Care Planning as an Aspect of the End of Life Care Strategy - Essay Example

?Care Planning as an Aspect of the End of Life Care Strategy: its Implications for Community Health Care Providers, Service Users and Significant Others With the establishment of the National End of Life Care Programme on 2004 and The End of Life Care Strategy on 2008 by the Department of Health to address the formerly low-profiled end of life care planning, there is an expected light of improvement of the end of life care management system in the United Kingdom. After the sixth month of the implementation of the strategy, only half of its objectives were delivered and is assumed to benefit only less than a half of its total benefits (Department of Health, 2008), but according to a survey of the Economist Intelligence Unit, the United Kingdom made it to the top globally in terms of end of life care (BBC News, 2010). There is progress, but it is considered to be a very slow trend which needed to be sped up to deliver the potential gains of the strategy (Department of Health, August 2010). An aspect of the End of Life Care Strategy wherein the Department of Health focused on its initial implementation is the care planning (inclusive of assessment) which comes after the identification of people approaching the end of life and will follow the step of coordination of care in the care pathway. It is also where nurses, being part of the multidisciplinary health care team, have active involvement whether working in hospitals or in community settings, more particularly in assessing the patient and the family regarding their needs, wishes and preferences, and is involved in initiating reviews of the care plan to the team if with patient’s permission, thus influenced the selection of the strategy’s aspect to be discussed by this paper. This will explore the implications of the care planning aspect for community heath care providers (nurses in particular), service users (patients) and significant others (family and carers). Community Health Care Providers The Strategy will give emphasis on the nurses’ role in assessment and documentation of patient’s needs, wishes and preferences in addition to her roles regulated by international, national and local policies during the end of life care. As per the code in Nursing & Midwifery Council (2008), nurses are responsible in gaining patient’s trust, treating them as individuals, respecting their dignity, working with others, providing high standard of care, being open and honest, acting with integrity and uphold reputation of profession. This will require nurses to assess and record the needs, wishes, preferences and agreed set of actions of the dying patient (advanced decisions, where to die, etc.) and to participate with the review of the care plan. An example is the Advanced Decisions to Refuse Treatment as a valid and applicable legally-binding document where the nurse is obligated to follow the physicians’ order to withhold life-preserving treatment as stated therein (NHS, 2010). Other options to be considered are the advanced statement and the DNACPR (Do Not Attempt Cardiopulmonary Resuscitation). Service Users (Patients) The care planning of the Strategy aims to enforce assessment and recording of needs, wishes and preferences of patients undergoing their end of life. This will grant patients with greater autonomy in making decisions for their own health, including decisions on where they would like to die. Moreover, it will enforce the community health care providers to assess and record their needs, wishes and preferences even if the patient or family have not yet initiated the discussion of these matters, thereby raising patient’s awareness on his treatment options. The Strategy slightly decreased the number of patients dying at the hospital and die at home instead by offering the patient an option to die at home instead (Department of Health, August 2010). Significant Others Families and/or carers of the patient in end of life are also included with the care planning of the Strategy in terms of reviewing the care plan, yet not as specific as the roles of the patient and the multidisciplinary team. They can also provide reliable information to health care professionals about the observable symptoms of the dying patient (McPherson, 2003). With proper implementation of the Strategy, the significant others will be a help in decision making should the patient’s condition changes and would even minimise unnecessary hospital admissions of a dying patient when an advanced decision is already made at home. Health Education and Promotion Strategies The second annual report of the End of Life Care Strategy (August 2010) provides health education and promotion strategies under care planning, which are the development of the Single Holistic Assessment, Palliative and End of Life Care Clinical Programme Board and the Gold Standards Framework (GSF) approach covering the subject areas of training in communication skills, assessment of needs and preferences, advanced care planning, symptom control and end of life tools. While the end of life care is part of the nursing education curriculum (White, Coyne and Patel, 2001), these strategies will further enable nurses to provide appropriate assessment using end of life tools as introduced by the Strategy (GSF, Preferred Priorities and Liverpool Care Pathway). The next annual report will determine the status of these recently-proposed health education and promotion strategies as a way to deliver the full potential gains of the End of Life Care Strategy. Nurses indeed are participants in the fulfilment of the goals of the Strategy in terms of care planning. Nurses’ Role and Participation Care planning is initiated by the nurses as she coordinates with other members of the health care team in providing the best possible care for the dying patient, beginning from assessment to evaluation. The central focus of the nurse is to provide comfort and allowing the patient to undergo a dignified and peaceful death (Kozier et al, 2004). Part of fulfilling these responsibilities are fulfilling the wishes and preferences of the patient during his end of life care and allowing him to die a dignified death by not undergoing futile medical interventions to revive him. The Strategy simply gives emphasis on the patient’s needs, wishes and preferences to their expected roles in assessment and documentation. However, even though nurses have participation in implementing the Strategy in assessment and documentation, the roles of nurses in end of life care is still limited which frustrates nurses who have greater understanding of their patients’ experiences and wishes than physicians (Asch, 2009). Even though most physicians claim that nurses have a participation in end of life decisions, but has little control once physicians made a decision (Benbenishty, 2006). Legal and Ethical Issues It is uncertain whether the strategy is bounded with legal considerations should nurses fail to assess and record an advanced decision, but the Advanced Decisions to Refuse Treatment requires the nurse to adhere to what is stated therein if it is valid and acceptable, like withholding life-preserving treatment, and might face consequences if failed to do so, unless cal for another nurse who is not sharing the same dilemma as her (London Evening Standard, 2006). The legal system of the United Kingdom (Act of Parliament, Common Law, Mental Capacity Act, etc.) does not fully protect her prom prosecution due to absence of ruling therein but rather on valid legally-binding documents (Patient UK). However, this only covers the withholding of feeding and fluid therapy, and CPR (in DNACPR) and not euthanasia, so as to minimise the nurse to act against her own conscience. It is also important to note that patient’s wishes will prevail despite opposition of family once a legally-binding document is made. The End of Life Care Strategy Second Annual Report of August 2010 clarified the nurses’ roles on advanced care planning and the legal status behind it. There are differences in ethical concerns among nurses in terms of withholding and withdrawing treatment (Dickenson, 2000) and also between physicians and nurses regarding ethical decisions (Benbenishty, 2006). Though euthanasia remains to be illegal, the requirement of withholding life-preserving treatments as stated in a valid Advanced Decisions to Refuse Treatment still allows ethical dilemmas of nurses to emerge. However, the nurse may pass the responsibility to another nurse in withholding treatment stated in an advanced decision if it is against her own ethical belief, though cannot refuse accepting a patient with a valid living will. Pathophysiology One problem in the implementation of the Strategy is that the pathophysiology of patients approaching end of life tend to be variable (with different aetiologies) and rather hard to predict, which can be days or months, and patients experience multiple symptoms. Cancer patients in particular are expected to experience moderate to severe pain, weakness, anorexia, dyspnoea, constipation, fatigue, dry mouth, depression and insomnia (MacDonald, 2002; The SUPPORT Principal Investigators, 1995). A number of clinical manifestations can be observed from the patient approaching the end of life stage subdivided into orientation, cardiovascular, pulmonary, gastrointestinal, and renal and mobility, which marks physical, behavioural and cognitive changes (Black and Hawks, 2005). The estimation of the duration of the end of life is likely to be underestimated (Vigano et al, 1999), a reason why conversations on end of life matters are often not discussed by physicians (Curtis et al, 2004), but must be addressed as it is required by the Strategy to gather these necessary data. As soon as the progression of a terminal illness is anticipated, the nurse is expected to intervene by initiating a conversation between the patient and the physician regarding end of life care planning. Communication There is indeed a need to emphasise the importance of communication skills to effectively implement the Strategy, since severe communication problems exists during end of life care (Higginson and Costantini, 2002). One study revealed that 95% of patients during end of life lack decision-making capacity and only 20% of them have had their preferences known. Moreover, it also shown that discussion on end-of-life decisions is hindered by patient’s unresponsiveness, the unavailability of the family and the assumption that they won’t understand (Cohen et al, 2005). This will pose as a challenge in the implementation of the Strategy by the nurse in assessing the needs, wishes and preferences when the patient can no longer participate due to the progression of the disease process. Since the nurse’s role is to assess the needs, wishes and preferences, she can offer the discussion at an early stage while encouraging them to open it up later if they are not yet comfortable talking about it, especially during the Kubler-Ross (1969) stages of denial and anger, while it’s best during the acceptance stage. Being a patient’s advocate, it is the nurse’ role in communicating these patient’s needs, wishes and preferences to the physicians and conduct regular review of the care plan which will include the patient and significant others, more often during conferences. After being informed of the treatment options that the patient and family can choose from, the health care providers should allow more opportunity for the patient and family to speak (McDonagh et al, 2004) in order to elicit their needs, wishes and preferences should the patient’s condition worsens. This study will then suggests that patients with a progressing terminal illness must be encouraged to have an early discussion of his needs, wishes and preferences before the actual signs and symptoms of imminent death to occur, when the patient can still participate. It is safe to assume that patients and significant others generally have “high levels of information need” (Parker et al, 2007), even if it is not yet certain if the patient and family will be comfortable or not regarding this matter. Conclusion For a span of two years, there is a significant improvement of the end of life care in the United Kingdom after the implementation of the End of Life Care Strategy, yet the perceived success of the program is still on its way to achieve the full potentials of this program. This slowly progressing success of the Department of Health depends on the participation of community health care providers, the service users (the patients) and significant others. More extensive approaches in hastening the improvement of end of life care should consider the legal and ethical issues, pathophysiology of the dying process and the communication issues and eliminate these barriers from reaching the success of implementing the Strategy. Still, there is limited research on estimating the success of the Strategy other than that of the government’s own pilot studies, thereby it is recommended that further independent end of life care studies on the United Kingdom are suggested to validate the government’s claims about the success of its own strategies. References Asch D 2009, ‘The limits of suffering: critical care nurses’ views of hospital care at the end of life’, Social Science & Medicine, 45, 11, 1661-1668. BBC 2010, UK comes top on end of life care – report, BBC News, http://www.bbc.co.uk/news/health-10634371 Black J & Hawks, JH 2005, Medical-surgical nursing: clinical management for positive outcomes, 7th edition, Elsevier Saunders. Benbenishty J et al 2006, ‘Nurse involvement in end-of-life decision making: the ETHICUS Study’, Intensive Care Medicine, 32, 1, 129-132. Cohen S et al 2005, ‘Communication of end-of-life decisions in European intensive care units’, Intensive Care Medicine, 31, 9, 1215-1221. Curtis JR et al 2004, ‘Patient-physician communication about end-of-life care for patients with severe COPD’, European Respiratory Journal, 24, 2, 200-205. Department of Health 2008, End of Life Care Strategy, Crown, UK. Department of Health 2010, End of Life Care Strategy: Second Annual Report, London, UK. Dickenson D 2000, ‘Are medical ethicists out of touch? Practitioner attitudes in the US and UK towards decisions at the end of life’, Journal of Medical Ethics, 26, 254-260. Higginson I & Costantini M 2002, ‘Communication in the end-of-life cancer care: a comparison of team assessments in three European countries’, Journal of Clinical Oncology, 20, 17, 3674-3682. Kozier B et al 2004, Fundamentals of nursing: concepts, process, and practice, 7th edition, Pearson Education Inc., Singapore. Kubler-Ross E 1969, On death and dying, Macmillan, New York. London Evening Standard 2006, Doctors face prison for denying right to die, http://www.thisislondon.co.uk/news/article-23374924-doctors-face-prison-for-denying-right-to-die.do MacDonald N 2002, ‘Refining symptom management’, Journal of Palliative Medicine, 5, 2, 301-304. McDonagh J et al 2004, ‘Family satisfaction with family conferences about end-of-life care in the intensive care unit: Increased proportion of family speech is associated with increased satisfaction’, Critical Care Medicine, 32, 7, 1484-1488. McPherson C 2003, ‘Judging the quality of care at the end of lie: Can proxies provide reliable information?’, Social Science & Medicine, 56, 1, 95. NHS 2010, The differences between general care planning and decisions made in advance, National End of Life Care Programme, http://www.endoflifecareforadults.nhs.uk/publications/differencesacpadrt Nursing & Midwifery Council 2008, The code: Standards of conduct, performance and ethics for nurses and midwives, www.nmc-uk.org Parker S et al 2007, ‘A systematic review of prognostic/end-of-life communication with adults in the advanced sages of a life-limiting illness: Patient/caregiver preferences for the content, style, and timing of information’, Journal of Pain and Symptom Management, 34, 1, 81-93. Patient UK, Advanced Directives (Living Wills), http://www.patient.co.uk/doctor/Advance-Directives-%28Living-Wills%29.htm The SUPPORT Principal Investigators 1995, ‘A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT)’, Journal of the American Medical Association, 274, 1591-1598. Vigano A. et al 1999, ‘The relative accuracy of the clinical estimation of the duration of life for patients with end of life cancer’, Cancer, 86, 1, 170–176. White K, Coyne P & Patel U 2001, ‘Are nurses adequately prepared for end-of-life care?’, Journal of Nursing Scholarship, 33, 2, 147-151. Read More