Communication Vignettes Research Articles

Communication Vignettes: 'I Don't Think I Can Cope, Nurse'

Communication Vignettes: 'I Don't Think I Can Cope, Nurse'

Communication vignettes: Telling a Child That Her Dad is Dying

Communication vignettes: Telling a Child That Her Dad is Dying

Communication vignettes: 'You Must Get Her Out of Bed, Nurse!'

Communication vignettes: 'You Must Get Her Out of Bed, Nurse!'

Communication Vignettes: She Wants Her Misery To End, Nurse!

In palliative and end-of-life care, holistic patient assessment involves considering patients’ physical, psychological, social and spiritual concerns. As part of psychological assessment, it is important to discuss with patients their perception of body image and whether it is affecting their interactions with others and their ability to live their life in the way they want. In both general and palliative care, assessment of body image is a neglected area. However, such assessment is necessary so that care can be planned appropriately with the patient. Assessing body image requires sensitivity and good communication skills. Nurses’ knowledge in this area needs to be improved so that they are thinking actively of body image as a potential patient concern. This article will discuss the importance of assessing body image concerns as part of overall psychological assessment. It will provide an overview of some of the main conditions in terminal disease that can cause patients to feel distress and embarrassment. It will then explore how nurses can assess patients with regard to body image dysfunction. Conflicts of interest: none

Communication vignettes: ‘He made a living will nurse!’

Healthcare professionals do not often encounter patients who refuse treatment. Generally, ill people are grateful to receive treatment, or may even demand it. However, some patients refuse treatment. Their reasons for so doing are often complex, associated with deep-seated emotions, and should be of concern to healthcare professionals. Nurses in particular must endeavour to understand why treatment they consider to be beneficial to a patient may not be viewed as such by said patient. Most treatments have what is called a risk–benefit ratio, an uneven balance of the risk of adverse outcome compared to desired effect. It is the patient who receives the treatment and takes the risk. As such, health professionals must be aware that patients have the right fully to understand their treatment and any resultant risks. For example, how often do nurses administer an arachis oil enema without ascertaining whether the patient has nut allergy? Arachis oil is extracted from peanuts ( Arachis hypogaea ) and about one in 100 people in the UK are allergic to peanuts (www.patientuk.co.uk). The risk to the patient may be hidden, illustrating the need to obtain informed consent to all treatments. In the NHS, patients do not have the right to demand specific medical treatment (General Medical Council, 2010; Royal College of Physicians, 2010). However, they have the right to refuse specific treatment. Advance refusal of treatment will be considered in this article. Such refusal usually means that a person has thought about which clinical treatments they wish to forego in the event that they are unable to express their wishes for treatment at a future date. In other words, at the critical time of decision-making, an individual might be unconscious, too unwell, or mentally incompetent to make or express an informed decision. This sort of planning for future care is termed …

Communication vignettes: ‘How seriously ill is she, nurse?’

When relatives/friends visit a very ill patient in hospital, they may notice a marked clinical deterioration in his/her condition, evoking anxiety and fear that the patient is about to die. This will probably cause them to ask for information. The first person to whom relatives/friends often turn to communicate their concern is a nurse on the ward. The relative may be unaware of the nurse’s level of seniority or experience. The nurse may be junior, or lack the appropriate knowledge to assist. It is vitally important that the attitude and words of the person first approached are sympathetic and truthful. If that nurse is unable to provide the required information, then he/she must exhibit a willingness and openness to refer the relatives/friends to someone who can. Giving appropriate information about someone who is seriously ill to their nearest and dearest is not an easy task. It requires sensitivity, empathy, adequate clinical knowledge and listening skills. The standard advice is that breaking bad news, whether to the patient or relatives/friends, is best done by a senior practitioner (Brewin, 1991). Information of this kind may not be received in the way in which it is intended. During stressful conversations, it is not uncommon for relatives/friends to find it difficult to absorb information. Inappropriate or ‘blocking’ behaviour on the part of the nurse, i.e. not providing the right amount of information, may lessen the chance of patients/relatives/friends understanding and retaining said information (Maguire and Pitceathly, 2002; Table 1 ). This can lead to misunderstandings, failed communication and even complaints by the family against the nurse concerned (Abraham, 2004). As Buckman (1996) stated: ‘It has been said that if breaking bad news is done well…patients and their relatives… never forget us, but if it is done badly, they will never forgive us.’ View this table: Table 1 Blocking behaviour …

Communication vignettes: ‘Help her nurse, she’s drowning!’

Death rattle is the term commonly used to describe noisy, rattling breathing that occurs at the very end of life. It usually affects terminal patients who are unconscious or too weak to expectorate. Its cause is unknown. It is thought to be the result of the oscillatory movements of secretions/saliva accumulating in the patient’s upper airways (Twycross and Wilcock, 2007; Wildiers et al, 2009). However, there is no strong evidence regarding the pathophysiology of death rattle and further research into the mechanisms resulting in the noisy breathing is required (Wee and Hillier, 2009). The death rattle is accepted as a clinical indicator that death may soon occur, i.e. in hours or days (Wildiers et al, 2009). Full discussion of the management of death rattle is outside the remit of this vignette. The topic will be covered in a future issue of the journal. Interested readers should refer to the Palliative Care Formulary , which sets out best practice guidelines (Twycross and Wilcock, 2007). Death rattle is one of the symptoms in palliative care for which no strong evidence base exists relating to treatment (Wee and Hillier, 2009). Traditional treatment has been the administration of antimuscarinic drugs (the aim being to reduce the amount of secretions accumulating), positioning the patient in a semiprone position to encourage drainage (or, if the secretions are the result of pulmonary oedema or gastric reflux, positioning in an upright or semirecumbent position) and suctioning (if the patient is unconscious) (Twycross and Wilcock, 2007; Wee and Hillier, 2009). However, these interventions have varying levels of success. A recent Cochrane systematic review confirmed the lack of high-quality evidence for such practices (Wee and Hillier, 2009). For example, there is currently no strong evidence that one antimuscarinic drug is more effective than another. Until definitive research …

Communication vignettes: ’Why am I on a pathway nurse?‘

The Liverpool Care Pathway for the Dying Patient (LCP) was developed to transfer the hospice model of care for people in the last days or hours of life into generalist settings. It is a multidisciplinary, integrated care pathway to guide the way in which care is delivered to dying people and their families, friends and carers, e.g. whether there is a continued need for invasive procedures and current medications (Ellershaw and Wilkinson, 2003). However, the pathway is only as effective as the expertise of the practitioners using it. Healthcare professionals are required to use their own clinical judgment in the process and continually reassess the patient’s condition (Department of Health, 2008, 2009). Communicating with dying patients and their loved ones should be in the skills base of every nurse. Effective communication is integral to the success of the LCP. It is essential that the patient (if conscious and capable) and their family/friends are aware of the diagnosis and that the clinical signs indicate that the dying phase is approaching. A recent audit found that the LCP improves the quality of clinical care that people receive in the last hours and days of life. However, certain aspects of care still require improvement. One of these relates to communication with the patient and their relatives/ loved ones during the dying phase (The Marie Curie Palliative Care Institute and Royal College of Physicians, 2009). The audit found that only a third of patients (who were not comatose) were provided with an explanation about their condition at the time the LCP was commenced. Just under three-quarters of carers in the audit sample understood that the patient had entered the dying phase. This article is the fourth in a series of fictitious communication vignettes wherein conversations that commonly occur within end-of-life care are …

Communication vignettes: ‘I want to kill myself nurse!’

Nurses are the health professionals most commonly confronted with patients expressing suicidal feelings and a desire for an early death. However, it has been found that nurses often do not know how to respond when a patient expresses such feelings. They instead say nothing, turn the focus of the conversation onto physical issues, or change the topic altogether (Hudson et al, 2006a). Common reasons for patients’ desire for an early death include fear of being a burden to relatives, loss of autonomy, distressing physical symptoms, depression, hopelessness and fear of the future (Seale and Addington-Hall, 1994; Emanuel et al, 2000; Hudson et al, 2006b; Ganzini et al, 2008). Psychological distress is the most persistent symptom experienced by people with incurable disease (Edmonds et al, 1998). It reduces the patient’s ability to cope with the final illness (Hotopf, 2004). This article is the third in a series of fictitious communication vignettes wherein conversations that commonly occur within end-of-life care are highlighted. The intention is to provide readers with suggestions of how to conduct difficult conversations. Individual nurses will, of course, bring their own expertise and personalities to such situations. This vignette relates to a patient who divulges to a nurse that he is planning to commit suicide. The case scenario is the same one that is the subject of the ethical and legal discussion on pages 26–30. In that article the patient does eventually go on to commit suicide. This communication vignette will only deal with the initial conversation between the nurse Sally and the patient Jack to examine whether some of the pitfalls encountered by Sally in the extended version could have been avoided. Jack Thomas is 87 years old. He has a 5-year history of prostate cancer. Unfortunately, all curative treatment has been unsuccessful. He has …

Ethics and the Law: The Suicide of a Terminally Ill Patient

Suicide is one of the most distressing and difficult situations that healthcare professionals will encounter. It is a violent act, the impact of which reaches well beyond the actual person who commits suicide. Inevitably it leaves family members, friends, carers and professionals feeling helpless, inadequate and responsible. However, failure to prevent a patient committing suicide is rarely a reflection on the competence of the clinician. Despite the high incidence of depression and sadness in terminally ill people, suicide is extremely rare amongst dying people. The highest risk of suicide for those with cancer is at the time of diagnosis. This article examines the ethical and legal implications of an 87-year-old man, in the advanced stages of his disease, who expressed a wish to kill himself to a district nurse and subsequently committed suicide (see Case scenario box). It raises issues surrounding patient confidentiality and a health professional’s duty of care. It examines the nurse’s actions and asks whether she could have done anything differently to prevent the death. This case scenario is also the subject of the ‘Communication vignettes’ series on pages 22–25. Conflicts of interest: none

Communication vignettes: ‘She’s starving to death nurse!’

It is the duty of all healthcare professionals to acquire the knowledge, skills and attitudes to communicate sensitive information to relatives (Thorns et al, 2004). According to Sykes (2004), the crucial area in relation to symptom control at the end of life is ‘preparedness’, e.g. ensuring that all appropriate drugs such as analgesics, sedatives, antiemetics and anticholinergic agents are available and prescribed to counter the symptoms that the patient may experience. However, just as essential an aspect of ‘preparedness’ is effective communication with the patient’s family and loved ones (Sykes, 2004). This article is the second in a series of fictitious communication vignettes, wherein conversations that commonly occur within end-of-life care are highlighted. The intention is to provide readers with suggestions of how to conduct difficult conversations. Individual nurses will, of course, bring their own expertise and personalities to such situations. This scenario relates to artificial nutrition and hydration which is examined in detail in the article on pages18–24 of this issue. Ethel Smith is an 84-year-old woman who is in the terminal stages of secondary liver cancer with an unknown primary. She has been admitted to a medical ward in an acute hospital following a fall at home. On admission she presents with weakness and fatigue, abdominal ascites, loss of appetite and cachexia. She did not sustain specific injury from the fall, just generalised bruising to her hip. Since the death of her husband 9 months prior to this admission, Ethel has lived with her daughter, Jane. Ethel has no other children. Jane is 59 years old. She retired early from her job as a primary school teacher to take care of her parents. Jane has no partner or children. During the first week of her admission Ethel was able to eat small amounts of a soft diet and …

Communication vignettes: ‘Should I cancel my holiday nurse?’

Good communication skills are a key element of end-of-life care (Department of Health, 2008). As nurses, we cannot prevent the distress that families/friends feel when they know their loved one is dying. However, we can support them through the process. This involves ensuring that families are aware of what is happening to their loved one, e.g. the signs and symptoms indicating that the person is in the end stage of their disease and what to expect from thereon. If the dying person and the family are not aware that death is approaching they will be prevented from saying their goodbyes and sorting out their affairs (Ellershaw et al, 2003). Such closures can help ease a patient’s fear of dying and the bereavement process for those left behind (Buchanan et al, 1996). This article is the first in an occasional series of fictitious communication vignettes, whereby conversations that commonly occur within end-of-life care are highlighted. The intention is to provide readers with suggestions of how to conduct difficult conversations. Individual nurses will, of course, bring their own expertise and personalities to such situations. Gregory Martin is a 74-year-old retired university professor. He was diagnosed with congestive heart failure 7 years previously. He lives with his wife Enid. They have one son Mark and three grandchildren. Gregory has had two recent admissions to hospital for shortness of breath and oedematous legs. In both cases, following treatment, he was able to return home. For the past year he has been having carers every morning to help him with his hygiene needs. However, over the past 3 months, he has become increasingly weak and fatigued and has been losing weight. Gregory has now been admitted onto a medical ward with a 5-day history of shortness of breath on gentle exertion and recurrence of leg …

Communication skills training for dental students

It is important to teach future health professionals about human interaction, a process that will underlie their technical procedures throughout their careers. In the past there have been problems with student acceptance of such teaching. This paper reports a promising attempt to increase the perceived relevance and credibility of a course in communication skills for dental students. Two important features of this course are (1) the use of video-taped communication vignettes, derived from actual dental office situations, to increase the perceived relevance of the program for the dental student and (2) the use of selected clinical dental faculty members as group facilitators to increase the credibility of the program.