Reflections I Experienced While Assisting in a Tracheostomy - Essay Example

Clinical Incidents- Reflections Clinical Incidents- Reflections Clinical Incidents- Reflections This paper is being written to convey my thoughts, ideas and reflections I experienced while assisting in a tracheostomy, a first for me and watching as a patient refused treatment of dialysis after attempting to commit suicide. Abiding by the Gibbs model of reflection, I have gone through the various stages of my experience which have been mostly good (Jasper, 2003). First I will elaborate on the procedure of tracheostomy and what it is indicated for. How the patient Mr. Halliday was subjected to this life-saving procedure will be explained along the way. Then I will focus on the ethics issue involving the 19 year old patient who swallowed anti-freeze and refused dialysis which could speedily bring her out of the health problems she has. Scenario 1 Stage 1 Description of the event (Jasper, 2003) Mr. Halliday who had just undergone surgery for gastric carcinoma under general anaesthesia had respiratory distress during my posting in the post operative room. The anaesthetist advised tracheostomy. Immediately my senior whom I had assisted twice already in the procedure and observed it being done by her many times, posted me to the duty of assisting the anaesthetist to do it. I had half an hour to prepare myself, the patient and the family for the procedure. The moment that I learned that I had been posted, I felt a little shaky. Could I go through with it? It was my first participation in a tracheostomy. The senior boosted my confidence and told me she would be around if assistance was needed. First I ensured the availability of the emergency tracheostomy kit. I had to speak to the patient and his family of wife and son about the procedure and its outcome. The patient himself was a little hazy from the anaesthesia of surgery. The wife and son were easily convinced but they wanted to know whether it is just for now or long term. Informing them that it has been intended for a short duration now and is being done for controlling the secretions, I felt pleased that things had started off smoothly. Checking the list that is used for the packing of instruments and other equipment for the emergency tracheostomy during preparation for autoclaving, I felt everything needed had been ready. The outer tube, the snugly fitting inner tube, the flange which lies against the patient’s chest and the 15mm termination which fits all ventilators and respiratory equipment were the main components necessary (Tracheostomy care working group, 2000). The optional parts were the cuff which helps fix the tube in position, the air inlet valve which prevents the escape of air, the air inlet line which would allow air to move from the air inlet valve to the cuff and the pilot cuff which is an indicator of the amount of air in the cuff (Tracheostomy care working group, 2000). Checking for the equipment at the bedside was my next job: spare tracheostomy tubes, tracheal dilator, suction apparatus which was checked if in working condition, humidification for heating apparatus, sterile gloves, an infectious waste bag, and a dry clean container for holding the spare inner cannula (Tracheostomy care working group, 2000). Checking with the anaesthetist, I found that he is not allergic to rubber gloves. Hoping that things would be fine, I waited for the anaesthetist to give the cue for washing up for the procedure. I got ready in the theatre garb as the procedure was in the post operative room inside the theatre. Having washed up and suitably attired, I unpacked the autoclaved instruments. Meanwhile the patient was positioned appropriately. He was in the supine position with the head hyperextended with a sand bag or a roll under the shoulders and given a sedative and a local anaesthetic at the site of surgery (Serra, 2000). The anesthetist who was performing the tracheostomy put out his hand and I placed the knife in it. Thus started the procedure. I forgot my anxiety and was in a different world where I had to perform and hand over the right instruments to the anesthetist at the right time. The skin incision was made and the muscles were separated. The trachea was in view. A hole was made in the trachea between the second and fourth tracheal rings and a piece of trachea removed (Serra, 2000). The tracheostomy tube was inserted and sutures were placed on either side to close the wound. The flanges of the tube were also stitched to the skin (Serra, 2000). When I handed over the dressing gauze to prevent oozing from the wound, I heaved a sigh of relief. It was over The anaesthetist complimented me on learning that the assistance was my first for tracheostomy. The patient was reassured and then I went to the family after checking the instruments and other equipment used. They were informed about the smooth flow of the procedure and that they were to watch for the collection of secretions. They were to inform the nurse on duty in such a situation. Stage 2 Feelings (Jasper, 2003) Though anxious and a little worried, I managed to go through the procedure without any flaws. The anaesthetist did not even notice that I was new to the procedure. My one thought was that I was doing a social service and that I had to make it good and useful for the ill patient. Never once could I waver. It might have damaged a life. How much a tracheostomy is useful to a patient’s life was evident on that day. Excessive or tenacious secretions could cause harm to a patient’s life. Mr Halliday went through a peaceful period following the tracheostomy. Stage 3 Evaluation (Jasper, 2003) On reflection, I find that I have it in me to withstand pressures and face up to new situations. It has given me the confidence for facing more of such novel events in my professional life. I do not fidget or be all thumbs in an emergency situation. Having been responsible and accountable, I have used my personal autonomy in delivering my service to the patient. Taking care to conform to ethical, psychological, ethnic and human rights aspects, I had managed fairly well. Stage 4 Analysis (Jasper, 2003) My actions were accountable. Having been partially successful in building a relationship with Mr. Halliday and his family, he turns to me for help more than he used to. “Responsibly going about my duty” was the description my senior gave of me. My ability, knowledge and skills were evident from my actions. The patient and his family became close to me. The anaesthetist did his part expertly. Together our team work was commendable. We were able to execute our duties in an able and professional manner. The patient was also good and not unduly distressed. Stage 5 Conclusion (Jasper, 2003) Accountability is an essential part of nursing. Nursing requires the nurse to observe ethical, psychological, ethnic and human rights aspects (Stuart, 2003). The special relationship of nurses with the patients builds the confidence and trust of the patients in the relationship. Responsibility is the main component of accountability. Having the ability, knowledge, skills and values to make decisions before actions is a pre-condition (Stuart, 2003). A give and take policy may be adopted. The autonomy to take the responsibility is the next essential requirement; both personal and structural. Personal autonomy is the “expertise, knowledge and skills concerned with the specific work, the understanding of the personal limits of competence and the willingness to take personal responsibility” (Stuart, 2003). The authority to act is the structural autonomy. Accepting responsibility for professional decisions is professional accountability. The expectations of society is that maximum discretion skills would be exhibited by the nurse for keeping her professional conduct within prescribed standards. (Stuart, 2003). She would be practicing ethical and professional behaviour in safeguarding her patient. Learning through role modeling is the manner of learning in nursing practice. Setting a pattern of behaviour by following another is the usual manner of securing experience in the profession (Stuart, 2003). Watching the experienced and knowledgeable nursing practitioners is how the student manages to attain enthusiasm and commitment for the work, much greater than if they were merely taught procedures in theory classes. The nursing student has no excuse for providing the patient unprofessional care. Professional competency is a must for students as much as it is for the professional (Stuart, 2003). Stage 6 Action Plan (Jasper, 2003) Future occasions of assisting in a tracheostomy would be faced with confidence and eagerness. My actions would mostly be the same. However, senior nurses have informed us that each occasion would have something different to offer by way of experience. This has prepared me for all kinds of challenges. Refreshing my memory theoretically would take me through different kinds of tracheostomies, different types of tubes, the procedure of suctioning, the evidence-based practice guidelines of recent researches, care of the cuffed tracheostomy tube, care of the fenestrated tracheostomy tube, care of the Passy Muir speaking valves, decannulation or removal of the tube, dealing with anticipated emergencies and resuscitation through a tracheostomy tube (Tracheostomy care guidelines, 2000). The after-care in tracheostomy is extremely important. Ensuring success, I would adhere closely to the guidelines for care. The outer tube will be removed after seven days by the anaesthetist. All further changes were to be done by two nurses, one to remove the soiled one and one to insert another new tube. The inner tube had to be changed twice very day. Stoma care was equally important. Suction and humidification had to be done. Scenario 2 Stage 1 Description of the event (Jasper, 2003) A 19 year old section 3 patient (known to the unit and to theatre for previous attempts on her life) was deteriorating after refusing treatment following the drinking of anti-freeze to commit suicide. It upset me that there was nothing we could do. After patiently discussing the options with her she decided she would accept the haemofiltration with no dialysis. She pulled through; with suicidal tendencies I wondered when we would see her back on the unit. Stage 2 Feelings (Jasper, 2003) A patient has a right to refuse treatment. The patient is allowed this fundamental right as a respect of the patient’s autonomy (Kleinman, 1991). This is the reason for informed consent to be taken before treatment. Informed consent is an ethical necessity which promotes a patient’s “personal well being and self determination” (Kleinman, 1991). The nurse is never able to contain the idea that a patient can refuse treatment which can save him from illness and death as the sanctity of life is a principle ingrained in all human beings especially care givers. She may have a conflict trying to balance the two and it would be hard to resolve such an issue. The reason for the refusal must be explored. A religious conviction or a fear of the mode of treatment may be the reason (Kleinman, 1991). A competent patient especially must be respected for his choice of no treatment. Some people believe that a person who attempts to commit suicide must be treated differently from people who purposely refuse treatment so that they die early. A doubt arises if a patient who attempts to commit suicide is a competent person. The patient may be suffering from depression or bipolar disorder. Attempts must be made to enquire into the history to investigate if she needed psychotherapy to prevent further suicidal attempts. The most important strategy for managing the suicidal patient is by a therapeutic alliance. It would do well to enquire into the history of psychiatric disorders in the patient and the family. A complete assessment of the “suicidal ideas, wishes, intent, plans, availability of means, and future plans would help to determine if the patient is competent and whether he needs any psychotherapy. Treatment decisions would rely on the history and clinical assessment. Stage 3 Evaluation (Jasper, 2003) Competence of the 19 year old patient must be determined. Incompetent patients must not be allowed to suffer from harmful effects of bad decisions (Kleinman, 1991). The nurse may have a difficulty to attain a balance. Competence has no universal definition. Legal standards consider competence as the “ability to communicate choices, understand information about a treatment decision and appreciate the situation and its consequences” (Kleinman, 1991). Logical processes must be able to assess the usefulness of treatment for the patient. Decision making must be done only if the person has values and goals, the ability to communicate well and understand information well (Making Health Care Decisions, 1982). Another source, the Ontario Electro-convulsive Therapy Review Committee defined competence thus: “Patients should be judged incompetent if (a) they are unable to express a settled choice or their desires constantly fluctuate, (b) their treatment choice is founded entirely on delusional beliefs or (c) they have a mental disorder resulting in an emotional state that prevents them from applying the information learned about the treatment.” Evaluation of the competence of the emotional state may amount to infringement on the rights of the person. Mentally ill patients can have an advance directive which focuses on psychiatric illness. The patient communicates his wishes to close family members who would take steps to carry them out (Bosek et al, 2008). The advance directive is a new aspect which must be knowledgeable to the patient and the health care team, otherwise barriers may mar its use (Swanson et al, 2006). The patient must know about it and have the cognitive abilities to fill it. He must understand that it would be beneficial to him where health is concerned. Having a surrogate decision maker is difficult to achieve so the advance directive comes in handy. The patient must be able to share the advance directive with his health care team. Another set of barriers involves the healthcare team (Bosek et al, 2008). Moral anguish of the nurses is another conflict with a patient’s refusal to take treatment (Angelucci and Carefoot, 2008). This is because there is a clash between the nurse’s ethical framework and the ethical beliefs of the patient. The nurse-patient relationship involves promises to be kept, contracts and commitments to be honored and sharing of truths (Angelucci and Carefoot, 2008). The nurse beliefs are driven by beneficence, benevolence and non maleficence. Benevolence is the quality of the nurse which makes her obliged to act when the patient is in need. Helping the patient to express her desires as ethical principles is another of the nurse’s duties. Though health providers know what is good for the patient, it is best to allow the patient to express his autonomous decisions (Angelucci and Carefoot, 2008). Many of the problems in ethical practices can be solved. However persisting problems can lead to a state of exhaustion and fatigue among nurses. Abiding by the patient’s autonomy helps us to go by the patient‘s desires. Ethical dilemmas are stressful experiences. Stage 4 Analysis (Jasper, 2003) The 19 year old patient’s history and ethical dilemma must be analysed and sufficient help be provided to the patient to confidentally face issues or ill health. This patient must also be analysed for psychiatric problem for the possibility of repeated suicide attempts. If necessary she must be given psychotherapy and pharmacotherapy. Her wishes may not be given a hearing as she may be considered incompetent to make her own decisions. Her fundamental right may be provided if she is competent. Stage 5. Conclusion Nurses must be leaders in helping the staff find ways to solve ethical dilemmas. Ethical clarity would help resolve moral anguishes of the staff and the dilemmas of the patients. Stage 6 Action Plan Discussion of moral anguishes must be open among staff members and must be solved as and whenever possible (Angelucci and Carefoot, 2008). The aspect of care that is causing the most problems must be first solved. Informal debriefings with individual nurses and then formal ones among the staff are advisable. Ethical situations must be researched for better evaluation and analysis. Bioethics committees must be set up for appropriate issues. Staff must be educated on ethics issues and encouraged to communicate directly and openly (Angelucci and Carefoot, 2008). Leadership must be provided by the senior nurses or nurse administrator in guiding the staff towards ethical clarity. References: Angelucci, P. and Carefoot, S. (2008). Working through moral anguish, Nursing Critical Care, Vol. 3, No. 2 Bosek, M.S.D. (2008). Do Psychiatric AdvanceDirectives Protect Autonomy? JONA’S Healthcare Law, Ethics, and Regulation Volume 10, Number 1, 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Carpen, H. (2005). Tracheostomy care guidelines, Sydney West Area Health Service, ICU Liaison CNC Jasper M. (2003) Beginning Reflective Practice – Foundations in Nursing and Health Care Nelson Thornes. Cheltenham Making Health Care Decisions: a Report on the Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship, (1982) Vol 1, Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Washington Serra, A. (2000). Tracheostomy care, Nursing Standard, Vol. 14, No. 42, p. 45-52 Stuart, C.C. (2003). Assessment, supervision, and support in clinical practice: a guide for nurses, midwives, and other health professionals. Published by Elsevier Health Sciences Swanson J, Van McCrary S, Swartz M, Elbogen E, Van Dorn R.(2006). Superceding psychiatric advance directives: ethical and legal considerations. J Am Acad Psychiatry Law. 2006;34: 385–394. Tracheostomy care working group, (2000). Tracheostomy care guidelines St. James’s Hospital / Royal Victoria Eye and Ear Hospital Read More