Practice team blog
All posts from: June 2012
Many years ago I nursed a man, Jim (not his real name) who was a widower.
He had a few visitors, a couple who lived next door, an old friend called Pete (not his real name) who came every day and his daughter visited at the weekend.
Jim had a series of complications following an MI and his condition suddenly deteriorated one evening. His daughter was called and over the next few days it became clear that he was going to die.
The day after he collapsed his old friend popped in. Pete was in fact his partner and they had been in a relationship for many years but had kept it a secret from their families for fear of their reaction.
What followed was a very difficult situation. As Jim deteriorated his daughter sat with him and Pete continued to play the role of concerned friend. He told the nurses how they had been part of each others lives for 20 years but at the end he was not able to sit and be with Jim or take any part in his funeral arrangements.
The nursing team found it difficult to balance the need for secrecy with the need for Jim and Pete to spend time together. We did our best but we knew that when Pete left the ward he would grieve on his own.
Last week the National End of Life Care Programme published guidance on care for lesbian, gay, bisexual and transgender people at the end of their lives.
While guidance cannot change societal attitudes it can help healthcare staff understand and respond to the challenges faced by a person has not previously “come out” or those isolated from their families because of their sexuality.
We all make assumptions and judgments about people and their relationships: the family who never visit, the wife who bullies her husband and stays too long, or the person who has no one who cares about them. These guidelines challenge us to examine our attitudes to relationships and what we understand by the term “next of kin”.
Sam Turner, director of public engagement at the National Council for Palliative Care, sums up the consequences of failing to do this. She says: “We only have one chance to get end of life care right for people who are dying”.
For Pete and Jim the fear of being “found out” and of rejection surpassed their wish to spend their last days together and that is profoundly sad. We couldn’t fix their problem but perhaps with guidance we may have had more understanding and the confidence to support Jim and Pete and ultimately make their lives easier.
Nurses’ understanding of pain treatment is essential for its effective management. Yet effective pain control often eludes those who most need it particularly when opioid analgesics are involved.
Last month NICE clinical guideline on prescribing opioids to relieve pain was published. It highlighted that up to two-thirds of people with cancer that experience pain need strong opioid and the number is similar in many other advanced and progressive conditions. Yet pain remains under-treated in these groups of patients.
Opioids, especially morphine are vital drugs in our treatment of pain but the public and many health professional misunderstand and misinterpret their use. Myths surround morphine: it is often viewed as a drug of last resort for those who have no hope. We have all seen relatives shake their heads and whisper “They’ve started him on morphine” or met patients who tolerate pain and pride themselves on resisting their opioid medication because they do not want to become addicted. How many nurses believe you can’t give opioids to patients with COPD? Yet they are vital drugs in the management of breathlessness at the end of life.
The Harold Shipman case has left its mark on how prescribers view opioids and I wonder if fear of scrutiny has resulted in an over cautious approach or avoiding prescribing opioid drugs at all. Yet these anxieties should not exist in a health service that has considerable expertise in pain control and palliative care. All health professionals should be able to access this expertise and be confident in their understanding of pain, the drugs used to treat it and their ability to communicate this to patients.
The new NICE guidance highlighted the vital role nurses have in demystifying opioid analgesia for patients and ensuring they understand the benefits and side effects of treatment. To do this, nurses need to challenge their own beliefs and anxieties about these drugs and ensure they approach this vital part of care as knowledgeable practitioners.
The only way health professionals can be sure of spotting it is if initial assessment on admission is thorough, and is repeated at appropriate intervals. It is also important that all members of the healthcare team are clear about what treatments or interventions are appropriate.
The latest publication from the National Confidential Enquiry into Patient Outcome and Death reports on the care received by patients who received CPR after a cardiac arrest in hospital. NCEPOD found that in almost half of cases the patient’s initial assessment was deficient, and that senior doctors were not involved in managing many of the patients.
While a variety of reports have made recommendations on how to respond to patient deterioration, this one also identified the need to focus on those patients whose best interest may not be served by initiating CPR or life-prolonging treatment. This may be the case even in patients who are receiving active treatment to try to improve their condition.
When health professionals see a patient’s condition deteriorating, the instinct to save usually kicks in. However, when patients are dying, CPR is inappropriate and can make their last hours painful, distressing and undignified.
Thorough initial assessment of acutely ill patients is crucial, but should also include assessment of whether or not this patient should be resuscitated in the event of cardiac arrest. Of course decisions not to attempt CPR should not be taken lightly. They must involve senior doctors and, if possible, the patient and/or next of kin - which must be done with care and sensitivity. Once taken, however, DNACPR decisions must also be respected.
Acutely ill patients are extremely vulnerable if their condition deteriorates. They deserve thorough assessment and observation to ensure the care they receive is appropriate to them - and sometimes that means stepping back, keeping them comfortable and letting nature take its course.