End-of-Life Care

Questions:

1. Discuss current debate regarding the nurses role in promoting ‘patients choices;’ in areas such as end of life care?

2. Using current evidence, please discuss communication within health care teams. Please focus on;

(a) the role of the Registered Nurse

(b) the impact of poor communication and patient safety

(c) the value of TeamSTEPPS and ISBAR 

3. Write an ejournal entry that addresses the following;

(a) What are some of the complexities in identifying a deteriorating patient?

4. Identify, describe and reference an assessment tool that you could use in on your placement to identify deterioration in a patient under your care.

5. Use current evidence to discuss the management of the difficult situation outlined in this week’s scenario.  Please outline the key resources that you might use to prepare a plan to support Sophie and her family.

6. In your eJournal, cite and summarise a journal article which takes into account the role of the Australian Registered Nurse in the discharge planning process. Briefly outline how discharge planning in the acute care setting may maximise health and minimise costs.

Most of the patients who expire in hospitals, use up time in an intensive care unit obtaining high-tech, aggressive and costly health care. However, the end-of life days are frequently filled with pointless suffering (Fedoruk and Hofmeyer, 2012). The substitute to this situation is palliative care that focuses not only upon extending life but also on offering supportive care which supports the dignity and comfort of the patients. The nurses can create a key contribution in relieving the transition from aggressive management to palliative care, despite of the set up. To perform the same the nurses should prepare themselves to make compassionate and ethical decisions and simultaneously consider approaches to avoid legal responsibility. Palliative care is considered as a total and active care of the clients whose ailments no longer act in response to curative treatment, as per the World Health Organization. This regards dying and affirms life as normal process neither accelerates nor delays death and gives remedy from pain and different suffering indications (McIlwraith and Madden, 2010). While the palliative care principles are embedded in hospice movement, its deliverance should not be restricted to the clients who are supposed to die within few months, as initially considered by Medicare and also this should not be provided only to the clients enrolled in hospitals. Nurses play important role in promoting patients choices. If a patient is obtaining palliative care, the nurse can be a central player of a multidisciplinary team and a part of a health care team. The structure of a team differs, but can include more than a single nurse and a primary care practitioner of the patient. Primary care practitioner can include chaplain, dietician, social worker, occupational therapist, physical therapist and associated health personnel (Burkhardt and Nathaniel, 2008). Nursing responsibilities comprise evaluation of pain and other suffering indications, giving evidence based interferences to alleviate these problems and stopping those interventions initiation which may not modify the life quality and comfort of life.  The nursing professionals work with the team members to focus on the spiritual and psychological aspects of life-threatening illnesses. Finally, the nursing personnel should work along with the family members as they may shift their concentration from patient curing to palliative care. The promises to family members need to continue after the death of the patients with assistance and recommendation for counseling, if applicable (Bird, 2011). End of life care frequently includes options which are ethically complicated and produces fears of probable liability. Abandonment of life sustaining care for example feeding tube or dialysis and the necessity for escalating or large opioids dosages or sedatives are typically troubling matters (Johnstone, 2009). Nurses need to use efficient medication dosages ordered for indication control and should have moral responsibility to advocate in support of the clients while prescribed medicines are ineffectively controlling pain and other suffering symptoms. The increasing medication titration to attain proper indication control is morally justified. Withdrawing and withholding life sustaining therapy is ethically and legally permissible if the patients are completely informed and generously made wish or if treatment is causing or will cause harm to the clients or presents no profit to the clients.

Importance of Effective Communication

Communication refers to the act of conveying significant information during the substitution of opinions, instruction or messages amongst individuals. Several techniques of communications are: distribution of verbal communication, undisclosed languages, visuals, manners or writing. The practice of nursing uses constant communication between nurse and patient, patient’s family, colleagues, managers and others (Stubbe, 2013).  Communication process in healthcare setup can be difficult process. The likelihood of passing on incorrect information often takes place in treatment communication. Health care professional should be well conscious of primary components of communication procedure. Fail in preserving communication can reason negative results. This sequentially affects the health of patients. As a result, health care providers should develop their skills of communication, and should recognize and correct the probable complications that exist with errors in communication.

ISBAR represents identify situation, background, assessment and recommendation. It is said to be a mnemonic formed to develop safety during the transfer of vital information (Levett-Jones and Bourgeois, 2011). This initiates from SBAR and is said to be the most commonly applied mnemonic in health and other bigger threat situations like the military. The ‘I’ (identity) is to make sure that proper indication of these participating handover and patient is set up (Sahealth.sa.gov.au, 2015). ISBAR is also considered as a tool to assist the safe patient information transfer in medical handover. It is a standard aide and need to be adapted to suit the medical context. Getting used to ISBAR for medical context is considered as a prospect for the patients and the health care personnel to  choose what important information need to be always handed over, for example probable blood loss during handover of surgical patient.

Team STEPPS is considered as an evidence-based structure to optimize the performance of the teams across health care delivery set up. It has five main principles. It depends upon the structure of the team and also four teachable and learnable proficiencies; these are mutual support, situation monitoring, leadership and communication.

                                                                      Interaction of Team STEPPS; source: (Sahealth.sa.gov.au, 2015)

The interaction of Team STEPPS can be easily represented with this diagrammatic presentation. The arrows here illustrate a two-way dynamic relationship between team associated consequences and four skills. Association between the skills and consequences is the center of a group attempting to deliver quality care, safe care and maintain quality improvement. Enclosing the four competencies is considered the team construction of the client care group that symbolizes not only the care consumer and direct care providers but also those who act a supportive function within the health care set up. 

Researchers Birmingham et al. (2014) have focused on the impact of poor communication and patient safety (Birmingham et al., 2014). They have mentioned that efficient communication during hand over is vital for patient wellbeing. Research is required to understand the way information processes taking place during intra-shift handover and its impact and effectiveness. The researchers have implemented a qualitative research study to analyze the perceptions of surgical nursing staff regarding techniques, which hinder and promote patient safety during handover and shift change (Belyansky et al., 2011). Their results have showed that the capacity of the off-going nursing professionals to understand the situation intra-shift was important to communicate the entire picture during handover (Schwartz, Wright and Lavoie-Tremblay, 2011). While oncoming nursing professionals understood the situation being communicated at the handover, professionals jointly highlighted an entire picture. Arriving and parting he handover with this stage of information exhibited patient safety. Nevertheless, disruptions during intra-shift often obstructed the nursing staff in their approaches to understand the story, as a consequence creating threats to the safety of the patients. 

Complexities in Identifying Deteriorating Patients

Patient safety in hospital is hampered at times, leaving ward patients at significant threat of life threatening, gradual deterioration (Odell, 2014). It is seen that improper nursing practice beside management and monitoring has been identified as threatening to the patients’ safety.  Significant parameters have been known to depart in single patients hours prior to adverse events but this understanding has not been commonly rooted among medical and nursing in-hospital personnel, contributing to misapprehension of single inadequate and vital signs beside act being taken (Baugher and Mattu, 2011). Consequently this understanding of predictable deviations value beside fundamental parameters has not recently been revealed in ward patient monitoring practice. Not only this monotonous shift and overload of work can also be mentioned as a kind of complexity. This is because times may come when nursing staff are less but more patients is getting admitted in the hospitals. In that case, the particular numbers of nurses need to share the overloaded task among them and that can have negative impact on patients’ health. So, adequate nursing staff may not be present in order to look after a deteriorating patient. Another complexity can be proper prior knowledge of nursing staff to understand vital signs of patient deterioration (Purling and King, 2012). The student nurses or fresher nursing aide may not train well in order to understand vital signs of a deteriorating patient; this can represent a major complexity within a health care set up. This is because it is the nursing staffs’ sole responsibility to monitor and look after their patient frequently and understand any vital signs expressed buy the patient. Thus they should convey that message to the other staffs or should report immediately to the doctor in order to take rapid action.  Sometimes it is also seen that the fresher nurses feel uncomfortable to ask or clarify their queries from the senior and experienced nursing staffs. In that case, the knowledge gap keeps continuing and the nursing staffs fail to determine the expressed vital deteriorating signs by the patients.

GCS score or Glasgow comma scale can be sued as an assessment tool which can be used to identify deterioration of a patient. It is said to be a neurological scare which aims to provide an objective and reliable way of tracing the conscious state of an individual for initial and subsequent assessment (Hamilton, 2006). A client is assessed against the scale criteria and the resulting points put patient score between3-15. Lesser score indicates deep unconsciousness. The elements of scale consists three main observations: eye, verbal and motor response. If the score shows less than 8 or 9, then the patient condition is deteriorating and moderate score shows 9-12 and minor condition is represented by the score more or equal to 13 (Iankova, 2006). This assessment tool is good to select because qualitative questions are not always help to detect a patient’s condition. It may sometimes happen that the patients is not in a state to answer properly all the questions rather scoring system or a quantitative tool is always reliable where the healthcare professionals assign scores depends upon the patients’ verbal, motor and eye responses.

Assessment Tools for Identifying Deterioration

In caring for critical patients it is sometimes important to perform actions which restrict their movement freedom (Tumeinski, 2005). Commonly this is performed for good care or practical considerations or a necessity. In Sophie’s case applying hand restraints is considered as a part of good care. But the difficult arise when it is mentioned that the family members are not involved in this decision making. So in this context it is quite justified for the patient party to lodge a complaint against the team leader that they have not consulted prior regarding the use of physical restraint. Therefore to manage this type of difficulty involvement of clinical ethics is of utmost importance (Haut et al., 2010). This resolves ethical complications which takes place in clinical practice and consists two fundamental parts, one: the problem and two: the solution. Physical restrain may affect a patient psychologically, respect for dignity and autonomy but it is the care professionals’ responsibility to appropriately follow the ethical guidelines regarding the application of physical restraints in order to promote the patient wellbeing. Clinical ethics never restrict them to an illustration of clinical state of affairs; they should interpret the clinical actuality in terms of human dignity (Hamers, 2012). Clinical values are weighing up moral values and standards, which serve as principles for medical actions. 

The care team of the hospital should assist the family members by instruction at an initial stage, for instance on admission about the policy of the hospital regarding physical restraint. Though the purpose is to involve family members in decision making process, it should be highlighted that the final decision is taken by the care service providers and they hold full accountability for their choice (Heinze, Dassen and Grittner, 2011). Often, the family members are under stress because of being dealt with patient’s decline and should not feel responsible for the complete process of treatment as well, as this could give rise to the guilt feelings.

(5) Bauer, M., Fitzgerald, L., Haesler, E. and Manfrin, M. (2009). Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence. Journal of Clinical Nursing, 18(18), pp.2539-2546.

Scientist Bauer et al. (2009) have illustrated a review on hospital discharge planning for older patient and their family and also intervene whether the nurses are delivering best practices. The aim of this research was to analyze available evidences regarding hospital discharge practices for older people and their family care providers and the practices which were most helpful for this population group. It is mentioned by the researchers that discharge planning practices in hospitals are putting an amplifying care burden on family care providers. Planning for patient discharge and implementation are important for any patient where improper practices can be connected to adverse consequences ad an augmented threat of readmission (Morris, 2012). The researchers have reviewed literature and stated that various aspects impact on discharge planning of patients (Nordmark, Söderberg and Skär, 2015). The researchers have also focused on the fact that the discharge planning bridge the gap between care required within the community and treatment offered in the hospital, its probability to diminish the duration of hospital stay, impact of discharge process on care providers and requirement for coordinated health personnel approach which comprises information dissemination, active support and clear communication (Crookes, 2009). They have concluded that discharge panning for patients need to be improved if interferences point out family education, inclusion, communication between family and health care providers, ongoing support and communication after discharge (Jacob, McKenna and D’Amore, 2014). Their research also demonstrated a clear correlation between hospital readmission and discharge planning quality. They have also concluded that inferences should be commenced well prior to discharge and relevant to medical practices (Chaboyer et al., 2004). An understanding of how the implementation of discharge plan is perceived by the main and primary care provider, will allow health care personnel and other associated nursing staff involved with discharge planning to better reunite the care providers’ expectations and requirements with discharge method provided by their convenience. 

Management of Complex Situations in Healthcare

References

Bauer, M., Fitzgerald, L., Haesler, E. and Manfrin, M. (2009). Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence. Journal of Clinical Nursing, 18(18), pp.2539-2546.

Baugher, K. and Mattu, A. (2011). Ten rules to assess and manage the acutely deteriorating patient: a practical mnemonic. Patient Safety in Surgery, 5(1), p.29.

Belyansky, I., Martin, T., Prabhu, A., Phillips, R., Sindram, D., Norton, J., Howley, L. and Stefanidis, D. (2011). Poor Resident- Attending Intraoperative Communication May Compromise Patient Safety. Journal of Surgical Research, 165(2), p.203.

Bird, E. (2011). Promoting end of life care across care homes: the role of the specialist palliative care nurse. BMJ Supportive & Palliative Care, 1(2), pp.248-248.

Birmingham, P., Buffum, M., Blegen, M. and Lyndon, A. (2014). Handoffs and Patient Safety: Grasping the Story and Painting a Full Picture. Western Journal of Nursing Research.

Burkhardt, M. and Nathaniel, A. (2008). Ethics & issues in contemporary nursing. Clifton Park, NY: Thomson Delmar Learning.

Chaboyer, W., Foster, M., Kendall, E. and James, H. (2004). The impact of a liaison nurse on ICU nurses’ perceptions of discharge planning. Australian Critical Care, 17(1), pp.25-32.

Crookes, P. (2009). What is the role of the Registered Nurse?. Collegian, 16(2), pp.47-48.

Fedoruk, M. and Hofmeyer, A. (2012). Becoming a nurse. South Melbourne, Vic.: Oxford University Press.

Hamers, J. (2012). The reduction of physical restraints in nursing homes: the impact of nursing research on clinical practice and health care policy. Pflege, 25(6), pp.405-407.

Hamilton, R. (2006). Comparison of Consciousness Level Assessment in the Poisoned Patient Using the Alert/Verbal/Painful/Unresponsive Scale and the Glasgow Coma Scale. Yearbook of Emergency Medicine, 2006, pp.235-236.

Haut, A., Kolbe, N., Strupeit, S., Mayer, H. and Meyer, G. (2010). Attitudes of Relatives of Nursing Home Residents Toward Physical Restraints. Journal of Nursing Scholarship, 42(4), pp.448-456.

Heinze, C., Dassen, T. and Grittner, U. (2011). Use of physical restraints in nursing homes and hospitals and related factors: a cross-sectional study. Journal of Clinical Nursing, 21(7-8), pp.1033-1040.

Iankova, A. (2006). The glasgow coma scale clinical application in emergency departments. Emergency Nurse, 14(8), pp.30-35.

Jacob, E., McKenna, L. and D’Amore, A. (2014). Senior nurse role expectations of graduate registered and enrolled nurses on commencement to practice. Australian Health Review, 38(4), p.432.

Johnstone, M. (2009). Bioethics. Sydney, N.S.W.: Churchill Livingstone/Elsevier.

Levett-Jones, T. and Bourgeois, S. (2011). The Clinical Placement. London: Elsevier Health Sciences APAC.

McIlwraith, J. and Madden, W. (2010). Health care and the law. Rozelle, N.S.W.: Thomson Reuters (Professional) Australia.

Morris, J. (2012). Registered Nurses’ Perceptions of the Discharge Planning Process for Adult Patients in an Acute Hospital. Journal of Nursing Education and Practice, 2(1).

Nordmark, S., Söderberg, S. and Skär, L. (2015). Information exchange between registered nurses and district nurses during the discharge planning process: cross-sectional analysis of survey data.Informatics for Health and Social Care, 40(1), pp.23-44.

Odell, M. (2014). Detection and management of the deteriorating ward patient: an evaluation of nursing practice. J Clin Nurs, p.n/a-n/a.

Purling, A. and King, L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23-24), pp.3451-3465.

Sahealth.sa.gov.au, (2015). ISBAR – Identify, Situation, Background, Assessment and Recommendation :: SA Health. [online] Available at: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/safety+and+quality/clinical+handover/isbar+-+identify+situation+background+assessment+and+recommendation [Accessed 30 Jan. 2015].

Sahealth.sa.gov.au, (2015). TeamSTEPPS :: SA Health. [online] Available at: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/safety+and+quality/clinical+handover/teamstepps/teamstepps [Accessed 30 Jan. 2015].

Schwartz, L., Wright, D. and Lavoie-Tremblay, M. (2011). New Nurses’ Experience of Their Role Within Interprofessional Health Care Teams in Mental Health. Archives of Psychiatric Nursing, 25(3), pp.153-163.

Stubbe, D. (2013). Communication Commentary: It Takes a Village: Effective Interprofessional Collaboration in Health Care Teams. FOCUS, 11(4), pp.521-524.

Tumeinski, M. (2005). Problems Associated With Use of Physical and Mechanical Restraints in Contemporary Human Services. Mental Retardation, 43(1), pp.43-47.