Free Nursing Essays - Experiencing a crisis: User-centred case study that explores the user's experience of a crisis and examines nursing implications for practice
Introduction
As we go through life, unless we are exceptionally fortunate, we will meet a number of crises which will need to be coped and dealt with. These generally do not present insurmountable difficulties to the average person. When someone is debilitated or ill (particularly with some forms of mental illness), crises – that they would otherwise perhaps deal with without difficulty - can actually become of much greater significance in their lives and may even take on overwhelming proportions. In this essay we shall consider a fundamental challenge faced by many patients, that of impending death, and explore how a nurse can empathise, understand, explore and assist the patient in dealing with the problem.
The case study
This study revolves around a Mrs.J., a 62 year old lady who presented in casualty with sudden onset leg pain and immobility. A simple X-Ray showed changes diagnostic of a pathological fracture with huge amounts of focal bone loss in her mid femur. A skeletal survey then revealed multiple bony metastatic deposits. Clinical examination showed her to have a large fixed lump in her right breast and initial blood tests showed gross metabolic abnormalities including abnormal LFTs and severe anaemia.
Clearly the diagnosis was of a fairly terminal breast malignancy which had clearly been present for some time and had spread widely at the time of presentation.
Discussions with Mrs.J. revealed that she had observed the breast lump eleven months previously but had chosen to deal with it by frank denial.
Discussion
The learning point and discussion in this case study is the illustration that some patients such as Mrs.J. cope with crises in their life by simply ignoring them. This is not an uncommon experience. Any experienced healthcare professional will testify that patients will commonly utilise a variety of such mechanisms of cognitive distortion (CDs) ranging from undue optimism to complete denial ( as in Mrs.J.’s case). (Dobrantz 2005).
One of the major stumbling blocks which has been identified in past studies, and certainly one that we must be aware of, is the fact that it is a common finding that the patient will often not openly accept that they have a terminal prognosis. This can either be because of frank denial or it may be that choose to remain intrinsically optimistic. (O'Rourke N 2001)
The therapeutic difficulty for the healthcare professional here is the degree of collusion that can be ethically employed (Sugarman J & Sulmasy 2001). This was beautifully illustrated in a fictional work by AJ Cronin (1934). The eponymous Dr Findlay faced a dilemma in telling an old lady that she was about to die despite the management strategy of his partner Dr Cameron who told her that she “looked better “every time he met her. He wrestled with his conscience and decided to tell her the truth. Within a week she was dead. The point of the story was shown with the lady’s husband talking to Dr Findlay at the end of the book. Dr Findlay expresses surprise that the old lady died so quickly after being told her real prognosis, and the husband replies by pointing out the Dr Findlay took away the one thing that was keeping her alive - and that was hope.
This illustrates one of the real dilemmas for the healthcare professional, of this type of situation “Just how truthful should one be?”.
To some extent this is a matter of personal judgement with most professionals agreeing that truth is probably the best policy, but the degree of truth can be a matter of negotiation. (Parker and Lawton 2003).
This matter has been the subject of many excellent papers, perhaps one of the best being by The (et al 2000). The paper examined the degree of collusion between healthcare professionals and patients when discussing imminent death. It particularly noted that even when patients were told overtly about terminal prognoses, they could completely ignore the comments and remain optimistic ( presumably as a coping mechanism).
The nursing response
There are a great many different nursing models which we could employ to try to analyse Mrs.J.’s situation. These are all used under the overall umbrella of the Nursing Process of assessment, planning, implementation and evaluation
(Fawcett J 2005)
If we apply the Roper, Logan, Tierney model (2000) and assess the activities of daily living in a problem solving manner, we can see that this process is primarily of use in those situations that are physically orientated. Although Mrs.J. clearly had massive physical problems with her sudden inability to walk, self care and her other sequelae from the main malignancy, the major thrust of this essay is her denial of the diagnosis, which Roper et al. is not particularly useful in describing.
The Roy Adaptation model (1991) is more helpful as it can be useful to describe the adaptive processes that a patient makes to the “illness-role”. In this particular circumstance however, Mrs.J. has entered into a period of complete denial of her illness which enabled her to maintain her facade of “wellness” and thereby did not have to consider herself as “ill” until the reality of a pathological fracture of her leg forced her to both admit and adapt to it.
Johnson’s Behavioural System model (Wilkerson et al 1996) is more useful still, as it allows for the denial element of Mrs.J.’s behaviour, but equally does not prove particularly useful in describing the adaptive processes that Mrs.J. will have to face in coming to terms with her physical disability.
In short, we have to conclude (like Wadensten et al 2003), that there is not one ideal nursing model that can be employed for this type of situation with a multi-dimensional aetiology
Psycho-social and spiritual effects
This is the crux of the good management issue. The whole concept of “health” is underpinned by the realisation that the Anglo-Saxon word “health” is best translated as “wholeness”. A healthcare professional cannot realistically try to provide a patient with “health” unless they try to practice holistic medical care. This recognises both the spiritual and psycho-social elements of health as well as the overtly physical. (Wright et al 2001)
In this context, one should consider the very well written paper by Murray (et al 2003) which provided the unusual and fascinating insight into the spiritual needs of the dying in two completely different societies. It underlines the fact that the patient’s spiritual needs are largely determined by the culture in which they live. The nurse must be empathetic to this. This difference was summed up in the sentence:
The emotional pain of facing death was the prime concern of Scottish patients and their carers, while physical pain and financial worries dominated the lives of Kenyan patients and their carers. (Murray et al 2003).
Mrs.J.’s emotional pain of trying to cope with imminent death was clearly too great for her to assimilate. This must be understood by her medical attendants if she is to have a “good death” (Seale et al 2003)
Explore the role of technology in supporting the critically ill
Technology has advanced beyond all recognition in the past two decades. Mrs.J. can expect a rather different set of options in her care plan today than she might have done had she presented two decades ago. The ability to image the interior of the body with the MRI and CAT scan technologies has absolutely revolutionised the ability of the healthcare professional to deal with malignant disease
Analyse the acute service provision including an insight into pre-hospital care.
Clearly there was no pre-hospital care in the case of Mrs.J. so this element of the evaluation cannot be specifically answered in her case. The acute hospital care was, by any evaluation, excellent. From the moment of presentation a working diagnosis was made within about two hours and a full management decision was made within about four hours. She was made pain free within 30 minutes of that decision of the working diagnosis.
She was admitted onto the ward and assigned a nurse, (me), who was able to make a full assessment of her problems, contact her family, and assist in an agreed revelation of her situation, which gave her a chance to maintain her dignity and to confront her spiritual needs by preparing to say goodbye to those that she loved. (Marks-Moran et al. 1996)
She contacted orthostatic bronchopneumonia and died peacefully in her sleep with no discernible distress with close members of her family present.
Had she survived longer, we may have had the opportunity to explore hospice input but this was not an option for her in the circumstances (Billings et al. 2002)
Explore psychological reactions to acute illness .
The psycho pathology of the adverse illness trajectory is explored in some detail by Jennings (et al 1997). We have discussed Mrs.J.’s reaction to the discovery of her breast lump above. Jennings discusses the process in considerably more detail.
The typical patient contemplating a terminal prognosis (either overtly or covertly), experiences emotional turmoil to a degree that is seldom experienced in other circumstances. Their reaction can range across a series of psychological reactions including depression, false optimism, denial and sometimes culminating in varying degrees of acceptance. This spectrum must be regarded as part of the normal spectrum of illness behaviour, and should be seen and understood as such by the concerned healthcare professional. (Cuttini et al 2003)
Meredith (et al 1996) explored the patient reaction to being given a terminal diagnosis in terms of just how they quantified the information given in terms of being eventually cured. We have already commented on the patient’s inability to sometimes assimilate the frank discussion of a terminal prognosis. Both Leydon (et al 2000) and Costain (et al 1999) have produced excellent and detailed studies on these issues. Another aspect of the denial issue is highlighted in the paper by Dean (2000) who examined the phenomenon of patients who will overtly collude with their doctors about the possibility of a cure, but will equally confide in a trusted nurse that they know a cure is simply not possible. It is as if they do not wish to openly question the doctor’s belief that they can cure the patient. (Lynn J. 2001)
Demonstrate a wider understanding of patho-physiology and its application to the treatment options in acute illness.
Mrs.J.’s problems proved to be far too far progressed to allow any realistic chance of a cure as she died less than three days after admission. In those three days I was able to build up a rapport with her and to understand her mental state quite well. Once she had come to terms with her overt denial, she proved to be very inquisitive about her disease process and asked for a lot of information on the subject
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