Educating Nurses-Practitioners About the Aforementioned on the Importance of End-of Life Care
Introduction
Nature of the Problem
This palliative and hospice care study shall establish the existing situation in the field as it relates to the focus on the current medical set-up. The capability of registered nurses, licensed nurses, and certified nursing assistants to handle end-of-life patients shall also be considered. Knowledge of the current competence of medical practitioners in the field of palliative and hospice care would help to opt for ways to enhance competence in providing the best possible evidence-based care. Application of research-based methods and palliative care literature for training staff in palliative care would enhance the effectiveness, competence, and skills of practitioners. The health care industry needs to focus on improving pain management and other components of palliative care. The community would benefit from such a study in that the number of people treated through improved palliative and hospice care will increase; hence, suffering and deaths will decrease.
Awareness of the demand for palliative care would help healthcare institutions to increase their focus on their services to customers. Management of staff and enhancement of their skills boost the institutions’ capability to serve their customers well. Offering more complete healthcare services reduces costs incurred as a result of employing specialists because such an approach focuses on equipping current staff.
Review of the literature
Chronicle
Studies have proved that many Americans do not have access to end-of-life care. It was revealed in a study that 40% of patients aged 80 and above experienced severe pain during their last three days of life (Vig, 2002, p. 1541). The recommendations issued by the Institute of Medicine on addressing the deficiencies identified at the end-of-life include strengthening the knowledge base for end-of-life (Vig, 2002, p. 1541).
Nursing homes in the United States have been termed as increasingly becoming places of death given the increasing number, frailty, and age of terminally ill individuals residing there (Renee et al, 2005). These numbers include patients transferred there from hospitals during their final days. In contrast to the beginning of the twentieth century, when most people died at home, a quarter of the deaths in the United States now occur in nursing homes (Renée et al., 2005, p. 1651). Recently, more people have been able to postpone, if not avoid, admission to nursing homes thanks to options that are increasingly becoming available. Considerable physician presence at nursing homes has been the expectation of families and residents owing to their perception that such places are healthcare institutions. Concerns have been raised about insufficiency of staff for good care, pain treatment, and appropriate assessment of end-of-life care in nursing homes (Teno et al, 2004). Many problems such as:
- dissatisfaction of residents and their family members with nursing homes,
- poor communication and decision-making,
- inadequate symptom management,
- high rates of hospitalization, and
- mistaken patient diagnosis have been linked to inadequate physician presence in nursing homes (Renee et al, 2005).
The importance of patients having an active role in determining the quality of end-of-life care has been discussed. Preferences of patients may help the health professionals to understand them and develop patient-centered care plans (Vig et al., 2002). Terminally ill adults and older adults are the two distinct populations that face end-of-life issues and that have higher mortality rates than other populations. There has been a belief among investigators that caregivers and healthcare providers may not accurately interpret the dying experience of others (Vig et al., 2002). For example, older adults’ preferences for end-of-life interventions like resuscitation are not understood adequately among healthcare providers or the patients’ families (Vig et al, 2002). It has been found in one study that end-of-life treatment preferences among older adults was influenced more by the anticipated outcome of serious illness than the medical interventions employed to sustain life (Vig et al, 2002). According to Vig et al. (2002), the latter research failed to address the views of older adults about good and bad deaths, the associations between current values and preferences for the end-of-life, and the reasons for the preferences. (Vig et al, 2002).
Cassel and Kathleen, (1999) cite that the efficiency of Hospice and Palliative Care practitioners is also an important aspect of end-of-life care; therefore, the organization of services and facilities must provide support for end-of-life care. Cassel and Kathleen (1999) further state that among the 2.5 million people who die in the United States yearly, many of those who die at ages above 65 do so from complications of neurobiological disorders like Parkinson’s, Alzheimer’s, or stroke.
Establishing a common focus and basic principles that underlie the roles and responsibilities of medical practitioners in end-of-life care is necessary because different specialties may see different aspects regarding the care of dying patients (Cassel & Kathleen, 1999). Differences exist among the patients as relates to the type of or the extent of clinical needs (Cassel and Kathleen, 1999). According to researchers statistics indicate that more than 2 million people die every year in the United States (Austin, 2003) but the mechanism of health care delivery is fragmented. End-of-life care uses 10 % of the total health care budget and 27 % of the Medicare budget. In addition, appropriate use of hospice resources during the last months could help save 46.5%, if used during the last six months a 17 % savings could occur (Emanuel, 1996).
The World Health Organization in 2002 defined palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO, 2004, p.14).
WHO also advocates that interventions need to be established early, effective support systems be instituted and multidisciplinary approaches be selected. Additionally, it is known that though most deaths occur in hospitals, integrated palliative medicine programs are minimal in number (Estfan, 2008). One study showed 40% of patients who were discharged from the Taussig center were ready for admission for palliative care (Walsh, 2001). Two groups have been recognized as suitable for palliative care: the chronically ill and the dying.
Hindelang (2006) notes that the way each person experiences the end of life is as unique as the individual is: common fears that accompany people who are nearing death are (a) fear of pain, (b) fear of loneliness, (c) fear of loss of control and the (d) fear of going into death alone. Additionally, as healthcare professionals caring for the dying and their families, it is imperative to present competence, choice, compassion and offer our best practices of palliative care in helping them find relief, support, and meaning at the end of their lives (Hindelang, 2006).
Furthermore, patient and family education is the cornerstone of comprehensive end-of-life care. Hindelang believes that lasting dignity and growth are important features of human beings. These last through the to the end-of-life even when the last days are stressful and filled with pain even with no hope of cure (Hindelang, 2006).
Having advance knowledge about palliative and hospice care can expand the quality of life and amorous interactions between nurses, and or practitioners. Hindelang (2006) comments, caring for someone who is dying is emotionally and physically demanding, and that can be particularly true for family members who are primary caregivers.
Effective hospice program can reduce the hospital stay and thereby increase savings as inpatient utilization would be reduced. It also ensures that the quality of care provided is to the satisfaction of the patient and family and betters their quality of life (Teno, 2004). District nurses provide hands-on nursing care to patients who remain at home in Australia. They provide palliative care too to elderly patients. Their function helps the elderly and end-of-life patients to remain at home. They are described as patient assessors, care coordinators and team leaders (Shipman et al, 2008). Their role is recognized as making a difference.
Wright (2001) concluded that hospice nurses, whose patients have a terminal illness, do not receive adequate preparation for the specialty during their basic program of nursing. Educational preparation is a necessity especially graduate education for advanced practice in hospice nursing. Policy makers need to look into the matter and ensure that nurses are prepared for the heavy and distressing work of caring for the dying. A lot more preparation is needed if they have to be alert and attend to the different problems they face in the palliative care ward. Problems can arise from any body system and the carers must be well armed.
Communication skills and active listening are basic assets to be effective teachers. Hospice nurses must feel comfortable communicating about sensitive and difficult topics. In addition, Wright found that most nurses do not confront issues of death and dying with every patient, as do hospice nurses (2001). The author further comments that when patients and families are dealing with the stress of impending death, hospice nurses often must be careful to explain or translate medical information to them (Wright, 2001). Bereavement counseling is also an essential component of a death. In general, hospice nurses need technical skills as well as good assessment skills and how to start and manage intravenous solutions, ventilators, and other equipment, as well as provide comfort measures and social support (Wright, 2001). Moreover, according to Wright, nurses need to know the cost of medications, insurance benefits, and Medicare regulations and be aware of available community resources.
The Department of Health in England spent £6m for a national education and support program, which lasted 3 years, for palliative care (Shipman et al, 2008). Ten thousand of the District Nursing teams were trained for their function as palliative care teams (Shipman et al, 2008). Initially a core curriculum was prepared, patient and career needs were assessed and their issues were anticipated. This resulted in good management of symptoms. Additional specialists, if needed, were approached for their support and advice. Communication and counseling skills were sharpened. The topics were selected according to the knowledge level of the District Nurses (Addington-Hall et al, 2006). In addition, learning tools were varied, core topics were taught to the District Nurses, formal teaching was resorted to most of the time, and some teachers used the experiential method.
The Nurse Professionals
The nurse practitioner is a registered nurse with the necessary qualification to practice (Wilson & Shifaza, 2008). Her autonomy allows her the freedom to make decisions appropriate within her practice. Overall satisfaction with the treatment offered by the nurse practitioner was examined by using a questionnaire (Wilson & Shifaza, 2008)
Ethics and Morality
Nursing has a moral dimension (Wright, 2009). Care, integrity, trust, and personhood nursing are morally relevant aspects in the concepts of care (Wright, 2009, p 222). Palliative care makes all these aspects exemplary. Compassion is the alternative when the nurse’s responses do not produce the desired effect of alleviating symptoms. Nurse-family relationships are important in palliative care but policies do not guide the nurses in their endeavours. When an ethical problem arises they are left to sort it out themselves (Meiers, 2008). The complex nature of experience-as-lived in palliative care cannot be fully addressed by ethical standards related to nursing.
References
Addington-Hall, J., Shipman, C., Burt, J., Ream, A., Beynon, T. & Richardson, A. (2006).Evaluation of the Education and Support Programmes for District and Community Nurses in the principles and practice of palliative care. Report to the Department of Health, King’s College, London, Department of Palliative Care and Policy, UK
Austin, B. and Fleischer, L. (2003) Financing end-of-life care challenges for an aging populationPrinceton, N.J.: Academy Health, Robert Wood Johnson Foundation. Web.
Cassel, C., & Foley, K. (1999). Principles for Care of Patients at the End of Life: An Emerging Consensus among the Specialties of Medicine. Milbank Memorial Fund. Web.
Emanuel, E. (1996) Cost savings at the end-of-life JAMA, Vol. 275, p. 1907-1914.
Estfan, B., Davis, M.P. Walsh, D., Heintz, J. Shaheen, P.E., Cheema, B. et al, (2007). The Business of Palliative Medicine- part 5: Service utilization in a comprehensive integrated program, American Journal of Hospice and Palliative Care, Vol. 24, p. 211 Sage Publications.
Hanson, L. C., Danis, M., & Garrett, J. (1997).What is wrong with end-of-life life care? Opinions of bereaved family members. Journal of the American Geriatrics Society 45, 1339–1344.
Hanson, L. C., Henderson, M., & Manon, M. (2002). As individual as death itself: A focus group study of terminal care in nursing homes. Journal of Palliative Medicine 5, 117–25.
Harrison, J. P. (2007). A comprehensive community-based model for hospice care. American Journal of Hospice and Palliative Care, Volume. 24, p. 119.
Higginson, I., Wade, A., & McCarthy, M. (1990). Palliative care: Views of patients and their families. British Medical Journal 301, 277–281.
Hindelang, M. (2006).To help you live until you die: Patient education in hospice palliative, and Cancer Care. The Journal for the Home Care and Hospice Professional Issue: Vol. 24(3), pp 142-144.
Holtzman, J. & Lurie, N. (1996). Causes of increasing mortality in a nursing home population. Journal of American Geriatrics Society 44, 258–264.
Meiers, S.J. and Brauer, D.J., (2008). Existential caring in the family health experience: a proposed conceptualization. Scand. J. Caring Science, Vol. 22, p. 110-117.
Renee, S.R. , Wetle T, Welch L. Miller S, Teno J. (2005). Family perspectives on physician and staffing problems in end-of-life care in nursing homes. The Gerontologist 45 (Special Issue II): 375.
Seckler, A. B., Meier, D. E., & Mulvihill, M. (1991). Substituted judgment: How accurate are proxy predictions? Annals of Internal Medicine, Vol.115, 92–98.
Shipman, C., Burt, J., Ream, E., Beynon, T., Richardson, A. & Addington-Hall, J. (2008). Improving district nurses’ confidence and knowledge in the principles and practice of palliative care. Journal of Advanced Nursing 63(5), 494–505. Web.
Teno, J.M., Claridge, B.R., Cassey, V. et al.(2004). Family perspectives on end-of-life care at the last place of care, JAMA, Vol. 299, p. 88-93.
Vig, K. E., Davenport, A. N., & Pearlman, R. (2002). Good deaths bad deaths and preferences for the end of life: A Qualitative Study of Geriatric Outpatients. The American Geriatrics Society 50(9), 1541–1548. Web.
Walsh, D. (2001). The Harry H. Horwitz Center for Palliative Medicine (1987-1999): Development of a novel comprehensive integrated program. American Journal of Hospice and Palliative Care, Vol. 18, p. 239-250.
World Health Organisation, Europe, (2004). Web.
Wright, D., Brajtman, S., & Bitzas, V. (2009). Human relations at the end of life: An ethical ontology for practice. Journal of Hospice and Palliative Nursing Vol. 11, p.219-227.
Wright, M. (2001). Spirituality: A developing concept within palliative care? Progress in Palliative Care 9(4): 143-148.