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In patients suffering from terminal illness they generally develop an intention to die at home in spite of presence of best palliative care available. This type of wish cannot be always considered symptomatic of suboptimal care. The wish or intense desire to die at home is mainly due to the presence of family comfort, support and privacy that cannot be obtained at the hospitals. According to an audit conducted by the Royal College of physicians and Marie Curie palliative care institute it is observed that 70% of the patients preferred dying at home. Important to convey that in course of addressing this issue it is imperative for the healthcare professionals to discuss the patient’s last desire, the extent of medical support can be provided to the concerned patient and the expected consequences. However, studies clearly indicate the presence of a good number of disparities with respect to the availability of support that can be provided to the concerned patient (Chapman, 2015).
Another key finding in this respect that demand attention is the consent issue of the family of the terminally ill patient willing to die at home. Research revealed that in majority of cases the family members do not feel comfortable in taking the ultimate decisions. Also about 65% of the general practioners is evident not to give their confident support towards discussing the end of life discussion. According to the verdict given by Dr. Lucy Iscon a senior house officer at North Middlesex hospital, death being an important and inseparable part of every human life, everyone has the right to decide the place of death ("Healthcare professionals must listen to patients’ dying wishes", 2014).
Hence referring to the information provided on the introductory note it can be stated that considering the wish of a dying individual is very important both on ethical and humanitarian ground. Therefore it is the diverseness and controversial aspects that can be considered as the primary reason for selecting this particular topic.
Role of community nurse to provide palliative care at home for terminal patients:
Community nurses play a pivotal role in providing palliative care for the critically ill patients. Apart from addressing the medical needs of a terminally ill patient, a community nurse if also responsible for providing emotional support to the patient and his family members. They are involved in guiding the concerned patients through effective and therapeutic communication process. Hence a community nurse act as a teacher, psychologist, preacher, trusted messenger, rescuer for the terminally ill patient receiving palliative care at home. Furthermore a community nurse associated with providing palliative care to a terminally ill patient gradually prepares the family members towards the adverse consequences of the concerned patients. The implementation of advanced directives can be cited in this respect (Morley, 2010).
Policies and priority to patient’s expectation or desire:
This particular issue indicating a terminal patient’s wish for place of death can also been brought into consideration by various government organization. According to the guidelines of the National Cancer plan the choices of the terminal patients in this respect can be considered. referring to the pledge published by the National Health Service entitled ‘ building on the best: choice, responsiveness and equity’ assurance was given to provide the best possible care for such patients irrespective of their place of stay for the last few days remaining in their lives (Cosgrove, & Bari, 2012). However, the feasibility issue regarding the support system and medical care can be provided to such patients staying at home is evident to be one of the issues of concern. Terminal patients wish to die at home also got acceptance in the House of Commons Health Committee supported by Marie Curie Cancer Care’s campaign ("More people fulfil wish to die at home with Marie Curie care", 2012).
Researches further reveal that the hospitals and palliative care units of the United Kingdom supporting this matter preferred to keep the terminal patients for a short interval and giving them a quick discharge as possible. However, the key problem in this respect is providing proper care to the patients at their place of stay as it appeared to be a risky matter of providing the required medical support at home for such patients (Frearson et al., 2013).
Therefore in light of the above mentioned statement it is justified to convey that thee exist a prominent link between the degree of care coordination and the patient’s wish to palliate at home. Nevertheless, the patient’s desire has been given priority in every case (Wheatley, & Baker, 2007).
The ethical aspects:
This mater of discussion being very sensitive one, the ethical consideration also are evident to be surfaced. In many published literatures it is evident that this particular tropic can be aligned with various ethical theories. The task of decision making can be linked with ethical principles. Hence in light of moral theory it can be stated that the primary duty of the healthcare professionals can be linked with non-malfeasance, beneficence with respect to justice and autonomy. However, ethical dilemma comes into play that is very dominant while decision making is done. Aligning with the ethical aspects of non-malfeasance the healthcare professionals should avoid causing any harm to their patients. However this particular harm can be both physical and psychological. Ethical dilemmas are an evitable factor the healthcare professional while deciding the quick discharge of terminal patients (Wheatley, & Baker, 2007).
Considering the ethical principles related with beneficence the healthcare professionals should benefit the patients wherein it is important for them to act proportionately which considering their duty to act beneficently. Autonomy in ethical aspects can be identified as the capacity to make or express the choices and it should be free from any external constraints or obligations particularly coercion. However, the patients at coma are not applicable to this aspect. Researches also indicate that too much dependency on autonomy is a matter of concern for the case of terminal patients with complete absence of mental balance (Wittenberg-Lyles, Oliver, Demiris, & Baldwin, 2010).
Justice is another significant element under ethical principles of decision making. Incorporation of fairness and emphasis to equality of consideration are evident to align with this aspect. Hence it is evident that the healthcare professionals prefer to apply the concept of pragmatism in balancing with a key focus to bypass the conflicting issues (Manima, 2010).
Significance of communication between the inter-professional team:
Literatures also support the significance of communication between the inter-professionals team’s members while addressing this particular issue. Communication is important is order to decisions the medical aid to be providing for such terminal patients expressing the desire to palliate at home. The decision making task is done only after the medical experts, the nurses and the care providers discuss the concern topic. However, chances for conflicting situation is also evident to surface in certain cases. Communication is witnessed to be equally crucial for the primary care providers of the concerned patient to work efficiently (Powazki, Walsh, & Shrotriya, 2014).
In this content it is essential to highlight that the hospice and palliate team comprise of physicians, nurses, social workers, chaplains, volunteers, bereavement councillors, dieticians and pharmacists forming an interdisciplinary team. The presence of perceptions of collaboration and knowledge level of such team is one of the pivotal players in this content. Collaborative communication is hence effective as one of the important aspect that reflects an effective and successful team meeting.
Citing the example of hospice care, the fluid and interactive process of collaborative communication are distinct from the interpersonal communication incident between the interdisciplinary team members (Kobayashi, & McAllister, 2013).
The preparation and finalisation of discharge planning is also evident to demand a good amount of interaction between the healthcare team, the care providers and the nurses. While communication or discussing this particular issue it is observed that whether the patient’s mental capacity is able the make a decision for the place of care is taken into consideration. Risk of home discharge and issues related with resource allocation is also brought under consideration while interaction between the inter-professionals team members. The communication process between the such team member are include considering the patient’s autonomy and issues related with providing the feasibility to provide optimum care (Rackow, Ofori, Rodkey, & Beveridge, 2015).
Hence it can be inferred that the process of discharge planning for terminal patients with expressing a deep desire to palliate at home demand extensive level of communication between the inter-professional team member. On a contradictory note it is also evident that the healthcare professionals involved in such cases avoid the unwanted delays increasing the risk wherein the concerned patient may miss the window opportunity for being palliated at home (Wheatley, & Baker, 2007).
Importance of team meeting:
The involvement of multidisciplinary team for providing palliative patient’s care for terminally ill patients (cancer patients) at home begins with providing the patient’s family member with complete information regarding the medical situation of the concerned patients. However, the benefits of regular team meetings by the multidisciplinary team are evident in many cited publications. It is observed that such meetings are usually held weekly and may also include teleconference or video conference (Aggarwal, & Roy, 2014).
Citing the example of terminal cancer patient; expressing the wish to palliate at home through regular team meeting the inter-professional team members care capable for providing bettering training and guidance to the participating physician and nurses. Also such team meeting is evident to be reflecting a god communication platform providing an opportunity for them to share their ideas. researches has also indicated that particularly in the Western countries the recommendations given by the multidisciplinary team while handling a case of terminally ill cancer patient is given only after discussing the issue with each patient conveyed by one the member of the care team (Silbermann et al., 2013).
Barriers and facilitators to care coordination:
Referring to a survey data a number of barriers with respect to providing a well coordinated care to the terminal patients at home is evident. Lack for sufficient time, presence of adequate working force small caseloads and insufficient funding are the key issues. According to a qualitative survey data it is observed that lack of proper identification of the health care professional’s roles and responsibilities, improper communication between the specialist and primary care providers, hierarchical boundaries, equal involvement of the team members are the major barriers or limitation in terms of providing a well coordinated care to terminally ill patient at home. Apart from this it is also observed that issues related with decision making, ignorance with respect to nurses contributed in providing patient centered information are the other barriers in this respect (Walsh et al., 2010).
However researches can also indicated the presence of certain factors that contribute as facilitator to providing a well coordinate care to the terminal cancer patients. Efficient leadership skill encouraging inclusiveness and open table discussion, team dynamic reflecting mutual respect and trust, presence of support at an administrative level and participation of the concerned patient has been include as the facilitators in this respect (Silbermann et al., 2013). However, the issues related with patient’s involvement are subjected to the medical and psychological condition of the patient wherein the patient’s in coma or in suffering from mental retardation cannot be considered. Important to highlight that as the nurses play a significant role in providing care to terminal patient’s at home team dynamic shall also indicate the nurses concern regarding the psychological requirements of such patients (Oâ??Brien, & Jack, 2009).
Inclusion and exclusion criteria:
Emphasis has been given on considering certain factors under inclusion and exclusion criteria as this assignment has focused to critically the issue related with terminal patient’s wish to palliate at home an extensive literature based research has been undertaken. The data assimilated and presented in this can be considered as a good source of secondary research data.
The factors considered as exclusion criteria are:
No other language other than English language has been considered
The case studies exemplifying patients in coma, brain death condition and or in mentally retarded stage has been excluded
The factors enlisted under the inclusion criteria:
The journal only in English language has been considered
Only published article has been referred
Palliative care, community care, nurses, multidisciplinary team, cancer patients, healthcare professionals, service providers, ‘wish to die at home’ are the key words used in search engine.
The journals published between the times span of 2000-2017 has been include as reference source.
The case studies of United Kingdom have been primarily considered.
Referring to the analytical discussion presented in the above sections it can be inferred that responding to the terminal patients wish to palliate at home is very sensitive and ethical issue wherein the healthcare professional need to pay a significant attention. However, it can be further added that the inter-professional team cannot be considered as a single dose intervention of in providing medical support to such patients at home. The fact that the inter-professional team member reflects a longitudinal care structure is important to consider. However, in order to embed a well coordinated care structure for handling such patient it is essential for understanding the team structure composition, its culture, process and performance efficacy. The concept of personalised oncology can be exemplified as one of the emerging issues to surface in future in this respect.
Aggarwal, G., & Roy, M. (2014). Multidisciplinary team meetings foroptimalmanagement of cancer patients: A must?. Indian Journal Of Cancer, 51(4), 495. http://dx.doi.org/10.4103/0019-509x.175337
Chapman, S. (2015). A good death at home: home palliative care services keep people where they want to be - Evidently Cochrane. Evidently Cochrane. Retrieved 27 March 2017, from http://www.evidentlycochrane.net/a-good-death-at-home-home-palliative-care-services-keep-people-where-they-want-to-be/
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Healthcare professionals must listen to patients’ dying wishes. (2014). the Guardian. Retrieved 27 March 2017, from https://www.theguardian.com/healthcare-network/views-from-the-nhs-frontline/2014/nov/24/healthcare-professionals-patients-dying-wishes-die-at-home
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More people fulfil wish to die at home with Marie Curie care. (2012). Cancer Nursing Practice, 11(10), 4-4. http://dx.doi.org/10.7748/cnp2012.12.11.10.4.p10100
Morley, R. (2010). Community Palliative Care – The Role of the Clinical Nurse SpecialistCommunity Palliative Care – The Role of the Clinical Nurse Specialist. Nursing Standard, 24(35), pp.31-31.
Brien, M., & Jack, B. (2009). Barriers to dying at home: the impact of poor??Oâco-ordinationof community service provision for patients with cancer. Health & Social Care In The Community. http://dx.doi.org/10.1111/j.1365-2524.2009.00897.x
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Silbermann, M., Pitsillides, B., Al-Alfi, N., Omran, S., Al-Jabri, K., & Elshamy, K. et al. (2013). Multidisciplinary care team for cancer patients and its implementation in several Middle Eastern countries. Annals Of Oncology, 24(suppl 7), vii41-vii47. http://dx.doi.org/10.1093/annonc/mdt265
Walsh, J., Harrison, J., Young, J., Butow, P., Solomon, M., & Masya, L. (2010). What are the current barriers to effective cancer care coordination? A qualitative study. BMC Health Services Research, 10(1). http://dx.doi.org/10.1186/1472-6963-10-132
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Wittenberg-Lyles, E., Oliver, D., Demiris, G., & Baldwin, P. (2010). The ACTive Intervention in Hospice Interdisciplinary Team Meetings: Exploring Family Caregiver and Hospice Team Communication. Journal Of Computer-Mediated Communication, 15(3), 465-481. http://dx.doi.org/10.1111/j.1083-6101.2010.01502.x