-
FIFTEEN: The Role of Nurses and Nursing Education in the Palliative Care of Patients and Their Families
- Johns Hopkins University Press
- Chapter
- Additional Information
mc h a t e r f i f t e e n The Role of Nurses and Nursing Education in the Palliative Care of Patients and Their Families Elizabeth Furlong, R.N., Ph.D., J.D. A hospice program is one ethical model of delivering palliative care to patients with Alzheimer disease (AD) in the terminal stages. This chapter , while addressing the role of nurses in promoting a palliative model of hospice care, also provides insight into nursing education challenges in this area. I begin with a description of a hospice model of care and clinical research on this model, and then describe ethical conflicts. I then focus directly on the nurse’s role in promoting a palliative model of hospice care. The hospice model of palliative care for patients with AD can meet the conflicting demands among the four ethical principles of nonmaleficence, beneficence, autonomy, and justice and it also integrates with the nursing ethics model of care (Post, 1998). Because of AD’s effect on individuals, families, and society, it is recognized as a major public health problem in the world. Because it is a major public health problem, it is imperative to address the ethical aspect of palliative care for this population. m A Hospice Model of Care and Clinical Research Nurses who wish to promote a palliative model of hospice care must first gain a clear understanding of the premises and limits of this model. Hospice is a“philosophy of care emphasizing comfort and quality of life in contrast to life prolongation except as a side-effect of palliative treatments” (Post, 1997, p. 649). Post distinguishes hospice as a philosophy from a locus of care since there can be many sites—home, hospice, nursing home, hospital, and so forth. Some writers advocate its use in the terminal stage of AD (Zerzan, Stearns, & Hanson, 2000; Post,1997).Besides being an advocate for hospice for patients with end-stage AD, for the earlier stages Post also recommends routinized treatment limitations, according to advance directives and family entrustment (1997). In 1986, Volicer et al. described a hospice model of care for patients with advanced AD that had five levels of care. Patients were assigned to the five levels during interdisciplinary team meetings with family members. Level 1 included an aggressive diagnostic workup, treatment of co-morbid conditions, cardiopulmonary resuscitation (CPR),tube feedings,and transfer to an acute medical unit if needed. Level 2 included the same level of care as in level 1, but excluding CPR. Level 3 care also excluded CPR. In addition, it excluded a transfer to an acute medical unit, thereby eliminating the use of respirators, cardiovascular support, and so forth. Level 4 care excluded CPR and mandated no transfer to an acute care unit, no aggressive diagnostic workup, and no antibiotic treatment of lifethreatening infections (pneumonia, urinary tract, etc.). Patient comfort needs were met with analgesics and antipyretics. In level 5 care, strategies such as cardiopulmonary resuscitation, transfers to acute medical facilities, diagnostic workups, antibiotics, and tube feedings were not done. Patient comfort care and supportive care were continued. This research is fifteen years old, and changes in practice are acknowledged; for example, nursing homes are sites now for the delivery of care that once only took place in hospitals (ventilators and so forth); percutaneous endoscopic gastrostomy (PEG) tubes have frequently replaced nasogastric feeding tubes; evidence-based outcomes have changed treatment regimes. However, this model of hospice approach continues and research has been done on the decision-making model to decide which level of care to utilize (Hurley et al., 1995). This qualitative study reinforced the ethical nursing model of care in which staff did not separate potential patient outcomes from potential family outcomes (i.e., they viewed the context of the situation). Further, another indicator of nurses’ contextual understanding of the situation was their integration of clinical and ethical judgments about proposed patient care. Luchins, Hanrahan, and Murphy (1997) researched the criteria for enrolling patients with dementia into a hospice program.They note that this model of care delivery is optimal for patients with end-stage dementia both because their 244 Organizational Ethics Issues [44.221.43.208] Project MUSE (2024-03-19 03:20 GMT) prognosis is terminal and because their care is best met by palliative care. Further , others believe aggressive medical care is neither wanted nor ethical (Zerzan, Stearns, & Hanson, 2000). Palliative care will facilitate the individual’s comfort, relieve symptoms, and control pain...