With respect to setting, the task of the nurse is to make the physical and psychological space where care is occurring to be as comfortable and non-threatening as possible (Rancour, 2000). Because the end of life is an uncomfortable subject and experience for many people, as many of the obstacles to honest and open exploration of and conversation about this subject should be removed as are possible. Rancour (2000) also explained that the patient should be permitted to retain as much control over the environment as is feasible given the regulations of the hospital setting and the limits of his or her cognitive functioning. The writer adds that the age of the patient and the composition and nature of his or her family and support system are also important variables that will determine how the setting can be established and maintained throughout the palliative care process. In the case of the patient who was being cared for by the writer, the environment that needed to be created was one that was free of judgment and one in which the family members were put in a position of authority and knowledge, invited to share information about their religious beliefs and their decision-making processes regarding the patient’s care with the nurse. Not surprisingly, the parents of the patient had experienced a great deal of criticism in the community and within the hospital, as well as pressure from medical care providers to provide medical intervention for their daughter. It was understandable, then, that they were initially suspicious of the nurse, and were defensive, prepared both to be attacked and to attack in return. Although the writer had vastly different beliefs than the family and struggled daily with not allowing those personal beliefs to interfere with caring for the patient and her family, he maintained neutrality by admitting that he knew little about the family’s religion and invited them to share their knowledge and experiences with him. This approach was genuine and resulted in the creation of a setting that was respectful and which did not subject the patient to unnecessary conflict and the stress that such conflict could cause..

Rancour (2000) explained that perception refers to determining what the patient and his or her family know about the illness and what they believe about its trajectory. Often in this stage of palliative care the nurse, as professional medical care expert, will be bombarded with questions and requests about any last-minute interventions that could be applied to save the patient’s life. In this particular case, however, the entire family, including the patient, had accepted the inevitability of the child’s death and appeared to be at peace with the decision that they had reached mutually based on their religious beliefs. Again, while the nurse had strong personal feelings and doubts about an eight year old child’s ability to make a decision about dying, the fact that no legal intervention could reverse the parent’s decision meant that the nurse had to work within the constraints of the situation; given those circumstances, he decided not to call the parents’ decision into question, particularly in front of the child. Rather, the nurse spent one-on-one time both with the patient and with her parents to ascertain whether they had any specific questions about the expected course of the illness. He also affirmed that they could ask questions at any time throughout the care process.

Somewhat related to the assessment of perceptions is the issuance of an invitation from the nurse to the patient and her support system, and following-up with knowledge (Rancour, 2000). The purpose of the invitation is to create the opportunity for the patient and her loved ones to ask questions that only a medical professional could answer based on his or her specialized knowledge (Rancour, 2000). It is important, wrote Rancour (2000), that the answers the nurse provides be congruent with the patient’s developmental and cognitive capacities. In the case situation described here, the patient was a child and so the information that the nurse provided in response to the questions asked during the invitation phase was tailored to an eight year old’s ability to understand. The nurse utilized supportive materials, such as books with pictures, to explain what was happening in the child’s body, and also used humor and other resources as appropriate.

Regarding explorations, Rancour (2000) explained that the palliative care nurse has a particular responsibility to check in regularly with the patient and the support system to determine how they are feeling. Based on the nurse’s active and reflective listening to all parties, he should ask questions that are intended to clarify and confirm each person’s feeling state throughout the palliative care process (Rancour, 2000). The nurse should also keep in mind that feelings can change quickly and dramatically in situations where a patient’s life is nearing its end. The patient and her family in the case described here had difficulty identifying and discussing their emotions, so the nurse brought in a feelings chart, which had been given to him by a social worker, and referred to the chart daily. Over time, the nurse noticed that the patient and her parents became more adept at both identifying their feelings and talking about them, and he kept a log that tracked their feelings from day-to-day. The log provided a tangible record and served as a conversation piece during daily contact with the patient and her family.

Finally, the last step in the Buckman Protocol is called “summary and strategies,” and as the name suggests, this stage involves working with the patient and support system to make plans for the future (Rancour, 2000). Depending on the patient’s particular situation and prognosis, the nurse will want to make short-term and long-term plans, both for the patient’s life and his or her death, as well as plans that will help provide ongoing support for the bereaved. Because the patient and her family in this case were remarkably pragmatic, they found talking about plans, which were concrete, to be easy and even comforting. Plans helped create a sense of control because each person had a task, and control created comfort for this family. Planning may involve, as it did in this case, appropriate referrals for ancillary support services, such as social work, pastoral counseling, and even funeral planning. In this case, planning involved the minister of the family’s congregation, who was an integral part of the end-of-life experience for the patient and her parents.

Analysis of Theory and Situation for Future Practice

The traits and skills identified in the previous section are particularly valuable for palliative care nurses, and the writer found them indispensable in the particular situation he confronted during the clinical experience. Such characteristics and skills, however, are also transferable to any other aspect of nursing, as well as to one’s own personal life. Palliative care skills, when considered broadly and philosophically, are about being conscious of the quality of life and being present throughout the process of caring for another (Sharp & Oldham, 2004; Ury, Arnold, & Tulsky, 2002). What the skills that are so necessary to palliative care share in common is that they require that the nurse shift gears and slow down from a fast-paced, hands-on version of nursing to a paradigm and praxis that is more inclusive, engaged, and reflective (Heming & Colmer, 2003).

Given my experience with what may be a fairly unusual case and my expanding knowledge about the theory and practice of palliative care, I feel confident that I can embody the skills and competencies that I developed in any other nursing situation or specialty. This clinical experience was extraordinarily challenging because it required that I examine and then set aside my personal beliefs and even what I considered to be my professional responsibilities in order to provide end-of-life care that was characterized by my ability to be present and attentive, providing what the patient and her family needed, rather than what I may initially have wanted to give. This particular experience also reaffirmed the value and importance of clinical supervision and continuing education. Without a supportive, thoughtful, and intelligent supervisor, and without the knowledge and information acquired in my academic program, it is unlikely that I would have felt as calm, confident, and in control of the situation as I did, or that I would have learned so much about myself, both as a person and as a nurse, because of it.

Summary and Conclusion

All nurses share the same basic commitment to providing care to patients that is intended to improve and sustain the individual’s quality of life, taking into account the realities of the patient’s medical history and prognosis. In acute care, the nurse’s role is typically to introduce, implement, and monitor physical interventions that the treatment team believes will boost quality of life. In palliative care, however, the task is somewhat different. Having exhausted or rejected all possible interventions, the patient’s quality of life is supported in other ways, using strategies that are less reliant upon physical interventions and which are more reliant upon emotional, psychological, and social strategies that will allay the patient’s concerns and increase his or her comfort, as well as that of his or her family and support system. Palliative care theory offers clear-cut strategies and skills for practice with patients at the end-of-life, the most important of which were reviewed and analyzed in this paper by applying them to a specific clinical situation. The writer concludes that while these skills are of particular benefit in the palliative care setting, they are transferable and useful in all care environments because they promote awareness and a patient-centered focus.

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