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METHODOLOGICAL INSTRUCTIONS

June 28, 2024

METHODOLOGICAL INSTRUCTION

FOR 1-ST YEAR STUDENTS

OF THE MASTER OF nSCIENCE IN NURSING PROGRAM

INSTITUTE OF NURSING

LESSON n№ 8 (Practical – 6 hours)

Themes:

1. nCommunication with the patient and family ipalliative medicine – n2 hours.

2. nTalking with families and children about the death of na parent – 2 hours.

3. Communicatiobetween professionals – n2 hours.

Aim:

Communication is ncritical in all health care situations but is of special significance at the nend of life. Strong collaboration and communication between professionals is a nprerequisite to communication with Patients and families. Palliative nursing ncare requires skill in verbal and non-verbal communication, listening and npresence.

Professional orientation of students:

The course objectives included enabling students to:

· nDefine the importance of ongoing communication with the interdisciplinary nteam, Patient and family throughout an end-of-life process.

· nIdentify three factors that influence communication in the palliative care nsetting.

· nDescribe important factors in communicating bad news.

· nIdentify communication characteristics that Patients / families expect of nhealth care professionals.

Methodology nof Practical Class:

Work in groups: The discussion of clinical case studies, specific nto the topic of the lesson

Case Study #1

Mr. Jones: nBreaking Bad News To Family

You have received a hospice referral for Mr. Jones, nage 54, who has ALS (amyotrophic lateral nsclerosis). He and his family (wife and n3 children—ages 9, 16, 19), who are confused and anxious, nlisten to you as you describe what they should expect from the hospice experience. The family does not seem to understand why nyou are discussing end-of-life issues with them. You call Mr. Jones’ family physician who ntells you that the patient assured him that he talked to his family about his nprognosis. You determine that Mr. Jones nhas in fact not told his family. You ntalk with Mr. Jones who admits that he has told his family he is very stable nand expected to have many years of life remaining. He asks you to help him break the reality of nhis poor prognosis to his family.

DiscussioQuestions:

1. nWhat is your role now?

2. nWhat communication gaps do you recognize?

3. nWhat strategies would promote continuity of ncare and improve team communication?

4. nHow might a family meeting be helpful in this ncase?

5. nWhat special needs would you perceive the nchildren having at this time? How would you meet these needs?

Case Study n#2

Cindy: Disagreement

Cindy is a 36-year old female with pancreatic cancer nhas been hospitalized for two weeks. She nhas been in the intensive care unit for the past 5 days. Her physical deterioration and suffering had ncreated anguish in her husband and in the health care team. The attending physician discussed with the nhusband the likelihood of his wife having a cardiac and/or respiratory arrest, ndescribed the actions the team would take for a full resuscitation as well as nthe varying levels of resuscitation approved by the treatment setting, which nincluded a do-not-resuscitate option, and asked the husband to express his npreferences regarding resuscitation. The nhusband initially chose the do-not-resuscitate status for his wife and ncompleted all of official paperwork to implement that decision. During the next 12 hours, the husband nactively solicited from nursing and medical staff their definitions of ndo-not-resuscitate. He then contacted the nattending physician to rescind his decision, choosing instead to have a full nresuscitation order in place. He nexplained his decision change as, “When I saw that the nurses and doctors ndid not all define resuscitation in the same way, I decided that I would not nleave that in their hands. I am my nwife’s husband and I will be her husband to the end.” This new decision was enacted and over the nnext four days, the patient showed clear signs of dying. Her husband stayed with her in the intensive ncare unit and witnessed the changes in his wife’s physical appearance. He began commenting on those changes and ohis wife’s obvious suffering. Within two nhours of her death, the husband told the staff that he did not want his wife to nbe resuscitated. This information was nimmediately conveyed to the health care team and a brief discussion with the nphysician, husband, and nurse was convened to affirm this decision.

Discussion Questions:

1. What nwere the barriers to effective communication in this case?

2. How nmight these barriers have been eliminated?

Case Study #3

Max: Communicating Sudden Death

Max Klein is an 84-year-old retired plumber who has nbrought his 83-year-old wife, Mary, to the hospital complaining of chest npain. Mary’s condition declines, she nexperiences cardiac arrest and full resuscitation is attempted. During this time Max communicates to the nsocial worker and chaplain that “This just can’t be. Mary is healthy as an ox.” He doesn’t want to notify his children who nlive out of town “until she’s stable because I know they’ll get her nstraightened out.” Max seems nanxious but distracted and talks incessantly about how Mary’s been sick before nbut “always gets better before you know it.” After 2 hours of numerous procedures and nattempts, Mary dies.

Discussion Questions:

1. nWhat are useful communication strategies while nMary is still receiving aggressive care to communicate her status?

2. nHow should Max be told of Mary’s death?

3. nWhat is the role of the interdisciplinary team nin communication in this case?

Case Study #4

“Mr. Quartera Has A Question”

Valenzio Quartera is a 56-year-old man with widely metastatic prostate ncancer. He is currently undergoing nradiation therapy for bone metastasis. nHis wife died one year ago from breast cancer. He currently lives at home with his twidaughters, age 15 years. As you, the nradiation oncology nurse, enter the treatment room, Mr. Quartera asks you, n“Susie, you don’t think I’m going to die do you?” “What would happen to my ndaughters if I die?”

Discussion Questions:

1. nHow nwould you respond?

2. How nwould you address his concern about his daughters?

3. What nwould you recommend that he discuss with his daughters at this time?

4. What nother members of the healthcare team would be appropriate to contact to help nMr. Quartera with his daughters?

Case Study #5

“Mr. Ahmed: nActive Treatment and Palliative Care?”

Mr. Ahmed is a 49-year-old with a recurrent brain tumor currently nhospitalized after experiencing seizures. nMr. Ahmed was diagnosed at age 44 and has had extensive surgery, nchemotherapy, and radiation therapy. nThree months ago, his oncology team advised him and his family that nthere were no further treatment options and recommended palliative care. The family was not interested in palliative care, they requested that “everything be done.” He has experienced weight loss, increasing nsevere headaches, nausea and now seizures. Following a severe seizure last week, his nwife brought him back to the cancer center seeking possible new treatments and nwonders if he can receive palliative care, too. nAs Mr. Ahmed waits in radiology for a scan, you, as member of the noncology healthcare team, come to see him as you heard he was iradiology. He tells you he is so tired nof treatment and being taken far away and just wishes his family would “give up nand just let me be at home so I can play with my dog and be with my nfriends.”

Discussion Questions:

1. How would you respond to Mr. Ahmed?

2. Is it npossible for Mr. Ahmed to receive treatment and palliative care at the same ntime? If so, how would you describe this nto Mr. and Mrs. Ahmed?

3. How ncould you use attentive listening and presence with this patient and his wife?

4. Role play the scene of how you would respond to Mr. Ahmed’s nlast statement. In addition, role play how you would describe palliative care to this nfamily. Lastly, role nplay how you would elicit Mr. Ahmed’s end-of-life goals.

Individual Students Program.

You should be prepared for the practical class using nthe existing textbooks and lectures. Special attention should be paid to the nfollowing questions:

1. nCommunicatioand palliative medicine

2. Informationeeds of patients and their families

3. nDecision-making preferences of patients ipalliative care

4. nCommunication and stress experienced by nfamilies

5. nEmotional impact of communication in palliative ncare on doctors and nurses

6. Inadequate communication skills

7. nFear of provoking distress and handling ndifficult emotions

8. Containing one’s own emotions

9. Being nblamed for failure, over-identification, and confronting one’s own death fears

10. nEffects nof minimization or ambiguity

11. nDoctors’ nstyles of communication

12. nDiscussing nprognosis

13. nEffect on patients of truth about prognosis

14. nDealing nwith the misinformed patient

15. nAnxiety nand depression

16. nCommunicationeeds of the family

17. nPractical ways to help with informatioprovision and communication

18. nTalking with families and children about the death of na parent

19. nCommunicatiobetween professionals

Seminar ndiscussion of theoretical issues.

Tests evaluation and nsituational tasks.

1. Because clients and nurses may differ in their nperceptions of caring, it is important that the nurse:

A) Focus on keeping the nrelationship on a business level.

B) Follow his or her owbeliefs about what is appropriate.

C) Seek information regarding nwhat is important to the client.

D) Allow a more experienced nnurse to establish the nurse-client relationship.

2. Which of the nfollowing nurses is showing behavior that indicates that the nurse is providing npresence in a caring relationship?

A) The clinic nurse who pats nthe client on the back for reassurance

B) The newly licensed nurse who braces the client as he or she gets out nof bed

C) The home care nurse who focuses attention on the older adult client nsharing a story

D) The staff nurse who stays with a client who is undergoing aunfamiliar procedure

3. The nurse demonstrates listening skills by:

A) Blocking nonverbal ncommunication so that the verbal communication is more defined

B) Waiting until mealtimes so nthat the conversation can be more sociable

C) Surrounding the client nwith family and friends to make him or her comfortable

D) Paying attention to the ntone of voice in addition to the client’s words so the meaning is clear

4. The nurse can best demonstrate caring to a client who has recently nsuffered a loss through miscarriage by:

A) Sitting with the client isilence

B) Sharing a personal account nof a similar loss

C) Offering some literature non the grieving process

D) Asking the hospital nchaplain to visit the client

5. A nurse who normally nuses touch when caring for clients might consider this inappropriate for which nof the following clients?

A) A client of the opposite nsex

B) A client from a different nculture than that of the nurse

C) A psychiatric client who nis displaying suspicion and fear

D) A client who has many nfamily members present in the room

6. Family members make the following comments about the nursing care nbeing received. Which one should be ninvestigated further?

A) “The nurses showed us nhow to keep Mother’s arm propped on a pillow.”

B) “Our nurses don’t nseem too optimistic about the outcome of Dad’s stroke.”

C) “The night nurse ntells us to wait and ask the doctor the questions we have.”

D) “The nurses have nwritten down the turn schedule and taped it above the bed.”

7. In caring for a nclient, the nurse would describe learning about the client’s family as:

A) Essential

B) Unnecessary

C) A waste of time

D) Okay to do when one has nthe time

8. Regarding a request for organ and tissue donation at the time of ndeath, the nurse should be aware that:

A) Specially educated npersonnel make these requests.

B) These requests are usually nmade by the nurse caring for the client at the time of death.

C) Professionals should be nvery selective in whom they ask for organ and tissue donation.

D) Only clients who have ngiven prior instruction regarding donation can become donors.

9. A home health nurse nis asked by a family member what he should do if the client’s serious chronic nillness continues to worsen even with increased medical interventions. The nurse recognizes that the family member is posing na question about goals of care at the end of life. The nurse should:

A) Encourage the family to nthink more positively about the client’s new therapy.

B) Avoid the discussiobecause it has to do with medical, not nursing, diagnoses.

C) Begin the discussion by nasking the family member what he believes the goals should be.

D) Initiate a discussioabout advance directives with the client, family, and health care team.

10. A client’s family nmember remarks to the nurse, “The doctor said he will provide palliative ncare. What does that mean?” Which of nthe following is the nurse’s best response?

A) “Palliative care aims nto relieve or reduce the symptoms of a disease.”

B) “Palliative care is ngiven to those who have less than 6 months to live.”

C) “The goal of npalliative care is to cure a serious illness or disease.”

D) “Palliative care nmeans that the client and family take a more passive role and the doctor nfocuses on the physiological needs of the client. Death will most likely occur nin the hospital.”

Individual student work are checked by solving situational tasks for each topic, nanswers in test evaluations and constructive questions (the instructor has tests & situational tasks).

Students should know:

· nCommunication with the patient and family ipalliative medicine.

· nTalking with families and children about the death of na parent

· nCommunicatiobetween professionals.

Students should be able to:

· nExplain the value of good patient-provider ncommunication about end-of-life care.

· nDescribe several competencies in communicating nwith patients and families.

· nExplain how HIV/AIDS impacts this ncommunication.

· nIdentify barriers to communication and actions nto take that can improve communication with patients and families.

· nList the 6 steps in giving bad nnews.

· nAdapt the bad news protocol to ntheir work setting.

· nExplain how the manner in which bad nnews is given can impact patient outcome and patient care.

· nExplain how culture impacts patient ninformatioeeds and decision-making.

Answers to the nSelf-Assessment:

1. C. It is important to nassess the client’s needs and expectations of care. Clients relate to nurses oa personal level. The client’s beliefs must be considered. Personnel at all nlevels of nursing should have effective relationships with clients.

2. D. Coaching a client nthrough an experience is an example of presence, as is sitting by a client’s nbedside. The nurse is providing safety while helping the client get out of bed. nIn option 3, the nurse is listening.

3. D. The client’s tone nof voice supplies cues that allow the nurse to better understand the client’s nframe of reference. Nonverbal cues add meaning to the verbal communication and nincrease understanding. Surrounding the client with family and friends serves nas a distraction to communication between client and nurse. A client’s hunger, npain, or other distractions can hinder communication.

4. A. Offering self is a npowerful demonstration of caring and allows the client to trust and feel the npresence of a caring person. Therapeutic communication should focus on the nclient, not the nurse. Offering literature may be helpful at some point whethe client indicates she is ready and asks for information. Chaplain visits may nbe helpful but do not replace the need for a caring relationship with the nnurse.

5. C. A psychiatric nclient may interpret a gesture as a threat, and further assessment is required. nThere is no contraindication to touching a client of the opposite sex or to ntouching a client when family members are present unless the client indicates nthat he or she is uncomfortable.

6. C. A caring nurse nshould show interest in answering questions and giving clear explanations. The ncomment in option 3 indicates that the nurse is shirking responsibility. nTeaching the family is important and gives the family the feeling of being nuseful. Keeping the family informed and included in care is a sign of good nnursing. Honesty is a quality of caring. False reassurance is dishonest and is nnot helpful.

7. A. Each individual nexperiences life through their relationships with others, so learning about the nclient’s family is essential in learning about the client.

8. A. A specially ntrained professional makes requests for organ and tissue donation at the time nof death. The person requesting organ or tissue donation provides informatioabout who can legally give consent, which organs or tissues can be donated, nassociated costs, and how donations will affect burial or cremation. If the ndeceased did not leave behind instructions for organ and tissue donation, the nfamily may give consent at the time of death.

9. C. The nurse must nfirst assess the family’s goals before any further discussions can take place. nThen, with the appropriate knowledge, the nurse can continue discussions nregarding options for future care, either disease treatment or end-of-life ncare, based on the family’s needs and wishes.

10. A. The goal of npalliative care is the prevention, relief, reduction, or soothing of symptoms nof disease or disorders without effecting a cure. Palliative care is for nclients of any age, with any diagnosis, and at any time, and not just during nthe last few months of life. Generally clients accepted into a hospice program nhave less than 6 months to live. Palliative care aims to relieve pain and other ndistressing symptoms, not cure the disease. Palliative care is a philosophy of total ncare. Care options encompass the physical, psychological, social, spiritual, nand existential aspects of the client’s illness. Care is provided by ainterdisciplinary team, and the client and family take an active role idecision making. The location of death may or may not be the hospital.

References:

А – Basic:

· nWeb-portal of the University=> nIntranet => Practical classes materials

· nVachon. M.L.S. (2010). The emotional problems nof the patient in palliative medicine. In G. Hanks N.I. Cherny, N.A. nChristakis, M. Fallon, S. Kaasa, & R.K. Portenoy (Eds.), Oxford textbook of palliative medicine, 4^th nedition (pp. 1410-1436). Oxford, nUK: Oxford University nPress.

· nDahlin, C. M. (2010). Communication ipalliative care: An essential competency for nurses. In B. R. Ferrell & N. nCoyle (Eds.), Oxford ntextbook of palliative nursing, 3^rd edition (Chapter 5, pp n107-133). New York, NY: Oxford nUniversity Press.

В – Additional:

· nCoyne, P. J., & Drew, J. (2010). Palliative ncare. In

B. St. Marie

(Ed.), Core curriculum for pain management nursing n(2^nd ed.). Philadelphia: W. B. Saunders Co.

· nGoulette, Candy (2007). Doctors and nurses: Professional relationships make for better npatient care. Advance for nNurses, July 9, 2007, 21, 22, 36.