Running head: NURS 627 END OF LIFE DECISION MAKING1

2NURS 627 END OF LIFE DECISION MAKING

NURS 627 End of Life Decision MakingHeather ShepherdUniversity of New Hampshire

AbstractThis paper introduces the topic of end of life decision-making. Hospice, comfort care to facilitate death, is under utilized in the United States. This is directly correlated with the lack of education and comfort that nurses and physicians have with initiating end of life decision-making conversations. Communication and assessment are the two main components of end of life decision-making. Nurses and physicians need to be adequately trained on the difficult subject of end of life care. The avoidance of ambiguous words in conversation is essential to facilitate the start of these conversations. This reduces confusion among patients and families about prognosis and helps them to make educated end of life decisions. Preparedness for death is important to assess to help patients maintain the highest quality of life and quality of death. Wishes for death are also important to assess early on in patient care before ill patients lose the ability to communicate. If families feel confident in implementing the needs of their ill, loved ones, the grieving process may be less complicated.

IntroductionNursing practice requires nurses to obtain a complex set of skills. Caring for patients and enhancing the lives of others is one of the main goals of nursing. However, when it comes to life, death is inevitable. Nurses are advocates for patients; end of life decision-making may be difficult for some patients and their families. Part of the nursing role is to help patients and loved ones transition into the final stages of life. Hospice care is something that is under utilized in the United States. An article from ABC news confirms that only one third of Americans die under hospice expertise (Mundell, 2015). The author also mentions that this issue of not utilizing professional hospice care will become more problematic as the baby boomers start to reach their final years of life. As new nurses enter the clinical practice, education of this branch of nursing is a key component in modern education. More conversations about appropriately choosing hospice care and other end of life decisions are important. Nursing care is all about what the patient wants and this includes what he or she desires in the final stages of life. The challenge of when to transition to hospice care or how to make decisions regarding end of life care will affect everyone in some way; whether it be the patient, the family, or other loved ones of the patient. Case StudyOne specific example of this challenge can be related to Patient X. This patient is a 69-year-old female with a medical diagnosis of metastatic breast cancer. She is an outpatient at a local cancer center where she receives chemotherapy treatments. More recently, she has had frequent visits to the same hospital as an inpatient on a medical surgical unit. The breast cancer spread to her lungs and there is question of a presence of a mass in her colon. Even after knowing her metastatic diagnosis, this patient still elects to remain a full code and continue her chemotherapy treatment. Her frequent inpatient hospital visits and chemo side effects have decreased the quality of life for this patient. Considering this client is an older adult, the chance of remission is decreased. A discussion between the patient, primary nurse, and primary care provider about end of life care and wishes is essential; unfortunately this has yet to happen. End of life decisions should not be left to when the patients are terminally ill. Decisions like this need to be clearly discussed between patients and their family members before patients are not able to accurately input their wishes. For Patient X, even if she does not wish to become a DNR or transition to hospice care, she should still have a conversation with the people in her life about her end of life wishes. In this case, the patients husband, sister, and even her mother can be included in this conversation. These people are her support system, they visit her each time she is admitted to the medical surgical floor at her local hospital. Review of the LiteratureTwo components of facilitating end of life decision-making were found throughout the literature. These two components consist of communication and assessment. After proper communication and assessment, a discussion can take place between health care workers and patients about wishes for end of life. Norton and Talerico (2000), used a grounded theory study with a total of twenty participants to examine health care staff behaviors that facilitate end-of-life decisions. According to the nurses, physicians, and family members that participated in this study, staff members who are experienced and familiar with this subject are more likely to use enabling communication and assessment strategies. CommunicationThis study found that adequate communication about treatment options as well as the possibility of death is crucial in aiding end-of-life decision-making (Norton & Talerico, 2000). Participants of the study examined overall comfort and experience of health care providers to bring up the topic of end of life. The participants further assessed three categories of communication. The categories included being willing, being clear, and clarifying prognosis and goals of treatment (Norton & Talerico, 2000). It was found that nurses and providers that are uncomfortable with discussing end-of-life issues deferred these important conversations. Being clear in this study was related to nurses and providers using terms like death and dying. Participants felt that health care staff that avoided these terms sent mixed messages regarding fatal diagnoses. Other unclear terms that were common included hope and better. Participants found these words to be ambiguous and found it difficult to accept the terminal prognoses of their family members with the inclusion of these words. Clarifying prognosis and goals of treatment were found to be important in communication so that patients and families can make adequate decisions. Participants concluded that a lack of clarification gave patients and families false impressions about the patients conditions.A separate study examined the deferral of negative prognostic communication with patients and families in the ICU setting. Gutierrez (2012), states that about fifteen to thirty five percent of patients die in ICUs. He also mentions that many of these patients are too critical to participate in end of life decisions. Avoiding communication about prognoses leads to a limited amount of time for families to make end of life decisions. The delay in negative prognostic communication ultimately leads to a reduction in hospice care utilization and a decreased quality of life for these patients. In a second study found, Roscoe, Tullis, Reich, and McCaffrey (2013), investigated patients perceptions of communication with their oncologists. This particular study included patients with head and neck cancer, but also mentions that patients with other types of cancers are dying without having proper discussions with their health care providers. The research from this study found only three out of fourteen participants utilized hospice care even though eleven out of fourteen patients died within a six-month time period. This study concluded that patients rated their health care team highly when asked about communication skills. However, it was also discovered that tone of voice from health care providers when speaking about end of life was not preferred. Though the patients respected the honesty, some physicians were thought to be cold and uninviting. Other issues with the communication about end of life decisions included patients receiving information only if they provided the questions and patients misinterpreting information received. Therefore, communication must not only be initiated, but it must also be sufficient to facilitate end of life decision-making.AssessmentNorton and Talerico (2000), describe assessing as an ongoing process by health care providers. Their study mentions that it is critical for physicians and nurses to assess for and identify a need for end of life discussions. There are four categories that need to be assessed which include recognizing deteriorating conditions, assessing understanding, assessing end of life wishes, and assessing patient and family goals and expectations (Norton & Talerico, 2000). This study found that experienced health care staff members were able to recognize worsening conditions and then initiate end of life discussions. These conditions included worsening symptoms, weight loss, and increased use of assistive devices. Assessing understanding of the patients conditions was important to look for in family members as well as patients. Adequate understanding of prognoses leads to informed decision-making by the clients and loved ones. Another key component of assessing is the examination of patients end of life wishes (Norton & Talerico, 2000). Advanced directives are important aspects of care to discuss with patients in order to preserve proper quality of life for each individual patient, whether this means resuscitating him or her or not. The final important factor in assessing patients includes assessing the patient and family goals and expectations. After asking the patient, what are you health goals?, the health care team can then assess whether or not these goals are achievable (Norton & Talerico, 2000). Further assessments and teachings can be performed in order to educate clients of all treatment and end of life options. In a concept analysis, Mcleod-Sordjan (2013), assessed patients readiness for death. Along with communication about end of life decisions, an assessment of readiness for death must occur. Communication may not be effective if the patient is not willing to accept his or her prognosis. This study did a literature review to analyze the concept of death preparedness. It was found that there are six components of death preparedness. Mcleod-Sordjan (2013), states interaction between the patient and health care team regarding end of life decisions, acceptance, awareness, transition in death attitudes, acknowledging participation in end of life decisions, and an end of life plan are all part of death preparedness. This study also mentions that the preparedness for death is correlated with the quality of death (Mcloeod-Sordjan, 2013). The primary finding of this study is that death preparedness should be the main concern in regards to improving advanced directive and palliative care initiation. Montagnini, Smith, and Balistrieri (2012), set out to examine ICU staff members opinions of their own end of life care proficiency. ICU workers were given a survey to assess this. Overall, ninety-three surveys were completed. Nurses were one of the highest responding sub groups of ICU staff members. Montagnini, Smith, and Balistrieri (2012), mention that about seventy percent of participants stated they had some form of previous end of life education. The areas that participants felt most comfortable included providing emotional support, spiritual support, symptom management, and decision-making regarding end of life (Montagnini, Smith, & Balistrieri, 2012). Areas that participants felt less competent in included communication, staff support, and continuity of care (Montagnini, Smith, & Balistrieri, 2012). This study concluded that, although many staff members had previous education regarding end of life care, interventions still needed to take place to provide additional education. Further education is needed; especially for the areas of care previously mentioned that nurses and other workers felt less competent in. Application of the LiteratureAfter a review of the literature, there is evidence that shows end of life decision-making is not as efficient as it can be in the United States. As it pertains to Patient X, end of life decisions were not discussed. There may be a multitude of reasons why this topic was not discussed. The nurses and physicians may not have felt that the patient was in need of making end of life decisions. Oncologists may believe that this patients cancer is not terminal. Another possible reason that end of life decisions were not discussed may be that the nurses and primary physician were not confident in their abilities to initiate this conversation. Regardless of prognosis for this patient, advanced directives and palliative care should have been discussed. Any patients with pain related to cancer are eligible for palliative care if not hospice, professional care. As mentioned before, quality of life is an issue for this patient. In order to improve quality of life, as well as quality of death regardless of when death occurs, a conversation about the patients wishes for the future is essential for this patient. The family members of this patient were active participants in her care; therefore, they need to be included in the conversation of the patients wishes. This will help family members to respect those wishes if it comes to the point in which the patient can no longer communicate. This is the case for all patients, not only Patient X. Other than an improvement in communication, an adequate assessment must occur to determine the current condition of the patient and her understanding and the familys understanding of this current prognosis. This may help nurses and physicians understand when to initiate end of life conversations as well as the patient to question her current end of life choices. ConclusionIf the nursing staff and all physicians were educated and confident regarding end of life decision-making and care, the quality of life would be vastly improved for Patient X. In order to improve quality of death for all patients, quality of life must be maximized. Palliative and hospice care may be utilized more frequently when nurses and other health care staff become educated and comfortable with discussing death with their patients. When workers are educated, facilitation of end of life decisions can occur with the incorporation of communication and assessment strategies. Communication is key to helping patients and families understand current health conditions and help them make informed decisions to maximize quality of life and death. Assessment is also important to recognize when it is appropriate to initiate these conversations and to help patients and families prepare for death. After these discussions take place, family members will be able to better understand patients wishes and thus may have less complicated grieving processes after patients pass. This may help families feel more at ease knowing that their loved ones wishes were evaluated and met. ReflectionReviewing the literature and applying it to Patient X has put end of life issues into perspective for me. I now have a better understanding of how beneficial this knowledge would have been when caring for this patient. I would have talked to the primary nurse for that day and possibly had a conversation with the patient myself about end of life wishes. I have learned in class that hospice care and palliative care is underutilized. However, after researching end of life decision-making, I now understand that this is not always the fault of patients. Nurses and physicians are not providing adequate opportunities for patients to think about and choose palliative and hospice care. Advanced directives are also something that need to be incorporated more into practice. I can understand that it would be challenging as a nurse to initiate a conversation about end of life wishes and advanced directive; however, this is important to maximize patients quality of life and death. To facilitate the start of these conversations, it is also important to inform patients that decisions about end of life are important for all patients and not only those who are nearing the end of their lives. I will keep this in mind when caring for patients throughout my nursing career. While improving the quality of life of my future patients, I will also strive to help my colleagues improve the lives of their patients as well.

Works CitedGutierrez, K. (2013). Prognostic categories and timing of negative prognostic communication from critical care physicians to family members at end-of-life in an intensive care unit. Nursing Inquiry, 20(3), 232-244. Retrieved April 30, 2015 from doi: 10.1111/j.1440-1800.2012.00604.x Mcleod-Sordjan, R. (2013). Death preparedness: A concept analysis. Journal of Advanced Nursing, 70(5), 1008-1019. Retrieved May 1, 2015 from doi: 10.1111/jan.12252Montagnini, M., Smith, H., & Balistrieri, T. (2012). Assessment of Self-Perceived End-of-Life Care Competencies of Intensive Care Unit Providers. Journal of Palliative Medicine, 15(1), 29-36. Retrieved May 1, 2015 from doi:10.1089/jpm.2011.0265.Mundell, E. (2015, March 23). End-of-Life Hospice Care Underused. Retrieved April 29, 2015, from http://abcnews.go.com/Health/Healthday/story?id=4508069&page=2Norton, S., & Talerico, K. (2000). Facilitating End-of-Life Decision-Making Strategies for Communicating and Assessing. Journal of Gerontologic Nursing, 26(9), 6-13. Retrieved April 29, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3732104/Roscoe, L., Tullis, J., Reich, R., & Mccaffrey, J. (2013). Beyond Good Intentions and Patient Perceptions: Competing Definitions of Effective Communication in Head and Neck Cancer Care at the End of Life. Health Communication, 28(2), 183-192. Retrieved April 30, 2015 from doi: 10.1080/10410236.2012.666957