A. Personal Perceptions about Quality of Life and Health Promotion
I believe the most important thing to do for a terminally ill patient when providing at-home care, is to ensure they are as comfortable as possible during their last days. The quality of care is just as important for a person who is dying as it is for a person who has a chance of fighting through cancer. It is important for the nurse to be aware of what the patient is going through, particularly if that person doesn’t have long to live and is battling depression. The patients usually wants to be heard – they usually feel invisible and they often feel the nurse doesn’t do enough to manage the pain of their condition. Nurses need to educate the patients in order to ensure they are aware of why they are receiving the type and amount of medication that they are. The patient also needs to be aware of why they are feeling the types of pain they are.
Too often in the health care service, patients don’t receive the at-home treatment they need. This is why it is important that before the patient is discharged from hospital, there needs to be a plan set in place. “Effective discharge planning with appropriate referral to home care services upon hospital discharge can be of great benefit to cancer patients and their families,” (Yost, 1992). A thorough enough plan doesn’t appear to have been set in place in the case of Mrs. Thomas. The plan should include a careful analysis of the specific needs of the cancer patient. For example, a complete schedule of the patient’s activities should be attained so that care scheduling can work around the patient’s activities. This will ensure that the patient is receiving all the care they need. Also, knowing the activities in which the patient is involved will allow for the determination of whether the patient is involved in healthy activities, or if they will further destroy their condition; for example, smoking. Even healthy activities such as hiking might not be beneficial for a patient who needs to conserve energy. In Mrs. Thomas’s case, participating in activities might be beneficial because she currently doesn’t get out of her bed much. She is the victim of severe depression, as she lays in bed crying for most of the day.
These are the days in which she should be visited by her relatives. While she feels she would be a burden to them, seeing her children and other family and friends, could help her be more happy in her last days, which is something that I think is very important. My family is very close and I know they would want to be with each other on their last days. I question whether Mrs. Thomas has made her children and other loved-ones aware of the situation she is in. She has said that she doesn’t want to be a burden to them, so this could indicate that she has kept secret the severity of her condition. It is a relief, however, that her husband is so supportive, but he still needs to work as a police officer. This means that Mrs. Thomas is alone for much of the day, and she doesn’t have visitors because she said she doesn’t want to be a burden. Mrs. Thomas should have company during the day in order to attempt to lift her spirits. While her situation is extremely troubling, a councillor might be able to help her try to make the most of the last days of her life. I think it is important for the patient to know who they want to spend their last days with, where they want to spend them, and how they want to spend them.
A. Three Strategies I Could Use in Mrs. Thomas’s Situation
1. Mrs. Thomas and her husband might benefit from mental therapy. It is clear that
each is extremely emotionally troubled and Mrs. Thomas even suspects her husband is suicidal. At the same time, Mrs. Thomas herself spends most days lying in bed crying. A therapist, at the very least, could offer both of them a person to talk to that has an objective view of the situation. It is very unhealthy for Mrs. Thomas to stay in her bed all day. A counsellor might find a way to motivate her to get out of bed and try to make the most of her day. In Mr. Thomas’s case, his wife getting out of bed and participating in life will likely make him happier as well. Because terminally ill cancer patients have such a prolonged course before they die, a counsellor could be necessary support for the victim of the disease, including her family. The patients also go through the emotional turmoil of remission and the progression. In fact, therapists are called upon to attend cancer victims more than any other terminally ill patient grouping. “Because cancer may be a progressively debilitating disease, the cancer victim can anticipate a long and often painful struggle, associated with aversive medical treatments. For many cancer patients, the disease involves a rollercoaster ride from remission to relapse, which is enormously stressful,” (Culkin, 2002). Just when the patient believes she might be getting better, she then learns that the cancer is worse than ever. This is extremely draining. However, in Mrs. Thomas’s case, she is well aware that she doesn’t have long to live. Even given this information, her survival could be anywhere from a few hours to years. The unknown is likely contributing to her depression and this is an area where a therapist can help. Therapists can prove handy at techniques such as desensitization and relaxation training. This can help cancer patients control the nausea and anticipatory stress associated with chemotherapy.
An opportunity should exist for terminally ill patients to deal with personal concerns. Because a therapist has worked with so many people and has seen how well some people handle their illness, the therapist can learn to teach the dying patient about how to best approach their last days. This can be extremely comforting. The therapy process can be much more intense, as there is limited time in which to attempt to treat the patient for depression and prepare them for death.
2. While a therapist could help with the torment Mrs. Thomas is feeling because of her illness, it would take another level to address her physical needs. As much comfort as possible should be provided to Mrs. Thomas during her final days. She has to this point been experiencing care that has been targeting curing her; however, because she won’t survive the cancer, the attention needs to switch to comforting her. The least invasive procedures should be utilized to ensure that she is as happy and comfortable as possible during her last days. This care needs to be given to her while preserving her dignity. Mrs. Thomas should be put into a routine in order to make her more comfortable. She should have a regular wake and sleep cycle. This will help improve the quality of her sleep because her body will become accustomed to going to bed at a certain time. It should be determined whether Mrs. Thomas is suffering from problems sleeping. The causes of these issues need to be identified. Some of the more common reasons a patient may not be getting the rest they need include: too many visitors, discomfort, fear of not waking up, restlessness, or day/night confusion, (Physical, 2012). We know that Mrs. Thomas hasn’t had many visitors because she hasn’t wanted to burden anyone. But she might be losing sleep because of the other possibilities. Once identified – if this is an issue for Mrs. Thomas – then there are ways to address the situation. She might be prescribed a sleeping pill, for example, or therapy might do its part to address the situation. Other improvements to her comfort might include placing a night light near her bed, or have a bell or intercom that she can use when she needs help.
Her nutrition should also be monitored very carefully. She should make it known what she enjoys eating and the food should be portioned, along with necessary healthy food, to create a complete diet that will help her get the best nutrition possible. Medication can often cause her to lose her appetite, and when she does eat, it is often met with vomiting, diarrhea and constipation. Options such as high-protein shakes should be considered as a regular diet. A gastric tube could also be placed into her nose in order to deliver the necessary medications and nutritional supplements. It should be noted, however, that many patients frown upon the use of gastric tubes, as it makes them feel too much like they are dying. It is also an uncomfortable feeling for many to have a tube running through their nose.
3. Because Mrs. Thomas cries in bed all day, it is likely that she is suffering from depression, much like her husband. She should be assessed to see if she is suicidal. This assessment should be routine and not just something done once. Mrs. Thomas should be screened to see if she has any suicidal thoughts. This should be done during a few separate times of the week, because her mood might change considerably. Mrs. Thomas might imply that she is suicidal by saying something such as, “I wish I would hurry up and die.” This is a red flag for any nurse to move ahead with an action plan that will be carried out in case Mrs. Thomas attempts to take her life.
While Mrs. Thomas hasn’t necessarily shown any suicidal tendencies, an action plan should be put in place to ensure that she is protected to the best of the nurse’s ability. It is relatively common for a terminally ill patient to be suicidal. While many people support physician-assisted suicide, it is considered by the Medical College of Wisconsin to be “the core obligation of physicians to prevent a patient from initiating suicide and to intervene medically to prevent a patient from dying after a suicide attempt,” (Marks and Rosielle, 2008). The college goes on to say a physician should restrain the patient against their will. Furthermore, medical interventions like the mechanical ventilation should be applied if needed. However, this is a bit restrictive to the patient’s freedom, so discretion should be observed.
In making the determination about whether Mrs. Thomas is suicidal, a nurse might look at her past to see if there is a history of suicidal tendencies. Another warning sign is if she has access to firearms, which would allow her to carry out a suicidal fantasy. At this point, it should be noted that the actual rate of suicide attempts in terminally ill patients isn’t documented, but cancer patients “have nearly twice the incidence of suicide than the general population (rate of 31.4/100,000 vs. 16.7/100,000 patient-years),” (Marks and Rosielle, 2008).
C. Holistic Nursing Action Plan
In developing a holistic nursing plan, it is logical to incorporate the three strategies that were previously discussed. While these strategies were already mentioned, in the following section I will go into more detail and explain exactly how these strategies can be carried out om a plan.
First of all, I would recommend that an at-home nurse be assigned to care for Mrs. Thomas, especially when her husband is not around. However, an at-home nurse may need to be at the home even when Mr. Thomas is home. This may decrease the burden put on him, and he has clearly suffered because of his wife’s illness. An at-home nurse, or at least somebody at the home, is especially important if it is determined that Mrs. Thomas is suicidal. This would make having a person around her at all times absolutely vital.
Before going any further, a psychological evaluation should be conducted on Mrs. Thomas to determine if she is at risk of killing herself. After asking Mrs. Thomas if she has had any suicidal thoughts, she should be asked if she has any specific plans for the way in which she would take her own life. However, while a lot of terminally ill patients may express a desire to die, they could be “simply communicating unresolved emotional and existential concerns about dying,” (Marks and Rosielle, 2008).
After the assessment, a complete schedule should be laid out for Mrs. Thomas. This should take into consideration the activities in which she likes to participate. As already noted, she lays in bed for most of the day crying, but it should be documented whether she does anything else. For example, she may watch the television soap opera All My Children at a certain time of the day, and therefore will need to be awake. There are many factors that need to be considered when arranging Mrs. Thomas’s plan. She needs to have a routine sleep and rest time in order to properly adjust her body to the schedule. This way, after going to bed at a certain time repeatedly, her mind will adjust and she should fall asleep at the given time quite easily.
Nutrition is a key component of health, and so Mrs. Thomas’s diet should be monitored extremely carefully to ensure she is receiving the types of nutrients she needs. Because food is so often associated with creating nausea in already ill patients, due mainly to medication, a standard diet of food that is easily digestible while not giving her diarrhea and not making her vomit, should be instigated.
Extra effort needs to be made to ensure that Mrs. Thomas’s home is kept clean. There could be instances where she vomits on the floor. In this case, it should be cleaned immediately, as well as any other mess that is brought on by her illness. This will help her to not be as embarrassed and ashamed that she is the cause of an unclean home. In turn, this could improve her confidence and make her not as depressed.
Mrs. Thomas’s skin should also be cared for regularly. If she isn’t moving regularly, she may develop wound sites that need attention. Regular bathing is a priority to avoid infection. Antibiotics may need to be on hand to deal with any infection.
Because Mr. Thomas still works, administering these requirements can only be carried out if someone is at the home caring for Mrs. Thomas at all times. Therefore, it is important that a nurse live at the home to ensure every requirement of the nursing plan is being met. However, a friend or family member may choose to fill that role. In that case, they should be well trained about how to execute every aspect of the care, including the amount of medication needed and at what time. The nutrition in the food also should be carefully noted and measured out. This will require the help of a nurse to bring the friend or family member up to speed.
D. How I Can Intervene With Mr. Thomas’s Chronic Depression
While I can’t force Mr. Thomas to attend counselling, if a therapist is brought in to talk to both Mrs. and Mr. Thomas, then he will likely want to participate. This could be a good time for him to get off his chest what might be bothering him. Mrs. Thomas views herself as being a burden already, but a group discussion could instigate the addition of someone else to ensure that Mrs. Thomas is cared for. A therapist might also recommend that Mr. Thomas spend some time doing the things he used to enjoy doing, such as golf, for example. Mrs. Thomas may need encouragement to confront Mr. Thomas about his depression. She may want to tell him that it’s okay for him to leave her alone and enjoy his life. This may encourage Mr. Thomas to get better.
Culkin, J. (2002). Suffolk Country Community College.
Marks, S. Rosielle, D. (2008, November). Medical College of Wisconsin.
Physical Needs of the Person with Terminal Cancer. (2012). Stanford Medicine.
Yost, L.S. (1992, Jan. 1). Determinants of Subsequent Home Health Care Nursing Services Use by
Hospitalized Cancer Patients.