PALLIATIVE CARE
What about dignity? A professional discussion Brian Nyatanga
Senior Lecturer in Allied Professional Studies and Lead for The Centre for Palliative Care, University of Worcester [email protected]
Symptom control Poor symptom control results from inadequate and irregular assessment that at times ignores the psychological and spiritual aspects of dying. It can be argued that when this happens, professionals may not have the skills to assess the psychological/emotional/spiritual needs of patients. Therefore, a balance is needed to identify and prioritise our intervention.
Communication Poor communication has come high in the list of complaints received in health care (PHSO, 2015) and suggests a deepseated problem and lack of skills in discussing patients’ impending death in an honest and sensitive manner. New sources of funding are required to continue with the Connected Advanced Communication Skills Training (developed by the NHS National Cancer Action Team) for
360
all who undertake palliative care. Community nurses should be included in such training, as dying at home is preferred by two thirds of dying patients. Moreover, there may now be a real need to review issues of confidentiality around those deemed important to the patient, as sharing such information might benefit the patient’s care.
Giving care 24/7 Making patients feel cared for during ‘after hours’ should start by us revising the notion of out-of-hours care, as it reflects only our working day of 9 am to 5 pm. For patients, their illness and accompanying symptoms are present 24/7, and therefore, staffing levels should reflect the needs of patients and not the time of day. Patients may feel anxious during the ‘out of hours’ period, and this might increase the severity of other symptoms like pain—a cycle that is repeated each night.
Conclusion People typically create boundaries of privacy through how they dress and what they choose to divulge to others. When stricken with an illness, the first doctor’s appointment signals the beginning of the dismantling of their privacy. What might be a ‘routine test’ to doctors and nurses, may be a difficult compromise with a patient’s privacy. Community nurses and other health professionals who help patients with intimate care (e.g. bathing, toileting, and catheterization) should not forget how these necessary activities also ‘tear through’ patients’ privacy boundaries and eventually their dignity. There is an argument that when these intimate activities happen in the patient’s home, the effect on their privacy is reduced when compared to being in a hospital/institution. In the final analysis, while death is inevitable, poor dying ought not to be (Chochinov, 2012), and we can do better to afford all patients the dignity they require or, indeed, deserve. BJCN Chochinov HM (2002) Dignity-conserving care--a new model for palliative care: helping the patient feel valued. JAMA 287(17): 2253-60 Chochinov HM (2012) Dignity Therapy: Final Words for Final Days. Oxford University Press, New York Marley J (2005) A concept analysis of dignity. In: Cutcliffe JR, McKenna HP, eds. The Essential Concepts of Nursing. Elsevier Churchill Livingstone, Edinburgh Parliamentary and Health Service Ombudsman (2015) Dying without dignity: Investigation by the Parliamentary and Health Service Ombudsman into complaints about end of life care. http://bit.ly/1HtV3HF (accessed 17 June 2015)
© 2015 MA Healthcare Ltd
T
he recent report by the Parliamentary and Health Service Ombudsman (PHSO) (2015) concluded that most people were dying without dignity. This can be viewed as a serious indictment on palliative and end-of-life care providers, as the concept of dignity has been discussed for over a decade now (Chochinov, 2002; Marley, 2005). The report identifies a number of areas in which poor care contributed to dying without dignity. If the above areas are contributory factors, then it raises the difficult question of ‘What exactly is dignity?’ Most health-care literature has discussed dignity as a ubiquitous concept, that is, everyone is aware of dignity and can clearly articulate it. Definitional discussions are beyond the scope of this comment, and interested readers should consult Chochinov (2012). Although dignity may prove difficult to articulate, Marley (2005) claims that its absence is easily identified. The irony is that, while dignity is an elusive concept, we need to understand dignity in order to afford it to our patients. The challenge for community nurses, as they care for dying patients in their own homes, is how best to afford the patients the dignity they wish for. There are common factors associated with dignity: effective total symptom control, effective communication at all times, and the patient feeling cared for 24/7, just to name a few. These factors are not new, but somehow remain poorly addressed, and below I shall speculate the reasons.
British Journal of Community Nursing July 2015 Vol 20, No 7
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on October 22, 2015. For personal use only. No other uses without permission. . All rights rese
What about dignity? A professional discussion Brian Nyatanga
Senior Lecturer in Allied Professional Studies and Lead for The Centre for Palliative Care, University of Worcester [email protected]
Symptom control Poor symptom control results from inadequate and irregular assessment that at times ignores the psychological and spiritual aspects of dying. It can be argued that when this happens, professionals may not have the skills to assess the psychological/emotional/spiritual needs of patients. Therefore, a balance is needed to identify and prioritise our intervention.
Communication Poor communication has come high in the list of complaints received in health care (PHSO, 2015) and suggests a deepseated problem and lack of skills in discussing patients’ impending death in an honest and sensitive manner. New sources of funding are required to continue with the Connected Advanced Communication Skills Training (developed by the NHS National Cancer Action Team) for
360
all who undertake palliative care. Community nurses should be included in such training, as dying at home is preferred by two thirds of dying patients. Moreover, there may now be a real need to review issues of confidentiality around those deemed important to the patient, as sharing such information might benefit the patient’s care.
Giving care 24/7 Making patients feel cared for during ‘after hours’ should start by us revising the notion of out-of-hours care, as it reflects only our working day of 9 am to 5 pm. For patients, their illness and accompanying symptoms are present 24/7, and therefore, staffing levels should reflect the needs of patients and not the time of day. Patients may feel anxious during the ‘out of hours’ period, and this might increase the severity of other symptoms like pain—a cycle that is repeated each night.
Conclusion People typically create boundaries of privacy through how they dress and what they choose to divulge to others. When stricken with an illness, the first doctor’s appointment signals the beginning of the dismantling of their privacy. What might be a ‘routine test’ to doctors and nurses, may be a difficult compromise with a patient’s privacy. Community nurses and other health professionals who help patients with intimate care (e.g. bathing, toileting, and catheterization) should not forget how these necessary activities also ‘tear through’ patients’ privacy boundaries and eventually their dignity. There is an argument that when these intimate activities happen in the patient’s home, the effect on their privacy is reduced when compared to being in a hospital/institution. In the final analysis, while death is inevitable, poor dying ought not to be (Chochinov, 2012), and we can do better to afford all patients the dignity they require or, indeed, deserve. BJCN Chochinov HM (2002) Dignity-conserving care--a new model for palliative care: helping the patient feel valued. JAMA 287(17): 2253-60 Chochinov HM (2012) Dignity Therapy: Final Words for Final Days. Oxford University Press, New York Marley J (2005) A concept analysis of dignity. In: Cutcliffe JR, McKenna HP, eds. The Essential Concepts of Nursing. Elsevier Churchill Livingstone, Edinburgh Parliamentary and Health Service Ombudsman (2015) Dying without dignity: Investigation by the Parliamentary and Health Service Ombudsman into complaints about end of life care. http://bit.ly/1HtV3HF (accessed 17 June 2015)
© 2015 MA Healthcare Ltd
T
he recent report by the Parliamentary and Health Service Ombudsman (PHSO) (2015) concluded that most people were dying without dignity. This can be viewed as a serious indictment on palliative and end-of-life care providers, as the concept of dignity has been discussed for over a decade now (Chochinov, 2002; Marley, 2005). The report identifies a number of areas in which poor care contributed to dying without dignity. If the above areas are contributory factors, then it raises the difficult question of ‘What exactly is dignity?’ Most health-care literature has discussed dignity as a ubiquitous concept, that is, everyone is aware of dignity and can clearly articulate it. Definitional discussions are beyond the scope of this comment, and interested readers should consult Chochinov (2012). Although dignity may prove difficult to articulate, Marley (2005) claims that its absence is easily identified. The irony is that, while dignity is an elusive concept, we need to understand dignity in order to afford it to our patients. The challenge for community nurses, as they care for dying patients in their own homes, is how best to afford the patients the dignity they wish for. There are common factors associated with dignity: effective total symptom control, effective communication at all times, and the patient feeling cared for 24/7, just to name a few. These factors are not new, but somehow remain poorly addressed, and below I shall speculate the reasons.
British Journal of Community Nursing July 2015 Vol 20, No 7
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on October 22, 2015. For personal use only. No other uses without permission. . All rights rese
