End Of Life Care And Its Implications

Published Date: 02 Nov 2017

Whilst on placement during the first week, I was shadowing a consultant along with his team throughout the week in a medical ward setting. One of the patients, whom I would like to refer to as Paul, was an 84 year old male suffering from multiple systems failure due to severe sepsis. As per Dickson (2009), sepsis is described as the systemic inflammatory response syndrome caused due to infection, in which more than two of the clinical features such as hyper/hypothermia, hyperventilation, tachycardia and increased/decreased presence of white blood cells are diagnosed. The case with the addition of one or more organ dysfunctions such as: acute lung injury, renal, liver or cardiac failure, coagulation abnormalities, altered mental status or thrombocytopenia is defined as severe sepsis (Abraham et al, 2006).

The main aim of this placement was to be able to reflect upon the implications on patient care during/after certain situations that I have been exposed to such as end of life care, which I have chosen as the theme to discuss about. According to NHS (2010), end of life care is described as the last part of the palliative care in which, the support given for people who are approaching death can vary from being the next twelve months to the next couple of hours. Many different healthcare professionals may be involved and the aim of this care is to make the person live comfortably as possible by relieving pain and other distressing symptoms, as well as providing psychological, social and spiritual support for the person and the people around them, and to help them die with dignity (NHS, 2010).

A reflection can be defined in several different ways and one of the ways defined by Chirema (2007) meant that reflection was a technique that individuals used as an engaging process to explore their experience leading to new understandings and appreciations. Therefore, allowing the individual to handle similar clinical situations competently by responding freely and making appropriate clinical judgements (Chirema, 2007). In order to reflect upon an incident, one of the many reflective aids can be used, such as John (1994), Borton (1970), Gibbs (1988) and Benner and Wrubel (1989). Therefore, for this reflection, I am going to use John, C. (1994) reflective model cited by Davies, (2010). I will be choosing this model because it is a structured model of reflection that focuses the importance of experienced knowledge and the capability of a practitioner to retrieve, understand and put into practice the information that has been learnt through experience at a faster pace (McBrien, 2007).

Description

It was the first day of my placement and I was following my allocated consultant who was accompanied by his senior house officer (SHO) and a nurse on a general ward round along with another student, which was in a medical ward. My consultant explained me about the patient’s case straight after visiting them in the ward round in the breaks between visiting the patients.

Paul is one of the patients that I met during that ward round and he was being under treatment in the side room with an oxygen mask on and an IV inserted in his arm. I was told that he has been under treatment for over a couple of weeks whilst entering his room and when inside his room, all we could hear was him questioning about why his daughter didn’t visit him today, and his complaints about the pain and refusing to treatment involving needles. I tried to talk to him but he was in no situation to understand what I was saying and he only kept on querying about his daughter to which, the nurse replied saying that its hard due to travel due to weather as the roads were filled with snow and black ice. However, he failed to understand this statement as well and repeated on his question in a depressed tone. His records were continued to be observed for every two hours by the SHO for the next two days and was concluded that there was no improvement or response to his treatment and so discussions were made that resulted in giving up on Paul’s treatment. Instead, he was prescribed with ‘comforting’ drugs that reduces pain, agitation, dyspnoea, respiratory tract secretions, and nausea and vomiting. During this stage, he was unable to communicate or understand the surroundings properly and was mostly feeling drowsy and was sleeping all the time along with having decreased food or fluids intake and loss of appetite. By this time, he was also surrounded by his family towards whom he failed to recognize or socialize with.

Reflection

The aim of this placement was to be able to understand the implications on the patient care at different situations and I tried to understand as much as possible on my chosen theme of end of life care. Due to me being a student, I was unable to intervene with any patient care process as I was only allowed to observe. At that time, I felt so helpless and wished I could do something to reduce his suffering and also, felt that the situation has to be considered to let his family to be allowed to stay with him. As soon as I was told about Paul’s treatment being discontinued, I felt a bit relieved at first due to his freedom from the artificial suffering in the name of treatments and then thought that his family should at least be allowed to stay with him for the last moments of his life to make the environment a bit homely.

As Paul was now put under end of life care, I felt that it was the right thing to do since Paul was in a state that he couldn’t recognise what was happening to and around him that time. However, at first, his family members seemed to be quite negligent towards the decision to undergo passive euthanasia due to not wanting to lose Paul but later on supported the decision in order to save him from further pain and suffering, and die with dignity.

Influencing Factors

The decision making in these types of cases normally involves asking the question that evaluates when to let the person die as per Curtis et al (2006). It was decided on the following basis: to kill or let them die; is death a burden or a benefit to them; or whether or not to choose their family member to be the decision maker.

As per Pierson (1998), this type of euthanasia seemed to be natural as it states that dying was a natural and private event that due to the medical profession and the advances in medicine, it enabled to delay death and also prolong the dying process. According to Destarac and Ely (2002), it is believed that aged patients like Paul would be too weak to be able to cope with the physiological demands that are present for the survival of the septic process and so, the survivors are more likely to require social and economic support, which leads to them losing dignity. Therefore, by providing aggressive care, their pain and suffering is increased, which means that for them, death would be a benefit.

Alternative Strategies

I feel that this situation could have not been dealt any better than this. This is because this decision was made due to one of the main contradictory factor as stated above. Destarac and Ely (2002) also explained that mortality rates with severe sepsis in older patients were higher. Therefore, continuing treatment that has been unresponsive might just lead to the waste of resources that can be used for another patient as well as increasing the suffering of the present patient.

Learning

In order to conclude with, as per John’s (1994) reflective model, my understanding of this theme and its impact on patient care are described as follows.

Aesthetics

I felt I approached it quite ignorantly, since I had lacked knowledge about his condition and he only met me then. Though the main concern I had was to stop him from worrying about his daughter and feel a bit relieved off his tense, I strongly felt that this response was the right thing to do at that moment to which, the accompanying nurse supported by telling him gently by holding and stroking his hand. However, I also felt that I shouldn’t be interfering with this situation since I was just a student, who was there merely for observational purposes. On the bright side, I also felt that my action didn’t seem to have any consequences that led anyone to feel a bit awkward. Due to my lack of experiences that involved someone at a critical condition as this, at first all I could think of was to stop him worrying and feel relaxed and this resulted in me to just go forward into communicating with the patient while the medical team was checking and discussing his reports.

Ever since I have met Paul, every time I walked past his room, I always thought about how his health was coping and two days later, my SHO informed me that Paul has been put off life support. This made me feel somewhat like I have expected this to happen due to the condition he was in when I met him and every time I walked past his room; I felt the need to have a glimpse at him to see how he was taken care of from that moment and realised that his family was sitting around him, all of them silent while Paul was sleeping. However, when I had a glimpse, I strongly felt that this was inappropriate as it might make Paul’s family members feel a bit uncomfortable as if there is no privacy or personal space in addition to the state of mind they were in due to his condition.

Personal

I feel terrible for making them feel like invading their space due to my concern and curiosity as a result of lack of experience in a situation like this. I truly felt that this was mostly due to the door being open and in the interest of getting to know how things happened during the last few hours of a life. As a result, I noticed that the care for Paul was taken care by the SHO and a specialist nurse to assist and support Paul and his family during such phase in life. This is when I realised that it is better to not intrude or show special interest in a situation like this as it might make the person involved feel more upset.

However, I also felt quite relieved to see Paul being put under passive euthanasia, which is defined by Henk and Hermsen (2002) as, "the deliberate producing of the death of a person by withholding or withdrawing the ordinary means of nutrition or treatment", due to all the suffering he was going through at that moment due to multiple systems failure. I felt that this was the only way to relieve him off his suffering and to die with dignity.

Ethics

In terms of patient care and passive euthanasia, there are a lot of arguments that prevents people allowing it. Since Paul was an 84 year old man with multiple systems failure and the medical team having spent a lot of time with treatment that resulted in no progress of healing, stopping the treatment was the best thing they could do. However, many people against euthanasia would feel that euthanasia will shows as an acceptance that Paul’s life is worth less than others or as a way to save money or even as a discouragement towards the search for new cures and treatments. It is also believed by some that the suffering is god’s punishment and euthanasia acts as a loophole.

Empirics

Empirical knowledge is said to be the positivistic science by Carper (1978) that sees the reality as something that can be measured, tested and verified. When I did not know anything about Paul’s condition nor did I introduced myself to him, my intuition towards the sight in front of me led me to think that euthanasia was the best thing for him according to the suffering he was going through since the past couple of weeks. He was at the state that even if his health started improving, he would have to be supported by someone through all/most of his everyday activities. Dwyer (2008) described this as the patient becoming physically and emotionally vulnerable resulting in the loss of their dignity.