Role of a Palliative Care Nurse

Role of a Palliative Care Nurse Palliative Care The role of the expert palliative care nurse is complex and unique. The nurse functions as an integral part of a Multidisciplinary team, providing expert skilled assessment and nursing care, supporting the patient and the family to make informed choices thereby encouraging the patient to continue to make autonomous decisions about their care towards the end of their life. However, often the nurse will find herself dealing with difficult family dynamics with family members having differing expectations of the type of care that the patient should be receiving, staff conflict over treatment methods or strategies and high workloads. These issues can only compound the stresses on the Palliative Care Nurse and to cope with the many dilemmas she must be well armed. The complex needs of the terminally ill patients and their families make the multidisciplinary team approach the most effective method of care Staff from a range of disciplines including medical, nursing, social work, dietitian, physiotherapist, pharmacist and others bring diverse and unique skills. As a team they provide an excellent sounding board for ethical dilemmas thereby hopefully- enhancing ethical practice. (Latimer, 1998) The Nurse in her role is required to act as patient advocate and ensure that the patients rights are respected. Unfortunately this advocacy is sometimes perceived negatively as a threat or implied criticism of medical care. Doctors need to listen to the nurses more accurate perspective of patient concerns. Consistency across the team leads to better outcomes for patients. Reinforcing the same information by both medical and nursing staff help to allay patient anxiety far more than conflicting views on such things as symptom control. (Jeffrey, 1995) The members of the Multidisciplinary team sometimes make decisions regarding treatments, which they may perceive to be of the most benefit to the patient whilst in fact the patient, does not perceive the benefits in quite the same way. Nurses have more prolonged contact with the patient than most other members of the team due to the hands on patient care that they do. They often establish a close rapport with the patient and the family and are most likely to be aware of the patients likes, dislikes, hopes and dreams and are privy to often delicate and very private details of the patients life. The very fact that the nurse spends so much time with the patient makes them more likely to have knowledge of this kind of information. Doctors rounds in a Palliative Care Unit enable the doctor to spend perhaps 30minutes maximum per day in talking to the patient. In the community, appointments times with Doctors are restrictive and Home Visits limited. Patient Nurse dependency ratios in hospit als and palliative care units mean that Nurses are spending approximately four hours per day on one to one patient contact. Again, other team members are very limited in the amount of time they spend with patients due to the number of clients/patients they may have. A dietitian for example may spend 15 minutes with a patient twice during their six-week stay in a Palliative Care Unit or 30 minutes as an outpatient during the course of the Terminal illness. Social workers often spend long periods at a time with patients and/or their families in lengthy discussion however these discussions may only take place a couple of times over the period of the illness. Therefore the Nurse is far more likely to be aware of issues affecting patient care. There can be many difficulties for the Nurse expert providing high quality care to palliative patients whilst respecting their right to autonomy in the setting of the Palliative Care Unit, the role of the Nurse is to painstakingly assess the needs of patient and family. These needs may be constantly changing and there is no room for the Palliative Care Nurse to become complacent in her patient care. Symptoms may be physical such as pain, nausea, and dyspnoea or psychosocial or spiritual. In identifying care needs the nurse must be able to determine who is the most appropriate team member to refer to provide optimum management of these needs. E.g. although the expert nurse will have counselling skills, she must be aware of her limitations and refer on where appropriate to counsellors, psychologist or social worker. Mount (1993) suggests that we must first attend to physical needs and that to do this we need a detailed knowledge of therapeutics. Skilled listening and attention to detai l are paramount in Palliative Care. Our listening skills not only apply to what the patient is saying, but what they may be leaving unsaid. Nonverbal cues such as facial expressions and demeanour, the need to keep the door to their room open at all times or to constantly keeps the curtains drawn. In order for patients to make choices they need to be accurately and appropriately informed, yet Vachon (1993) suggests that whilst caregivers sometimes decide not to tell patient and family what is likely to happen, at other times they may give too much negative information not allowing the patient and family to have any hope. Patients need to know at what stage their disease is and their prognosis in order to choose where to spend their remaining time. The ethical communication of information should be timely and desired by the patient, accurate and given in words understandable to the patient and family and conveyed in a gentle, respectful and compassionate manner. (Latimer, 1998) An example of such communication would be that when asked by my patient (speaking about his fungating tumour) When will this thing on my neck stop leaking? I need to gently but truthfully explain that it will most likely continue to leak blood and fluid until he dies but also that we will continue to con tain the fluid and minimise the discomfort and attempt to disguise the drainage appliance as best we can. To not advise him of the eventuality of the fluid discharge continuing is to encourage him to have false hope and expectations and further disappointment when the discharge continues and probably worsens. However, the nurse needs to recognise that some patients do not wish to have information relayed to them e.g. a patient who did not want to talk about her illness future and continued to deny that her disease was terminal. Dont tell me that, I dont want you to say those words! Yet respect for patient autonomy demands that patients be given honest answers to their questions. Without this, patients become more uncertain and unable to make decisions about their future. Dying patients are by virtue of their physical and emotional situation, frail and vulnerable their treatment and management during this final phase of their life must be of a high standard both professionally and ethically. The Nurse and other members of the team should seek to do the best for the patient and their family. This includes respecting autonomy, through the provision of truthful information and helping them to set realistic goals while providing genuine attentive care during the full course of the illness. Provision of symptom control hinges on accurate assessment. McCafferty and Beebe (1989) suggest that we dont always make assessment easy by the fact that sometimes we dont readily believe what the patient tells us or the patient may deny having pain or refuse pain relief although they may be hurting. The expert Nurse should remember that the person with the pain is the authority- they are the one who is living the experience and we must believe them if they tell us they have pain. It is all too easy to allow ones own values and beliefs to cloud our judgement Unfortunately I have seen it happen where a nurse usually not experienced in Palliative nursing will make a statement such as He says he has pain rated 8 out of 10 but he doesnt look distressed or She was laughing and talking with her visitors 5 minutes ago and now shes buzzing for pain relief. Such comments display the Nurses ignorance and lack of understanding of pain. It seems apparent that they do not understand about adapta tion or distraction or that laughter stimulates the relaxation response throughout the body systems by lowering blood pressure, deepening breathing and releasing endorphins. Also of great importance is the need for the nurse to explore further if a patient denies pain despite indications that they are in fact suffering pain. There may various reasons for denial for example; sometimes our language when asking questions about the patients pain may be inappropriate. Some patients may not consider a dull constant ache as pain but an ache. Others may feel sore. Other words such as discomfort and pressure may be used instead of Pain We as nurses need to avoid misinterpretation by using such other words. The Nurse needs to explore the issue of pain and help to identify the source. Location. Intensity, and Quality of the pain help to identify the source. Eg. Bone, visceral or nerve pain. Identifying the source aids in determining the appropriate treatment method. The expert Nurse will be aware that nerve pain will not respond as well to opiates and that neuroleptic agents need to employed. As suggested earlier, as Nurses spend the most time with the patients they are able to obtain the most information on the patients response to pain management plans, they are able to educate patients on the need to take regular analgaesia; and they can be the most influential in management of pain (Lindley, Dalton and Fields, 1990). Of course we as nurses in Palliative Care need to be aware that not all pain will respond well to traditional or orthodox treatments. Seeing a patient in pain and trying all pharmacological methods without success is distressing for staff as well as the patient and it is then that nurses should further attempt to employ other methods such as relaxation, distraction and music. Studies have shown that that listening to music disrupts the chronic pain cycle. Laughter, Massage and relaxation therapies have also been shown to interrupt this chronic pain cycle (Owens Ehrenreich, 1991) and massaging a dying patients back or feet with oil blends incorporating lavender instils in many cases a feeling of peace, contentment and lessening of pain. Heat and cold packs are also said to be beneficial in the treatment of chronic pain however heat applications are said to be contraindicated in patients with poor vascular supply and in malignancy. Most institutions have policies related to the use of thermal applications. As most nurses working with palliative patients will know, bowel management is of MAJOR importance! The Narcotics we administer to alleviate the symptom of pain have the side effect of causing the symptom of constipation. Vigilant monitoring of a patients bowel status is essential but it is of great importance that patients are not quizzed about their bowel actions in front of visitors or during meal times. Privately and quietly please! Cameron (1992) describes the types of constipation, these being primary and secondary due to pathology or iatrogenic. The goal of bowel management should be the prevention of constipation rather than treatment of constipation and appropriate assessment, regular administration of aperients, appropriate diet and fluids and provision of conditions favourable to bowel evacuation should all be part of the nurses management plan and patient education is paramount here for without the knowledge that opioids will contribute to constipation but that regular ap erients will counteract this symptom, the patient is unable to make informed choices about his symptom control. Nausea and vomiting are other symptoms the nurse can provide valuable assistance in controlling again through adequate assessment and intervention. The nurse needs to be aware of possible causes of nausea and vomiting such as hypercalcaemia, disseminated carcinoma, renal failure and vestibular stimulation particularly in patients with primary brain tumours or secondary cancer deposits. Constipation and radiotherapy, urinary tract infection and chemotherapy- the causes are many and varied. Hogan (1990) suggests that an understanding of the various pharmacological and non-pharmacological interventions is the foundation of symptom control but that the nurses commitment to alleviate the symptoms is the most important variable. Simple techniques like minimising cooking smells, presenting small meals and ensuring offensive odours such as foul linen bags from the vicinity can all be employed in conjunction with pharmacological methods to minimise nausea and vomiting. Successful management r equires an understanding of the cause of the symptoms. Other symptoms that may prove troublesome for the terminally ill patient include oral thrush and stomatitis, diarrhoea, lethargy and insomnia. Dyspnoea can be the cause of great distress and the expert nurse will be aware of the need to employ techniques to minimise discomfort. These may include reducing exertion by the patient, positioning them to allow maximum comfort when breathing and improving air circulation by use of fans or open windows. Humidification by methods such as nebulised saline may also be helpful. Pharmacological methods such as morphine either orally, subcutaneously or as a nebulised solution have also been found to decrease the perception of breathlessness (Chater, 1991) and anxiolitics such as Lorazepam s/l are quite helpful. Reassurance and providing a calm environment are also helpful techniques to employ. Distressed relatives around the bedside can further increase the patients respiratory distress and it is at such times that the nurse needs to take them asi de and explain to them what is happening and how they can help by remaining calm and distracting the patient or helping them to relax. For the terminally ill patient, being in control is vital and the nurse must appreciate that the patient though suffering an illness from which he will eventually die must be allowed to keep his self respect. This self respect can be eroded enough by the nature of the disease its symptoms and suffering, sorrow and emotional pain. There are times when we as nurses see patients admitted to hospital who have already had their autonomy undermined. Whilst it may have been their wish to stay at home longer or until the end, families may feel the burden of care is too great and that they can no longer cope. This is usually when a new symptom presents that the family feel unable to manage. Nurses in the community may sometimes be able to prevent this situation arising by offering a more frequent or higher level of care supported by a Palliative Care Service, education of the family about the patients symptoms and how to help manage them. Sometimes admission is not what the patient wishes but the service is unable to provide appropriate management in the home. There is then an onus upon those providing the care to look at all options to enable the patient to achieve his goal of returning home. To be autonomous means to have choice and control in our own lives yet we must accept that total autonomy is hardly ever possible. Sometimes there are circumstances in which it is not possible to challenge on the patients behalf- times when the patient may wish to have their autonomy eroded. There are times when the patient may not want our advocacy and times when we may not be able to give it- for example controversial ethical issues such as euthanasia. (Coyle, 1992). The nurse may sometimes develop feelings of helplessness and insecurity because of her unrealistic expectations of herself. The complex role we play in management of the terminally ill sometimes may lead the nurse to think she should be all things to all people the doctors handmaiden the patients advocate, the families sounding board. Sometimes nurses can become over involved, infringing on the autonomy of the patient and the family (Scanlon, 1989) and must be aware of when to withdraw. At times when caring for a patient with uncontrollable physical or emotional pain the nurse may feel herself to be a failure. Add to this the likelihood of inadequate resources and staffing, staff conflict and role conflict and there is a pretty good recipe for stress. Abraham and Shandley (1992) list five main sources of work stress. These being: 1. Work overload, 2. Difficulties relating to other staff, 3. Difficulties involved in nursing critically ill patients 4.concerns over patient treatment an d 5. Nursing patients who fail to improve. This again emphasises the fact that nurses specialising in palliative care are likely to suffer high levels of stress. CONCLUSION To help cope with these high demands and continue to maintain the delicate balance between what the patients want and what the health professionals think the patient needs, nurses need to arm themselves with expert knowledge of symptom control, and be well aware of ethical issues related to palliative care. Nurses also need to maintain open active communication with their peers and other members of the facility. We must also realize that even if we do not influence a situation or supply an answer to all needs and if our patients do not maintain total autonomy, it is enough that we have been with them, supporting them as best we can in their journey to the end of their life. Bibliography:

SHIP OF THE HUNTED: A BLEND OF FACT AND FICTION :: essays research papers

Historical fiction is a type of genre that helps paint a more captivating and colourful picture of the past. It combines fact and fiction as it presents mostly fabricated characters set in a definite period of history. Ship of the Hunted, by Yehuda Elberg, defines this genre as it entwines the lives of a fictional family with historical facts and elements such as life in the Warsaw ghetto, hiding to survive, and the Brichah movement of Jews out of Poland. History has recorded that over half a million Jews were crowded into the Warsaw ghetto between October and November of 1940. The squalor, starvation, disease, exposure to cold, and the daily shootings claimed the lives of about 5, 000 to 6, 000 Jews each month. In Ship of the Hunted, the Heshl family struggles to survive this trend. Like so many others living in the ghetto, Golda and her son, Yossel, scavenge the blocks, looking for any items that can be smuggled out of the ghetto in exchange for food. After his father and older sister are deported, Yossel is confronted by Golda, who wants him to stop smuggling. â€Å" ‘This stuff buys food. We have to eat, Mama.’ ‘Yossel, you’re still a child. You know they shoot children for scavenging!’ ‘They shoot mothers for scavenging, too.’ ’’ (Elberg, 17) This conversation demonstrates the desperate measures taken by the Jews to obtain food. The raids in the ghetto also caused their numbers to dwindle. Daily, thousands of Jews were removed from the ghetto and transported to concentration camps. After surviving one such raid by hiding in a bunker, Golda surfaces to find out about another raid on a hospital. â€Å"Liquidated, floor by floor. On foot and by stretcher, they had been sent off – a man with an incision still open; an infant, newly born.† (Elberg, 23) These raids led to deportations, which eventually led to extermination. News spread, and those who refused to be led away to death took part in what would be one of the greatest periods in Jewish history. The Warsaw ghetto uprising began on April 19th of 1943, as the surviving inhabitants of the ghetto resisted the German troops and police who had come to deport them. This battle held out for 20 days till the Germans finally overpowered the lightly armed Jews. In t he novel, Golda is a witness to the uprising and its end.

Veterans

Also, currently not enough care is given to veterans. Veterans have devoted their lives to this country and have made many sacrifices. There are approximately 21. illion veterans In the U. S. as of 2012. Of those veterans over 32,000 soldiers were wounded in Iraq. Also 4,787 U. S. troops died in Iraq serving their country. This service is not as appreciated as you would think, and I believe more effort should be put into taking care for all our veterans. The New Affordable Care Act makes it very difficult for veterans to receive reliable medical benefits and some even do more for our country. Many veterans still contribute to the nation's work force, even after returning home from war. Over half of the veterans In the U. S. are still able to work after returning rom war.Many veterans suffer from post-traumatic stress disorder (PTSD) and are not given the proper attention and care to get back on their feet and find a job. 1 OF2 stu01es snow tnat 4 cases 0T PISD were present arter tne Vletnam war, ana 1 million lifetime cases as a result of the same war. A third of the veterans in the U. S. are out of a Job due to the symptoms of PTSD. The VA needs to take it upon themselves to help veterans cope with life after the war, so that they can get their life back on track. After returning home from war veterans find it very difficult to get a Job and provide or themselves.Especially the individuals who were wounded, while defending their country. A majority of these people are wounded mentally as well as physically, and they cannot provide for themselves anymore. Many people believe that veterans are more of a pain than anything else. Since their tax dollars are being used to fund programs like the VA. These organizations are making it very difficult for veterans to receive any health benefits. The new rule is that veterans must be active duty for 24 continuous months in order to be eligible for any kind of medical coverage.Veterans hat have put their lives on the line to defend their country should not have to worry about how they are going to provide for themselves. It is my firm belief that the VA should extend their support for all veterans for everything they have done for our country. This service should be provided to veterans forever. Veterans have done more than enough to deserve this care, and they can still contribute to the labor force. Finally, not enough care is given to our veterans. Between 130,000 and 200,000 veterans are homeless in America. This represents between one fourth and one fifth of all of the homeless people in the country.

The Flaws of the Socratic Method - 1798 Words

The Flaws of the Socratic Method In Plato’s Republic, as well as in most of his other works, the philosopher writes dialogues between the character of his mentor, Socrates, and various figures meant to illustrate contradictory positions. He carefully scripts the engagements in a form of discussion now called the Socratic Method, where Socrates critiques the positions of the other characters in order to find flaws in inaccurate arguments. Although this method is prevalent even today, I will make the case that even when Plato himself is using it, the Socratic Method, while not without benefits, is an extremely flawed way of conducting educational discourse. The Socratic Method is a dialectic method of argument, meaning that the†¦show more content†¦The very nature of the Socratic Method makes for long and winding discussions, because the Method aims to strip away any falsehoods but provides few tools for building towards the truths for which it aims. Without a way to cull the ideas presented by the students, a professor must engage each of them as comprehensively as the next regardless of their accuracy, or else compromise the integrity of the dialogue. If he or she instead opts to inseminate information in a more traditional education style, each lecture and discussion can be tailored to divulge a specific concept and a specific and relevant set of arguments and objections can be presented and rejected, rather than struggling through a freeform conversation with inconsistent results varying from classroom to classroom (Ford 3) (Chen and Taylor). Additionally, the constant refutation of students necessitated by a teacher engaging them in a Socratic Dialectic has a questionable impact on the academic outlook of students. Christopher Ford describes the modern usage of the Socratic Method as psychologically abusive, saying that the public questioning is terrifying and that the style is both ‘invasive in that student’s knowledge/intelligence is publically examined, and evasive in that the professor ‘hides the ball’ from the students.† This practice of systematically and ruthlessly deconstructing any and all flaws in a student’s argument can be extremely humiliating and can triggerShow MoreRelatedImmanuel Kant : A Worthwhile Life In Platos Five Dialogues1632 Words   |  7 PagesPlato’s Five Dialogues, provides a method for examination, it is not very clear what is always right or wrong. Immanuel Kant through his work, Groundwork of the Metaphysics of Morals, expands on how to though tfully examine one’s decisions and decide if they have a moral foundation or not. 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