Clinical Decision-Making in Complex Care - Essay Example

?Clinical decision making Clinical decision making Clinical decision making Mrs. Jones was passing through the terminal days of her battle with cervical cancer with secondaries. The physician had felt that Mrs. Jones would not live long and that she was not responding to the symptomatic treatment in palliative care. He also felt that it was time to decide on stopping her support systems and symptomatic treatment for palliative sedation and thereby raise the quality of her remaining life and allow her to go smoothly and comfortably. The decision was to be made by the family as the patient was slipping into unconsciousness. The family had a hard time to decide on the removal of life-support systems and the changeover to palliative sedation. The nurse manager advised me to empower the family to make the decision required of them. When I told her that I had never before handled this situation, she advised me on how to do it and convinced me that I would be able to achieve the target and that my few years of experience were sufficient. My feelings The message that I received today was that this situation was a common occurrence and I had to be prepared. I was feeling unhappy that I was not competent enough to handle the situation. It was the nurse’s duty to empower the family in times of crises. With the intention of redeeming myself, I needed to use evidence-informed decision-making in this frequently occurring situation in my practice (Brown et al, 2009). This day had been conducive to my learning a new experience which had stimulated me to further my comprehension of bioethics and empowerment of family members of end-of-life patients. Evaluation This often-occurring situation in the nursing profession and its solution was revealed to me today. That I needed to learn much more to become competent was another revelation. Both of these appeared good to me as I could learn from experience. Another good thing was that I had the support of my seniors. The fact that I was not confident enough to handle this crisis was the bad part but I take this as an opportunity to think positively and find ways to solve this problem so that I am equipped to cope with it at any moment in my profession. Analysis Clinical decision-making could also be termed clinical reasoning, judgment, inference or diagnostic reasoning (Hardy and Smith, 2008). Clinical decision-making could be defined as the process of making an informed judgment over the treatment necessary for patients. Intuition as a form of reasoning had been associated with clinical decision-making (Nyatanga and De Vocht, 2008). Clinical decision is a type of informal decision-making that combines clinical expertise, patient concerns, and evidence gathered from scientific literature to arrive at a diagnosis and treatment recommendation. Participants, process, an outcome and setting formed a major portion of the nurses’ clinical decisions (Gurbutt, 2006). Clinical reasoning was the process by which the judgments were made. The judgments were difficult propositions and could be managed only if the nurse could understand the salient details and difficulties of a situation (Tanner, 2006). She should also be able to interpret and respond accordingly. In today’s situation, I should have been able to understand the illness and end-of-life experiences of the family when I reached my station, much before the actual situation arose. Their emotional strengths, physical health, social well-being and coping mechanisms should have been gauged before the crisis (Tanner, 2006). Clinical decision-making affected the quality of care for the patient and his safety. In fact it had been described as the essential component for professional nursing care (White, 2003 in Hagbaghery, 2004). The resolution of family conflicts and the provision of information on care provider services were also a part of the decision-making. The decision- making performance of the nurse and her capability of reaching heights were hindered by various interruptions expected in a hospital atmosphere (Ebright et al, 2003). The fact that the patient was lapsing into unconsciousness, the reaching of the terminal stage of illness, the presence of the family members and the advice of the nurse manager together played associative roles in the decision-making for the empowerment of the family members. Had the patient been conscious, the decision-making would have involved her. As she was becoming unconscious, her family members were included in respect to the patient. Competent decision-making involved appropriate use of knowledge and experience (Hagbaghery, 2004). The ever-changing and complex uncertain atmosphere in the healthcare services made it all the more difficult for competent decision-makers from implementing their plan. Indecisiveness of family members on end-of-life decisions was a fact that frustrated nurses (Browning, 2009). Mrs. Jones’ family was in a similar situation. The treating physician had advised them about the non-progressive state that Mrs. Jones had gone into. Mrs. Jones deserved to be enjoying as good a quality of life as she could possibly have. For this she had to have her active symptomatic treatment and life-support systems of oxygenation and ventilation stopped. She was to be administered palliative sedation which was expected to keep her more comfortable than in her current situation where she seemed to react to almost all her medicines by vomiting, retching and feeling the extreme pain of bone secondaries. The palliative sedation was to hopefully ease her discomforts after treatment limitation; it was to reduce unconscious pain when other drugs were withdrawn by bringing down perception of pain and unconscious nervous reactions (Bauman et al, 2011). Previously this act of treatment limitation and the institution of palliative sedation would have been illegal and would have been condemned as a covert euthanasia. However recently, revision of Article 37 of the French code of medical ethics had acknowledged both treatment limitation and palliative sedation as legal and ethical and had saved physicians from being implicated in an accusation of euthanasia. This revision served as a model for countries where euthanasia was illegal and where it was legal but prevented in patients who could not ask for it even when treatment-limitation had been decided upon by removing mechanical ventilation, hydration and nutrition (Bauman et al, 2011). I should be perfectly ethically correct when I set out to speak to the family and initiate their empowerment for the treatment limitation and palliative sedation. Improved communication helped me to assess the patients’ and families’ beliefs, how they responded culturally, their spiritual thoughts, social status, how they wanted the patient to spend her last days, the reasons for considering treatment limitation and reasons for palliative sedation and whether their mental make-up could make a decision on the treatment limitation and palliative sedation (Browning, 2009). They had many doubts which I could clear to the best of my ability. They were anxious that Mrs. Jones should have the best possible management and were willing to consent to the decision if they were sure that she would not feel any pain. With my reassurance, they were convinced. I had facilitated a comfort level for the family and they trusted me as I had already begun to build a rapport with them (Browning, 2009). Our shared decision-making through a collaborative technique was a sound one. I had been able to make them feel that they were not being coerced and that they had the right of decision (Browning, 2009). Action Plan Going by John’s Model of Structured Reflection, I would be keeping a journal of the experience, step for step (Jasper, 2003). Analysing the factors which had contributed to the experience was the next step. The change of clinical situation of the patient, the physician’s request and the fact that I was on duty enabled me to have the experience of handling the ethical dilemma here. My journal would be having my reflections in the details of the procedure I followed, how I managed to convince the family and which statement had turned their thoughts in favour of the decision-making (Jasper, 2003). Then I would be adding the factors which influenced the decision-making process (Jasper, 2003). Competence and self-confidence were the more important of the personal factors which affected decision-making (Hagbaghery, 2004). These were the same factors which helped me in my decision-making today. The external factors that could have influenced me were the support in the ward and from my seniors, my level of education and the atmosphere of this hospital. My choice of decision of empowerment of the family was justified in this situation. Hagbaghery said that recognizing facilitators and barriers was the first step in strengthening and empowering nurses for better decision-making (2004). I do not feel that I had mishandled the situation as the family easily understood me and responded well. However the next time, I would not wait for a situation to develop before I initiate the process of empowerment. My patients and their families would be empowered from the day they enter my ward. Empowering the family members for an end-of-life decision was not a simple task as I had discovered. The scenario of my empowering patients and families for making decisions would be very frequent and I would be using the same procedure with a few improvements each time I go through the same scenario. Conclusion The skill of reflection would provide me the ability to associate theory and practice (Kofoed, 2011). My reflections for the crises in hospital would be a continuing daily process. Setting aside time for reflection was essential in a nursing practice. Though this was difficult in a busy career, priority listing would help me find time for reflection. I would be remembering that professional transformation of nurse leaders occurred by reflective self –awareness because the patient care they accorded needed to be improving from day to day (Sherwood and Horton-Deutsch, 2008). Reflective practice could produce a positive change in my healthcare setting (Kofoed, 2011). References: Baumann , A, Claudot, F, Audibert, G, Mertes, P-M and Puybasset, L, 2011, Philosophy, Ethics, and Humanities in Medicine 2011, 6:4 Bowen, S., Erickson, T., Martens, PJ and Crockett, S., 2009, More Than “Using Research”: The Real Challenges in Promoting Evidence-Informed Decision-Making, Healthcare Policy Vol.4 No.3, 2009 Browning, AM, 2009, Empowering Family Members in End-of-Life Care Decision Making in the Intensive Care Unit, Dimens Crit Care Nurs. 2009;28(1):18/23] Ebright, PR, Patterson, ES, Chalko, BA, & Render, ML, 2003, Understanding the complexity of registered nurse work in acute care settings. Journal of Nursing Administration, 33, 630-638. Gurbutt, R, 2006, Nurses Clinical Decision-making, Radcliffe Publishing Hagbaghery, MA, Salsali, M and Ahmadi, M, 2004, The factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study, BMC Nursing 2004, 3. BioMed Central. Hardy, D and Smith, B, 2008, Decision making in clinical practice, British Journal of Anaesthesia and Recovery Nursing, Vol. 9 (1), p.19-21 Jasper, M, 2003, Beginning Reflective Practice – Foundations in Nursing and Health Care Nelson Thornes. Cheltenham Kofoed, NA, 2011, Reflective Practice for Personal and Professional Transformation, JCN July/September 2011, Nyatanga, B and De Vocht H, 2008, Intuition in clinical decision-making: a psychological penumbra International Journal of Palliative Nursing, 2008 Oct; 14 (10): 492-6 ISSN: 1357-6321 PMID: 18978695 Silen, M, Tang, PF, Wadensten, B. and Ahlstrom, G, 2008, Workplace Distress and Ethical Dilemmas in Neuroscience Nursing, Journal of Neuroscience Nursing, Vol. 40 No. 4 August 2008 Tanner, CA, 2006, Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing, Journal of Nursing Education, June 2006, Vol. 45, No. 6 Yingling, J and Keeley, M, 2007, A Failure to Communicate: Let's Get Real About Improving Communication at the End of Life, Am J Hosp Palliat Care 2007; 24; 95 DOI: 10.1177/1049909106297244 , APPENDIX. Mrs. Jones had been suffering from cancer cervix with secondaries in the liver. Having become emaciated, she was looking extremely thin and bony. Her life support systems had included the ventilator, oxygen inhalation, the intravenous feeding and hydration systems. Urine was being drained through a catheter. She was unconscious in addition. I was wondering why this person was being removed from the support systems. The drained urine was reddish today. The physician had checked her blood results and urinary output, checked her respiratory and cardiovascular systems before he informed me that he needed to meet the family consisting of her husband and her son. Having conveyed the message, I accompanied the doctor to the meeting room. He was very considerate and calm while speaking to the members. The husband and son were crying but they seemed to agree with the doctor. Overcome with emotion, I was sobbing. The doctor had spoken about withdrawing life support for Mrs. Jones after starting palliative sedation. The decision for treatment limitation was a new one for me. I always believed that one was to do whatever was possible for a patient till God took her. Her condition was so bad that she could not possibly survive for long. Renal failure had set in and she was not tolerating medicines and even food. Palliative sedation would help her not feel any pain. The husband and son were allowed to make the treatment -limiting decision. They believed that it was the best they could do for her. This scene would never leave my mind. Did we have the right to decide when treatment for a patient needed to be stopped? I decided to read widely on the subject and clear my mind. Engaging in reflective practice could help me improve my own capability and patient care as well. Read More