Introduction
It is apparent that nursing care for a patient in multisystem failure requires more than physiological care tools. That is, it involves working with the family of the patient, particularly when it is evident that the patient is in an end-of-life situation. In such a scenario, communication becomes the fundamental tool of care. This plan discusses fundamental communication issues of palliative care, advanced directives and organ donation, provision of a humane and healing environment, ethical issues related to end-of-life situations, the interdisciplinary team for such care, and other important healthcare issues from the perspective of the patient’s family. Realistically, issues are not experienced or occur in a linear fashion but are likely to happen concurrently. However, for orderliness and simplicity, I have discussed them separately.
Palliative care for the patient
Effective communication is vital for a patient with an uncertain future. A terminally ill patient needs an honest disclosure, to pursue realistic hopes as well as reorganize his or her priorities and make adaptations in coping with the process (Siminoff, 2001). According to the American Nurses Association (2003), nurses have a duty to educate patients and families about end-of-life issues, to encourage the discussion of life preferences, to communicate relevant information for any decision, and to advocate for the patient. To achieve this, I’ll be initiating optimal interaction with a patient. Pierce (1999) specifically states that a nurse fulfills three critical communication tasks in end-of-life care: (a) they create an environment conducive to communication, (b) they ease the interaction between physician and patient, and (3) they facilitate interaction between family and patient.
Communicating advanced directives and organ donation
Dealing with the administration of advance directives has a possibility of causing a conflict between the advanced instructions and the contemporaneous patient and family interests. Practically, the judicial resolution is seldom used to solve such cases. It, therefore, means that it is the responsibility of the nurse to interpret an advanced directive to accord with the contemporaneous interest of the patient. In other words, as the nurse in charge, I am legitimately allowed to examine whether the issuer of the directive really contemplated and intended to encompass the situation confronted at present. When the assessment reveals that implementing such a directive will obviously cause harm to the incapacitated patient, it is necessary that such a directive be given a second thought or ignored completely to allow for an action that complies with the present situation. According to Cantor (1993), even if the advanced directive is misinterpreted by the nurse or implementers, it is common that decisions to favor the perceptible, contemporaneous interests of a now incompetent patient will seldom be challenged or overturned- Medical staff, surrounding family, and courts are likely to acquiesce in decisions to maintain an ostensibly happy patient or allow a severely anguished patient to die, regardless of the apparent intention of the directive (Cantor, 1993, p.112).
However, commentators have varied responses as concerns this controversial issue. A few have argued that prior directives must prevail, no matter the outcome. But Professor Dresser cited in Cantor (1993), argues that an advanced directive should not be followed if the incompetent patient has any significant interest in the continued life-meaning a capacity to interact with the environment (p. 113). Cantor (1993) agrees that in some situations where a directive calls for withholding life-preserving medical intervention from an apparently content, though demented patient, it should not precede other decisions to continue preserving such a life. In such a scenario, the nurse should discuss the issue with the family and the decision reached should precede all the previous directives (Cantor, 1993).
Passing information that will involve advanced action on the patient such as organ transplant and a donation can be complex because information alone is never sufficient (Pierce, 1999). For instance, it would involve getting informed consent from the family members (Siminoff, 2001, p. 72). One study established that in the United States, about 25% of family members are not in favor of donation (Siminoff et al., 2001, p. 74). In this case, information must be given the inappropriate context of educational, developmental level (patient’s age), stress level, and time constraints (Siminoff, 2001). Pierce (1999) says the process should start with the nurse listening to the patient’s concerns without interrupting, explaining the technical medical terms involved, conveying empathy through acknowledgment of the family and patient’s concerns, and offering encouragement to the patient to continue expressing the concerns.
Provision of a humane and healing environment
A conducive environment for end-of-life care is that which has a humane nature. According to Coyle & Sculco (2003), an effective environment is essential and should take place in a comfortable, private area and not at the patient’s bedside (p.206). It’s my duty to ensure the environment is comprised of people who have been accepted by the family members. Then the focus would be on the patient, where he or she will disclose the people to be entrusted with the medical information.
Many have agreed that even though having a well-designed physical facility fit for healing is important for end-of-life care, the programs designed for the period of care are equally important. Flesner & Rantz (2004) say that the cornerstone of any long-term care facility is its activities program, which becomes the healing program. Such programs may entail artwork and theatre performances such as dancing, singing, playing a musical instrument, storytelling, and other visual arts like painting and knitting (Flesner & Rantz, 2004). Coyle & Sculco (2003) further notes that such programs can be made successful through a partnership between staff members with such talents and the family members.
Ethical issues related to end-of-life situation
Sensitivity to cultural, religious, spiritual, racial, gender, and language are ethically critical in the communication process. According to Pierce (1999), not only is it important to appreciate verbal cues, but also nonverbal cues (p.12). Common knowledge informs us that communication varies in different cultures. In such a case, it’ll be ethically right to focus communication towards beneficence. Any form of disclosure must be viewed in the context of the patient and the family, with an understanding of and respect for their values and beliefs (Pierce, 1999).
It thus follows that good care provision for a dying patient needs a lot of background knowledge of the patient’s ethical issues related to end-of-life or death (Cavalieri, 2001). This is to ensure that the patient’s autonomy is observed despite all the drawbacks such inability to make a decision or talk. Some of the issues that are likely to emerge are the use of artificial nutrition in a case where the patient’s ethical belief does not allow such intervention, a request for nurse-assisted suicide, and a patient’s demand for particular traditional methods of treatment to be carried out in conjunction with the contemporary medicine (Cavalieri, 2001). According to Cavalieri (2001), the nurse should be ready to incorporate spiritual issues in such scenarios to maintain his or her integrity as a moral agent.
The interdisciplinary team for care
It’s my role as the nurse in charge to coordinate the whole team and be the link between the team and the family members. Other members of the team would include physicians, social workers, and other clinicians. This diverse group requires proper coordination to effectively support the patient and the family. Scheduling a meeting between the team and the patient and his or her family is important in that it helps in information sharing (Pierce, 1999). Such information includes medical facts, prognosis, treatment options, and source of support and guidance (Pierce, 1999, p.13). Such meetings promote collaborative care by allowing the team to review the information in order to provide a unified and consistent message to the patient and family. I’ll ensure proper scheduling to allow the patient and the family to prepare emotionally and psychologically (Pierce, 1999). But the first important thing is to assess the patient’s physical, emotional, and psychological concerns so as to help the team plan the points for discussion during the meeting (Coyle & Sculco, 2003).
Other healthcare issues
Other than the issues highlighted above, the timing of the communication is critically important. The following ‘urgent’ issues as defined by Quill, cited in Coyle & Sculco (2003) will initiate immediate communication: (1) the patient is facing imminent death; (2) the patient is talking about wanting to die; (3) the patient or family is enquiring about hospice; (4) the patient has recently been hospitalized for severe progressive illness; and (5) the patient is experiencing severe suffering and poor prognosis (p.209). Coyle & Sculco (2003) thus note that end-of-life communication is more ‘routine’ circumstances; when stability or recovery is predicted, it normalizes the discussion of advanced care planning. To ensure effective communication, I will have to be sensitive, simple, straightforward, and understanding in terms of language.
Reference List
American Nurses Association. (2003). Position Statement on Nursing Care and Do-Not Resuscitate (DNR) Decisions. Washington, DC: ANA.
Cantor, N. (1993). Advanced Directives and the Pursuit of Death with Dignity. Indiana: Indiana University Press.
Cavalieri, T. (2001). Ethical issues at the end of life. JAOA. Vol 101, No.10. 616-624.
Coyle, N. & Sculco L. (2003). Communication and patient/ physician relationship: Phenomenological inquiry. J Support Oncol., 1:206-215.
Flesner, M., & Rantz M. (2004). Mutual empowerment and respect: Effect on nursing home quality of care. Journal of Nursing Care Quality, 19:193-6.
Pierce, S. F. (1999). Improving end-of-life care: Gathering questions from family members. Nurs. Forum, 34:5-14.
Siminoff, L. A. (2001). Gordon N, Hewlett J, Arnold RM. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA, 286:71-7.