End-of-Life Care - Essay Example

End-of-Life Care Introduction: End-of- life care is provided to people in the final stages of life and incorporates the principles of hospice and palliative care (Seow, King& Vida, p.57). In this paper, a clinical situation has been analyzed that addresses the impact of end-of-life care on patients and their families. The purpose of this paper is to highlight the unrealized needs of patients and their families at the end-of-life care. It will discuss evidence based recommendations to improve the care given at the end of life. This paper will also talk about the relevant gaps and implications for nursing practice; and how it will influence my practice as a future nurse. Situation and Overall Impact on Family: Preparing a patient for end-of-life is extremely important and care should be taken to focus on achieving the best possible death for the patient and compassionate care for both the patient and the patient’s family (Wingate & Wiegand, 2008, p. 84). In my clinical experience, I have taken care of a 78 year old South Asian male patient, Mr. K, who had been diagnosed with the last stage of chronic heart failure and was DNR (Do Not Resuscitate). He had been admitted to the cardiac floor and for three weeks had showed no signs of improvement. He was unable to carry out the activities of daily living. He experienced shortness of breath all the time and had repeatedly requested the oxygen levels to be increased. His symptoms of shortness of breath were becoming severe day by day. He lived with his wife in an apartment and had no children. While caring for Mr. K, I observed that his wife was present beside the patient all the time. Due to the end stage of heart failure, she was allowed to stay in the hospital. She looked worried and confused about the situation and was concerned about her future. While interacting with her, she told me that she was not ready for his husband’s death and didn’t know what she could do to ease his condition. She had been told that this was the end stage of her husband’s disease, but nobody had spent time with her in explaining the situation properly. As a family, Mr. K and his wife shared a strong bond with each other and both were worried about other. I observed that nobody spent enough time with Mr. K’s wife to support her through the process of her husband’s death and had not referred her to bereavement services. I went to my nurse when Mr. K requested me to increase the oxygen level as he was feeling shortness of breath. Nurse responded to me, “Don’t worry he is DNR, I need to look after other patients first”. Analyzing Nursing Literature: Impact of the unmet needs at the end-of-life care influences both patients and their family members. Research suggests that family members' psychological and physical health is affected by the patient’s illness (McClemant, Hack & Kristjanson, 2007). Mrs. K’s wife was depressed and isolated in this situation and she was not satisfied with the care she was receiving. Studies done by Fitzsimons et al. indicate that patients and careers at the end-of-life have various physical, emotional and social needs that are unanswered and believe that they deserve more co-ordinate and holistic care (2007). Another study done by Morss& Mularski (2008) demonstrates that at the end-of-life, health care shifts to meet the subjective needs of patients and families. Lack of communication from health care professionals with Mr. K and his wife left them feeling isolated and lost. Wingate & Wiegand have emphasized the importance of providing clear and basic information about the client’s current condition and anticipated prognosis to the client and family members and that the lack of information leaves them feeling lost (2008). Due to the lack of proper information and resources, Mrs. K was not prepared for the dying process and was not aware of the signs and symptoms of the end stage. Wingate & Lynn insist that patients’ families should be prepared for the dying process and also be prepared about what to expect at end-of-life. For e.g. they must know about and recognize the signs and symptoms at the end stage, like decreasing consciousness, changes in breathing pattern, changes in skin color; cooling of skin etc (2008). In this case the DNR status had affected the level of care Mr. K received. The nurse’s response showed that she was less interested in listening to Mr. K’s needs and that she prioritized the needs of other client’s over Mr. K’s. One of the themes that have emerged from the study done by Anselm et al. is “Risk of abandonment for DNR patients”. It states that DNR labels the patient and leads to abandonment or less aggressive care by others (2005). Different nursing literatures have discussed the importance of supporting a patient’s family throughout the dying process. Various qualitative literatures demonstrate that families and patients believed satisfaction to be important at the end-of-life care. A study by Morss & Mularski supports this view that in order to improve satisfaction among families regarding care, it is important to consider collaboration and consultation interventions and believe that improving satisfaction is one way to improve the lives of dying patients and their families. Mrs. K was having difficulty in accepting the truth that her husband was dying. Research shows that nurses can help the families accept the death of a family member by referring them to proper resources such as pastoral care and bereavement specialists (2008). For example, a timely reference to bereavement services should have helped Mrs. K in accepting the truth. In a qualitative study done by Fitzsimons et al., it was evident that at the end stages, deteriorating health status leads to decreased independence, social isolation, and increased family burden. Authors also raised questions regarding little support or respite services offered to family members which lead to decreased quality of life among family members (2006). The investigation done by Heyland et al. provided with both patient’s and family member’s perspectives of the most important elements related to quality end- of- life care. It was interesting that both patients and family members rated trust and confidence with health care providers; information communication in honest manner; to relieve symptoms and adequate plan of care at end stage among the top priorities listed (2006). Mrs. K showed a distinct lack of trust in health care providers; as she said nobody listened to her concerns properly. It is very important to understand that the needs of families whose loved ones are at end stage of life are different and should be assessed on regular basis. A study undertaken by Hermann also established that there is need to assess the spiritual needs of the patients and their family members. Interestingly, the study found that patients and families reported higher number of unmet spiritual needs (2007). Spiritual activities can include presence of others or independent activities such as prayer, reading from scriptures etc. From my observation, nobody assessed the spiritual needs for Mr. K and his wife and as a result their spiritual needs were unmet. Evidence Based Recommendations: The Conceptual Model used by Thacker recommends that advocacy behavior in nursing practice can help the patients and families to overcome barriers impeding care path at end-of-life stages. The advocacy practiced during the end-of-life should include safe care, improved quality of life for family and patient with comfort and minimal suffering (2008). Research by Bushinski & Cummings (2007); Wasserman (….) recommended importance of establishing therapeutic relationship with families and patients’. Authors suggest that professionals must first examine their own values and beliefs regarding death prior working with the dying. They also talk about how to begin dialogues about death and to consider the patient’s fear and hopes regarding care of loved ones. Authors further recommend that nurses should translate the language of medicine and the patient’s experience into a meaningful dialogue that the patient and his/her family can easily relate to and understand. Bushinski & Cummings (2007) further explored the field of specific communication skills needed at end-of-life care with families. The authors recommend that nursing schools should include specific focus on end-of-life communication in the curricula. They also suggest that orientation regarding communication skills to new nurses on the floor can help in providing better end-of-life care. An article by Gilbert (2009) recommends that in order to deliver high quality care to patients and families at such a crucial stage in their lives, it is important to incorporate end-of-life care education program in all stages of nurse training. The author also talked about the successes of the education program that is already in place. The education program includes modules on communication skills in bereavement, understanding loss, cultural and spirituality issues, providing support and information for the bereaved. An article by Rolland & Kalman says that although there are programs in place to educate nurses but many have not been evaluated for efficacy. They recommend including hospice and palliative care clinical rotations to provide practical experience with dying patients. They also recommend that healthcare institutions need to include end- of- life competencies for new RN graduates (2007). A study by Adams (2010) encourages the incorporation of end-of-life courses in nursing curricula so students can become more comfortable and confident when working with patients and families at the end-of-life care. It is interesting that the author also recommends the end- of- life continuing education to be mandatory for all nurses. I think these efforts will help to change attitudes of nurses and will improve end-of-life care for patients and families. All research studies believe that when nurses are educated in end- of- life care, they will be better able to help patients and their families at the end stage of terminal illness. An article by Wingate and Wiegand provides the summary of nursing actions and interventions to help patients and families at the end-of-life care. They talk about proper communication skills, providing comfort to relieve symptoms and to support them in treatment decisions. Most importantly they talk about providing resources to the family members about bereavement services, pastoral care, and follow up appointments. For example Mrs. K didn’t get support from the bereavement services as a result she was not prepared for the death of her husband. The article by Fields (2007), suggests the list of specific ways nurses can be involved in palliative care, keeping patient clean and dry, offering food, drinks and a place to rest for the family and also encouraging the family members to take care of themselves. The author also talks about making a counselor available to families, changing hospital culture and to increase hospital and staff accountability for making end-of-life improvements. Unfortunately, none of these measures were taken for Mr. K and his wife. Gaps and Implications for Nursing Practice: While caring for Mr. K, I did not find any care plans related with end-of-life care on the floor. Research done by Jackobsson, Bergh & Ohlen establish that healthcare records lack the concrete care plans which could have been a meaningful resource to care for patients and families at end-of-life care (2007). Most of the studies talk about palliative care at the end stages of chronic illnesses but I think it should be started at the time a person is diagnosed with chronic illness. According to World health organization (WHO), palliative care should not be offered just before death but it should be offered years before to help people who need help along the way (2005). For example, if Mr. K and his wife had received the palliative care along the way, she should have been better able to cope with the situation. Lack of effective communication strategies is another common gap experienced by many families and patients. Research done by Bushinski in both palliative care program and medical care intensive unit (ICU) talks about the factors that interfere with effective communication with the patients and families at end- of- life. Healthcare professionals talk about the factors that interfere with end-of-life care. Some of these factors are: Lack of time available to communicate properly Lack of knowledge about the issues related with end – of- life Lack of skills and experience in communicating these issues (2007). The Ministry of Health and Long –Term care (MOHLTC) with the support of Federal Health Accord, aims to improve end-of-life care for Ontarians with the main objective to improve, access, coordinate and maintain consistency of services and support systems across the province. In spite of all this there will still be challenges in providing improved quality of care at end-of-life. A study by Seow, Susan & Vaitonis talks about the shortage of nurses, palliative care physicians and physicians willing to make home visits. Although the study found that the strategy by MOHLTC has improved awareness of end-of-life care among providers but it believes that the public needs further education about end-of-life care options available to them in the community (2008). There are still many gaps that need to be bridged starting from federal level down to the staff level for this initiative to have a meaningful impact on the community. Analysis of this clinical situation will influence my practice as a future nurse. Read More