Nursing intervention and coping strategies to manage the difficulties of dealing with a dying patient and their families

For a nurse, caring for a dying patient is a complex responsibility. It has its set of challenges, both clinically and socially, and nurses need to deal with these every day. Through training and experience, some nurses are better equipped to manage the difficulties, but some are not. Not just the terminally ill patient, his or her families need to be dealt with too. That is precisely why palliative care has emerged as an important field of medicine, where nursing interventions and coping strategies are systematically instilled in professionals having to handle a dying patient and patient’s family. This paper tries to answer the project question in this regard — the kinds of nursing methods in managing palliative care situations.

A reading of medicinal journals and articles point to the fact that the role of nurses in dealing with dying patients and the patients’ families is extremely difficult and challenging. Exposure to death and worsening clinical conditions not only takes a toll on the nurses’ mental conditions, but also affects the quality of care that they provide to dying patients (Leombruni, et al., 2014). Nevertheless, palliative care is extremely important and a significantly critical model for end-of-life (EOL) care as the quality of the dying process (the last days/months of the patient) depends largely on it. Nurses are not only expected to cater to the physical and psychological needs of the patient, but are also trained to prepare the patient’s family for what to expect next.

Williams, et al. (2012) noted that the efficiency of a nurse in engaging family support to the fullest required clinical competency to recognize the dying stages and demonstrate appropriate EOL care behaviours with attention to family needs. The care of the patient does not stop at the patient, but extends to supporting the patient’s family during the dying process. Nurses would need to communicate compassionately with the patient and the family, help each one cope with the grief (pain management), handle multi-dimensional EOL care needs (physical, social, emotional, spiritual), and respect the patient’s wishes during the entire EOL term.

There could be many aspects in a dying patient that would require effective nursing intervention and strategies — pain, depression, coping with the idea of death, preservation of dignity, need for control and asking for physician-assisted suicides (PAS), and other complications like anorexia, sexual dysfunction, etc. (Woo, et al., 2006). It is important for nurses to understand these aspects in order to deliver EOL care successfully. However, robust understanding and good nursing skills may not be enough as there are many barriers nurses face in delivering palliative care. Healthcare provider barriers include inadequate training, institutional challenges include lack of leadership support in EOL care, patient- and family-related obstacles include reluctance to address EOL issues, unrealistic expectations from the healthcare professionals, etc. (Harris, 2014).

An important approach in palliative care is opting for hospice care or pastoral care, a comparatively new, home-based care of terminally ill patients where care is less focused on cure and more focused on lowering physical and emotional distress. Not only does hospice keep cost of EOL care low, it also allows patients to face death with dignity (Tsang, 2013).

On my palliative placement, I observed that the most common way to deal with the situation is by educating the patient’s family with accurate and up-to-date information about the patient’s condition — at what stage of the illness the patient was admitted, the approximate life expectancy of the patient, etc. The possible patient conditions during admission can be stable, unstable, deteriorating, terminal and dead. It is observed that mostly patients are admitted in the deteriorating stage and then they struggle for some time before slipping into the terminal state and eventually meet death. Justifiably then, and as rightly pointed out by Williams, et al. (2012), a lot depends on the nurses’ skills, attitudes and abilities to deal with the patient and his family’s expectations. Often families would complain that the patient was neglected in palliative care or they were less informed about the imminent death. To mitigate such displeasure or lack of trust in the medical institution, the family needs to be effectively engaged through the various dying stages of the patient. Family’s support is necessary in improving the quality of palliative care and that is why it is also important to keep the family aware right from the beginning, so that they do not grow ‘unrealistic expectations’ as mentioned by Harris (2014).

A nurse’s role in palliative care is multi-dimensional and each terminally ill patient is a unique case in itself with different symptoms and coping abilities. Therefore, nursing interventions and coping strategies vary from patient to patient. The interventions would include pain management, handling dehydration issues, ethical issues (e.g. how much information is good for the patient), helping the patient transition from terminal stage to death, treating depression and uplifting dying dignity (Woo, et al., 2006). On my palliative placement, I observed that a lot of importance is given to family touch points in case of terminally ill patients — families are asked to visit the patients regularly and spend substantial time with them, family meetings are also frequently arranged to formally update the close members of the patient about the patient’s condition, what to expect and how to engage with the patient, etc.

During my placement, I also closely observed the benefits of pastoral care, which my placement institute offered to dying patients. Though not a very traditional form of palliative care, it is true as Tsang (2013) notes, that hospice care has been found to be the best form of EOL care. It improves the emotional state of dying patients and thus leads to better termination of lives, and with dignity. Usually pastoral care is ideal for patients who have less than six months to live, so the focus is more on their psychological well-being than physical. On the whole, nurses have a colossal role to play in dealing with dying patients and helping their families cope with the impending bereavement.

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References

• Harris, Mary; Gaudet, JoAnne; O’reardon, Caroline (2014). Nursing care for patients at end of life in the adult intensive care unit, Journal of Nursing Education and Practice, Vol. 4, No. 6, ISSN 1925-4040.
• Leombruni, Paolo; Miniotti, Marco; Bovero, Andrea; Zizzi, Francesca; Castelli, Lorys; Torta, Riccardon (2014). Attitudes toward caring for dying patients: An overview among Italian nursing students and preliminary psychometrics of the FATCOD-B scale, Journal of Nursing Education and Practice, Vol. 4, No. 3, ISSN 1925-4040.
• Tsang, Stephanie (2013). Impact of Pastoral Care Services on Family Decisions and Experience in the Inpatient Hospice Setting, Proceedings of The National Conference on Undergraduate Research (NCUR), University of Wisconsin La Crosse, WI
• Williams, Beverly Rosa; Lewis, Donna R.; Burgio, Kathryn L.; Goode, Patricia S. (2012). Next-of-Kin’s Perceptions of How Hospital Nursing Staff Support Family Presence Before, During, and After the Death of a Loved One, Journal of Hospice and Palliative Nursing. Vol.14(8), pp:541-550.
• Woo, Jennifer A.; Maytal, Guy; Stern, Theodore (2006). Clinical Challenges to the Delivery of End-of-Life Care, Primary Care Companion Journal of Clinical Psychiatry. Vol.8(6), pp: 367–372.