Jasmine is diagnosed with acute lymphoblastic leukemia (ALL), which is the most common form of pediatric cancers. It is caused by malignant transformations that occur in hematopoietic stem cells, making them undifferentiated cells with increased longevity. In ALL, those cells are called lymphoid cells, and their rate of proliferation causes fast growth and destruction of healthy bone marrow. Because of Jasmine’s age, the chances for an initial remission can be estimated at 95 percent (Rytting, 2012). However, achieving a complete cure is not a likely outcome, and an open and honest communication with Jasmine and her parents about her condition is required to prepare them for palliative and end-of-life care.
Even though the prognosis may appear favorable and the initial remission can alleviate the symptoms significantly, subsequent remissions are difficult to achieve and symptoms are reduced only for brief periods (Rytting, 2012). That means Jasmine’s treatment may be successful in the beginning, but the life-threatening nature of ALL indicates that her treatment can only be used to maintain her condition for up to three or five years (Rytting, 2012). With that in mind, it is also important to provide full psychological support to both Jasmine and her parents and prepare them for end-of-life care.
Jasmine will require palliative care, meaning the goal of the treatment is to alleviate symptoms and reduce suffering. The first step in planning palliative care is to assign a multidisciplinary team according to the requirements of Jasmine’s condition. Multidisciplinary teams in palliative care can consist of doctors, nurses, pharmacists, dietitians, psychologists, social workers, and chaplains (National Cancer Institute [NCI], 2012b).
In Jasmine’s case, doctors and nurses are required to manage the disorder by conducting assessments and interventions to maintain her physical quality of life as much as possible. However, psychosocial support in nursing interventions can also be beneficial when required by the patient or the patient’s family.
Grieving is the first diagnosis that can be established. Everybody experiences the stages of grief upon experiencing loss or expecting a loss, and the goal of the intervention is to allow the family to express their grief and share it together. The nursing intervention should educate the parents to participate in care, help them set realistic goals, and encourage them to accept individual reactions to their impending loss. That approach will maintain the psychological integrity of the family by increasing understanding among themselves and promoting acceptance of the situation. The evaluation of the intervention needs to be conducted by assessing the length of denial and depression stages before and after treatment.
The second diagnosis in Jasmine’s case is social isolation. With her condition, she will most likely experience feeling useless, have concerns for survival, and perhaps feel the desire for more social contact with her peers. The goal of the intervention is to identify ways she can improve her relationship with peers and find appropriate activities for entertainment. The intervention needs to identify Jasmine’s likes, hobbies, assist her in finding activities to feel fulfilled, and find ways to increase social relationships. By identifying those factors and strategies, Jasmine’s parents can help her work with specific goals to avoid social isolation or feeling useless. An evaluation can be made by talking to Jasmine about her feelings of uselessness and isolation and comparing her answers to the initial assessment.
The third diagnosis is depression. While depression is a part of grieving, it is also a specific stage because it can occur throughout the entire end-of-life care process. Some common characteristics of depression include anxiety, worry, guilt, and feeling worthless. The goal of the treatment is to improve the patient’s mood and prevent self-destructive behaviors. The intervention needs to accept the reality of the situation, but it also needs to include some cognitive-behavioral therapy (CBT) techniques. Because depression can induce self-destructive behavior, CBT needs to be used to avoid negative consequences and improve Jasmine’s mood. The evaluation of the treatment can be done by assessing the patient with standardized questionnaires.
One of the potential diagnoses is spiritual distress. After the initial stages of denial, the patient and her family may begin to question the credibility of their belief system and experience significant disturbances in their interpretation of the belief system. The goals of the intervention are to restore Jasmine’s and her parents’ original belief system to decrease their guilt and improve spiritual satisfaction. The nursing interventions should include the assessment of the family’s spiritual state and offer an open discussion on how stress can challenge personal values and beliefs. By discussing the topic with the patient and her family, they have the opportunity to maintain their spiritual values and beliefs, which can be useful when dealing with personal loss. Evaluation can be done with patient interviews before and after treatment.
Another potential diagnosis is powerlessness. Powerlessness can develop as the disease progresses. Jasmine’s parents will most likely face that problem as they realize how little control they have over the situation. Other signs of powerlessness may include apathy, resignation, anxiety, depression, or anger. The goal of treating powerlessness is to help her parents identify factors they can control and encourage them to make the decisions related to Jasmine’s treatment. The intervention should consist of enabling the parents to participate in care decision-making, allow Jasmine to express her needs, and establishing a care plan that takes in account the family’s values and psychosocial needs. The intervention is designed to promote synergy among family members because resignation of a single member can lead to lack of support and further issues. The evaluation can be done by interviews or standardized questionnaires for anxiety, depression, or hopelessness.
Psychologists and chaplains can be a part of the multidisciplinary team to provide emotional and spiritual support to the patient and her family. A chaplain can help people explore their beliefs and values or help them find meaning in life and help them understand the situation they are in (NCI, 2012b).
The pharmacologist needs to be a on the multidisciplinary team because Jasmine will receive several types of medication, and her medication intake needs to be monitored properly. In the late stages of palliative care, when death is near, the role of pharmacological interventions is to alleviate the symptoms and conditions that may arise. For example, acute uncontrolled pain and dyspnea can be treated with morphine or diamorphine while nausea or vomiting can be treated with cyclizine (Marie Curie Palliative Care Institute Liverpool [MCPCIL], 2012). In most cases, a pre-authorized care plan is used to allow the staff to administer subcutaneous injections because that approach ensures quick interventions to address symptoms and alleviate suffering as soon as possible (MCPCIL, 2012).
The psychologist working on the multidisciplinary team has to fulfill two roles. First, the parents will require support. Caring for family members is difficult, and without adequate social support, emotions such as worry and fear can induce high stress levels and various psychological challenges that undermine their own health (NCI, 2012b). Second, the parents need assistance in coping with the stages of grief. The psychologist needs to guide the parents through the stages of grief. If the psychologist can help them reach acceptance as soon as possible, they will be able to enjoy the rest of their time with Jasmine better. Jasmine also needs to be included in psychological support sessions because children can go through stages of grief like adults, and keeping her in ignorance about her condition will not enable her to accept the reality of her situation.
According to Kavanaugh (1974, p. 107), there are seven stages of grief, and each stage is characterized by distinct feelings and reactions to those feelings. In each stage, a person needs help to cope with a different type of emotion. The seven stages of grief include shock or disbelief, denial, bargaining, guilt, anger, depression, and acceptance.
Initial shock is the most common reaction to losing loved ones. For Jasmine’s parents, the shock stage has started from the moment they received the news about her condition. While in shock, people do not completely understand the situation and maintain a certain psychological distance from facts. They are most likely going to look for evidence that the information provided is not correct, attempt to undermine the diagnosis of ALL, or look for alternative solutions in finding a cure. However, open and honest communication with patients and their families is critical at this stage because discussing care options and realistic prognosis decreases stress and improves the patient’s ability to cope with the condition (NCI, 2012a). With an honest approach and support in palliative care, this stage can be overcome quickly.
The second stage of grief is denial. After the initial shock and disbelief, people are most likely going to have a hard time accepting reality. Another possibility is that they will refuse to address the situation. It is usually a short stage, but people who are in denial need appropriate support to help them overcome psychological defensive mechanisms. Otherwise, they will not overcome the denial stage and consciously resolve the underlying anger that is responsible for their reasoning. If people remain in the denial stage, they will be at risk for developing various psychological disorders, such as depression or posttraumatic stress disorder (Dryden-Edwards, 2012).
Guilt can sometimes overlap with denial, but it is categorized as a distinct stage of grief because the patients and their family respond differently to the situation. For example, Jasmine’s parents may experience guilt because they will consider themselves responsible for Jasmine’s condition. Jasmine can also experience guilt because she can observe the situation as her own fault. She can consider that she is being punished for something she had done. During this stage, psychosocial support is necessary to provide an alternative viewpoint to patients and their family. Psychosocial and spiritual support can help them understand that there is no correlation between Jasmine’s disease and their sense of guilt.
Bargaining follows guilt, and it is the last stage in which emotions connected to grief are dormant. Making peace with the reality of the situation is still not an option, and they will still desire control over the situation to change the outcome. Jasmine and her parents will most likely need spiritual support because of the correlation between dying and religion. Jasmine’s parents may bargain with God to exchange their own lives in exchange for her life. Jasmine can also resort to bargaining by promising to live a fulfilling and productive life in exchange for an extending her life. Resorting to prayer for finding peace and spiritual consultation for understanding the situation from a religious perspective may be a suitable role for the chaplain in the multidisciplinary approach.
Until a person reaches the fifth stage, the emotions are mainly an internal affair because the conflict among accepting reality, denial, and bargaining is taking place. In the anger stage, the emotions are no longer directed towards blaming oneself or suppressed. When people express their anger, the grieving process becomes an emotional manifestation. During this stage, people’s needs have to be acknowledged, and they should be encouraged to express their feelings. At the same time, they need to be aware of their anger and manage it properly because it should not become a destructive and chronic behavioral pattern. At this stage, it is dangerous to suppress anger because understanding it is required for transcending into the next stage.
Depression is rarely a separate stage because it can frequently manifest throughout the entire grieving process. Because it is a recurring process, it can be beneficial to address it at every stage. However, when observed as a separate stage, depression can be the consequence of anger. When the anger caused by loss is expressed and managed, depression becomes a dominant state. In a way, people accept that they are helpless, but they also fail to find meaning and purpose when observing their situation. Social isolation is a common occurrence in this stage, but mental disorder experts need to prevent that condition because it can lead to self-punishment and similar forms of behavior. Psychological and spiritual support can help people find meaning and achieve self-preservation in this stage.
Finally, when people reach the acceptance stage, they can accept the situation as it is. When they understand that the loss is beyond their control, they are able to recollect themselves and plan ahead in life. They are also no longer at risk of developing psychological disorders because of suppressed anger or depression. Even though Jasmine is still alive, she and her parents are already going through the grieving process because they understand the outcome of her disorder. Attending to their needs is required because it will help them improve the quality of the remaining time they have as a family.
After death, follow-up support is required because Jasmine’s parents may relapse into the initial stages of the grieving process, even if they have accepted the situation while Jasmine was receiving care. Psychosocial and spiritual support activities remain equally valuable after death as they are while coping with the dying process because they can protect the parent’s physical and psychological health. Going through the stages once again with expert guidance will help them cope with their loss, express their emotions, and reach acceptance.
References
Dryden-Edwards, R. (2012). Loss, grief, and bereavement. Medicine Net. Retrieved from http://www.medicinenet.com/loss_grief_and_bereavement/article.htm
Kavanaugh, R. (1974). Facing death. New York, NY: Penguin Books.
Rytting, M. E. (2012). Acute leukemia. The Merck Manual. Retrieved from http://www.merckmanuals.com/professional/hematology_and_oncology/leukemias/ acute_leukemia.html
Marie Curie Palliative Care Institute Liverpool. (2012, October). Best care for the dying: Liverpool care pathway for the dying patient: Supporting care in the last hours of life. Retrieved from http://www.sii-mcpcil.org.uk/media/10843/ LCP%20Core%20Documentation.pdf
National Cancer Institute. (2012a). End-of-life care for people who have cancer. Retrieved from http://www.cancer.gov/cancertopics/factsheet/Support/end-of-life-care
National Cancer Institute. (2012b). Palliative care in cancer. Retrieved from http://www.cancer.gov/cancertopics/factsheet/Support/palliative-care
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