Meeting the Needs of a Dying Patient

Meeting the Needs of a Dying Patient Title: caring for a patient who is dying is an experience most nurses will face at some stage of their career. With reference to patients you have cared for, describe how you were able to meet the needs of dying patients. As a certainty, all of us will have to face death at some stage. Some of us are fortunate enough to be able to do so with caring, supportive and empathetic people around us. (Seale C et al. 2003). Nurses must be able to discharge their professional responsibilities in this area with this comment in mind. In this short essay we will explore how a nurse can empathise, understand and assist the patient in dealing with the various issues that arise. We will discuss these issues in relation to one specific case, Mrs G. The case was complex, but, in essence, it involved a lady who had just been given a terminal diagnosis and entered into a phase of complete denial and overt avoidance behaviour. She would change the subject when talking about her health and keep herself almost manically occupied with trivial tasks so as not to have to consider the reality of the situation. Dobrantz (2005) points to the fact that it is well recognised that some patients deal with life crises simply by ignoring them, other will use mechanisms of varying degrees of cognitive distortion (CDs), which may range from undue optimism to complete denial (as Mrs.G did). The main nursing dilemma here is should the nurse actively confront Mrs.G’s denial and allow her to see the reality of the situation or is it perhaps kinder to allow her to continue in her state of overt denial. (Dean A. 2002) On first analysis, one might take the view that, given the fact that Mrs.G had only a short time left to live, it might be a kindness to allow her not to confront the psychological pain of anticipating her imminent death. Against this argument is the concept of â€Å"a good death†. (Cuttini et al. 2003). Many authorities (viz. Roy C 1991) that in order for a patient to have â€Å"a good death†, they need time to accept the inevitable and to mentally come to terms with it, make what preparations they need (financial, practical, spiritual, personal) so that they can approach it in a calm and considered way. Clearly this cannot be achieved if they are actively entering into a degree of denial about the situation. (The A-M et al. 2000) Demonstrate ability to apply relevant nursing knowledge to individualised patient care The immediate therapeutic problem to be confronted by the healthcare professionals involved is to decide the degree of collusion with the denial that can be ethically employed. (Sugarman J Sulmasy 2001). To a degree, this is a matter of personal and clinical judgement. Most experienced healthcare professionals would suggest that truth is generally the best policy, the degree of truth however, can be a matter of negotiation. (Parker and Lawton 2003). The important concept to embrace in this type of situation is that of individualised patient care. In order to come to a considered decision, the nurse must carefully consider all the elements of the patient’s coping mechanisms and assume a holistic approach to the matter. We note that the concept of holistic care can best be visualised with the understanding that the concept of â€Å"Health† is based on a translation of the Anglo Saxon word for â€Å"wholeness† (or holism). The key to this approach is that it recognises that health has both spiritual and psycho-social elements as well as the overtly physical. (Wright et al 2001) The main elements of managing Mrs.G ‘s case seem to revolve around the ethical concept of autonomy (Coulter A. 2002). One has to make a professional decision whether or not Mrs.G is considered to have the right to make completely autonomous decisions for herself. In many clinical situations (such as consent, for example), the issue of autonomy is virtually inviolate. There are other situations, and we suggest that this is one, where other ethical principles may take precedence. The Principle of Beneficence suggests that the healthcare professional should effectively do â€Å"goodness† or more accurately in these circumstances, as doing what is the best for the patient. (Dordrecht et al. 1983 Demonstrate ability to make own judgment and decisions based upon the evaluation of the nursing situation. There are a number of nursing models which could be used to construct a response to this situation. They all assimilate the general nursing scheme of assessment, planning, implementation and evaluation. (Fawcett J 2005) The Roper, Logan, Tierney model (2000) would be appropriate to assess the activities of daily living in a problem solving manner, but this process is primarily of use in those situations that are physically orientated and therefore the psychological denial element is not clearly addressed by this model. The Roy Adaptation model (Roy 1991) is certainly more useful in explaining the adaptive processes that the patient experiences as they come to terms with the â€Å"illness role†. Mrs.G however, did not adapt and, by adopting a strategy of denial, was able to maintain her belief of â€Å"wellness† almost until the end, when her illness eventually forced her into accepting it. In real terms, Mrs.G did not adapt at all. The Johnson Behavioural System model (Wilkerson et al 1996) suits our purposes better as it clearly describes the processes of illness denial, but it doses not combine it with the adaptive processes that eventually overtook Mrs.G at the end of her life. Wadenstein (et al. 2003) sums up this type of situation with the conclusion that when there is multifactorial aetiology in a given situation there is seldom one nursing model that will encompass all eventualities. Conclusions Mrs.J.’s emotional pain of trying to cope with imminent death was clearly too great for her to assimilate. This must be understood by her medical attendants if she is to have a â€Å"good death† (Marks-Moran Rose 1996) In order to try to provide Mrs.G with the best care that she could have, the clinical staff tried to help Mrs.G towards the realisation that she should confront her own imminent mortality. Unfortunately for all concerned, this proved to be impossible and Mrs.G died about two weeks after her admission, only openly acknowledging the imminence of her death when she became too weak to lift a cup of tea to her mouth on the day before she died. Arguably, when this acceptance came home to her, the nursing staff were actually able to help and support her more than Mrs.G had allowed them to in the preceding two weeks. (Yura H et al. 1998 References Coulter A. 2002 The autonomous patient. London: The Nuffield Trust, 2002. Cuttini, Veronica Casotto, Rodolfo Saracci, and Marcello Orzalesi 2003 In search of a good death: Health professionals beliefs may undermine effective pain relief for dying patients BMJ 2003 327 : 222. Dean A. 2002 Talking to dying patients of their hopes and needs. Nurs Times. 2002 Oct 22-28 ; 98( 43) : 34-5. Dobratz, M 2005 Gently Into the Light: A Call for the Critical Analysis of End-of-Life Outcomes. Advances in Nursing Science. Nursing Care Outcomes. 28(2):116-126, April/June 2005 Dordrecht: Kluwer. Beauchamp, T. and Childress, J., 1983, Principles of Biomedical Ethics, 2nd edition., New York: Oxford University Press. 1983 Fawcett J 2005 Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories, 2nd Edition Boston: Davis Co 2005 ISBN : 0-8036-1194-3 Marks-Moran Rose 1996 Reconstructing Nursing: Beyond Art and Science London: Balliere Tindall October, 1996 Parker and Lawton 2003 Psychological contribution to the understanding of adverse events in health care Qual. Saf. Health Care, Dec 2003; 12: 453 457. Roper, Logan and Tierney (2000) Activities of Living model London : Churchill Livingstone 2000 ISBN 0443063737 Roy C 1991 An Adaption model (Notes on the Nursing theories Vol 3) OUP: London 1991 Seale C, van der Geest S. 2003 Good and bad death: introduction. Soc Sci Med. 2003. 58 (5) : 883–885. Sugarman J Sulmasy 2001 Methods in Medical Ethics Georgetown Univeristy Press 2001 ISBN: 0878408738 The A-M, Hak T, Koeter G, Wal Gvd. 2000 Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ 2000 ; 321 : 1376-1381 Wadensten Carlsson 2003 Nursing theory views on how to support the process of ageing J. of Advanced Nursing Volume 42, Number 2, April 2003, pp. 118-124(7) Wilkerson, S. A., Loveland-Cherry, C. J. (1996). Johnson’s behavioral system model. In J. J. Fitzpatrick A.L. Whall (Eds.), Conceptual models of nursing: Analysis and application (3rd ed., pp. 89-109). Stamford, CT: Appleton Lange. 1996 Wright S, Sayre-Adams J. 2001 Sacred space: right relationship in health and healing: not just what we do but who we are. In: Rankin-Box D, ed. The nurses handbook of complementary therapies. 2nd ed. London: Baillià ¨re Tindall, 2001. Yura H, Walsh M. 1998 The nursing process. Assessing, planning, implementing, evaluating. 5th edition. Norwalk, CT: Appleton Lange, 1998. =============================================================== 9.5.06 PDG Word count