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Carla which is a 54 year old female suffering from terminal stage metastatic ovarian cancer is going through both physiological as well as psychological trauma. This is her end of life stage and she is going through a dilemma of how to proceed with her palliative care and treatment. On one side her family and her husband are insisting on prolonging life to see face of her grandson which is due to be born after 4 months and at the same time she is afraid of the fact that her sufferings would be enhanced and she would lose dignity of life.
This assignment is ultimately aiming to develop a mechanism of palliative care which will address the issues associated with the patient and incorporate her wishes to the maximum extent possible. After diagnosis patient expressed her desire to go home and die peacefully without pain. She is calm and composed in appearance while her daughter and husband are distressed. However there are some hidden signs of stress in the patient as well. Patient wants to spend her last time with her family and die at her home only (Temel, et al., 2010).
Body of Essay
Integrated case management model can be applied in such situations which is a family focused strength based program that is used as an independent facilitator to bring in all relevant people associated with case. In this model GP of patient, her nursing professional and her consultant doctor would work as a team with the family members and friends of patient and together this model will incorporate desires of each member up to the extent possible. It can also be stated that this model encourages patient centred approach in treatment plan which will be coordinated with all stakeholders associated in the plan and it would move in continuum with changing needs of patient (Ouwens, et al. 2005).
Client Carla is suffering from metastatic ovarian cancer which is at terminal stage and patient is currently being given supportive treatment and palliative care. She has already been given multiple therapies, surgeries and chemotherapy but she has reached a stage where her disease is progressing and she is increasingly getting dependent on others for her daily care and basic activities. Her primary problem is that she is expressing her desire to have a pain free end of life while her husband and daughter are encouraging her to seek active treatment in a hospital so that her life can be prolonged and she would be able to witness her grandson which is due to be born in 4 months. She is in a dilemma where she knows that her family meant well and they all want her to have that happiness before she go, on the other hand she is also afraid that further treatment would make her end days very miserable and painful which she cannot bear (Bodenheimer, et al. 2002).
Her weakness includes the fact that she is in a dilemma and she is not able to make a firm decision. Her friend is supporting her in her desires but she is not able to confront her family and in result there is a stress in all relations of family members. Her husband and daughter are in a denial mode while her son understands that and have a more sympathetic approach towards her mother’s desire. Her strength includes her son and her friend who understand her point of view and not focusing entirely on a different perspective. These conflicting views and anger are clearly visible signs of denial and frustration over her illness and it is making situation worst for her in her near end days (Delgado-Guay, et al. 2009).
Nursing Diagnosis and Goals
On the basis of case study analysis and literature associated with metastatic ovarian cancer following nursing diagnosis are formed for Carla.
1. Anxiety related to threat of malignancy and lack of knowledge about the disease process and prognosis.
2. Grievance related to poor prognosis of advanced stage of disease.
3. Disturbed psychological health due to loss of good health, disease prognosis and family stress levels.
Goals for these nursing diagnoses would be as follows.
1. To reduce the anxiety level of patient as well as her family members, increase awareness level about illness and its impact on daily life.
2. To alleviate the grievance of patient and family, increase their morale and help them prepare for the upcoming end of life for patient.
3. To improvise the psychological health of patient and family through counselling, psychiatric consultations and family sessions which can reduce the conflicts between them?
Nursing Interventions and Rationale
First nursing intervention which is recommended in this case is to organize a family counselling session which will be participated by all family members under the guidance of a psychiatric professional (nurse or doctor). This counselling session would be an opportunity to exchange all view points and critically evaluate them on basis of their merits. This way Carla would be able to convey her desire strongly and her family member would also provide their view points. This nursing intervention will also help in refocusing the view of husband and daughter that priority should be Carla’s health and her wishes and they need to find an acceptable solution which does not interfere with the primary focus of patient and what is in her best interest. Family members would also be informed that they need to reduce the stress level and unnecessary arguments in front of Carla. Her friend would also be informed that she need to limit her interference in family matters because this would make husband and family alienate towards her (Lee, O'Connor and Sanchia, 2012).
Second intervention would be for patient herself where she will be educated and informed about various pain alleviation techniques which can be helpful in reducing her pain levels during treatment procedure. Advanced form of medication and elective surgeries, subcutaneous reservoir of pain killers with sustained release mechanism are some approaches which can be helpful for patient to seek further active treatment as well. There is a very real possibility that patient perceives pain levels in a very negative manner for her planned treatment and she is fearful of it. This intervention would encourage her to seek treatment in a gradual manner and perceive till what level she is comfortable. This way her life can be prolonged without compromising on the quality and dignity of patient (Smith & Godfrey, 2002).
Third intervention would be facilitating communication between family members and educating them about the priorities in end stage of life and mental situation of a patient suffering from such a terminal disease. Community nurses, General practitioner and a oncologist can collectively form a team and provide information on prognosis and treatment and impact of a healthy environment on the prognosis of such patients. It might be possible that with sufficient will power and positivity she would be able to face the hardships of active treatment and agree to it (Strang, et al. 2004).
Role of Allied Team
An allied team would have members from different specialities of health care services who would collectively provide the integrated care to patient through earlier identified integrated care management model. In this model a holistic treatment plan would be created for patient where patient would be at the centre of entire plan. While developing the plan wishes and desires of patient and families would be included to the extent possible. For this model a allied team would be needed which will include a consultant oncologists, a nurse with experience in palliative care, a psychiatric professional, a family counsellor and patient’s general practitioner. As a team they would be able to discuss and reflect upon each request of patient, how it can be integrated in the treatment plan and what could be the advantages and disadvantages of incorporation. One of the biggest advantages of an allied team would be that there would be no conflicting view points among health care professional once the plan is finalized because it would be finalized after discussion and approval of all team members. An allied team providing integrate care management model based plan would also have the advantage that it would incorporate the best of features of different treatment modalities. For example an oncologist would not be able to capture the full extent of psychological impact on a happy family in plan but a psychiatrist would and collectively they can increase the efficiency of the plan to a great extent (Clark, 2007).
First referral for patient would be to a pain management professional who would assess if Carla had a traumatic experience with pain in her previous treatments. Professional would help her in understanding what better could be done for her to alleviate the pain and what would be the precautions which will be taken for her in future so that she does not have to bear the same levels. Pain management professional can also introduce her to some non conventional techniques like meditation, Yoga, chiropractic, Aroma therapy etc to further help her with pain and discomfort.
Second referral would be to a psychiatrist who specializes in coping up mechanism and grief management. This referral would be for patient as well as family members of Carla so that they can all come out of denial, accept the reality and work together as a team and incorporate integrated care management model successfully (Hanson, Henderson and Menon, 2002).
In such situation care giver should focus on all aspects of care providing and ensure that there is no breach in any area at any point of time. It is an ethical duty of the care providing person to involve family members in the plan of palliative care and inform them that not involving patient in the plan can have very devastating effect on the entire supportive and care giving plan. They all collectively determine which treatment is to be provided with a symptomatic treatment which will mellow down the symptoms of not only disease but also symptoms of the chemotherapy and radiation therapy (Royal College of Nursing, Australia, 2008).
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Strang P, Strang S, Hultborn R, Arnér S (2004). "Existential pain—an entity, a provocation, or a challenge?". J Pain Symptom Manage 27 (3): 241–50.
Hanson, LC; Henderson, M; Menon, M. 2002, As Individual as Death Itself: A Focus Group Study of Terminal Care in Nursing Homes. Palliative Medicine; 2002; 5(1):117-125.
Clark, D. (2007). From margins to centre: a review of the history of palliative care in cancer. The lancet oncology, 8(5), 430-438.
Delgado-Guay, M., Parsons, H.A., Li, Z., Palmer, J.L. and Bruera, E., 2009. Symptom distress in advanced cancer patients with anxiety and depression in the palliative care setting. Supportive Care in Cancer, 17(5), pp.573-579.
Bodenheimer, T., Wagner, E.H. and Grumbach, K., 2002. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama, 288(15), pp.1909-1914.