Full Disclosure Concept in Nursing - Assignment Example

? The Health of The Truth Leadership and Management Nursing PICO MENT Can Full Disclosure in a hospice setting be implemented in a way that would benefits patients, family members, and staff while also following policy already in place? \ Setting My clinical experience took place over the course of six weeks, with one clinical day per week. My clinical location was Barnabas Health Hospice and Palliative Care Center (BHPCC). Barnabas provides hospice and palliative care to the patients, the nursing home or the assisted living facility depending on how well the patients is able to complete the activities of daily living and what level of care they need in completing these, Barnabas ensures through careful staffing that a myriad of services are available on site to meet patient needs. Along with nursing services, there are qualified social workers, with one being assigned to each patient, spiritual care services that are an option should the patient request them, volunteer services who are usually trained by hospice and use their time being companions and developing relationships with the patient and there is also bereavement support. This support will follow a family for thirteen months with phone calls and offers of support groups though they primarily provide support by allowing the family to talk about their lost loved one with one outside of the family circle and it also lets them know that the patient is well remembered by the staff at BHPCC. BHPCC can provide and does provide additional services as needed by the patient. Physical therapy, occupational therapy, speech therapy and swallowing studies and nutritional therapy designed to ensure the patient is getting the maximum amount of nutrients, often this will be quite creative when a patient does not want to eat. High protein shakes, ensures, and other high impact alternatives will be used to ensure that while the patient is exercising his or her right to refuse food they can usually be talked into one of these choices without feeling they’ve lost the ability to make the choice. BHPCC partnered with Van Dyke Hospice offer the client many other possible services and have situational arrangement should the client need. Some of those programs are Bethany Baptist Faith Program, separate special care programs for both dementia and cardiac and also pulmonary special care programs. Another very import program is the palliative care and support for family members and caregivers. The Nursing Supervisor is responsible for supervising all medical employees. Other business functions within the organizations have their own hierarchy of supervision, such as in payroll, staffing and front desk operations. Staff consists of registered and licensed practical nurses. There are also support staff such as aids and respiratory. Support staff such as the nursing aids spends the most time with the patient and it is often up to them to notice changes in function or cognition within the patient and report this to the patient’s assigned nurse. The nurse will then contact the doctor after their own assessment with any finding so that the doctor can determine if a visit is needed or medication change. Because the unit is a hospice unit and palliative care their can and usually is a high level of stress. Families are usually upset, patients are often angry, confused or in denial. Health care workers must carefully balance the primary needs of the patient with the needs that the family will also have for support and information about the patient’s condition. The model of care was one of a team method with the RN serving in a democratic way as team leader. Morning meetings are conducted daily and nurses are to present any cases they may have questions on or that need the team leaders input. These cases can be anything from patients complaints and how to better deal with them, to family requests and if we are able to meet them. Many times, Mary, the team leader would ask the Nurse their own opinion in the matter because the nurse has much more experience and interaction with the patient and is likely able to make good decisions based on what he or she has assessed the problem to be, Often Mary would agree with their suggestion and allow them to follow their own plan of care with her approval. Mary feels that though the process is democratic these nurses work very closely with the patient and the family and are well trained and educated and sometimes though they may ask it increases their self-confidence in their ability to treat their patient when their suggestion has been agreed on by Mary. A problem I noticed quite a bit in this area of care was the very basic premise of truth telling. In providing palliative and hospice care how much do you tell the patient? What is appropriate to withhold from the patient about their treatment plan? Whose job is it within the treatment team to tell the patient they are terminal? Comparison The problem seems to be being handled on a case to case basis with a heavy emphasis on what the family prefers. This does not consider the patients autonomy first. The Supervisor Nurse uses a democratic and team work leadership style which works well in the day to day functioning of the unit though it does not improve this situation. The situation is one that is primarily controlled by the treating Physicians, having the authority over what to disclose and to whom. It is the nursing staff’s responsibility to be supportive to the family’s frustration if they feel the Physician is not being candid; the nurse is not to disclose terminal diagnosis first hand. Once diagnosis has been given the nurse is then the one who will likely explain the diagnosis and offer support through education about the diagnosis. Though it is the responsibility of the Physician to tell the patient they are terminal, there are often several of them on the treatment team, each expecting the other to inform the patient. Intervention Misinformation can be subtle but deceptive. (Glass, p236) Not using full disclosure about the patient’s diagnosis, prognosis, and treatment options is treatment and the hardship of worth and is it likely to have an impact? Sometimes no treatment is the best treatment in end of life decisions Highlighting the positive of the information, making little mention of the negative aspects-leaves the patients with an unrealistic view of the illness Not answering patient and family’s questions and requests for more information; provider’s frequently say they do this in an attempt to maintain the patients sense of hope; is this fair to the patient who may be needing to begin dealing with the process of dying in its many stages and getting their affairs in order? Presenting information that is biased according to how the Doctor feels, believed because the patient and family trust the Doctor they are more likely to follow his plan of care which may include research treatment that they would not have ordinarily tried, Doctor recommendations carry great weight with many patients and should be given if the possible benefit is going to outweigh the possible side effects (Glass, Cluxton, p236-237) Research has shown that there are a number of reasons why Doctor’s do not tell the entire truth. They may have an unrealistic perception of their own ability to stop the dying process or have difficulty dealing with their own mortality. Obviously those types of Doctor’s may not be best suited for the Hospice environment. Some believe the only way to allow a patient to remain functional is by not telling them the truth, thus doubting their ability or the resilience of the human spirit and the individual’s ability to prepare for death on their own terms. Many, though dying, are able to meet goals they decide on before dying allowing them the satisfaction of doing anything they may feel was left undone during their lifetimes. The Physician may be unable to grieve the loss of a patient or may lack the opportunity to overcome their own personal fears so that they are unable to have open and honest conversations on the subject of dying. It is often easier for them to continue offering treatment though treatment will not be the cure than to attempt a difficult conversation (Glass, p237). Some believe that the patient doesn’t really want to know the truth and shields them from most of it and sometimes Doctors will respect the wishes of the family who may not want the patient to have the worst news though this violates the patients’ rights in itself but often the patients are in a medical condition where excuses can be made and the Physician feels justified withholding the information. Many times the patient has a treatment team and each member of the team may feel it is the responsibility of another member of the team to advice the patient. It is possible that by not providing the complete truth patients may receive less intensive treatments when more intensive treatments are likely needed (Shahidi, p592). As a whole the medical organization is moving towards more disclosure though non-disclosure is still the dominant practice. This problem is not just at Barnabas, it is a problem in most Hospice and Palliative care setting across the country. How it is dealt with usually considers many factors. Staff training, to include both Doctors and Nurses should be implemented several times a year with the focus on how to deal with mortality and how to give patients bad news in a positive way. The sooner the patient begins their end of life transitions the sooner they will be able to reach acceptance. Doctor’s allowing more time with a patient when they know this is going to be the topic of conversation is also a good practice, being there to answer questions and offer guidance. Often the patient is passed on to a clergy person when in reality the physician should best be familiar with the stages of dying that a terminal patient will go through though it may be many years since they’ve learned them or recognized them in practice. If the patient is fully functional then they should be told as much as possible despite family protests, it is their decisions to be made and their remaining time and they should be shown that respect at least. I feel it is a serious issue of mistrust if the family knows but it is kept from the patient. Most literature suggests a multidimensional approach in deciding when to tell, how much to tell, and whom to tell. Because the prognosis, diagnosis and treatment is the Physician’s arena the nurse is usually supportive of the decision even if it is one they disagree with (Leka, p5). As Nurse’s we must defer to the decision of the Physician and in this area we are helpless, often between the family and the patient, being aware ourselves of the true diagnosis. It is the job of the Nurse Supervisor to meet with the Physician with any questions or concerns but frequently these issues aren’t addressed or they are brushed aside. Developing Hospice and Palliative care truth in treatment initiative’s would be great, defining what and whom would be told and under what circumstance would information be withheld from a patient wanting full disclosure. Though patient’s sign many papers in medical facilities for treatment, many similar to this, they seem to become grey once the issue is palliative care and Hospice. Patients who are aware of their terminal diagnosis should be understood and recognized as they go through the different stages of dying as defined by Kuebler-Ross. There are many things that staff can still do to assist the patient in this process to help them reach goals and get to acceptance as smoothly as possible. Outcome Through the consistent and upfront truth telling patients would be better able to make end of life decisions regarding care and other matters they may wish to deal with. The grieving process can begin and hopefully the patient can reach acceptance and meet end of life goals they set for themselves. Full disclosure policy implementation will result in a consistent manner of treating hospice patients and allow staff members to rely on such policy when they are unsure of what should be disclosed, how the information should be disclosed and whom it should be disclosed to. Determining the awareness and cognition of the patient will ensure that the patient is advised at an appropriate communication level and that staff are using language that the patient can understand. Recognizing at what stage of acceptance the patient is in will allow staff to assist the patient in the process. Conclusion Because the problem is so wide spread in the Palliative and Hospice care industry the possibility of getting a change overall would rest with lobbyist’s’ for the issue to come up before the house, It is possible to implement change through policy and procedure in any one health care company regarding disclosure and removing some of the grey area that allows the Doctor to disclose as he sees fit, despite other circumstances. This is the only area of medicine where you will find this type of issue. Physicians are uncomfortable losing a patient and even more uncomfortable explaining the dying process to a patient; this has always been the nurse’s arena. As a nurse in a leadership role the Doctor still maintains authority of information disclosure such as this. References "N79 Nursing Care Delivery Systems." Home | The University of North Carolina at Chapel Hill. Web. 13 Jan. 2012. . Glass, E., & Cluxton, D. (2004). Truth Telling Ethical Issues in Clinical Practice. Journal of Hospice and Palliative Nursing, 6(4), 232-240. Leka, N. (2011). Truth telling dilemma... Johnstone, Megan-Jane. Ethics, cancer and truth telling, ANJ, March 2011. Australian Nursing Journal, 18(11), 5. SHAHIDI, J. (2010). Not telling the truth: circumstances leading to concealment of diagnosis and prognosis from cancer patients. European Journal Of Cancer Care, 19(5), 589-593. doi:10.1111/j.1365-2354.2009.01100.x Read More