Mrs. Thomas: Holistic End of Life Care

Governors university Scenario A brief synopsis of the scenario explored in this paper will be forthcoming so the following observations and detail will have context. The key points in the scenario explored for Mrs.. Thomas, her husband and family are as follows. Mrs.. Thomas is a candidate for palliative care; In specifically hospice If she Is given a prognosis of six months or less. She has suffered breast cancer twice In the past year.A year ago she had a right mastectomy with removal of five auxiliary lymph nodes, with chemotherapy and radiation. Six months ago she had a second mastectomy on her left breast, followed by chemotherapy and radiation. After said treatment it was discovered that the cancer had metastasis's to her lungs and further surgery is not a feasible option. She has not been taking her pain medication as she does not want to procure an addiction problem. Her pain has Increased and she spends most of the time In bed crying.She had to leave her job, but has a small stipend via disability. She and her husband, a police officer, are struggling to make ends meet financially Her husband suffers from chronic depression that is being managed by medication, but he is resorting to take his medication often. He is a supportive and able caregiver however, he Is showing signs of caregiver strain and Job stress. In response Mrs.. Thomas Is worried that he Is becoming classical because of the circumstances of her condition and this In turn Is causing her further suffering. Core family support Is minimal.Mrs.. Thomas' close female relatives are dead from the very disease that is killing her. Because she is sick, she and her husband no longer socialize; she does not seek help from her female friends. Her sons live far away, and call often but they do not come to see her. Mrs.. Thomas is saddened that her sons are not here, but Quality of Life and Health Promotion This nurse believes that quality of life is defined individually for each patient. Each individ ual is unique and how they perceive life and what their life circumstances are define what is needed for end of life care.Quality of life during a time when aggressive treatment is no longer possible needs to be focused on comfort and support of the patient, caregivers and family. This nurse believes comfort (quality of life) includes the right to be free from pain, unless the patient chooses to experience main in trade for mental clarity. It includes the right to not participate in aggressive treatment or in clinical trials if the patient has no wish to do so. Quality of life to this nurse is helping the patient to do the best with the situation in life in which the patient finds themselves.It includes helping the patient with what he or she perceives as unfinished business and helping the patient conclude this business to the extent possible. Holistic end of life care includes care of all aspects of the patient (physical, social and spiritual) and care for those who love the one d ying?the family. The family is whatever blood or non-blood ties this entails; whatever â€Å"shape† of family the patient has at this time. This nurse believes that holistic end of life care encompasses not only physical comfort for the patient but promotion of healthy interactions for the patient with those who love and comfort them.These sensitivities are the goals of this nurse and if applied diligently may provide the best outcomes for the patient in this time of life. Strategies Four holistic nursing goals to begin to improve quality of life for Mrs.. Thomas, her husband and family are the nursing diagnoses: Pain Management, Addressing Anticipatory Grieving and Situational Low Self-Esteem, as well as, Altered Family Processes. First one must establish a rapport with the patient. By providing an open nonjudgmental conversation the nurse can encourage an open and realistic dialogue about what Mrs..Thomas is feeling. By reviewing past life experiences one can get to know th e patient and what interests her and establish trust. This trust is of most importance as all nursing care success depends on creating a team effort with the patient. Family involvement in this time needs to be proactive to help Mrs.. Thomas' mental state and via this her physical functional ability. Nurseries) A beginning conversation with Mrs.. Thomas needs to be about the importance of pain relief. By bringing the patient to an understanding of how this relief of pain will benefit those around her, Mrs..Thomas may be more likely to try the medication for said relief. This may be the initial hook with which one can get her to take said medication. The nurse must determine a comprehensive pain history, including frequency, duration and intensity using a scale dependent upon the patient's perception of pain throughout her life span. Zero pain for no pain; ten for the worst pain ever. This call gives the nurse a baseline from which to assess pain management. Her pain has been increas ing for the last six months and this nurse would designate that as chronic pain, perhaps with acute episodes.Also, the nurse must ask about and continue to monitor when said pain is occurring, as well as where and how much. Morning or when? Identifying precipitating factors of pain will help in its long term management. (Nurseries) Pain is what the patient says it is; we as nurses need to accept that premise. Within the realm of pain lie both physical and emotional response. Because Mrs.. Thomas is no longer seeking aggressive cancer treatment, he â€Å"variations of aggressive treatment† pain control will not be discussed.However, as her disease progresses it is most likely that her pain will increase. Which brings up another point?reluctance of the patient to report pain because of fear that the disease is worse or that the pain is deserved somehow. The nurse must also be aware of unmanageable side effects (like hallucination) which if experienced must be dealt with in a ma tter of fact fashion and by trying another medication regime. To address pain management with Mrs.. Thomas one must address her fear of addiction. By talking with Mrs..Thomas openly and honestly about the need for pain relief, it is hoped that she is lead to the conclusion that pain management and pain medication abuse are two different things. At the end of life, pain medication addiction is not an issue. This idea needs to be gently but openly professed. One could point to the relief of stress for her husband if she is not in pain; as well as the physical benefit (and hence mental benefit) of remaining pain free. If she remains pain free she will be more able to take care of herself and her activities of daily living.She will be able to live in this time instead of living in dread of each day. Once she is taking said pain medication it must be monitored, adjusted and changed as needed for optimal effect and to support the ability to participate in activities of daily living to the fullest as possible. Also discussing non-pharmacological comfort measures like massage and diversionary activities like music is in order. What does Mrs.. Thomas respond to; what does she like? What kinds of non-pharmacological pain intervention has worked for her in the past?Ask questions so that she can verbalize these things to help herself. Being able to relax will help her focus her attention. Encouragement of stress management skills and complimentary therapies (relaxation techniques, biofeedback, LAUGHTER, music, aromatherapy, acupressure, acupuncture and touch are a few) helps the patient to actively participate and enhances a sense of control. Heat and cold may also help by decreasing muscle spasms and inflammation. Pain makes stress, stress makes stiff muscles and increases self-focus which, unfortunately, increases pain.As the nurse interacts with the patient it is important that the patient comes up with ideas about care and becomes a proactive member of their healthcar e team. (Nurseries) Mrs.. Thomas is also suffering, â€Å"Anticipatory Grieving. This is related to loss of her physiological health and change in lifestyle. It is interconnected to the knowledge that she is going to die, for real, and most likely soon. This nursing diagnosis is needed because of her change in social activity level, her reluctance to tell her sons that she needs them?now.It is evidenced by her denial that she does need them and help and support in general from her friends. (Nurseries) Outcomes that are desired include the patient being able to feel her feelings and express them. By doing this she will hopefully come to the place where she is able to take one day t a time and continue her normal activities; even planning for the future. Being able to admit that she is dying, understanding and verbalizing the process is a beginning is done, she must feel supported in her grief work. One must beware of debilitating depression, the like of which is indicated by the sce nario.To address this the nurse must be frank and direct in asking questions about the patient's mind state. (Nurseries) Frequent visiting by the nursing team and care providers, family and social support of friends can help relieve feelings of isolation and abandonment. Her ones need to be contacted with a â€Å"for your information† talk about coming to see their mom (and dad) and possibly who could be of help with caregivers as it is needed. Mr.. Thomas is also a source to find out about who may be able to help with this care this, as well.The nursing diagnosis, â€Å"Situational Low Self-Esteem† is related to how Mrs.. Thomas feels about her disfiguring surgeries and subsequent treatment side effects (aliped, muscle wasting, and more) as well as feelings of self-doubt and lack of control in her life. It is about the doubt about being accepted by others–of still eyeing a human in the world. It is also about her anxiety and fear of her disease process. This is evidenced by her not taking responsibility for self-care (not taking pain medication; crying in bed all day. ) Acceptance of her situation is an outcome that is looked for.She needs to be able to develop mechanisms to cope with her problems and set realistic goals. What coping skills has she used in the past? She needs to be able to participate in her own life by learning to adapt. The nurse can help her through this process by asking proactive questions about how she feels and perceives her world. By getting her to voice where she's at, she will also perhaps start to voice how she can manage. (Nurseries) This diagnosis ties in with the aforementioned, â€Å"Anticipatory Grieving† diagnosis. By defining diagnosis and disease process beginning problem solving can occur.By anticipating what can happen, some measure of control can be taken. By working with Mrs.. Thomas and planning how daily activities can be managed, adaptation can occur. (Nurseries) Discussion about her roles in life, as a worker, spouse, and mother and problem solving about how to accomplish her goals for these roles may help reduce problems that interfere tit her self-esteem. It may help her to see how she can cluster activities at home to conserve energy but be productive. It may help her to be more able to reach out to those who love her for inclusion and support.The nurse must acknowledge troubles she is experiencing and validate the patient's reality; this opens the door to the patient being able to seek measures that are necessary to cope, like counseling, and support groups. The nurse should readily be able to supply information about said resources so as to facilitate the patient in procuring more support. If Mrs.. Thomas is n hospice the social worker of the interdisciplinary team can help facilitate and direct this work; but the nurse must always continue it during her visits. Holistic Nursing Plan Amongst personal revelation the nurse must explore who may be able to help Mrs ..Thomas with her activities of daily living. Her husband is doing the Job, but he is suffering from care giver strain and could use some help. It may be that the people she has cut herself off from socially miss her and would love the chance to be able to help in some way. Caregivers avenues and their affordability need to be explored before they are needed. These interactions; providing pain control, helping with grief and esteem issues, and helping the patient to discover what will work best to live disease state progresses, but before it is needed, preparation for a lesser level of self-care must be addressed.Medicare provides a â€Å"compassionate allowance† for hospice care for those of any age with a metastasis cancer with a prognosis of six months or less. She needs to apply for this care in the beginning of the nursing visits if she qualifies. To receive hospice care via Medicare she must be eligible for Medicare Part â€Å"A†, be certified as terminally ill a nd then apply for hospice care. This care would be in her home. By signing an election of benefits Mrs.. Thomas would be choosing hospice care in lieu of routine Medicare-covered benefits.Hospice would pay for pain medications and those required by her terminal diagnosis, as well as services included in the palliative plan of care. Often the hospice doctor confers with the patient's primary doctor and others on the hospice interdisciplinary team are included. (â€Å"Your Medicare benefits,† 2014) Hospice of Kits County provides an interdisciplinary team consisting of the doctor, the patient's primary provider and nurse practitioners, sitting nursing care, a medical social worker, a chaplain, a home health aide. Also provided are complementary services, which include massage and music therapies.Volunteers are also enlisted to help with such things as grocery shopping and the like or simply for company. These persons come to the patient's home for service. Hospice care differs with regional coverage. Durable medical equipment is also covered, so if Mrs.. Thomas is in need of a hospital bed, oxygen, bedside commode, wheel chair and so on, it will be provided at no cost to her family via Medicare coverage. Grief and loss counseling is also provided. â€Å"Hospice of kits,† ) Providers for home care must be explored as Mrs.. Thomas declines.Often the expense precludes coverage of duties in this way. Exploration of service providers and means of payment need to be explored as a way to cover Mrs.. Thomas' needs as she declines. Medicare covers the cost of a short term inpatient care in a Medicare approved hospice facility, or nursing home if the caregiver is suffering from caregiver strain (for up to five days) or if it is determined by the hospice physician that symptoms must be managed in an inpatient setting. Because Mrs.. Thomas has no Eng term care health insurance this care could be instrumental in providing for her final days. â€Å"Your Medicar e benefits,† 2014) The fourth nursing diagnosis, â€Å"Altered Family Processes† must be addressed for the holistic health of Mrs.. Thomas. This holistic care includes her husband as well as Mrs.. Thomas' sons and families. Situational crises can develop when a family member has a long term illness. There is a change in roles in caring for a parent and an anticipated loss of said parent. (Nurseries) Those involved need to learn to express feelings freely and demonstrate individual involvement. This individual involvement must include a problem solving process that promotes suitable solutions for the situation.Mrs.. Thomas' sons need to be contacted and requested to attend a family conference. If they are unable (because of finances or schedule) to attend then this could be accomplished via phone. They must understand the need of their mother to see them in person and will hopefully comply. The reality of the situation must be broached to them in a caring way. It may be that the Thomas' or Mrs.. Thomas can go and stay with them for more available for care and support of their mother. Speaking with family members in a caring, respectful manner and providing information both written and spoken helps promote feelings of empathy.It stimulates individual feelings of value and capability in ability to handle the present situation. In answering questions and providing information one can empower Mrs.. Thomas' loved ones. Identifying patterns of communication and interaction between family members is an important nursing intervention. It provides information about how active said communication is. It can also identify what problems may exist that interfere with the family in helping the patient and what problems there are in adjusting to the prognosis.Role expectations must be explored and how each individual sees the situation, in sharing these thoughts the family can promote understanding within its unit. Assessing the way members are expending their ene rgy with which to deal with the situation is needed so as to provide guidance in positive focus for the well-being of patient. Acknowledging the difficulty of the prognosis, as well as, encouraging appropriate expressions of anger helps resolution in the stages of grieving. The nurse must remain centered.Stressing the importance f continuing dialogue that is open and honest between the family members helps communication to remain open and thus facilitates problem resolution. Mr.. Thomas must be educated by the community health nurse as with regards to how anti- depressants need to maintain a certain blood level to be effective. If he is not taking them regularly this will not happen. To help achieve this goal, a pill box with days on it can be set up; perhaps an alarm set to the same time each day enlisted, so that he can remember to take his medication and thus be better able to function at this time.To provide holistic nursing care to Mrs.. Thomas her needs as a person must be add ressed. Physical, social and spiritual realms must be explored. Plans of action to provide for her physical care and the demise of her abilities must be explored; help must be sought out from the aforementioned sources. Method must be applied via nursing diagnosis and indications of said diagnosis. Desired outcomes must be planned, as well as nursing interventions to work toward these outcomes. Mrs.. Thomas must be approached with honesty and treated as a human being, with a life, in her time of need.