2000 words ± 10%
Weighting: 40%
Having progressed through the content in Theme 1 and 2 of the Learning guides you will have an improved understanding of advance concepts in palliative care nursing while assessing and managing pain and other complex symptoms.
The purpose of this assessment is for you to demonstrate this knowledge by reflecting on a case study
For this assessment, with chosen patient in the case study and its significant that was significant to you, and analyses the situation of managing complex symptoms using a critical reflection framework such as Gibbs Model of reflection (Gibbs, 1988).
In the context of this assessment, \’critical\’ means that the incident in the case study had meaning for you, not that it was an emergency such as a palliative care emergency. It may have been a miscommunication or adverse event, which had an impact on you, causing you to reflect on the event.
The experience may have resulted in new learning and/or a change in practice.
Throughout your reflection, you are expected to refer and benchmark against the Registered nurse standards for practice (Nurses and Midwifery Board of Australia, 2016), National palliative care standards (Palliative Care Australia, 2018) and Competency standards for specialist palliative care nursing practice (Canning et al., 2005).
Assessment criteria
This assessment is marked against the rubric for reflective essay.
References
Canning, D., Yates, P. & Rosenberg, J.P. (2005). Competency Standards for Specialist Palliative Care Nursing Practice. [PDF report]. Queensland University of Technology. https://www.pcna.org.au/PCNA/media/docs/competystds_1.pdf
Nurses and Midwifery Board of Australia. (2016). Registered nurse standards for practice. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
Palliative Care Australia. (2018). National palliative care standards (5th ed.). https://palliativecare.org.au/standards
Theme 1
1.1 Wachholtz, A. B., Fitch, C. E., Makowski, S., & Tjia, J. (2016). A comprehensive approach to the patient at end of life: Assessment of multidimensional suffering. Southern Medical Journal, 109(4), 200–206. https://doi.org/10.14423/SMJ.0000000000000439
1.2 Krawczyk, M., & Richards, N. (2018). The relevance of “total pain†in palliative care practice and policy. European Journal of Palliative Care, 25(3), 128–130.
1.3 Malotte, K. L., & McPherson, M. L. (2016). Identification, assessment, and management of pain in patients with advanced dementia. Mental Health Clinician, 6(2), 89-94. https://doi.org/10.9740/mhc.2016.03.89
1.4 Wilkie, D. J., & Ezenwa, M. O. (2012). Pain and symptom management in palliative care and at end of life. Nursing Outlook, 60(6), 357–364. https://doi.org/10.1016/j.outlook.2012.08.002
1.6 Hussain, J., Neoh, K., & Hurlow, A. (2014). Managing pain in advanced illness. Clinical Medicine (London, England), 14(3), 303–307. https://doi.org/10.7861/clinmedicine.14-3-303
Required resource
Queensland Health. (2020). Section 5: Patient and family education. In Management of subcutaneous infusions in palliative care. Queensland Government, Brisbane. https://www.health.qld.gov.au/cpcre/subcutaneous/section5
Theme 2
2.2 Larkin, P., Cherny, N., La Carpia, D., Guglielmo, M., Ostgathe, C., Scotté, F., & Ripamonti, C. (2018). Diagnosis, assessment and management of constipation in advanced cancer: ESMO clinical practice guidelines. Annals of Oncology, 29, iv111-iv125. https://doi.org/10.1093/annonc/mdy148
2.4 Levine, J. M. (2017). Unavoidable pressure injuries, terminal ulceration, and skin failure. Advances in Skin & Wound Care, 30(5), 200-202. https://doi.org/10.1097/01.asw.0000515077.61418.44
2.5 Kozlov, E., Phongtankuel, V., Prigerson, H., Adelman, R., Shalev, A., Czaja, S., Dignam, R., Baughn, R., & Reid, M. C. (2019). Prevalence, severity, and correlates of symptoms of anxiety and depression at the very end of life. Journal of Pain and Symptom Management, 58(1), 80–85. https://doi.org/10.1016/j.jpainsymman.2019.04.012
2.6 Combes, S. (2016). Nursing assessment of anxiety and mood disturbance in a palliative patient: Table 1. End of Life Journal, 6(1), e000026. https://doi.org/10.1136/eoljnl-2016-000026
2.7 Atkin, N., Vickerstaff, V., & Candy, B. (2017). \’Worried to death\’: The assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians. BMC Palliative Care, 16(1), 69. https://doi.org/10.1186/s12904-017-0245-5
2.8 Rhondali, W., Reich, M., & Filbet, M. (2012). A brief review on the use of antidepressants in palliative care: Table 1. European Journal of Hospital Pharmacy, 19(1), 41-44. https://doi.org/10.1136/ejhpharm-2011-000024
Reflection Using Gibbs Cycle
Student’s Name
Institutional Affiliations
Reflection Using Gibb’s Cycle
Palliative care nurses tend to gain more skills and knowledge through learning by experience to allow them to make the best decisions to address various practice situations. Experiential learning can be defined as the ability of an individual to recognize, respect, accept, and apply the required knowledge and competencies to real practice (Cheng et al., 2020). Palliative care nurses handle patients with end-of-life issues based on the knowledge and skills they have learned from different practice settings alongside personal experiences and theoretical knowledge. Nursing students are learning continuously through the course and other learning programs. Gibbs developed a reflective learning model to be used in reflective learning (Cheng et al., 2020). It involves six stages including describing, feeling, evaluating, analyzing, concluding, and action planning. The purpose of this paper is to use Gibbs’ reflective model to analyze and reflect on the chosen case study.
Description of the Event
During my routine visit to Macquarie mental health facility. I met Mr. Caleb a 69-year-old father and a TV presenter who discovered a testicular swelling. He chose to ignore this, initially because he misinterpreted it as a sports injury, and later because he felt embarrassed about discussing this with a doctor. Nine months later he presented to the emergency admissions unit as he was becoming breathless far more readily than usual, and suffered a constant backache. These symptoms were found to be due to lung metastases and referred pain caused by metastases in the para-aortic lymph nodes. His prognosis was poor and his family was called so that they could be there when he received the diagnosis to help support him. The consultant delivered the news to Mr. Caleb and his family in a quiet room, with both myself and another staff nurse present. Understandably, both Mr. Caleb and his family were devastated.
Application of Gibb’s Cycle
Feelings
This case has had a huge impact on me. As this was the first time I had attended a case where bad news of this nature had to be broken to the patient and their family, I was naturally apprehensive before the event. On seeing the reactions of Mr. Caleb and his wife to the news, I was unprepared for the strength of my own emotions and found it hard not to cry. Initially, I felt helpless and unable to do anything to help relieve their suffering. I also felt awkward and as if I was intruding at a time when they should be allowed to grieve together privately. However, these feelings quickly passed and were replaced by a desire to do my best to make Mr. Caleb’s end-of-life care the best possible and provide as much support to both the patient and his family as I could.
Evaluation
The consultant broke the news to Mr. Caleb and his family very well and was able to draw on his considerable experience to handle the situation professionally while showing empathy and sensitivity. The choice of a quiet room rather than an open hospital ward provided an ideal environment that afforded Mr. Caleb privacy to receive the news (Canning et al., 2005). The consultant primarily focused on verbal methods to communicate effectively, but also used non-verbal methods, such as sitting down on their level, rather than standing while they sat down; maintaining eye contact with both Mr. and Mrs. Smith throughout the conversation; using open body language (e.g. not crossing his arms), and using a soft tone of voice. The consultant did not rush in breaking the news and took time to explain Mr. Caleb’s diagnosis and prognosis, ensuring that what he was saying was understood and providing clarification where necessary (Palliative Care Australia, 2018). He was also careful not to give unrealistic answers to any difficult questions that were asked and were as optimistic as possible, while still being open and honest. While the consultant was speaking, the other staff nurse observed the reactions of Mr. Caleb and his family closer to pick up on non-verbal clues to their thoughts and feelings and was quick to step in to place an arm around the shoulders of Mrs. Smith when she began to cry which was clearly of great comfort to her (Wachholtz et al., 2016). The only negative aspect of the incident was that I felt that having two staff nurses as well as the consultant present was excessive and initially unsettled the family, serving to emphasize the gravity of the situation.
Analysis
Effective communication
As this was the first time I had been involved in a case like this, my role was largely one of an observer. Nonetheless, this was still an excellent learning experience and provided me with the opportunity to develop my verbal and non-verbal communication skills through observation (Queensland Health, 2020). On reflection, I feel that I could have kept my emotions under control, but I was unprepared for the strength of Mr. and Mrs. Smith’s response to the news. The consultant played the key role with support from the other staff nurse, both of whom have considerable experience in palliative care (Krawczyk & Richards, 2018). It was clear that they had already gained the trust of Mr. Caleb during previous consultations. Trust has been identified as a major factor in establishing successful relationships between healthcare professionals, patients, and carers, and this enabled more effective, open, and honest communication.
In palliative care, it is important to relate to the patient on a personal as well as a professional level. There should be consistency between verbal and non-verbal communication for the healthcare professional to be perceived as genuine (Malotte & McPherson, 2016). Evidence has shown non-verbal methods of communication to be more powerful than verbal methods, with listening and eye contact among the most effective forms of non-verbal communication. Touch has also been identified as important for nurses in certain situations. The consultant relied mainly on verbal communication which may reflect gender-specific differences in communication with men using verbal forms more frequently and women tending to rely more on non-verbal communication methods (Atkin et al., 2017). Observing the other staff nurse readily use touch to comfort Mrs. Smith helped the rest of the family to relax and lessened the tension in the room slightly, also breaking down the ‘barrier’ between the healthcare professionals and the patient/family (Malotte & McPherson, 2016). I observed that the family appeared to view the nurse as a comforter and more approachable than the consultant, a view that continued throughout Mr. Caleb’s end-of-life care.
Although not relevant to this particular case, it is important to acknowledge that effective communication between members of the multidisciplinary palliative care team is also essential. This can be challenging if, for example, team members have different philosophies of care (Larkin et al., 2018). One of the key recommendations of the NICE guidelines on palliative care is the implementation of processes to ensure effective inter-personal communication within multidisciplinary teams and other care providers. During Mr. Caleb’s end-of-life care, I had to work closely with other members of the care team and there were instances where it was important for me to consider the perspectives of other team members to communicate effectively with them (Nurses and Midwifery Board of Australia, 2016). Regular team meetings were beneficial in creating a forum where difficulties could be discussed and solutions to problems found.
Reactions to receiving bad news in palliative care
After breaking bad news to a patient, healthcare professionals may have to be prepared to deal with a variety of reactions including denial and collusion, and emotional reactions such as anger, guilt, and blame. Denial is often a coping mechanism for patients who are unable to face the fact they have a terminal illness but patients will often begin to face reality as their disease progresses over time (Faulkner 1998). Family members and carers may encourage the patient to stay in denial, as this will delay the time when difficult issues have to be faced and discussed. Collusion between healthcare professionals and families/carers to withhold information from the patient is usually viewed as a way to try and protect the patient (Faulkner 1998). However, an honest and open discussion with the patient establishes their level of knowledge and understanding and can help to reassure them about their condition and accept reality.
Patients and their families and carers often show strong emotional reactions to bad news. Anger may sometimes be misdirected towards the healthcare professional as the bearer of this news, and the cause of the anger must be identified and addressed (Combes, 2016). Patients may feel guilt, and that they are somehow being punished for something they have done wrong. Alternatively, the patient may serve to blame their condition on other people. While healthcare professionals are unable to take away these feelings of guilt and blame, ensuring the patient has the chance to talk them through and discuss relevant issues can help them come to terms with these feelings (Kozlov et al., 2019). Mr. Caleb’s reaction to the news was one of self-blame and guilt – he blamed himself for not visiting a doctor earlier and felt guilty that he was putting his family through so much. He appeared to accept his poor prognosis and asked several questions which demonstrated a full understanding of his situation.
Spiritual and cultural beliefs can influence an individual’s experience of illness and the concerns of both patients and their families or carers may need to be addressed either at the time bad news is broken or at a later stage during end-of-life care when individuals are facing death (Matzo et al. 2005). Incorporating spiritual care into nursing is therefore particularly important in palliative care; however, since neither Mr. Caleb nor his family was particularly religious, this was not a key issue in this incident or his subsequent care.
Control of cancer-related symptoms in palliative care
Patients with advanced cancer are typically polysymptomatic. Common symptoms include pain, fatigue, weakness, anorexia, weight loss, constipation, breathlessness, and depression. Effective control of these symptoms is essential for optimal quality of life during end-of-life care (Wilkie & Ezenwa, 2012). As previously discussed, one of the main processes in the GSF framework involves assessing patients’ symptoms and planning care centered around these to ensure that the symptoms are controlled as much as possible.
Three symptoms that required effective management as part of Mr. Caleb’s care plan were pain, breathlessness, and depression. One of Mr. Caleb’s greatest concerns was that he would suffer considerable pain during the advanced stages of his cancer. This is a common fear held by many cancer patients (Larkin, et al., 2018). Pain is a symptom experienced by up to 70% of cancer patients. Pain may result from cancer itself, treatment, debility, or unrelated pathologies, and an accurate diagnosis of the cause(s) of pain is therefore important.
Pharmacological interventions for pain management include the use of non-opioids such as paracetamol, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs) for the control of mild pain. In Europe, oral morphine is the drug of choice for the control of moderate to severe cancer pain, but weak or strong opioids may also be used, either with or without non-opioids (Rhondali et al., 2012). Correct dosing of opioids and effective management of common side effects (e.g. constipation) is an essential and adjuvant treatment for specific pain may also be required.
Non-pharmacological interventions include the provision of emotional and spiritual support, helping the patient to develop coping strategies, use of relaxation techniques, acupuncture, or the use of a transcutaneous electrical nerve stimulator (TENS). Evidence from a meta-analysis of randomized controlled trials assessing nursing non-pharmacological interventions demonstrated these interventions to be effective for pain management but some trials showed minimal differences between the treatment and control groups (Hussain et al., 2014). Breathlessness is a common symptom among cancer patients which can be difficult to control and may cause considerable distress to both patients and their carers. Appropriate management frequently requires both pharmacological and non-pharmacological interventions (Hussain et al., 2014). Pharmacological interventions include the use of bronchodilators, benzodiazepines, opioids, corticosteroids, and oxygen therapy effective Non-pharmacological interventions include counseling and support, either alone or in combination with relaxation-breathing training, relaxation, and psychotherapy. There is limited evidence that acupuncture or acupressure is effective.
Both anxiety and depression are common among patients with advanced cancer but both of these conditions are frequently underdiagnosed. Furthermore, these conditions are sometimes viewed as simply natural reactions to the patient’s illness. Pharmacological interventions such as antidepressants should be used if the patient show symptoms of a definite depressive disorder (Rhondali et al., 2012). Non-pharmacological interventions include relaxation, psychosocial therapies, and massage. Optimal management of depression in patients with advanced cancer typically involves a combination of both pharmacological and non-pharmacological approaches.
Ethical and legal considerations in palliative care
There are several ethical and legal considerations in palliative care such as euthanasia and the right to withhold or withdraw life-sustaining treatment. Those aspects which were of importance in this account address the patient’s right to know their diagnosis (i.e. autonomy). Evidence shows that the majority of cancer patients wish to know their diagnosis and the likely progression of their disease (Faulkner 1998). This may present a challenge for clinicians and nurses who may wish to try to protect the patient and convey an optimistic outlook even when the prognosis is poor. In the case of Mr. Caleb, he wanted to know as much information as possible about his diagnosis and treatment and the consultant and nurse answered his questions as openly and honestly as possible.
Conclusion
Reflective practice is important both as a learning process and for the continuing professional development of nurses. The use of a model such as Gibbs’s cycle enables the nurse to move logically through the reflective process and provides a structured approach. Effective communication is essential in palliative care. Nurses and other healthcare professionals must be able to communicate effectively both with patients and their families/carers but also with other members of the multidisciplinary care team. The nurse plays a key role in the provision of supportive and palliative care and must develop excellent verbal and non-verbal communication skills. Breaking bad news such as that given to Mr. Caleb is one of the hardest tasks for healthcare professionals, regardless of their level of experience, and it is essential that the situation is handled professionally, but also with empathy and sensitivity, taking full account of the ethical and legal aspects of the situation. The use of non-verbal communication by the nurse is as important as verbal methods of communication.
Action plan
This incident provided me with a valuable learning opportunity and was I to encounter a similar situation in the future, I would feel much better prepared to deal with this. I have learned that preparation is important, for example, selecting a suitable environment in which to break the news, and ensuring that chairs are placed correctly within the room (Levine, 2017). Rather than relying primarily on verbal communication, I would be more aware of the effectiveness of non-verbal methods, particularly touch, if this was appropriate. I have also developed a greater awareness of the ethical issues surrounding breaking bad news in palliative care, and the need to be open and honest with the patient and their family where possible.
Conclusion
Learning by experience learning is critical for nurses because it allows them to apply theoretical knowledge to real-life situations in clinical practice. Therefore, experiential learning promotes knowledge development among nurses. The reflective paper used the Gibbs reflective framework to understand the context of the situation. Healthcare providers, especially nurses should have adequate knowledge of the model.
References
Atkin, N., Vickerstaff, V., & Candy, B. (2017). \’Worried to death\’: The assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians. BMC Palliative Care, 16(1), 69. https://doi.org/10.1186/s12904-017-0245-5.
Canning, D., Yates, P. & Rosenberg, J.P. (2005). Competency Standards for Specialist Palliative Care Nursing Practice. [PDF report]. Queensland University of Technology. https://www.pcna.org.au/PCNA/media/docs/competystds_1.pdf
Cheng, Y. C., Huang, L. C., Yang, C. H., & Chang, H. C. (2020). Experiential learning program to strengthen self-reflection and critical thinking in freshmen nursing students during COVID-19: A quasi-experimental study. International Journal of Environmental Research and Public Health, 17(15), 5442. https://doi.org/10.3390/ijerph17155442
Combes, S. (2016). Nursing assessment of anxiety and mood disturbance in a palliative patient: Table 1. End of Life Journal, 6(1), e000026. https://doi.org/10.1136/eoljnl-2016-000026.
Hussain, J., Neoh, K., & Hurlow, A. (2014). Managing pain in advanced illness. Clinical Medicine (London, England), 14(3), 303–307. https://doi.org/10.7861/clinmedicine.14-3-303.
Krawczyk, M., & Richards, N. (2018). The relevance of “total pain” in palliative care practice and policy. European Journal of Palliative Care, 25(3), 128–130.
Kozlov, E., Phongtankuel, V., Prigerson, H., Adelman, R., Shalev, A., Czaja, S., Dignam, R., Baughn, R., & Reid, M. C. (2019). Prevalence, severity, and correlates of symptoms of anxiety and depression at the very end of life. Journal of Pain and Symptom Management, 58(1), 80–85. https://doi.org/10.1016/j.jpainsymman.2019.04.012.
Larkin, P., Cherny, N., La Carpia, D., Guglielmo, M., Ostgathe, C., Scotté, F., & Ripamonti, C. (2018). Diagnosis, assessment and management of constipation in advanced cancer: ESMO clinical practice guidelines. Annals of Oncology, 29, iv111-iv125. https://doi.org/10.1093/annonc/mdy148.
Levine, J. M. (2017). Unavoidable pressure injuries, terminal ulceration, and skin failure. Advances in Skin & Wound Care, 30(5), 200-202. https://doi.org/10.1097/01.asw.0000515077.61418.44.
Malotte, K. L., & McPherson, M. L. (2016). Identification, assessment, and management of pain in patients with advanced dementia. Mental Health Clinician, 6(2), 89-94. https://doi.org/10.9740/mhc.2016.03.89
Nurses and Midwifery Board of Australia. (2016). Registered nurse standards for practice. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
Palliative Care Australia. (2018). National palliative care standards (5th ed.). https://palliativecare.org.au/standards
Queensland Health. (2020). Section 5: Patient and family education. In Management of subcutaneous infusions in palliative care. Queensland Government, Brisbane. https://www.health.qld.gov.au/cpcre/subcutaneous/section5
Rhondali, W., Reich, M., & Filbet, M. (2012). A brief review on the use of antidepressants in palliative care: Table 1. European Journal of Hospital Pharmacy, 19(1), 41-44. https://doi.org/10.1136/ejhpharm-2011-000024
Wachholtz, A. B., Fitch, C. E., Makowski, S., & Tjia, J. (2016). A comprehensive approach to the patient at end of life: Assessment of multidimensional suffering. Southern Medical Journal, 109(4), 200–206. https://doi.org/10.14423/SMJ.0000000000000439.
Wilkie, D. J., & Ezenwa, M. O. (2012). Pain and symptom management in palliative care and at end of life. Nursing Outlook, 60(6), 357–364. https://doi.org/10.1016/j.outlook.2012.08.002.