Dealing with the psychosocial and spiritual aspects in palliative care

Background: Palliative care is the provision of end of life care to the patient with a terminal disease; its primary focus is on improving the quality of life rather than quantity of life. While palliative care emphasizes over physical body pain reduction, it also suggests psychological comfort and spiritual wellbeing. Several research studies corroborate that interventions are done to keep the patient mentally relaxed greatly affects the patient's bodily functions and reduces the sensation of pain. Case Presentation: In this case, the physical attributes were excellently managed but neglect was done in terms of mental and spiritual need that was evident through her verbalization of hopelessness and fear, that the disease condition is a severe punishment by God. In addition, the patient was less likely to socialize with people including friends and family. Therefore, this case has been investigated in light of multiple recent articles (2010-2015) and pointed out the evidenced-based practices that need to be done to provide care emphasizing holistic approach in order to enhance comfort to the terminally sick patients. Management & Results: It was observed that the health care providers were only concerned for the physical problems and they provided care focusing only physiological component whereas the psychological and spiritual determinants of health were greatly neglected as such that they were not included in the plan of care of the patient. Conclusion: Palliative care involves not just physiological, but also psychological and spiritual care. Based on the findings of the case study, caregivers must consider psychological and spiritual aspects of care in order to provide holistic as well as peaceful end of life care.


Introduction
Chronically or terminally ill patient suffers physically, emotionally, socially, morally and spiritually thus they encounter an immense number of symptoms associated with each domain. Similarly, the pain of such people is impossible to treat just through painkillers, so it is important to assess every aspect of health in order to provide holistic care (Maqsood et al., 2013). According to bio-psycho-sociospiritual model given by George Engel in 1977, an individual with a life-threatening disease responds in many different ways like physically, psychologically, socially and spiritually (Maqsood et al., 2013).
According to World Health Organization, (2018) the palliative care is defined as "Palliative care is 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 early identification, impeccable assessment, treatment of pain and providing physical, psychosocial and spiritual care (WHO.int, 2018)." Successful palliative care is achieved through a health care provider's ability to elicit and comprehend the problems of dying patients; however, many health care  (Gunser, 2017). In other words, spiritual coping is associated with positive mental health, similarly, if health care providers solely emphasize over physical and mental health excluding the spiritual aspect of care then the goal of complete wellbeing will not be attained (Selman et al., 2014).
Active listening, therapeutic communication using a nonjudgmental approach and using therapeutic touch helps in fears verbalization by the patient (Rego & Nunes, 2016). Psychological, social and spiritual distress are common among palliative care patients and they often trigger the thoughts of accelerated death while physical symptoms have been treated that lead to demoralization and hopelessness (Fan et al., 2017). According to the proximal-distal model of kidney disease, it has been observed that physiological factor along with psychological factors influences the overall health outcomes (Chan et al., 2011).

Case-Presentation
A 63 years old female patient with a complaint of chronic renal failure came for routine dialysis at a private hospital. Patient's comorbid were type 2 diabetes and hypertension. Complete interview using Gordon's functional health pattern was conducted with the patient. Patient was haemo-dynamically stable and oriented to time, place and person. Physical examination showed severe lower back and limb pain, using the numeric pain scale, the patient's pain score was 6/10. Secondly, the psychological assessment was done using Gordon's psychological assessment tool, revealed hopelessness and depression related to lack of social support system patient also verbalized spiritual distress due to inability to perform spiritual practices moreover patient's social domain was also compromised because meeting people increases pessimistic thoughts in her mind. After the case analysis, spiritual and psychological domains of palliative care were prioritized.

Results
Based on the patient's interview and assessment done by Gordon's functional health pattern it was observed that this patient was mentally depressed and hopeless that may be due to lack of someone who actively listens to her and empathize her current health state. It was also observed that most of the time, due to lack of attention from the immediate surroundings such as family, friends, significant others as well as health care personnel, the patient was reluctant to share her concerns, fears, emotions to others that further made her stressed and uninterested to life. Further, it was also observed that the patient was spiritually depressed; due to lack of privacy and physical problems, she was unable to perform her practices that increased her stress as well as remorsefulness, therefore, like many other patients, she considered her illness as God's penalty and she was guilty about that. This also increased levels of anxiety in the patient that also resisted her from socialization with other people that is why she needed care providers who not only treat her physically but also psychologically and spiritually in order to provide comfort and healthy mind, body and spirit.

Discussion
Suffering involves the perception of feeling fearful, helpless and danger about the disease (Juarez et al., 2013). Mostly people response in such a way that they think now the life has completely changed and it is irrevocable, while many people face guilt that this is all because of their mistakes in life (Mateo-Ortega et al., 2018). They Naureen Rehman 56 regret that if they had approached for the treatment earlier so they might not be this close to death. Another thing is that like the above patient, many people with the terminal disease become hopeless and depressed (Mateo-Ortega et al., 2018). Whereas some people feel anxious about the time they have to live with their significant others regarding the fulfillment of their impending responsibilities based on their role within the family (Juarez et al., 2013).
Researchers have also shown that spirituality has a greater impact on individual health and disease onset. It expresses various aspects of individual personality and views of their life (Gualdani & Pegoli, 2014). According to Dallas and his colleague, palliative clients want optimism, hope and gratitude for their values and need to follow all the religious beliefs for the sake of spiritual healing (Dallas et al, 2012). People sometimes due to sedation or lack of privacy cannot verbalize their intense need of spirituality thus they face the guilt of not following their practices so they end up into spiritual distress (Maqsood et al., 2015). Just like mentioned in the above case scenario, many patients perceive illness as God's punishment for them or because of their bad deeds (Berton, 2015).
Several interventions can be helpful for patients to relieve their emotional pain like mind based techniques such as yoga, meditation, muscle tensing exercises, relaxation techniques (Malik, & Mazahir, 2015). Nurses should perform a complete psychological assessment to understand that mind and body are associated so sometimes psychological treatment also reduces patient's physical suffering (Gunser, 2017). Active listening, using verbal cues and providing emotional support may help in reducing fears and anxiety regarding death as it allows patients to ventilate their feelings and thoughts (Fan et al., 2017) Nurses should reassure that they are always available to help them whenever they want. In addition, nurses must also encourage patients to reflect back to their lives, recall their strong and positive points so that they can attain selfsatisfaction (Maqsood et al., 2015).
It is an important responsibility for nurses to assess clients and families spiritual beliefs to overcome spiritual distress but for that first of all, they need to be self-aware about their own spiritual beliefs (Dallas et al., 2012). They must ask those questions to themselves before inquiring the patients (Hendrick & Cobos, 2010). For this category (Dallas et al., 2012). Institutes must train the nurses regarding the way of proper psychological and spiritual communication and an assessment on daily basis, In addition, they must get spiritually engaged with the patient for their wellbeing (Penman et al., 2013). Health care personals should provide culturally appropriate care based on patients beliefs with the purpose of meeting client's needs and optimum care (Gualdani & Pegoli, 2014). Encouraging patients to perform their respective religious practices are helpful in the spiritual expression of individual and family (Rego & Nunes, 2016).

Conclusion
Palliative care deals with the provision of holistic care to terminal patients and caregivers in every aspect of their lives. Mind based researches say that making a person mentally relaxed, effects positively on bodily functions so proper psychological assessment must be done to identify their emotional needs and interventions should be done accordingly. Everyone has a different way of expression of spirituality so nurses must be aware of the fact that spiritual beliefs also affect a person's health. Health care providers should analyze and understand a patient's spiritual concepts. And they must work to find out patients spiritual needs and address them.
As it is beneficial in palliative care to provide comfort, reduce pain and other symptoms that improve quality of life.