Introduction
Palliative care, also known as end-of-life care, focuses on mitigating the painful symptoms of a dying person (Curtis, 2008). It provides an immense support system to help the patient and family deal with challenges arising from the patient’s illness (Curtis, 2008). Spathis and Booth (2008) assert that palliative care ensures active, compassionate care that respects the patient and family, patient-healthcare professional cooperation, regular and systematic assessment of deterioration, advanced care planning, effective teamwork, and sensitivity to spiritual beliefs and practices.
Due to social alienation, hospital workers found it difficult to provide high-quality palliative care during the coronavirus pandemic (Kim et al., 2021). This essay will reflect and critically review end-of-life care principles throughout the coronavirus period using Gibbs reflective Cycle Model (NursingAnswers.net. 2018), which was established for nursing due to its simple cyclical structure (NursingAnswers.net. 2018). The name was changed for patient privacy (NMC, 2018).
Case study scenario
William, 67, shares a close relationship with his son and lives alone. After twenty years of employment, he retired from the National Health Service (NHS) due to Complex Chronic Pulmonary Disease (COPD). William enjoyed gardening and going on walks to his brothers’ houses. Despite having greatly decreased his nicotine consumption over the previous year, William’s medical history indicated that he was a heavy smoker. Within a year, he had experienced two COPD exacerbations and contracted Covid 19 virus. As a result, he was hospitalised, and although he did not require ventilation, he became oxygen dependent due to his FEV130; his pain and shortness of breath were effectively handled. A pulmonologist diagnosed him with COPD in its terminal stage. His son could not see him because of the Covid 19 pandemic visitation restriction policy. Therefore, he called during the day to express discontent with his dad’s care. Doctors had an overwhelming number of patients, leaving nurses busy and unable to communicate due to frequent redeployments and fatigue. William became upset when palliative nursing professionals explained his options; he rejected the circumstance, asked to go home to his son, and stopped speaking. She departed due to her overflowing caseload but changed her appointment to the following week.
Discussion
According to World Health Organisation WHO (2010), collaborative practices in end-of-life care is when healthcare workers from diverse backgrounds work with patients, families, and caregivers to provide the best care. Unfortunately, from the case scenario above, nobody had the time to meet William or fully understand and explain his predicament because of a lack of collaboration (Rosser and Walch, 2014). This was essential to help patients make informed therapeutic patients (Spathis and Booth, 2008). Also known as Advance care planning (ACP), this approach integrates effective treatment decisions that reflect the patient’s values, thoughts, and preferences (Brinkman-Stoppelenburg et al., 2014).
Although Rosser and Walch (2014) assert that Advance care planning (ACP) is effective for treatment, Russell and Russell (2007) contend that effective communication between the patient, family, and members of the MDT is essential for ACP to occur. Additionally, NICE (2019) advises that a member of the MDT be designated as the top healthcare professional. This individual should be well acquainted with the patient and have a good rapport with the patient’s family. This will facilitate coordination and ensure that the MDT and family are involved in the patient’s care (NICE, 2019). The primary healthcare provider in William’s case was a palliative nursing specialist. However, she rescheduled the meeting for a different day because William was reluctant to discuss ACP, and she didn’t follow up on the update with his family or the other MDT members. I was perplexed as to why she didn’t try to look into it more. This is because William needed oxygen to function. He might have preferred writing or another form of communication if he didn’t like the surroundings or wanted to speak with his family first (Silverman et al., 2017). Evidence suggests that although people are open to these conversations, they anticipate that healthcare providers will start them (Great Britain, 2015). Silverman et al. (2017) posit that a lack of communication among health care providers and patients has been described as a significant roadblock to effective relationships. Shannon et al. (2011) assert that poor communication was linked not only to language issues but also to the inability of clinicians to address patients’ concerns and needs. According to Shannon et al. (2011), health professionals generically approach patient care and do not consider individual needs. Another issue was health providers’ failure to interact with family and friends seeking care because of elderly ill people. Despite evidence of worsening problems, Russell and Russell (2007) note that there was often a perception that health professionals were unwilling to intervene and provide the help needed.
For example, she could have used a communication tool such as Ask-tell-ask, asking open-ended questions to clarify the patient emotional response to illness (Shannon et al., 2011), or use silence, such as where she would actively listening to the patient (Shannon et al., 2011). This would encourage William to talk openly and might change his mind about discussing ACP (Gardener et al., 2019). Nurses are morally and ethically obligated to provide the best care (NMC, 2019). On the one hand, it is evident that time constraints due to COVID 19 pandemic contributed to the lack of communication between the MDT team and patient (Russel and Russell, 2007). Further, the overwhelming number of deaths, isolated patients, and the present fear of being infected had a big impact on the emotional and psychological well-being of the whole MDT team, reducing the quality of care (Hossain and Clatty, 2021). However, this is a well-known concern in end-of-life care before the pandemic according to (Russel and Russell, 2007). This remark backs up Curtis et al. (2004) claim that only a third of patients with oxygen-dependent COPD had addressed end-of-life care with their healthcare professionals.
To look back, we could have implemented Gold Standards Framework approach to ensure “good death” in end-of-life care (Croft, 2010). This systematic evidence-based approach is expected from all organisations providing end-of-life care (Department of Health, 2008). This strategy was created to improve coordination and collaboration of the teams who assist end-of-life patients and would have provided reassurance, training, and communication skills for team members regarding end-of-life care (GSF, 2019). Selman et al. (2020) point out that people cannot correctly express their health problems because they cannot communicate effectively with medical staff. This can lead to a person feeling more stressed, refusing medical care, or undergoing unnecessary tests and treatments. Although interpreting services have improved in recent years, there are still concerns about the lack of interpreters, especially in primary care. This would result in the Multidisciplinary team playing an important role as the only facilitators of patient-family communication in the hospital during covid 19 pandemic, including nurses, physicians, or healthcare assistants that could have created an environment for communication using non-face-to-face means such as using electronic devices, phone calls, using Face time (Selman et al., 2020). Hence, it is vital to encourage William to discuss ACP with medical practitioner.
Although ACP is optional for every patient, it includes Advance statements of preferences, Advance decisions to refuse treatment (ADRT) plus their thoughts on Cardiopulmonary resuscitation (CPR), and choosing lasting power of attorney (LPA) in case they lose capacity (Gold Standards Framework, 2017) it is highly recommended for end of life COPD patients (Lunney et al. 2003). A study has shown that the greatest challenge in EOL care in COPD patients is unpredictable disease trajectory, with slow decline, punctuated by dramatic exacerbation that often ends in unexpecting death (Lunney et al. 2003). Therefore, people with COPD are more likely to be admitted to the ICU, placed on a ventilator, and die in the hospital than cancer patients (Heffner, 2011). However, most of those patients that were mechanically ventilated didn’t want to do so nor did not want CPR (Curtis, 2008), and families of those patients experienced difficult brief with a feeling of neglect (Selman et al., 2020). Therefore it might have been essential to have those discussions with William, although he was reluctant to do so as this would have improved his and his family’s end-of-life experience (Borson et al. 1992).
Besides good communication and MDT team, Brinkman-stoppelenburg et al. (2014) assert that a holistic assessment was necessary to plan appropriate ACP. This was surprising to me because that same day, a nurse in charge assessed William using a PEPSI-COLA Aide Memoire assessment holistic tool for end-of-life care, which is recommended by UK guidelines for patients in palliative or end-of-life care (Curtis, 2008). It is also an excellent approach for cancer patients because of its length and design for palliative care. However is mainly practitioner-led, contrasting with patient-completed tools that actively support a person-centered approach by ensuring that areas of support need to be identified and discussed are prioritised by patient, such as COPD (Gardener et al., 2019). Other tools such as Holistic Common Assessment, Well-being Star, Kirklees health needs Assessment tool or SPARC (Sheffield Profile for Assessment and referral to care) focus on disease burden and patient functionality. Despite being good indicators of need, they do not directly identify the areas where COPD patients could manage life, negatively impacting ACP (Gardener et al., 2019). On the other hand, tool that was The Support Needs Approach for Patients (SNAP) identifies those specific support needs, furthermore, was designed for compatibility with busy clinical settings, which was in Williams’s case, contrasting with Pepsicola tools that is too lengthy (Gardener et al., 2019). Assessment tool has led to rushed assessment where spirituality was assessed very briefly, however, this was necessary because spiritual well-being plays a fundamental role in both physical and mental health being (Heidari et al., 2016). According to (Nolan et al., 2011), William’s religious and spiritual questions would allow him to express meaning and how he connects to himself, nature, and significant or sacred ones. Those beliefs would be an important influence on future treatments and wishes and on patients’ families (Nascimento et al., 2016), hence positively impacting the process of ACP.
William has struggled with depression, in addition to recognizing areas in which he may require further support to handle his later years. Antidepressants could be seen being prescribed, which a wise decision on the doctor’s side is. This approach aimed to lift the patient’s spirits while reducing ratings of dyspnoea and other physical symptoms (Borson et al., 1992). However, it was only partially successful, and depressed people are likely to alter their treatment preferences as their condition improves, according to Rosenfeld et al. (1996). According to Stapleton et al. (2005), who discovered that COPD patients with depressive symptoms have a stronger preference against CPR, depression needed to be addressed because it could negatively impact ACP. . ADRT could avoid future overtreatment that could result in harm, such as aggressive mechanical ventilation that leads to “poor death” or unneeded CPR (Taylor and Murray, 2017).
Additionally, the mental health Act (2008) affirms that ADRTs are legally enforceable documents requiring mental competency. Consequently, a mental health professional reference might have been made (Mental Health Act of 2008). In turn, families feel anxious or guilty for not directly participating in end-of-life care, and they might experience difficulty in making decisions without seeing the patient, as well as difficulty in receiving assistance from other members of their support network due to social distancing (Moris et al., 2020).
On the other hand, the Nurse in charge of her team referred William to discharge planning team, which was a very good approach because William has wished to go home. In terms of self-care, resilience, and potential burnout, the nurses in the Covid 19 pandemic were redeployed to other wards. In addition to reducing demand on the frontline during the height of the epidemic, this allowed nurses to acquire new skills, develop in their specialty, and share their knowledge (National Institute of Health Research) (NIHR, 2020). Alternatively, this increases the risk to oneself, along with inadequate preparedness and quickly changing protocols and policies (Dunn et al., 2020). With this logic, I concur with Porter et al. (2021). ‘s assertion that the healthcare staff was more susceptible to the traumatic effects of witnessing so many dying patients and delivering end-of-life care. I observed that nurses’ stress levels were greater when providing EOLC than when providing standard care. This was due to severe workloads, conflicts, a lack of EOLC experience, physical exhaustion, and mental agony or helplessness (Kim et al., 2022).
Therefore, healthcare personnel were at a greater risk of neglecting self-care and experiencing burnout, decreasing job satisfaction, retention, and quality of care (Boudrias et al., 2020). Wearing PPE created a physical barrier between dying patients and personnel, limiting communication to primarily eye contact and gestures (Andertun et al.,2017). In contrast, amid tight disease containment standards, workers could establish a rapport with dying patients (Andertun et al., 2017). Maunder et al. (2006) discovered that the trajectory of health care employees’ rehabilitation following the SARS crisis mainly was determined by perceptions of organisational support (training, protection) and dysfunctional relationships with co-workers ( anger, anxiety). Fear, stigma, and isolation were impediments to delivering end-of-life care; this had detrimental effects on myself and others. To avert this, we may have used self-care practices in conjunction with compassionate leadership (Gibiino et al., 2020). However, Gibiino et al., 2020 argue that self-care is difficult, especially when healthcare providers are faced with occupational stress. Andertun et al. (2017) note that the covid 19 period made nurses develop stress due to long working hours and a high number of patients in healthcare facilities. As a result, fatigue and burnout would lead to low performance among nurses in giving quality healthcare practice to covid19 patients. Emotional distress was also found to be a critical challenge in dispensing quality healthcare services to patients. Nurses would easily feel overwhelmed with work which added to their stress levels.
Conclusion
Self-care is an essential aspect for all people. It helps people under palliative care to take care of themselves in their daily life to enhance our overall well-being and happiness. It also functions at the maximum levels of nursing practitioners’ endeavors. Healthcare practitioners provide emotional support to palliative care patients. They provide guidance through means of therapeutic and effective communication. Every time William verbalised his feelings, it would help him open up to communication which is essential in improving the patient emotionally. Besides, the health practitioners easily respond to patients’ emergency cases which helps in recovery and improve the health of the patients. There are vital recommendations that can help reduce or eliminate obstacles when accessing mental health services in the country. Previous studies indicates that palliative health practitioners lack an in-depth understanding of the cultural background of people in the United Kingdom. This affects the quality of care and therapy provided to palliative care patients. Hence, more attention must be given to the patient’s cultural needs, improving the existing techniques, and deploying evidence-based practice when treating patients in hospice care. Concerns raised regarding the language barrier can be eliminated by hiring an interpreter whose primary role will be to interpret different languages. People cannot correctly express their problems because they cannot communicate effectively with medical staff. This approach is essential to enhance communication and mutual understanding between health care practitioners and palliative care.
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