLY
• REFER WISELY
![Page 61: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/61.jpg)
Principles of pain management
1. Always enquire about pain.
2. Treat the underlying cause of the pain.
3. Treat the pain meticulously.
4. Treat the pain proportionately.
5. Constantly reassess.
![Page 62: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/62.jpg)
Bowels
• Constipation is common in the elderly
• Risk factors – immobility, opioids,
depression, hypothyroidism, autonomic
neuropathy, hemorrhoids
• Treatment – combination of softeners and
stimulants
![Page 63: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/63.jpg)
3. Support for the family
![Page 64: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/64.jpg)
Caregiver burden
• Physical burden of care
• Emotional toll
• Frustration, guilt, irritation with other family
members, relative social isolation, the
competing interests of other generations,
exhaustion
![Page 65: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/65.jpg)
How can we possibly help their situation ?
![Page 66: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/66.jpg)
Physical supports
![Page 67: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/67.jpg)
How equipped and able are local services
to set things up at home for carers ?
![Page 68: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/68.jpg)
Emotional support
“Family caregivers’ impression of having
been listened to by health professionals
improves well-being and clinical outcomes
for both the patient and the caregiver.”
Oxford Textbook of Palliative Medicine, 3rd ed, p.939.
![Page 69: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/69.jpg)
4. Support for the carers
![Page 70: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/70.jpg)
Role of Nursing Homes
![Page 71: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/71.jpg)
Dementia is the main reason
for admission to a Nursing Home.
Van Rensbergen, Nawrot 2010
![Page 72: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/72.jpg)
Half of all residents in
Australian Nursing Homes
have a diagnosis of dementia.
Australian Institute of Health and Welfare 2009
![Page 73: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/73.jpg)
What is the level of training in the care of
persons with dementia, support and wages
and conditions of nursing staff in
Nursing Homes ?
![Page 74: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/74.jpg)
What is the access to, and level of training in
the care of persons with dementia by,
doctors in Nursing Homes ?
![Page 75: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/75.jpg)
Elements of living well :
1. Communication
2. Symptom management
3. Support for the family
4. Support for the carers
![Page 76: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/76.jpg)
HOPE
![Page 77: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/77.jpg)
The preservation and
maintenance of hope
Resetting the focus of care
I agree that there is no hope for
cure, but there is hope that you
will be comfortable and
supported throughout.
![Page 78: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/78.jpg)
Not be abandoned.
Always be listened to.
All symptoms treated to the best of our ability.
Will not needlessly suffer.
Treated with respect and dignity at all times.
![Page 79: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/79.jpg)
There are three things that now become
very important for people with dementia :
![Page 80: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/80.jpg)
Dignity
![Page 81: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/81.jpg)
Love
![Page 82: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/82.jpg)
Legacy
![Page 83: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/83.jpg)
Gilgamesh by Spencer Reece
When we visited your Aunt Annie in the nursing home,
her walker dominated the room like a kennel.
She did not know who I was, her senility rendering me oblique.
Long ago, when your mother died,
your father sent a letter and a photograph of the four children to Killeen,
asking Aunt Annie to come. As she strove across the sea,
she watched the Connemara ponies disappear,
then Knock, Letterfrack, Roundstone, and Cashel Bay blurred,
blurred and blurred until there was nothing but green.
She left Ireland for good and raised you
and your three sisters – Joan, Ann, and Maureen.
In America, she went about her days unseen.
On her day off, she lit four candles for each one of you
at the Shrine of St. Anthony on Arch Street, in Boston.
She never married. She adored you.
When we visited, she kept saying :
“Paul, Paul, I have to get the cows across the stream.”
Poetry, Volume 196, Number 1, April 2010.
![Page 84: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/84.jpg)
![Page 85: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/85.jpg)
![Page 86: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/86.jpg)
![Page 87: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/87.jpg)
![Page 88: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/88.jpg)
As things change and become more difficult
decisions may need to be made.
![Page 89: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/89.jpg)
Ethical issues
Who gives consent to treatment ?
![Page 90: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/90.jpg)
Should every medical presentation be
treated actively without exception ?
- UTI, pneumonia, hip fracture
![Page 91: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/91.jpg)
Nutrition and hydration
![Page 92: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/92.jpg)
• Goals of care – is treatment aimed at cure
of the complication (eg.pneumonia) or
simply relieving symptoms ?
• Cardiopulmonary resuscitation.
![Page 93: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/93.jpg)
End of Life
![Page 94: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/94.jpg)
The Terminal Phase
• Care remains important for the patient and
especially the family.
• Their view of the manner of dying and the
care given will have a major effect on their
bereavement and will echo down the years
in the way they view death.
![Page 95: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/95.jpg)
“I’m sorry there is nothing
more we can do.”
![Page 96: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/96.jpg)
The Terminal Phase
FOR THE PATIENT :
1. Comfortable bed, pressure mattress.
![Page 97: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/97.jpg)
2. Cease unnecessary medications.
![Page 98: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/98.jpg)
3. If patient is not swallowing,
cease oral medications and use sci medications. Consider converting all necessary medications into a syringe driver.
![Page 99: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/99.jpg)
The Terminal Phase
4. Pain – look carefully for signs of
discomfort on moving and turning.
![Page 100: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/100.jpg)
5. Agitation/restlessness – Midazolam.
![Page 101: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/101.jpg)
Terminal Phase
6. Terminal secretions – Atropine drops, Hyoscine,
Glycopyrolate, Buscopan
![Page 102: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/102.jpg)
7. Mouth care –
moist mouth – water spray; cotton
sticks.
8. In-dwelling catheter
![Page 103: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/103.jpg)
Terminal Phase
FOR THE FAMILY:
Ensure there is an open comforting
environment for the family.
![Page 104: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/104.jpg)
Terminal Phase
EMOTIONAL SUPPORT
Physical care of themselves – “Are you
eating ? Are you sleeping ? …Everyday
take a break…You are each other’s
greatest allies. Look after each other.”
![Page 105: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/105.jpg)
If I had but two loaves of bread I would sell one and
buy hyacinths, for they would feed my soul.
Sheikh Muslih-al Din Sadi, 13th century Persian poet.
![Page 106: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/106.jpg)
For the
Health Professionals
• Need to acknowledge the cumulative
effect of our work on ourselves.
• Need to take care of ourselves and
each other.
![Page 107: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/107.jpg)
Grief
![Page 108: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/108.jpg)
After a loved one dies, waves of grief roll
onto to the shore of ourselves. Those waves
can be overwhelming.
![Page 109: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/109.jpg)
The grieving will need to speak. They may
not want to speak every time you see them.
But at some time they will want to do so. Be
ready to listen to those that are grieving. To
be listened to is precious. Blessed are the
listeners for they bear the greatest gift to the
grieving.
![Page 110: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/110.jpg)
•
Writing in The Irish Times Marie Murray states :
Listening is more than hearing. It is heeding.
It is concentration. It is paying attention…
Listening is silencing one’s own voice to hear someone else.
It is wanting to know rather than wishing to inform.
It is suspension of self in the service of other. It is not giving
advice, providing solutions or solving problems.
It is silent. It is unselfish. It is reverential. It is healing.
[i] Murray M. The Art of Listening. Irish Times, 2007.
![Page 111: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/111.jpg)
But how often does the opposite happen ?
When comments are said to the bereaved
person : ‘Please don’t upset yourself’, ‘Don’t
dwell on it’, ‘Isn’t it time you moved on’,
‘After his illness it must be a blessing’, ‘Well
that’s life isn’t it ?’ ‘Well, after all, he’d had a
good innings’ or, of you, ‘Surely she must be
over it by now.’
![Page 112: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/112.jpg)
Well meaning but false, sometimes cruel,
belittling the sheer size of what’s happened,
of what you are going through, of what that
person meant to you.
![Page 113: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/113.jpg)
And one of the commonest mistakes we can
make is to assume that, simply because the
person who died was elderly or had
dementia, that the family will feel less grief.
Grief is vast, grief is mysterious and grief
does not respect age.
![Page 114: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/114.jpg)
Memories, language, mortality, grief.
It is right that we think of these things.
We may or may not speak of them but they
are there.
![Page 115: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/115.jpg)
No one of us are the same. No one of us will
experience this the same way. For we are
both unique and mortal. Therein lies our
sorrow. But therein also lies our grace.
![Page 116: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/116.jpg)
![Page 117: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/117.jpg)
Other pieces of literature …
![Page 118: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/118.jpg)
A Very Easy Death
by Simone de Beauvoir
![Page 119: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/119.jpg)
“I did not understand that one might sincerely weep for a relative, a grandfather aged seventy or more.
If I met a woman of fifty overcome with sadness because she had just lost her mother, I thought her neurotic : we were all mortal; at eighty you are quite old enough to be one of the dead. But it is not true. You do not die from being born, nor from having lived, nor from old age. You die from something.”
![Page 120: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/120.jpg)
“The knowledge that because of her age my mother’s life must soon come to an end did not lessen the horrible surprise…it is as violent and unforeseen as a plane engine stopping in the middle of the sky…There is no such thing as a natural death: nothing that happens to a man is ever natural, since his presence calls the world into question. All men must die : but for every man his death is an accident and, even if he knows it and consents to it, an unjustifiable violation.”
![Page 121: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/121.jpg)
Patrick Kavanagh
Memory of My Father
![Page 122: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/122.jpg)
Every old man I see
Reminds me of my father
When he had fallen in love with death
One time when sheaves were gathered.
…
Every old man I see
In October-coloured weather
Seems to say to me :
“I was once your father.”
![Page 123: Palliation and Living Well Not a Contradiction · Aquaspray, artificial saliva . Nasogastric tube feeding does not decrease the risk of aspiration pneumonia, Some studies actually](https://reader033.fdocuments.us/reader033/viewer/2022042621/5f5d9df843805b12e9201db9/html5/thumbnails/123.jpg)