NRSG635 Extended Clinical Nursing Unit Outline

Palliative care is an approach that is comfort-focused in nature especially for the life-threatening and the life-limiting illness. The goal of palliative care is to provide an overreaching goal and to maximise the quality of life of the clients (Bowen, Mansfield & King, (2014). Making of decisions in healthcare is quite a demanding task especially regarding the palliative care. The ethical decision making model consists of the following six steps that involves proper identification of the ethical problem, additional information collection in order to identify the problems and also to establish solutions and the development of analysis using other alternatives in order to carry out the comparison and the analysis (Cabañero-Martinez et al., 2016). Along with it the model involves selection of the best possible alternatives along with justification, steps taken to develop the various practical ways so that the ethical decisions could be implemented along with the actions and finally it involves the evaluation of the effects in addition to strategy development in order to prevent a similar occurrence. This paper thus highlights the importance of the ethical decision making model formulated by Park in terms of providing care to the individuals requiring palliative care. This is done through the process of self-evaluation and self-determination involving the clinical practicum.

In order to make good ethical choices, one of the most important ingredient is self-reflection. From my point of view I feel that this process of decision making consists of several combined factors that is related to the patient along with their family members as well as the professional and the professional individuals and team members. We often face several ethical dilemmas and several problems also arise related to the decisions that are related to place of care, several decisions. According to some reports it has been perceived that an ethical decision that is made might be assuming three pathways which consists of a dogmatic one which is a decision that is made in accordance to a certain principle or rule, it might be a dilemmatic one, in which deliberation is made by confronting two principles; a problematic way, determined by a set of possible worlds, which considers both the theoretical frame of ethical principles, values and attitudes and the specificity of each singular and particular situation as well (Bükki et al., 2014). When considered in terms of palliative care it is clear that ethical decisions which needs to be made by assuming and by the conduction through a problematic pathway. While practising, we most of the time face this problem due to the issue of end of life which are significantly complex and most of the time influenced by the complexities of life and by the philosophical view each person assumes.

Autonomy can be defined as the capacity for self-determination, which is also referred to as the ability of the person to make choices or decisions about their own life that is based on their values and beliefs regarding what is important. The primary notion of relational autonomy is able to draw the attention towards the embodied nature associated with the social interdependence of human beings. This reflects the embeddedness present in a family along with the language group, or a cultural context. In the context of application of the ethical decision making model, we should ensure that both our social interdependence and embodiment needs to be provided in the context of care and treatment of the patient that are made available and within our ability to choose amongst the ones that are facilitated and enabled (Cabañero-Martinez et al., 2016). This autonomy-centred perspective makes the health professionals more obliged to focus on the experiences of the person receiving care in addition to what matters most to them. It can also be made to tune in the way in which people are able to make sense or are able to make out meaning out of the world. Additionally it also enables us to help the person in order to express themselves in a better way and also to meet the person where they are in themselves and in their environment of care. Finally this enables and fosters relationships that are important to the person and to recognise the relationships as well as foster the person who are important (Druml et al., 2016).

While I was involved in caring of a patient Mrs. White who is a 78 year old lady. She has been inpatient on the ward for the last 10 days after she had been diagnosed with cerebral haemorrhage. Due to this, she had been aphasic which has left her weak on one side. After examination it was established that Mrs Wade has been suffering from a perforated bowel and after discussion with her family from the medical staff it was decided that Mrs Wade was for no further active care and was to remain in the wards single room for palliative care. However while caring for the patient I felt a little lack of confidence while carrying out proper communication with the patients and their families. This was a negative aspect of my care while caring for the palliative care patients where I felt the need of incorporating the ethical decision making. In accordance to Park’s ethical decision making process, it is quite important to incorporate communication which is an integral part of maintaining a high quality of record keeping which is regarded as a vital standard of practice by the NMC (Nursing and Midwifery Board of Australia [NMBA], (2015). In addition to communication, certain written records also help in establishing a continuity of care. It also calls for a holistic approach for the continuity of care while care is provided to the patents of palliative care therefore the role of the nurses become very crucial at this point. It is also very important to note that any information which is needed to be given to Mrs Wade and her family should be given in a very open additionally in a very honest manner. This was to ensure that they understand and give opportunity to ask questions. It was seen that Mrs Wade was a palliative care patient therefore the care also required to give rise to effective teamwork within the multi-disciplinary team. This was required in order to ensure that all the provisions that Mrs Wades needs were able to be met along with the needs of her families, so that is can be ensured to continue the care of whilst showing clinical excellence.

A significant part of the specialist palliative care nurses’ role is to form trust along with the building of therapeutic relationships with the clients as well as their families using proper and effective communication skills (Evans et al., 2014). As Nyatanga, (2013) states in one of the studies, it is been reported that one of the important skill in regards to the community palliative care nurse is to choose the accurate time in order to facilitate or to initiate the process of discussions that is surrounded by the death and dying. It is also stated that the nurses often work as part of a multidisciplinary team. This includes the pastoral carers along with the social workers and these individuals are able to further explore the client and their family’s wishes regarding the end of life, and which in turn can ensure the client and family who are needed to be cared for in a holistic manner. From the studies it can be stated that with the foundation of a trusting therapeutic relationship can be helping in enabling the client to disclose their wishes freely, which is able to facilitate autonomous decision-making for interventions which includes the interventions like APH at end-of-life (Gabriel & Tschanz, 2015). I had managed to develop a mutually trusting relationship with the patient.

According to WHO, palliative care is referred to a care that is involved in improving the quality of care and the life of the patients and their families who are facing any life- threatening illness. This can be done by preventing and helping the patients by relieving their sufferings through the process of early identification of pain along with impeccable assessment. It also involves treatment of pain and other problems which includes several physical along with psychosocial and spiritual (Nursing and Midwifery Board of Australia [NMBA], 2016). Therefore in order to take ethical decisions, while caring for the patient Mrs Wade, a holistic approach was taken into consideration where all the above mentioned factors like the physical, psychological, social, emotional and environmental needs are incorporated. When considering the needs it should be considered that only imperative to the patient but also I had to include all the near family members of Mrs Wade whom the patient has requested for.

According to (Taylor, 2015), it has been reported that the nurses should have a good communication skill. This statement was again stated by (Waldrop & Meeker, 2013), who mentioned in a study that communication is an integral part for the process of maintenance of a high quality of record keeping. This is also regarded as a vital standard of practice by the NMC. These documentation records and communication help in establishing a continuity of care. The process of communication also incorporates the capability of listening and supporting and ensuring the understanding. During the process of care giving an important aspect was working in the multidisciplinary team as this was required in palliative care. This aspect again made it clear that communication was an integral part of palliative care. Through this process, I gained confidence especially in terms of communication. This is felt especially with the family members as it was required of me to build up a rapport with the family and the patient which was both professional while being friendly as well as trusting (Raijmakers et al., 2013).

It needs to be ensures that Mrs Wade as well as any patient who are involved in receiving our care should receive care that is outlined by the priority of the people. It is very important that the patients involved in receiving palliative care needs to be made comfortable as well as pain free in order to be cared for in an environment that is safe and clean. Reflection from this incident has helped me to be aware of the level of involvement that is required with every member of staff starting from the health care assistants to the consultants who play a role in the care of patients. Therefore this was shown through various times I was involved in multi-disciplinary meets, re-assessment of care plans to ensure the highest standard of evidence based care was given to Mrs Wade (Peters & McDermott, 2014).

The outcome was positive in the aspect that a holistic approach to Mrs Wade’s care was taken in accordance with the model of ethical decision making related to the patient centred care. I had felt more empowered by the incorporation of the the use of the decision making model in effective collaboration with the multidisciplinary team that aided in clear communicating. This resulted in a consistent continuity of care for Mrs Wade. This at the end resulted in a positive outcome especially in the aspect that that a holistic approach to Mrs Wade’s care was provided in accordance to the model of ethical decision making of patient centred care. By incorporating this model I felt a sense of more empowerment and I made sure to follow the ethical decision making model. The process of providing care to a client who is in a phase of life that is the terminal stage, as with any other phase of their illness must focus on optimal comfort (Nyatanga, 2013). As seen from the situation it was seen that symptomatically Mrs Wade was not comfortable, given that she was undergoing stress and pain, which was unable to drink and likely mouth breathing; the need for thorough and regular care was required as part of providing comfort.

From this situation I was able to think in a more critical way before taking any decision as palliative care consists of very delicate events. Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection (Nyatanga, 2013). In nursing, thinking in a critical way is a significant component of professional accountability and quality nursing care. The critical thinkers involved in nursing are able to exhibit these habits of the mind which consist of contextual perspective, confidence, flexibility, creativity, inquisitiveness, intuition, open-mindedness, intellectual integrity, perseverance, and reflection (Peters & McDermott, 2014). The critical thinkers who are involved in nursing practice are involved in practising the cognitive skills of analysing, along with the application of standards. There is also discriminating, information seeking, and logical reasoning which is involved in predicting and transformation of knowledge.

When reflecting on my own experience of being involved in palliative care, I can put forward that this experience can help me in the transition of the nursing forms. Through this experience of implementing the values of the ethical decision making model I have gained more insights in the knowledge of palliative care, while I also understood the importance of good communication skills. This process of care also helped to highlight my knowledge and the importance of confidence of the knowledge which helped me to acknowledge the fact that I lacked some of the knowledge that was required to provide proper an efficient care. I was also able to admit the fact at some of time during my practise I failed to take proper and ethical decisions hence through this model I was able to seek guidance so that I could ensure the fact that I was following the correct protocol so that I was able to ensure patient safety as well as ensure continuity of care.

Thus it can be deduced that from consideration of the above situation that where the clinical decisions are made in a way that are relatively quiet as well as safe mood when considered at least from the point of view of the professionals while their scientific knowledge is considered.  Additionally the decisions are made in regards to their ethical problems or any dilemmas which might highlight a sense of insecurity especially in those who are implicated in the process of decision-making. Therefore, when the further developments are required to be taken, especially in the two main fields: research and education. It has been perceived that through research, certain questions which are relatable needs to be cleared and the involved ethical deliberation regarding the decisions which are related to end-of-life and palliative care will be understood in a better way. This in turn will contribute to the basis of the development in order to conduct ethical deliberation that is related to palliative associated with the end-of-life care in addition to playing a role in the improvement of education that is regarding the ethics in palliative care.

References

Bowen, P., Mansfield, A., & King, H. (2014). Using subcutaneous fluids in end of-life care. Nursing Times.net, 110(40), 12-14. Retrieved from https://search.proquest.com.ezproxy1.acu.edu.au/docview/156557690 ?accountid=8194

Bükki, J., Unterpaul, T., Nübling, G., Jox, R.J., & Lorenzl, S. (2014). Decision making at the end of life – cancer patients’ and their caregivers’ views on artificial nutrition and hydration. Support Care cancer, 22, 3287-3299. doi: 10.1007/s00520-014-2337-6

Cabañero-Martinez, M.J., Velasco-Álvarez, M.L., Ramos-Pichardo, J.D., Miralles, M.L.R., Valladares, M.P. & Cabrero-García, J. (2016). Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study. Palliative Medicine, 30(6), 549-557. doi: 10.1177/0269216315616763

Druml, C., Mallmer, P.E., Druml, W., Oehmichen, F., Shenkin, A., Singer, P.,… Bischoff, S.C. (2016). ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clinical Nutrition, 35, 545-556. https://dx.doi.org/10.1016/j.clnu.2016.02.006

Evans, N., Pasman, H.R., Deeg, D., & Onwuteaka-Philipsen, B. (2014). How do general end of-life treatment goals and values relate to specific preferences? A population based study. Palliative Medicine, 28(10), 1206-1212. doi: 10.1177/0269216314540017

Fritzson, A., Tavelin, B., & Axelsson, B. (2015). Association between parenteral fluids and symptoms in hospital end-of-life care: an observational study of 280 patients. BMJ Supportive and Palliative Care, 5, 160-169. doi: 10.1136/bmjspcare-2013-00051

Gabriel, M.S. & Tschanz, J.A. (2015). Artificial nutrition and hydration. In B.R. Ferrell, N.Coyle & J. Paice (Eds.), Oxford textbook of palliative nursing (4th ed.) (pp. 1-30). Oxford University Online. doi:10.1093/med/9780199332342.003.0013

Gent, M.J., Fradsham, S., Whyte, G.M., & Mayland, C.R. (2015). What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature. BMJ Supportive & Palliative Care, 5, 223-231. doi: 10.1136/bmjspcare2013-000562

Gillespie, L. & Raferty, A-M. (2014). Nutrition in palliative and end-of-life care. British Journal of Community Nursing, 19(Sup7), S15-S20. https://dx.doi.org/10.12968/bjcn.2014.19.Sup7.S15

Lynch, M.T. (2014). Palliative care at the end of life. Seminars in Oncology Nursing, 30(4), 269-279. https://dx.doi.org/10.1016/j.soncn.2014.08.009

Malia, C., & Bennett, M.I. (2013). What influences patients’ decisions on artificial hydration at the end of life? A Q-methodology study. Journal of Pain and Symptom Management, 42(2), 192-201. doi: 10.1016/j.jpainsymman.2010.11.022

McCabe, M.S., & Coyle, N. (2014). Ethical and legal issues in palliative care. Seminars in Oncology Nursing, 30(4), 287-295. https://dx.doi.org/10.1016/j.soncn.2014.08.011

Nakajima, N., Takahashi, Y., & Ishitani, K. (2014). The volume of hydration in terminally ill cancer patients with hydration-related symptoms: A prospective study. Journal of Palliative Medicine, 17(8), 1037-1041. doi: 10.1089/jpm.2013.0557

Nursing and Midwifery Board of Australia [NMBA]. (2015, 2). Code of ethics for nurses in Australia [Document]. Retrieved from www.nursingmidwiferyboard.gov.au

Nursing and Midwifery Board of Australia [NMBA]. (2016, 1). Renewal for registered nurses and midwives [Fact sheet]. Retrieved from www.nursingmidwiferyboard.gov.au

Nyatanga, B. (2013). Palliative care in the community using person-centred care. British Journal of Community Nursing, 18(11), p. 567. doi: https://dx.doi.org/10.12968/bjcn.2013.18.11.567

Peters, L., & McDermott, F. (2014). Surviving and thriving: the nurse-patient relationship in palliative care. In M. O’Connor, S. Lee, & S. Aranda (Eds.), Palliative care nursing – A guide to practice (3rd ed.) (pp. 31-41). Melbourne, Australia: Ausmed publications Pty Ltd.

Raijmakers, N.J.H., Clark, J.B., van Zuylen, L., Allan, S.G., & van der Heide, A. (2013). Bereaved relatives’ perspectives of the patient’s oral intake towards the end of life: A qualitative study. Palliative Medicine, 27(7), 665-672. doi:10.1177/0269216313477178

Taylor, H. (2015). Legal and ethical issues in end of life care: Implications for primary health care. Primary healh care, 25(5), 34-41. doi:https://dx.doi.org.ezproxy1.acu.edu.au/10.7748/phc.25.5.34.e1032

Van de Vathorst, S. (2014). Artificial nutrition at the end of life: Ethical issues. Best practice & Research Clinical Gastroenterology, 28, 247-253. https://dx.doi.org/10.1016/j.bpg.2014.02.005

Waldrop, D.P. & Meeker, M-A. (2013). Communication and advanced care planning in palliative and end-of-life care. Nursing Outlook, 60(6), 365-369. doi: https://dx.doi.org/10.1016/j.outlook.2012.08.012