Palliative Nursing FOR END-OF-LIFE CASES

Palliative Care Nursing Theories

Theories and a Theoretical Framework for Nursing

A nursing theory helps structure decisions and practice for the nurse professional (Scribd, 2014). The three major types are the grand theory, the middle-range theory and the nursing practice theory. The use of any of these theories enables the nurse to provide more effective patient care more efficiently. Grand theories deal with the overall nature and goals of nursing, as discussed by Marilyn Parker in "Nursing Theories and Nursing Practice." The scope is broad and synthesizes nursing experience, observations and scholarship. Middle-range theories deal with specific and applicable concepts and research to nursing practice. They make available many practical strategies to the nurse in delivering quality patient care. And nursing practice theories tackle issues and questions relating to specific populations or settings. They provide models t help nurses address day-to-day practice experiences (Scribd).

The Comfort Theory

This theory was developed in the 1990s by Katharine Kolcaba, a clinical nursing specialist in gerontology. Kolcaba (2010) perceived comfort as existing in three ways, namely relief, ease, and transcendence. She saw patient comfort as occurring in four forms, namely physical, psycho-spiritual, environmental and socio-cultural. Comfort as relief is achieved when a patient experiencing postoperative pain is given prescribed analgesia. Comfort as ease or contentment is also achieved if a patient experiences anxiety and the cause is effectively addressed. And comfort as transcendence is achieved if the patient is able to bear or overcome challenges (Kolcaba). This theoretical structure is quite capable of directing the work and thought of healthcare providers.

The theory says that when the healthcare needs of a patient are correctly identified and appropriate nursing interventions are used to respond to these needs, the result enhances his comfort (March, 2009). When this happens, his health-seeking behavior is encouraged and can increase. The behavior may be internal, such as healing of wounds or improved oxygenation. It may also be external, such as cooperation in rehabilitation or a peaceful death. Achieving health-seeking behaviors also increases the integrity of the institution because it results in improved outcomes in the patient. As a further consequence, increased institutional integrity leads to the development and better implementation of best practices and best policies next to the attainment of positive patient outcomes (March).

The nature of the concept of comfort is universal and, therefore, likewise a universal goal of healthcare (March, 2009). Although Kocalba originally conceived of her theory only within the nursing domain, she also says that an institution, which is committed to meeting the healthcare needs of patients, can also apply this theory as an institution-wide approach. Doing so must modify and broaden the application of "nursing interventions" to "comfort interventions" in order to include any other healthcare practitioner who adapts the theoretical structure (March). This theory is applicable as well as necessary in meeting the comfort needs of patients with life-limiting illnesses.

The Middle-Range Theory of Transitions

Afaf I. Meleis created this theory, which provides transitions to guide anticipated interventions for older adults with dementia and their caregivers (Rose & Lopez, 2012). Meleis defines transition as a movement between two relatively stable periods of time, such as a particular life phase, situation or status to another. Her theory states that such transitions are impelled by certain stimuli or events, which require new reactions. These new reactions in a patient consequently call for new strategies to cope with the stimuli (Rose & Lopez). Dementia or Alzheimer's Disease is another life-limiting illness.

The Global Deterioration Scale lists seven global stages in the Dementia Trajectory according to the patient's cognition and function (Rose & Lopez, 2012). These stages cover memory loss and functional loss. The stages in memory loss descend from no subjective memory deficit, very mild decline, mild decline, moderate decline, moderately severe decline to very severe decline. Functional loss progressively deteriorates from normal function, some feeling of memory lapses, trouble remembering or misplacing items, increased functional difficulty, forgetfulness and difficulty choosing clothing but with some independence in basic functions, personality changes, and need for assistance in all aspects of care, combined with loss of verbal abilities, rigid muscles and difficulty swallowing. Transitions needed include obtaining the initial diagnosis of dementia, advanced planning for costs and healthcare, cessation of driving, handling behavior symptoms, changes in setting, and preparation for end-of-life (Rose & Lopez).

Implementation involves palliative care instead of aggressive, life-sustaining care for patients with advanced...

Few of them, however, receive this type of care and many die because of the difficult interventions required by such care. These include hospital transfers, emergency room visits, parental therapy or tube feeding, often accompanied by troubling symptoms like dyspnea, pain and restlessness. Obstacles to this type of care also include the failure to recognize dementia as a terminal illness and the lack of adequate communication. Most nursing homes may also enforce usual life-sustaining rather than palliative care. This present culture in many healthcare facilities is due to staff shortage and lack of education.
The responsibility of palliative care than falls into the hands of family caregivers who are the primary decision-makers for patients with advanced dementia. Yet, these family caregivers are often not prepared to make proper choices in the transition from aggressive or life-sustaining to merely comfort measures. They depend on nurses to guide them in making such decisions, yet nurses are themselves often reluctant to provide such assistance (Rose & Lopez).

Yet, nurses must play that important part of assisting family caregivers in guiding the latter through the transitions (Rose & Lopez, 2012). Family caregivers are confronted with intensely stressful, burdensome and depressing situation of handling those transitions from the start of the diagnosis to the death of the patient. Nurses must assist these family caregivers go through and survive these transitions (Rose & Lopez).

Typology of Journeys Theory

The lack of services and physicians' failure to inform patients and families about it deprive the latter of the chance to obtain palliative care (Lyles et al., 2011). Under the circumstances, nurses should fill the gap and enable these patients and families to obtain it. She will find this typology of illness journeys helpful in determining the characteristics of care suitable for them and advising them on the most appropriate care for the patients' illness. Palliative care is provided to relieve pain and suffering as well as improve the quality of life of patients with chronic, incurable, terminal or serious illnesses and their families. Palliative care covers curative and non-curative treatments and hospice care services. Patients in advanced cancer stages often need the last one (Lyles et al.).

Lyles and her team (2011) identified these three types of journeys as isolated, rescued and comfort. Families of adult cancer patients often tend to overestimate the chances of survival and choose aggressive therapies. This reflects the curative approach. Oncologists have the same tendency to overestimate prognosis, according to studies. The isolated journey is characterized by the type of medical care chosen by patients and families who are well-informed about health and disease. In contrast, those with low or marginal health literacy tend to opt for aggressive care only at the end of life stage. A struggle to shift from curative to non-curative cancer treatment surfaces in the rescued journey. Proper communication makes experiences more productive and realistic when decisions are made about how to deal with symptom control. Emotional support and realistic goals are then established. Focus shifts to concrete situations on a day-to-day basis. Discussions go beyond medical facts and into the distressing task of confronting the need for end-of-life care with the family. And the comforted journey establishes a patient-centered group of healthcare professionals in unity with the family. At this stage, there is frank communication about the treatment options, consisting of fewer aggressive life-sustaining medical interventions approaching death. The options also aim at an overall more rational view of the death situation for the family. Palliative care as preceding hospital provides support to patients and families through diagnosis and the side effects of treatment by directing care towards enhancing the qualify of life and fulfilling patient goals. The comforted journey is the path recommended by the authors for this case as most appropriately filling the requirements (Lyles et al.).

Implementation

Nurses need to rationally tackle communicating the concept of awareness of dying when dealing with patients who should receive palliative care. In this situation, the patient and the family become suspicious when the patient is indirectly informed or made to feel that his health is failing. This happens when symptoms appear, during conversations, treatment, through internet findings and other sources of information. At this point, patient and the family may subliminally and mutually pretend that the patient is not too seriously ill or terminal. This is called closed awareness. An open awareness, in contrast, is one wherein the patient's real and chronic or terminal status is plainly communicated and understood by the patient, the family and the healthcare professionals. An open awareness does not always mean acceptance of the true condition by the patient and the family. It is the nurse's responsibility to…