Anxiety and Care Plans - Case Study Example

 Anxiety and Care Plans A: Extended Reflective Account with my patient, Deborah It is said that reflection enables the practitioner to assess, understand and learn through her experiences. This can be true in my case with Deborah. John’s (1995) model of reflection is a personal process that is supposed to result in some changes for the individual in her perspective of a situation, resulting in new learning. To help practitioners to make sense of, and learn through experience, John offers the following cues: description, reflection, influencing factors, alternative strategies, and learning. My reflective account deals with Deborah, aged 36, single, a college professor, diagnosed for early-stage breast cancer (ESBC), and my patient in practice for about 2 months. Description Deborah came straight to the emergency room and said she was not feeling too well and was ready to be admitted. However, she didn’t know what it was that was ailing her. The doctor found a mass on her left breast and was advised to go for biopsy. After a time, she was referred for surgery. She valiantly underwent surgery and woke up with a thick white wad padded over her left breast. After some 4 days, she, herself removed the wad and found out that her left breast was gone! At first, she was dumbfounded that it had come to that point. Finally, she took everything all in grace. After all there was no pain felt with all the anesthesia injected into her. Deborah knew that she was supposed to go back for adjuvant therapy, and chemotherapy was scheduled for her. She had been reading a lot, however, of negative issues against chemotherapy, and so she started making her own kind of research. While she was in the hospital, she went round the patients looking at the open wounds of other women. All of them, to her knowledge, were very much worse off. A teacher whose case was very much advanced had a techni-colored wound and her eyes bore those cancerous spots like flesh-colored dots. The cells have reached new sites, and they continue to grow and form another tumour at that site (Understanding Chemotherapy, n.d.). As the hospital seemed to encourage some bonding with these patients, Deborah got the chance to compare and understand metastasis (Lyman, Dale & Crawford, 2003). It was then that the surgeon came to Deborah’s room and asked her if it was true she was not coming back for adjuvant therapy. She didn’t say yes, but she didn’t also say no. She answered the questions on the sheet given to her only to let the doctor go away. She felt that it was insuring her coming back for chemotherapy. Deborah roamed the hospital and came to a room where she found some three patients undergoing some procedure through the excretory opening. No attendant was in sight and so she entered the room. On the front desk, she saw some yellow records and on one, she saw her name. At the top left of the yellow board was written the small letter “C.” Cents, Deborah said to herself. Back in her room, she reviewed the laboratory report on her tissue quizzically which she was able to pick up after one week. She found hope that the figures did not tally. At the top portion, she was said to have two total nodes by the axial angle of her armpit. As the narrative progressed, the total became four. If the examiner could not do it properly, then it is possible he could be totally mistaken, and it is possible there might be no modes at all, she thought She turned her thoughts on the surgeon and wondered how much experience he had. At 25, he could not be that experienced to be so insistent about procedures. She dreaded chemotherapy as well as she lacked trust in her over-eager surgeon and the laboratory test which seemed inconsistent. Combining all of these, she did not return for adjuvant therapy. I came to know of Deborah’s story in the interview. Key issues. The key issues within this description that I needed to pay attention to were the following: Did Deborah need chemotherapy? The doctor said so. What then would I advise her? What do I need to know about the procedure? What was in chemotherapy that Deborah dreaded? What do I need to tell her to relieve her anxiety? The patient was undergoing a personal crisis and what she needed was an advocate. Edward Creagan (2005) said in cases like this, it is helpful to have someone with you to help unscramble the messages. But Deborah seemed to be well-read. She had her own set of arguments against chemotherapy and I had to really know her circumstances first. Creagan (2005) said to know the details of the diagnosis like finding out the name of the cancer, its size and location, where it started and if it has spread. I learned that Deborah was diagnosed of breast cancer and had a 2.54 cm. mass before surgery. She had had hysterectomy wherein she got the idea that she could never have an aggressive cancer as she had no way of having much supply of estrogen. She was particularly concerned about the success rate of chemotherapy. Besides, she said, if it cost that much, and she had to take it for six rounds, she didn’t like to buy life and was ready to die anytime. She also disdained what she was told to expect as side effects of the treatment while she lived to work and earn a living. Here was a patient who seemed well-read and knowledgeable about her own case. She was determined to have a good grasp of her circumstances and take control, but she was getting confused. She had gone back to the laboratory for the correct number of nodes found in her tissue, but the lady in white gown only read the paper and frowned. Deborah got the impression that she was not the proper person concerned. Deborah’s sister sent in drugs which she thought Deborah could use. Like the other members of her family, she was insistent that Deborah undergo all these radical measures. I had advised Deborah that the final decision lies with her and that she may seek second-opinion from an oncologist if she needed chemotherapy, which is the more expedient measure to take. According to Creagan (2005), if the two opinions are similar, it is very likely that all other cancer specialists will say the same thing. With her family who seemed too insistent on chemotherapy based on what they’ve learned from research, she does not have to take their advice. After all, they don’t fully understand the side effects and outcomes. If ever she would have to undergo some adjuvant therapy, there are many options to choose from. However, Deborah should weigh the supposed results compared to non-treatment (Creagan, 2005). With this advice, Deborah was relieved to find that after everything, she really had a choice. One day, Deborah was experiencing some troublesome shooting from inside her body like there was a quick quake. She immediately submitted for chemotherapy. She had one infusion of Adriamycin, administered by an oncologist in just 15. And then she stopped. There was no second round, or third. Nothing. A nurse- niece of Deborah had heard of the mother (sister of Deborah) sending in drugs for the procedure and had an argument with the mother. She was deeply against chemotherapy. Reflection I was trying to answer to the patient’s need to be relieved of anxiety by being a friend and advocate first. I had advised her, based on what I have learned of what one is supposed to do when first diagnosed of having cancer. I placed my self in the shoes of the patient and what I had advised her were the steps I would take myself, if I were the patient concerned. The client was very much relieved to find out that she had her problems untangled with someone who was patient enough to listen and understand. For her family, I guess, they had the best of intentions. Unfortunately, except for the nurse-niece, they were not well-informed about current knowledge in the field. For myself, I feel that I was being useful to others. For the people I work with, I also find satisfaction that in all our quest to do things right, that we are bound to keep updating ourselves of the required competencies of our field. Therefore, there is no need to unnecessarily doubt the measures taken by others as though there is one absolutely right and the others are wrong. When this experience was happening, I found myself involved in it the way the patient was, although at a less deeper level. But I was challenged to delve into her problem and study to help her find the best alternative open to her. I knew that the patient was happy as can be seen in her facial expression and at a much livelier disposition after I had given my advice. Influencing factors My decision-making and actions were based on what I have learned about the history of Deborah’s case, my knowledge in general about breast cancer, and her records. Externally, I had considered how she felt about her case. My readings about coping measures (Creagan, 2005) when diagnosed of cancer were my sources of knowledge that have influenced my decision making and actions My Alternative strategies I could have dealt better with the situation if I had access to her family and explain. However, there is the fear of holding on to more responsibility that I actually had. I am not a doctor and I am limited to my role as nurse. What other choices did I have? Lerman et al. (1993) reported increased anxiety, depression, anger and confusion among cancer patients who had experienced communication problems with their providers. I guess there is a limit even to making suggestions given that the patient is expected to undergo all the side effects possible in adjuvant therapies. The understanding of a patient of medical procedures cannot be gauged right away and the threshold of pain she can take, can only be told after she undergoes everything. Will she be brave enough to accept the consequences of her decision? Who knows? If she is not prepared to handle the side-effects, she may blame the source of the advice she had followed. If I was the one to suggest other measures aside from chemotherapy, there might be problems. I know this is the doctor’s role. I’ve learned that other treatment options for cancer include: radiotherapy, surgery, immunotherapy and hormone therapy. I’ve also learned that many cancers can be cured or controlled using these treatments, either alone or in combination (Understanding, n.d).As it is, the problem was either to submit to chemotherapy or not as her surgeon had already suggested just this measure. Besides, it was the question Deborah was pursuing. Learning Engaging in reflective practice is associated with the improvement of the quality of care, stimulating personal and professional growth and closing the gap between theory and practice according to Heath (1998). The case of Deborah was indeed a bit troubling, but things were slowly solved. I have learned that Deborah is well and alive today despite just one shot at chemotherapy where six rounds were expected. Somehow, not everything is explained by what happens when one does not take everything by the required dosage. I feel that this thing had added to my knowledge. Between not taking chemotherapy and taking it, I feel that taking it just once, like what Deborah did, could be an in-between measure. This procedure makes use of a very potent drug that the side effects are disastrous (Lyman, 1993). From this experience, I learned that one could only do according to available knowledge, the patient’s decision, and her active participation on issues regarding her health. One cannot also disregard the role of family and friends that can crisscross with the decision-making of the patient. Since Deborah was active in making the final say, there was not much problem. I had not taken an adversarial role regarding the number of nodes taken from the axial angle of the armpit of the client. It was not for me to explain metastasis or the extent, and the patient had already gone to the laboratory to find explanations. I believe there was no need for me to defend the laboratory personnel if there was a mistake or not. The client had not pressed on it anyway. As for the surgeon who was insistent on chemotherapy, there was no need to prove him wrong just because Deborah is well and alive now, despite not having taken the required dosage. I came across literature that said that patients need to be responsible for knowing all about their protocol, including the side-effects and that decisions about "cutting-short" chemo should be a decision made by both parties (Lyman et. al, 2003). Somehow, I felt responsible that I have not considered the surgeon’s advice in talking to Deborah. In Lyman’s (2003) study, he concluded that patients with early-stage breast cancer (ESBC) are at substantial risk for reduced relative dose-intensity (RDI) when treated with adjuvant chemotherapy for older patients and overweight patients. Slim and at 36, Deborah was able to carry it safely through just one round of chemotherapy. This may explain her luck. This experience has somehow taught me that, primarily, science is not perfect and an absolute master of life. Still, each practitioner must strive for the competencies required in the medical field to know what can be done for the patient. Despite the incompleteness of science, it has an array of alternatives to choose from. This is the reason the patient has to be an active decision-maker, too, although practitioners can advice her. Of course, this experience has changed my way of knowing in practice. References Creagan, E. T. You've been diagnosed with cancer: What happens next. Mayo Foundation for Medical Education and Research (MFMER). Interview. July 15, 2005. http://www.mayoclinic.com/health/cancer-diagnosis/HQ00379 Heath, H. Reflection and patterns of knowing in nursing. Journal of Advanced Nursing, Volume 27 Issue 5 Page 1054 - May 1998, doi:10.1046/j.1365-2648.1998.00593.x, Volume 27 Issue 5. Available at: http://www.blackwell-synergy.com/doi/abs/10.1046/j.1365-2648.1998.00593.x?journalCode=jan Johns C. (1995). The Value of Reflective Practice for Nursing. J. Clinical Nurs. 4: 23-60 Lerman, C., Daly, M., Walsh, W. P., Resch, N., Seay, J., Barsevick, A., Birenbaum, L., Heggan, T., & Martin, G. (1993). Communication between patients with breast cancer and health care providers. Cancer, 72(9), 2612-2620. Lyman, G. H., Dale, D.C., & Crawford, J. Incidence and Predictors of Low Dose-Intensity in Adjuvant Breast Cancer Chemotherapy: A Nationwide Study of Community Practices. Journal of Clinical Oncology, Vol 21, Issue 24 (December), 2003: 4524-4531. Understanding chemotherapy. Hong Kong Cancer Fund Service Network. Retrieved December 31, 2006, from http://www.cancer-fund.org/html/eng/pdf/Chemotherapy_e.pdf Using a model of reflection. Available at: http://www.health.uce.ac.uk/cpsu/Placement%20Support/using_a_model_of_reflection.pdf E: The importance of constructing a plan of care in partnership with patients, clients, their carers and family and friends. Brief review of what the literature says about patient involvement, compared with actual practice. Plan of care with carers and family It is important to construct a plan of care in partnership with patients, clients, their carers and family and friends first, because it is life that is at stake. Second, there are goals to be achieved towards getting the patient healed. Third, healing needs a strategic approach but many decision-makers may compete. Fourth, there are many factors vying for attention in the condition of the patient. The patient may be in a condition where he cannot decide of procedures available so that decision-making has to be shared in the medical case. In a facility, for example, it is not enough to just leave a patient there completely without getting involved as errors are possible of occurring and safety is important for the patient (Kapp, 2003). According to Harrington, Mullan & Woodruff (1999), a patient has rights which he must be able to exercise, and if a resident, includes being informed of one’s condition, and being free of reprisal when making complaints. When decision-making is shared, often there can be competing messages in the care of a patient, and there are psychosocial implications (Hall, 1994). Moreover, Cohen-Mansfield, Werner, & Weinfeld M, et al. (1995) found that care providers overwhelmingly believe that paternalistic actions on their part (such as initiating guardianship proceedings that otherwise might have been delayed or avoided) are compelled by the providers’ need to ensure resident safety as a matter of prudent legal risk management, even at the expense of other goals. This may set back curative measures for the patient. There are also matters that have to be considered such as patient satisfaction with the medical choice of others (Ethical issues, 1995), the clinical guidelines, and the targeted clinical outcome. Herein comes the legal and economic implications (Welch, 1991). For most patients, too, the rubric of managed care has to be considered. Managed care refers to a variety of techniques for influencing the clinical behaviour of health care providers and patients, often by integrating the payment and delivery of health care. The overall aim, accordingly, is to place administrative control over cost of, quality of, or access to health care services in a specific population of covered enrolees (Managed care, n.d.). Critics of managed care argue that this redounds to reducing the introduction of new technology (Iglehart, 1994), interfering with the physician-patient relationship (Fox & Wasserman, 1993), worsening outcomes (Macklin, 1993), restricting clinical research (Relman, 1992), reducing funding for physician training (Eckholm, 1994), and adversely affecting community-based hospitals (Schwartz & Mendelson, 1993). Others raise concern about ruthless business techniques and the subversion of medical ethics (Grumet, 1989). Emanual & Dobler (1995) summed up what was argued that managed care is producing a major change in the physician-patient relationship. According to them, when managed care restricts patients' choices of physicians; controls their access to care, limits the treatments their physicians can prescribe, limits their doctors' ability to refer them to specialists, and erodes the patients' trust in their doctors by creating a persistent, corrosive conflict of interest, it will ultimately destroy the doctor-patient relationship. In other words, while the care of a patient can be planned, the nuances of managed care may take precedence. Emanual & Dobler (1995) argue that many of the currently employed salary schemes which reward physicians and hospitals for not providing needed medical services produce a serious conflict of interest. There is worry about how health care providers, community hospitals and academic medical centres fare under managed care (Kassirer, 1994). Managed care involves reimbursements and as noted in a recent JAMA editorial, no method of health care reimbursement is devoid of financial self-interest (Clancy & Brody, 1995). In the midst of all these, it is clear that everyone involved must strive to make decisions that do not adversely affect the health of the patients. Patient involvement. In the medical field, there has been a gradual shift to more active patient participation in order to facilitate improved health outcomes (Charles, Gafni, & Whelan, 1997). Prior to the 1980s, it is said that decisions about treatment were made primarily by physicians. Such paternalistic model lacks participation which “connotes action, involvement, and influence within the health care environment” (Street, 2001). According to Cahill (1996), patient participation consists of several activities, which include health-related information seeking, sharing indecision-making, and having more knowledge and power in the consultation than available with the paternalistic model. Sharf (1988) describes participation or involvement as including the asking questions of clarification, inquiring about other treatment options, asking about the necessity of a suggested regimen, and other verbal strategies on the part of the patient that seek to improve his or her level of understanding of the condition and treatment, as well as communicate his or her opinions about the health situation. A study by Stefne Broz (2003) investigated cancer patients’ active involvement in their cancer care, their information-related preferences and behaviors, the extent to which they share cancer-related information with their health care provider, and whether having information to share leads to perceptions of increased participation in their cancer care. She carried out the study through a questionnaire mailed to callers to the Mid-West Region Cancer Information Service (CIS) who agreed to participate in the study and who had been diagnosed with cancer. Broz’s study revealed a general tendency among the participants for active participation, a general desire to be involved in decision making and a strong preference for being informed about their cancer. While generally satisfied with the information received from their doctors, these patients also seek information from many other sources and they consider that information to have more positive than negative effects on them. Another study done by Jones, Berney, Kelly et al. (2004) involved a sample of 24 general practitioners. They found that general practitioners (GPs) saw patient involvement in positive terms. In practice, however, Jones et al. (2004) said this is not being followed as these practitioners think this has to be budgeted for. Accordingly, although greater patient involvement has become a key goal of health care provision - …. If patient involvement in health care decision-making is to be increased, then questions of scarcity of resources, including time, will need to be taken into account. If strategies for greater patient involvement are to be pursued then demands made on consultation time should be addressed. Jones et al. (2004) then appears to endorse managed care where the physician is reimbursed some amount for extra time and effort with patients. Will the physician have to involve the patient in the medical plan? Yes, he may, but he must be paid for the risk, they said. Interactions with physicians have evolved into a more partnership-based approach, and there has been an increasing focus on communication between physicians and patients. Kutner, Steiner, Corbett, Jahnigen, & Barton (1999) argue that communication is “especially important in terminal illness, when the appropriate course of action may depend more on patient values than on medical dogma.” This has been encouraged by an increasing acknowledgment that patients are the ones who would have to live with tradeoffs between costs and benefits anyway. In practice, however, evidence suggests that patients cannot readily use or recall information provided in the consultation, which may have implications for their ability to participate effectively. In an earlier study, Tuckett, Boulton, & Olson (1985) explain that determining recall based on the quantity of information, can skew the picture of what patients actually remember. In sum, in practice, what still overrides the autonomy of patients is their safety (Kapp, 2003). References Broz, S. L. (2003). The Role of Information in Cancer Patients’ Involvement in their Cancer Care. Communication Graduate Program. The Ohio State University. Dissertation. Retrieved December 31, 2006, from http://www.ohiolink.edu/etd/send-pdf.cgi?acc_num=osu1070390568 Cahill, J. (1996). Patient participation: A concept analysis. Journal of Advanced Nursing, 24, 561-571. Clancy, C. M., Brody, H. Editorial, Managed Care. Jekyll or Hyde? JAMA January 25, 1995, 273(4)338-339 Cohen-Mansfield, J., Werner, P., Weinfeld, M., et al. Autonomy for nursing home residents: the role of regulations. Behaviour Sci Law 1995; 13:415–23. Eckholm, E.A. Town loses its hospital in the name of cost control. Reported in New York Times, September 26, 1994; Education and Counseling, 11, 95-108. Emanuel, E. J. & Dobler N. N. Preserving the physician-patient relationship in the era of managed care. JAMA, Jan 25, 1995, 273(4)323-39 Ethical issues in managed care. AMA Council on Ethical and Judicial Affairs. JAMA. Jan 25, 1995, 273(4)330-335 Fox, P. D., & Wasserman, J. Academic medical centres and managed care. Health Affairs. (Millwood). 1993; 12:85-93 Grumet, G.W. Health care rationing through inconvenience: the third-party secret weapon. N Engl J Med 1989; 321:607-6211 Hall, R.C.W. Social and legal implications of managed care in psychiatry. Psychosomatics 1994; 35(2):150-15 Harrington, C., Mullan, J., Woodruff, L. C, et al. Stakeholders’ opinions regarding important measures of nursing home quality for consumers. Am J Med Qual 1999; 14:124–32 Iglehart, J. K. Rapid changes for academic medical centres. N Eng J Med 1994, 331:1391-1395 Jones, I.R., Berney, L., Kelly, M., Doyal, L., Griffiths, C; Feder, G., Hillier, S., Rowlands, G. & Curtis, S. Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care. Social science & medicine (Soc. sci. med.), 2004, vol. 59, no.1, pp. 93-102. ISSN 0277-9536 Kapp, M. B. "At least Mom will be safe there": the role of resident safety in nursing home quality. Qual Saf Health Care 2003; 12:201-204. Kassirer, J. P. Academic medical centres under siege. N Eng J Med 1994, 331:1370-1371 Kutner, J. S., Steiner, J. F., Corbett, K. K., Jahnigen, D. W., & Barton, P. L. (1999). Information needs in terminal illness. Social Science & Medicine, 48, 1341-1352. Lambert, B. L., Street, R. L., Cegala, D. J., Smith, D. H., Kurtz, S., & Schofeld, T. (1997). Provider-patient communication, patient-centered care, and the mangle of practice. Health Communication, 9(1), 27-43. Macklin R. Enemies of Patients. New York, N.Y., Oxford University Press Inc., 1993, Chapters 1, 5,7,11 Managed Care. Ethics in Medicine.  University of Washington School of Medicine. Retrieved December 30, 2006, from http://depts.washington.edu/bioethx/topics/manag.html Relman, A. J. What market values are doing to medicine. Atlantic Monthly, March 1992, pp99-106 Schwartz, W. B., & Mendelson, D.N. Why managed care cannot contain hospital cost - without rationing. Health Affairs. (Millwood). 1992; 11:100-107 Sharf, B. F. (1988). Teaching patients to speak up: Past and future trends. Patient Education and Counseling, 11, 95-108. Street, R. L., Jr. (2001). Active patients as powerful communicators: The linguistic foundations of participation in health care. In W. P. Robinson & H. Giles (Eds.), Handbook of language and social psychology (2nd ed.). Chichester: John Wiley. Welch, H. G. Should the health care forest be selectively thinned by physicians or clear-cut by payors? Ann Int Med 1991, 115:223-226 Read More