Elderly Patient with Severe Dementia: Tube Feeding Devices - Coursework Example

Life Threatening Illness - Elderly Patient with Severe Dementia: Tube Feeding Devices - Table of Contents I. Introduction............................................................................... 3 II. My Personal Clinical Nursing Experience .................................... 4 III. The Application of Philosophy of Care in my Clinical Nursing Experience .............................................................................. 5 a. Autonomy or the Patient’s Right to Consent a Treatment ................................................................... 5 b. Nurses’ Decision-Making on Tube Feeding Application on Patients with Dementia in Acute Medical Ward ....... 7 c. Ethical Considerations When Providing Care for the Patient ................................................................................ 9 d. Issues on Equality and Diversity in the Practice of Nursing ........................................................... 11 IV. Related Theory of Grief, Loss, and/or Bereavement ........................ 12 V. Suggested Alternative Actions / Solution(s) ..................................... 13 VI. Conclusion ....................................................................................... 14 References ................................................................................................. 15 - 17 Introduction Health care ethics is crucial with the day-to-day practice of health care services particularly in the field of nursing. Basically, the study of nursing ethics focuses on the evaluation of merits, risks, and other social concerns with regards to the activities provided by nurses to the patients including their respective family members. In line with the practice of nursing, the codes of ethics, nurse practice act, standards of care, and the legal implications of the nursing standards of care has to be followed carefully to ensure that the best nursing practices will be rendered to the patients. (Aiken, 2005) Nurses are expected to deal with life-threatening situations. Coping with death remains a challenge for nurses since the ability of an individual to cope with grieve highly depends on the relationship of the affected individual with the person who died including his/her own personality. For this reason, nurses should learn to deal the proper way of dealing with grieving individuals as part of their profession. (Casarett et al., 2001) In the study, the researcher’s personal nursing experience with a patient who is dependent on the application of tube feeding and has been diagnosed with advanced dementia will be elaborated. In the process of reflecting and analyzing a critical life threatening situation based on the personal experience of the researcher, the study will explore the specific ethical and legal principles such as autonomy or the practice of informed consent; including the practice of non-maleficence, beneficence, and justice (Bailey, 2007) in the case of the researcher’s patient including the generally accepted ethical and legal principles to standards of clinical practice; the issues pertaining to the equality and diversity in the practice of nursing particularly with the application of tube feeding among the patients diagnosed with advanced dementia. The researcher will also link the clinical situation to a specific theory of grief, loss, and/or bereavement. At the end of the study, the researcher will suggest an alternative action which could lead to a more positive outcome in the case of the patient, the patient’s family, and the nurses involved. My Personal Nursing Experience In the past, the researcher had encountered attending to a 65 year old patient who has been diagnosed with a severe dementia. The patient was physically weak and had been heavily dependent on the use of tube feeding devices to support his nutritional needs. During the time I was assigned to render a basic health care service to the old patient, I have noticed some puss developing on the tube feeding device. As part of my duty and responsibility as the attending nurse, I had to inform the physician regarding the need to constantly change the patient’s tube feeding devices so as to avoid the patient from having further complications due to a possible infection. Eventually, the tube feeding devices had been regularly check upon and changed more frequently. Each time the tube feeding devices need to be change, it has been ensured that the practice of non-maleficence, beneficence, and justice were applied in the process of care. Despite the fact that I am very much aware of the consequences of using tube feeding devices on patients with severe dementia rather than feeding them manually, I felt that I was simply in no position to withdraw the patient from the tube feeding devices. I decided to work on my duty by ensuring that the patient will not suffer from any probable infection caused by the tube feeding devices. In case the patient was visited by his family members, I took the opportunity to communicate with them with them regards to the health condition and caring the patient is receiving. At the time of the patient’s death, I noticed that his family members did not grieve as much as I have expected them to see. Perhaps it is because the patient has been confined long enough at the hospital which made them accept the fact that their love one will eventually pass away. Despite the absence of grievance from the patient’s family members, I did extend my deepest sympathy to them. The Application of Philosophy of Care in my Clinical Nursing Experience Basically, nursing ethics and law are two different subjects that are correlated with one another. Nurses should take note that it is important to consider the nursing ethics together with the nursing law in order to avoid any possible legal problems with regards to nursing profession and practices. Autonomy or the Patient’s Right to Consent a Treatment Autonomy refers to the right of the patient in making a personal choice concerning the treatment he/she will be getting from the health care providers. (Bailey, 2007) Considering that the mentally incapacitated patients could not decide about his/her preferred care and treatment, nurses and other health and social care professionals should follow the guidelines developed by the Department of Health called ‘Mental Capacity Act’ (2005); ‘Reference Guide to Consent for Examination or Treatment (2001)’; ‘Seeking Consent: Working with Older People (2001)’; and/or the ‘Seeking Consent: Working with People with Learning Disabilities (2001).’ (NHS, 2006) The Mental Capacity Act (2005) stated that it is crucial for nurses to prove that the patient have no capacity to make decisions on their own when dealing with patients who are diagnosed with dementia. In general, nurses must provide all the available and necessary clinical evidences prior to concluding that the patient is not capable to make any decision. Therefore, nurses should avoid making unwise decisions wherein any decisions made on behalf of the incapacitated patient should be for the benefit or best interests of the patient. In the case of the researcher’s patient, the patient has already been clinically tested to be totally incapacitated to make any judgement or decisions. Therefore, it was no longer necessary for the researcher to conduct clinical evidences with regards to proving that the patient is no longer able to give consent. It is a very complicated situation to make decisions on behalf of the researcher’s patient since it is necessary for the nurse to communicate with the rest of the health care professionals / carers, and relatives in order to provide them the opportunity to participate in the process of deciding the best care and treatment for the patient. (NHS, 2006) In the case of the researcher’s personal nursing experience, the researcher immediately communicated the need to immediately and frequently change the tube feeding devices with the assigned physician. In the case of the patient’s family and relatives, the researcher constantly inform them with the current update regarding the patient’s caring and health condition. Nurses’ Decision-Making on Tube Feeding Application on Patients with Dementia in Acute Medical Ward The number of nurses agreeing to use tube feeding on patients with dementia greatly varies depending on the country. Australian, Canadian, and Swedish nurses are the ones that strongly not agreeable with the use of tube feeding among these patients. (McNamara & Kennedy, 2001) Nurses should not presume that all patients suffering from dementia in the acute medical ward would want to use tube feeding to sustain their nutritional needs since it will be considered as a great violation on the patients’ autonomy which could lead to a legal punishment. (NHS, 2006; DOH, 2001a) In general, nurses including the health and social care professionals are the primary decision-makers on matters related to the use of feeding-tube on elderly patients with dementia. (McNamara & Kennedy, 2001) The personal opinions of the physicians as well as the other health care professionals contributes a lot on the use of tube feeding in these patients. Decision-making process on the part of the physicians, nurses, and other surrogate decision-makers normally face difficulties in coming with a right judgment since critical decisions for the health of the patients with advanced dementia should respect the ethical principles particularly the autonomy, non-maleficence, and beneficence. Deciding on whether to use tube feeding devices on patients with advanced dementia that has gradually stopped eating but is not dying is a difficult challenge on the part of the health and social care providers including the patients’ family and relatives. (Hoffer, 2006; McNamara & Kennedy, 2001) The recent study of L John Hoffer (2006) stated that reduced food intake and weight loss are some of the normal signs of old age. It is also possible that factors such as ill-fitting dentures, functional disability, depression, isolation, and poverty could affect the food intake of the elderly patients. Several tests conducted in the past show that the use of tube feeding shows that tube feeding on patients with advanced dementia neither prolongs their life nor improves its quality life. (Chernoff, 2006; Fine, 2006; Casarett, Kapo, & Caplan, 2005; Monteleoni & Clark, 2004; Skelly, 2002; McNamara & Kennedy, 2001; Gillick, 2000) In fact, the use of tube feeding devices on patients could even shorten their life and has been proven to be inefficient in providing the required nutrients among patients with dementia. (Fine, 2006; Chernoff, 2006; Skelly, 2002; Gillick, 2000) Since people with advanced dementia have a low metabolic rate, the food intake requirement they need is much lesser than the nutritional requirements of people with normal metabolic rate. (Hoffer, 2006) Eating less does not mean that elderly patients with dementia are starving. Therefore, avoiding the use of tube feeding devices on patients with advanced dementia supports the ethical principle of beneficence wherein the nurses are required to do only good actions which could contribute to the welfare of the patients; and non-maleficence in such a way that nurses avoids injuring the patients with the use of tube feeding devices. Preventing the use of tube feeding devices gives ‘justice’ to patients with advanced stage of dementia. It is immoral or ethically wrong to deny the patients from the normal nutritional sustenance. (Chernoff, 2006; Fine, 2006; Jotkowitz, Clarfield, & Glick, 2005; Truog & Chochrane, 2005; McNamara & Kennedy, 2001) Therefore, nurses should always consider alternative solutions. Ethical Considerations When Providing Care for the Patient In general, ‘informed consent’ is a standard operating procedure of the health care service prior to the start of any treatment, physical investigation, or providing personal care for the patient. (NHS, 2006; DOH, 2001a; DOH, 2001b) Since the researcher’s patient being diagnosed with a severe dementia has no capacity to give informed consent, it is still important for the researcher to provide care for the patient to consider the practice of confidentiality. Basically, it is unethical to disclose the patients’ confidential records without getting their consent from the patient. Since the researcher’s patient is mentally incapable of making a decision, the context of the Mental Capacity Act (2005) with regards to disclosing the patient’s information should be applied. Writing an “Advance Statement” regarding a patient’s preferred care and treatment; including the refusal over a specific treatment such as test tube feeding (NHS, 2006; DOH, 2001a; DOH, 2001b); seek the power of an attorney in case the patient loses his ability to communicate; or selecting a preferred health care provider (NHS, 2006) is only applicable to patient with dementia but are still capable to make a decision. According to the Department of Health (2001a), it is possible for nurses and other health care providers to face a legal action from the side of the patient in case of failure to acknowledge the patient’s ‘Advance Statement.’ Since the researcher’s patient is totally incapacitated, it is the researcher’s duty and responsibility to provide care for the patient in accordance to the ethical principles such as the non-maleficence, beneficence, and justice. According to Bailey (2007), non-maleficence refers to the nurses’ obligation to avoid injuring the patients; beneficence demands nurses to do only good actions which may contribute to the welfare of the patients; and justice refers to the nurses’ obligation to act and decide on health care matters that is fair to all. For this reason, it is important that any decisions made by nurses on behalf of the patient should be for the greater benefit or best interests of the patient. (Mental Capacity Act, 2005; DOH, 2001b) With regards to non-maleficence, beneficence, and justice, considering that the researcher is very much aware of the fact that the use of tube feeding devices could do more harm to a patient with dementia more than good (Ersek, 2003; Mitchell, 2003), the researcher should not under her own judgement remove or withdraw the tube feeding devices from the patient without seeking a legal advice. According to the Department of Health (2001a; 2001b), in case of doubt with regards to sensitive matters like withdrawal of nutrition and hydration from patients with advanced dementia, the health and social care practitioners should get a legal approval from the court. It is also ethically acceptable for nurses to provide the patient’s family or close relatives with concrete information regarding the application procedure of tube feeding devices, its purpose and consequences, including the danger of using the tube-feeding devices. (DOH, 2001a; DOH, 2001b) In the process, nurses should be able to propose an alternative solution for the care and treatment before allowing these people to think and make an important decision for the care and treatment of the patient(s) with advanced dementia. In terms of rendering care such as dressing, the use of feeding tubes on patients with dementia, or even the administration of drugs, etc. to a patient, a part of the ethical rule as well as the common or case law that nurses and other health care professionals should seek consent prior to ‘touching a patient.’ Failure to seek consent from the patient could lead to a possible law suit for ‘negligence’ in case the patient has been harmed due to the unconsented care rendered to the patient. (DOH, 2001a) For this reason, nurses in general should not only be familiar with the nursing ethics but also the legal developments related to the nursing profession. According to the DOH (2001a), the common law in nursing is more or less based on the Human Rights Act 1998. Issues on Equality and Diversity in the Practice of Nursing As part of nursing ethics, equality and diversity in terms of delivering health care services to patients should be considered regardless of the patient’s gender, age, ethnicity, health condition and/or religion. (NHS, 2006) There should be non-discrimination in the provision of health care services to people with dementia. Language should never be a barrier to the care and treatment provided to these patients. In case a different language is spoken between the health and social care provider and the patient, it may be necessary for the health care provider to seek help from other people specifically on translating the patients’ needs and wishes concerning his care and treatment. (DOH, 2001b) Since patients with severe dementia are not in the position to defend their human rights, most of them suffer from abuse. (Koch & Nay, 2003; Nahmiash, 2002) As part of nursing equality and diversity, nurses must ensure that patients with cognitive and functional impairment are not denied to access good health care services. (NHS, 2006) In line with this matter, nurses are expected to identify the patient’s specific needs and record it in the patient’s care plan especially issues concerning the patient’s nutritional needs or diet. In order to acknowledge the diversity in the needs of patients with dementia, it is necessary for nurses to get proper training or skill development concerning dementia awareness and their roles and responsibilities as health and social care service providers. (NHS, 2006) Generally speaking, the dementia-care training should include educational programs on the early signs and symptoms of dementia; the impact of dementia on the patients including their family and relatives; palliative care approach; and the nutritional requirements of people with dementia including the application and consequences of tube feeding, etc. Related Theory of Grief, Loss, and/or Bereavement There are several theories that account for the coping process of a person with a life-threatening illness. In the case of the researcher’s personal experience, the task-based approach (Corr, Nabe, & Corr, 1997) will be used to describe the situation. Limiting factors such as denial, anger, bargaining, depression, and acceptance based on the explanation of Elizabeth Kubler-Ross (1969) will be included. Basically, the are four phrases of a life-threatening illness present in the task-based approach are known as: prediagnostic, acute, chronic, and recovery / death or the terminal phrase. (Doka, 1993) In the case of the dealing with the family members of the researcher’s patient, it was not difficult on the part of the researcher to try to pacify them since most of them has already fully accepted the death of the patient. In analyzing the reason behind the immediate acceptance during the time period in which the researcher has been extending care for the patient for almost one year, some of the patient’s immediate family members would come and visit once in awhile. Considering that the patient had a severe dementia, most of the family members were not really able to communicate with the patient the way they could with a person without mental illness. The fact that the patient was not able to communicate with his immediate family members for a very long time resulted to an immediate acceptance of the patient’s death. Suggested Alternative Action / Solution(s) Considering that the use of tube feeding devices with severe dementia patients neither prolongs their life or improve the quality of life (Chernoff, 2006; Fine, 2006; Casarett, Kapo, & Caplan, 2005; Monteleoni & Clark, 2004; Skelly, 2002; McNamara & Kennedy, 2001; Gillick, 2000) and the fact that it could shorten the patients’ life and has been proven to be inefficient in providing the required nutrients among patients (Fine, 2006; Chernoff, 2006; Skelly, 2002; Gillick, 2000), the researcher strongly recommends the use of alternative solutions such as skillful techniques in feeding, being patient while feeding the patients with advanced dementia, offering them their favorite foods or strong flavored energy- and protein-rich foods, and constantly reminding the patients to chew their food before swallowing rather than simply promoting the use of tube feeding devices on these patients. (McNamara & Kennedy, 2001) Studying and identifying the possible expected long-term and short-term effects of each alternative solutions must be compared with the pros and cons of using tube feeding on these patients. To avoid patients’ death from starvation, it is possible for the nurses to determine whether patients with advanced dementia are starving by weighing them. (Hoffer, 2006) By using the weighing technique, the health and social care professionals could determine whether the patient needs to be fed orally with rich flavored good nutritious food. This method is an effective way of avoiding solely the use of tube feeding devices. It also gives justice to patients suffering from an advanced state of dementia from going through a lot of discomfort and health risks associated with the use of tube feeding devices. (Hoffer, 2006; Galanos, 1994) Conclusion Nurses should always consider nursing ethics such as autonomy or the practice of informed consent; including the practice of non-maleficence, beneficence, and justice as well as its legality when caring for the patients. Doing so would prevent the nurse from having to face legal problems throughout their nursing careers. Since it is unavoidable for nurses to deal with life threatening illnesses or situation, it is equally important for nurses to be familiar with the different ways in dealing with grief, loss, and/or bereavement. This strategy will make it easier for the nurses to provide comfort to individuals who are badly affected by the loss of their love ones. *** End *** References: Aiken, T. (October 2005). Legal, Ethical, and Political Issues in Nursing. 2nd Edition Philadelphi, PA. in Davisl F.A. part 1 of Book Review. Critical Care Nurse , 25(5):72. Bailey, G. (2007). 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Are We Using Percutaneous Endoscopic Gastrostomy Appropriately in the Elderly? Current Opinion in Clinical Nutrition and Metabolic Care , 5: 35 - 42. Truog, R., & Chochrane, T. (2005). Refusal of Hydration and Nutrition: Irrelevance of the Artificial vs. Natural Distinction. Archives of Internal Medicine , 165: 2574 - 2576. Read More