End of Life Care free essay sample

It was recognised by Jevon (2009) that caring for the dying patient can be the most fulfilling whilst also most challenging times for nurses and healthcare professionals. This paper will introduce a case study based on personal experience within clinical placement, exploring and analysing the above statement. In accordance with the Nursing and Midwifery Council Guidelines (2008) names have been changed to protect patient confidentiality. The paper will seek to address issues relating to the case study examining relevant theory. Current policies and guidelines will be considered in relation to the patient. It will identify a framework involved looking at literature to assess the effectiveness against the case study. Finally, focusing on a specific area of care, which in this case will be communication, the paper will evaluate the care given within the case study before providing a conclusion. Mrs Jones, a 65 year old lady diagnosed with lung cancer in July 2010, lived with her husband of 29 years. They had two grown up daughters that lived close by their home. When Mrs Jones first received the diagnosis by her consultant her family were present. After discussions it was decided that the best care option for them was to care for Mrs Jones within their home. More investigative tests revealed that the cancer had spread; with this her condition seemed to deteriorate. Although appreciative of the support they were receiving within their home, Mr Jones and his daughters were finding it difficult to control Mrs Jones symptoms and pain management. Following a family discussion enquiries were made regarding the possibility of hospice care. Hospice care has been described as providing humane and compassionate care for people in the last phase of incurable disease (American Cancer Society, 2013). Within two weeks Mrs Jones was admitted into their local hospice. Symptom and pain management issues were addressed and Mrs Jones seemed relaxed and free from pain and discomfort. Mr Jones and her daughters visited frequently, towards her final days they decided to reside in the family room within the hospice. When it was no longer possible for Mrs Jones to consume food or liquids a decision was reached by the multi-disciplinary network within the hospice to commence the Liverpool Care Pathway. The hospice staff took the time to sit with the family and explain how the pathway works allowing time for any questions or objections. Within 48 hours Mrs Jones died surrounded by her family. ‘We cannot take away the whole hard thing that is happening, but we can help to ring the burden to manageable proportions’ (Cicely Saunders, as cited inEllershaw amp; Wilkinson, 2003) this was a comment made during a seminar in 1962 and is thought to be an early attempt at challenging the way in which health professionals approach end of life care. End of life care has been defined by the National Council for Palliative Care (2006) as helping ‘†¦all those with advanced, progressive or incurable illness to live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support. ’ Dame Cicely Saunders, founder of St Christopher Hospice in 1967 paved the way and had a major impact on changing people’s attitude and thinking regarding end of life care. Primarily a small sample of only four patients was chosen to experiment with drug dosages. This was to assess the impact of regular and consistent administration of medications. The results of this study indicated an improvement in quality of life. Consequently, since the work of Dame Cicely, end of life care has advanced, further studies undertaken by Professor John Hinton established a link between physical and mental distress of patients at end of life care. Professor Ann Cartwright was responsible for a large-scale epidemiological study through surveys to a random sample of patients and families in end of life care. This was a comparative study between 785 subjects in 1969 and 639 subjects in 1987. Results revealed an increase in the amount of people living longer with prolonged illness, greater awareness of death and dying alone within acute hospital settings. However, it did highlight an improvement in home help although, fewer visits where occurring (Cartwright, 1991). Referring back to Mrs Jones, the latter of the findings was evident. Although Mr Jones was appreciative for support being received within the home and community environment, he was having difficulties controlling his wife’s symptoms and pain management between health professionals visits. An implication of this is the possibility that Mrs Jones preferred place of care was compromised resulting in re-evaluation of the family’s situation, therefore, potentially meaning that Mrs Jones wishes were not met. It is from studies such as the ones stated above that progression in end of life care has evolved with the introduction of palliative care nurses such as Macmillan nurses and an increased number of hospice’s being provided worldwide. The main focus at end of life care was predominantly based on cancer patients. Initiatives such as the Comprehensive Cancer Care Programme was initiated in 1980 focusing on areas including prevention of illness, early detection, treatment and pain relief and palliative care. This programme was introduced by the World Health Organisation it is reported by Twycross (2007-2008) as prompting other associations and initiatives at global and national levels. However, after extensive work and research it was only in 2008 that a strategy was devised by the Department of Health, which aims to promote high quality care for patients receiving end of life care by giving patients the option to choose where they would like to receive end of life care (Department of Health, 2008). Nevertheless, one question that needs to be asked, is whether enough has been applied to healthcare services and nursing to manage and support patients and families in end of life care? The modern hospice movement was mainly devised from a Christian tradition, hospices are now well established within end of life care. Hospices began by being mainly focused on cancer patients altough better knowledge and understanding of other incurable desease has seen an increase in patients admitted with other conditions. An end of life care programme was formulated, consisting of six steps, within the end of life care strategy. It was recognised by the Department of Health (2008) that care pathways are useful tools within health care. Care pathways have been defined as anticipated care placed in an appropriate time frame, written and agreed by a multi-disciplinary team (Davis, 2005) it is believed that care pathways determine multi-disciplinary working by using evidence and guidelines for certain patient groups (Overill, 1998) however Kinsman, Rotter amp; Snow (2001) state that a definition is unclear and no agreement has been made. Considering the six steps of the end of life care pathway the paper will examine Mrs Jones situation. The pathway begins with discussions regarding diagnosis and recognising a patient needing end of life care support. Fallowfield, Jenkins amp; Beveridge (2002) suggest that health professionals try to protect themselves from breaking bad news to patients. This was not evident with Mrs Jones as her consultant was honest and informative when breaking the news of her diagnosis. Although, it still highlights the importance of communication, especially in the initial diagnosis as the patient deserves to have clear and factual knowledge about their prognosis. It was recognised by Watts (2009) that communictaion is a key component in end of life care, specifically in regards to psychosocial and spirtual care. Inadequate communication could prove detrimental to the care plans developed at a later stage. Step two relates to the assessment, care planning and review of care. This is where advance care planning is introduced to the patient and family. An advanced care plan allows the patient to express their wishes on care and treatment options, which can be recorded by health professionals and used when mental capacity is lost. It is believed that advanced care planning is a thoughtful process which allows for patient values and beliefs to be considered within their end of life care pathway (Schaffer, 2009). Mrs Jones discussed an advanced care plan and whilst it did not affect the outcome or care received the implications had this not have discussed could have been distressing for the family. Lynn, Schuster, amp; Wilkinson (2007) believe that without an advanced care plan a crisis situation could occur, causing conflict between family and health professionals. There could be many reasons why patient’s decline discussions on advanced care planning one of which being that they do not understand. When an advanced care plan has been recorded within patient records and transferred between health organisations coordination of care can be acheived. As the third step in the end of life care programme it ensures that patient preferences are being adhered to. The important component within this step is communication and multidisciplinary and mulitiagency working. Delivery of high quality care is covered by step four in the end of life care programme, referring back to Mrs Jones it could be argued that when being cared for within her own home high quality care was not being delivered consistently as her symptoms and pain management were not controlled adequately. A study conducted by OBrien (2010)found that poor discharge planning, co-ordination, difficulty in establishing additional quipment along with inadequate out of hours services resulted in patients care preferences not being adhered to. As was the case for Mrs Jones who was admitted into her local hospice. It is stated in the end of life programme that the same high quality of care should be received regardless of which setting. Within the hospice Mrs Jones needs were met upon arrival with analgesia which as Dame Cicely’s study revealed made an impact on a patient’s q uality of life in end of care provisions. It was recognised when Mrs Jones entered into the final phase of life, at which time the hospice staff spoke to Mr Jones and his daughters to explain about the Liverpool Care Pathway. The Liverpool Care Pathway was devised as a nurse led document to empower and provide a clear action plan when caring for patients during their final phase of life. Although the Liverpool Care Pathway is still relatively new to the National Health service, there has been much controversy due to bad media coverage. Devlin (2009) reported that a group of experts claimed patients were being wrongly judged as close to death. What media fails to report are cases where patients benefit from hospice levels of care ensuring that the patient is comfortable, without pain and having the ability to nurses to administer medications as soon as they are required without delays whilst waiting for medical staff. Once the pathway had been explained to Mrs Jones family and they was happy to proceed with the pathway it was commenced. The final step in the end of life care programme considers care after death. Last offices are performed after death when procedures are followed to prepare for transferal of the body to a chapel of rest, mortuary or undertakers (Jevon, 2009). It is important to consider the families religious and cultural beliefs when undertaking this final step as this stage focuses upon showing respect for the deceased whilst fullfilling requirements (Dougherty amp; Lister, 2004). Mrs Jones did not express any cultural or religious considerations and so a standard last offices was performed. Following last offices Mr Jones and his daughters viewed Mrs Jones body to pay their last respects and say their goodbyes. Altschuler (2004) recognises that end of life care and medical diagnosis sometimes leads to changes not only for the individual but also for the amily. Within this section of the paper, considering Mrs Jones and her family, support through end of life care will be explored. Before beginning it is important to respect that not all families function in the same way. A study by Campbell (1996) found that effective support by palliative care teams revealed more satisfied families of patients in end of life care. Hudson, Quinn, OHanl on, amp; Aranda (2008) state that communication between family, patient and health care professionals is paramount in end of life care and also integral to understanding and providing support which is required. Regarding Mrs Jones, at her initial diagnosis it can be said that individually she was well supported, surrounded by her family. Payne, Seymour, amp; Ingleton (2008) state that evidence shows most people do not require additional support as they are resilient and able to adapt to changes with the support of their own networks. It is important not to forget the people that may not have the same support networks in the community. Assumptions regarding support could be detrimental to the overall outcome of the end of life care received and also the aftermath with the family in the bereavement process. When examining literature some contridictory information was found regarding pre-bereavement support for families, whilst Field, Payne, Relf, amp; Reid (2007) found that families benefitted from such services Grande, Farquhar, Barclay, amp; Todd (2004) study indicated less helpful or beneficial results. These could be explained by the difference in expectations, services available and communication techniques. Considering Mrs Jones case study her family accessed support through the staff and services within the hospice. Also before admission into the hospice they were receiving support from MacMillan nurses and other community organisations. The hospice which Mrs Jones was admitted offerred her family bereavement support which includes councellors, and volunteers and the service is available on a self referral after the death of a relative also. Mr Jones declined this service although they did enquire about the rememberance evening held within the hospice. Rememberance evening are described as being mainly non-religious, although, there is a religious section added on for people who require it. Names of recently deceased patients are read aloud with lighting of candles, music, various readings and a chance to share experiences with others who are undergoing the same process of change as yourself(Wigan amp; Leigh Hospice, 2011). From the initial diagnosis Mrs Jones family seemed to support each other through acceptance and grief and therefore felt that it was unnecessary to use the bereavement service. It is evident from writing this paper that end of life care has evolved rapidly and seems to be of major interest at national levels. This will hopefully continue ensuring that better services can be provided in areas such as the community to ensure people like Mrs Jones can be cared for at home receiving the exact levels of treatment as would a patient within a hospice. Until this time advanced care plans can never fully be adhered to as revisions are often required for patients such as Mrs Jones, when symptom and pain management cannot be covered consistently. However it was also shown how hospice care is providing patients and their families with high standards and quality care, through physical and holistic approaches to care. Communication has been highlighted as a key component within end of life care. Overall Mrs Jones received good communication and with this the support systems were accessed as and when required by the family. It is also wise to note that good communication was received by the family regarding the Liverpool Care Pathway. This paper began with a statement by Jevon (2009) in which it was regarded that caring for somebody in their final phase of life can be the most challengin yet most rewarding experience. Further research would help to advance end of life care, making it even more widespread. Upon reflection the care which Mrs Jones received in the community could have been better although that is due to poor co-ordination such as out of hours services. The hospice still seems to provide better levels of care when comparing how Mrs Jones felt in the community compared with how she was in the hospice. Further work needs to be done in order to gather a true reflection on the difference in levels of care between settings. 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