Hospice care is a complex issue that needs a multi-disciplinary approach. As a patient’s disease progresses to its final stages, the patient needs increasing emotional, social, psychological, and spiritual support. A community hospice nurse is at the core of the healthcare team.
Quality of Life and Functioning
Perceptions About Quality of Life and Health Promotion and their Effects on Quality of Care
I see health as an active state of being, not just the mere absence of disease. For me, the most important duty of a healthcare giver is to increase a patient’s level of wellbeing, from whatever level the patient may have been at the moment the patient first came into my care. I also understand that people are multi-dimensional, yet unique, and that each person’s quality of life, level of wellbeing, and ability to function is impacted by the way they have learned to interact within their environment. Often, people don’t understand that, no matter their age, and no matter the challenge, they still have the power to make certain choices, and effect change. As a nurse, it is my duty to help patients learn how to modify their behavior so that their relationship with their environment improves and becomes more positive.
Quality of life encompasses a range of abilities, limitations, expectations, and attitudes that affect the way a person can function throughout life, and derive pleasure from life; therefore, positive changes in behavior and attitudes can help improve health and functional ability (McMillan, 1996). It is a lifetime process, and it is never too late to introduce a new change in life that that may translate into better quality of life; even if it comes at the very end of life.
For this reason, I believe that it is essential to help a patient understand that no matter the challenge of the situation, or how short the time, the patient has the power to improve life; and the patient needs to know that helping the patient achieve this goal is a service that I consider to be at the very core of my professional duties.
Improving the Patient’s Quality of Life
Establishing Rapport
There are internal and external factors that affect quality of life. I would begin by addressing the internal factors, which include emotional, spiritual, and psychological elements (Steele, 1996, and Spiegel and Giese-Davis, 2003). It is clear that Mr. and Mrs. Thomas’ have become so overwhelmed by the disease that they are unable to cope with it, or its ultimate implications, either physically, emotionally, or mentally; in essence, they have become paralyzed by worry and fear, and a sense of hopelessness (Humphrey, 1995).
It is difficult to reach out to Mr. and Mrs. Thomas in their current state of mind, so I would begin by opening as many mutual channels of communication as may be available. As Mrs. Thomas’ caregiver I need to establish a positive nurse-to-patient relationship, where she can feel safe to share her thoughts and feelings, and feel secure in her knowledge that I will respond to any concern, however small. I also need to connect with her husband, who is clearly suffering from caregiver stress, and exhibiting signs of premature grief (Humphrey, 1995). I need to impress on Mr. Thomas that the best way to take care of his wife, is to attend to his own personal needs first; his obvious distress is having a negative impact on the wellbeing of Mrs. Thomas (Humphrey, 1995). Together we must find a way to tap into his emotional reserves and bring him to a healthier state of being.
Enlisting Help
A multi-focal problem needs a multi-disciplinary approach. As a nurse, I can provide a lot of care and comfort, but a nurse is not a therapist or a spiritual guide.
Psychological counseling must start immediately, for both husband and wife (Spiegel and Giese-Davis, 2003). There is no question that Mrs. Thomas’ physical condition will only get worse, but this doesn’t mean that she cannot find the means to center herself psychologically; the stronger her mind becomes, the better she will be able to cope with her disease (Spiegel and Giese-Davis, 2003). The same holds for strength of spirit (Weaver, 2001).
There are also non-professionals who can offer their support. For example, there are usually members within the community that are willing to volunteer in a number of capacities; either simply to pay visits to just listen and comfort, or to help with small chores (Raphael, 2009). Many of these volunteers are quite familiar with hospice, and know how to adjust their interactions with the patient and the family as the disease reaches its final stages. Mr. and Mrs. Thomas have withdrawn from their family and friends and are trying to deal with the situation on their own, and not doing it well. Often it is easier to accept help from a stranger than from a family member or a friend (Humphrey, 1995, and Raphael, 2009).
Assistance may also come from Mr. Thomas’ workplace; although he may not be aware of it, there might be some programs that might be able to help him. Law enforcement agencies have well-developed counseling programs that Mr. Thomas can join, and he is in critical need of professional advice. Furthermore, law enforcement officers have strong connections within the community, and some help may be found there (Raphael, 2009).
At the very least, discussing these various options would help the Thomas’ understand that they are not alone, that help is available from a variety of sources, and individuals from multiple disciplines. My ultimate goal would be to enlist Mrs. Thomas’ sons to lend their full support.
Education
The stress is affecting the Thomas’ ability to make the right health choices; neither one is taking their medications (McMillan, 1996). True, things are very difficult now, but things will get worse. Mr. Thomas needs to learn how to provide hands on care to his wife, help her with medications, and offer small comforts. He also needs to know about the progression of the disease, the signs and symptoms of dying, and when and how to ask for help. I believe that, as difficult as it might seem, understanding outside factors can help people cope with inner factors, like stress and grief.
Holistic Nursing Plan to Manage a Hospice Patient
After considering the Thomas’ emotional, psychological, and spiritual suffering, my next step would be to focus on improving my patient’s overall physical quality of life (McMillan, 1996 and Weaver, 2001).
I would take steps to comfort Mrs. Thomas and relieve her physical suffering, and encourage her to take her pain medications; she must be made to understand that addiction is not something that should be of concern. And, of course, I would take care not to patronize her, and be sure to promote her dignity at each stage of her illness.
As Mrs. Thomas’ illness progresses she will need assistance with bathing and other activities related to personal care (McMillan, 1996). Although she has no long-term care insurance, the community may be able to provide her with volunteers that could provide her comfort and assistance. Her husband too can help her. As the disease progresses to the last stages, Mr. and Mrs. Thomas will need increasing emotional and spiritual support, to help them cope with loss of meaning and fear of death (Weaver, 2001). Family members are critical to the interdisciplinary care team; at some point the sons and their wives must step in and play a larger supportive role (McMillan, 1996).
Managing Chronic Depression
Mrs. Thomas is not taking her pain medication, and there is a correlation between depression and medication noncompliance (Spiegel and Giese-Davis, 2003). Depression also impacts quality of life and ability to function.
Therefore, the treatment of Mrs. Thomas’ depression must be of primary concern, especially since cancer patients become more depressed as the disease progresses (Spiegel and Giese-Davis, 2003).
Chronic depression is associated with pain and both can be treated with medication. Chronic depression and pain can also be reduced with psychological and social support (Spiegel and Giese-Davis, 2003). As her nurse, I would monitor her pain and psychotropic medications to ensure compliance, schedule therapy and counseling, provide access to a spiritual leader, and coordinate care with community volunteers.
One other possibility is to try and increase contact with Mr. and Mrs. Thomas and their sons. The family has been keeping in touch via the telephone, because the sons live out of state and are too busy to visit in person. But, there are some other alternatives, like Skype, that would allow the family to connect face-to-face. There is a strong social component to chronic depression (Spiegel and Giese-Davis, 2003), seeing her sons and their families would have a positive impact on Mrs. Thomas overall quality of life.
Mr. Thomas
It is not clear how long Mr. Thomas has been under treatment for chronic depression, that is, whether he was in the acute-phase, continuation-phase, or maintenance-phase of treatment for chronic depression. However, we do know that he has not been taking his medications, so even if he were in the maintenance- or continuation-phase of treatment, Mr. Thomas may be suffering a remission; thus, he should be evaluated for acute-phase treatment. My primary goal would be to treat Mr. Thomas’ symptoms of depression, to help him return to his normal state of wellbeing. To that effect, I would first seek to determine his medication protocol and his reason for discontinuing treatment, and I would then consult with his physician.
In addition to pharmacotherapy, I would recommend depression-focused psychotherapy, as combined therapy has been shown to be more effective in the treatment of chronic depression at all three phases of treatment (Mausbach, 2012). One possible consideration for immediate relief of Mr. Thomas’ depression would be short-term electroconvulsive therapy (ECT), at the discretion of his physician (Mausbach, 2012).
My secondary goal, once Mr. Thomas resumes his medications, whether or not he opts to combine it with psychotherapy, is to ensure that Mr. Thomas adheres to his pharmacotherapy protocol and takes the adequate dose without skipping medication, to ensure that the treatment is effective. This might represent a challenge considering that the extreme stress under which Mr. Thomas is operating is causing him to lose personal mastery and self-efficacy, which impacts his ability to cope (Mausbach, 2012).
My tertiary goal then, would be to help alleviate Mr. Thomas’ stress, by recommending spiritual counseling, reassuring him that his wife is getting all the necessary support, providing help with daily household chores; and, more important, letting Mr. Thomas know that I would seek any avenue to help him and his wife increase their QOL (Son, 2012).
References
Humphrey LJ. (1995). New insights on the emotional response of cancer patients and their spouses: where do they find help? Journal of Pastoral Care, 49(2):149-56
Mausbach BT, Roepke SK, Chattillion EA, Harmell AL, Moore R, (2012). Multiple mediators of the relations between caregiving stress and depressive symptoms.
Aging and Mental Health,6(1):27-38.
McMillan SC. (1996).The quality of life of patients with cancer receiving hospice care. Oncology Nursing Forum, 23(8):1221-8
Raphael D., Steinmetz B., Renwick R., et al. (2009). The Community Quality of Life Project: a health promotion approach to understanding communities. Health Promotion International, 14 (3): 197-210
Son KY, Lee CH, Park SM, Lee CH, Oh SI (2012). The factors associated with the quality of life of the spouse caregivers of patients with cancer: a cross-sectional study. J Palliat 15(2):216-24.
Spiegel D & Giese-Davis J. (2003). Depression and cancer: mechanisms and disease Progression. Biological Psychiatry, 54 (3):269-282.
Steele RG, Fitch MI. (1996). Needs of family caregivers of patients receiving home hospice care for cancer. Oncology Nursing Forum, 23(5):823-8
Weaver AJ, Flannelly LT, Flannelly KJ. (2001). A 10-year review of research on chaplains and community-based clergy in 3 primary oncology nursing journals:1990-1999. Cancer Nursing, 24(5):335-40
