NCM 118: The Family's Experience with Critical Illness PDF

NCM 118: THE FAMILY’S EXPERIENCE time to respond to family members’ emotional needs; family members may have unrealistic goals, WITH CRITICAL ILLNESS and expect...

NCM 118: THE FAMILY’S EXPERIENCE time to respond to family members’ emotional needs; family members may have unrealistic goals, WITH CRITICAL ILLNESS and expectations of the health care staff. STRESS SYNDROME SELYE 1956, discussed the role of stressors, the COPING MECHANISM stimuli that produce tension and that could Coping mechanism can be defines as a person’s contribute to disequilibrium. response to a change in the environment; they can Stressors can be physiologic (ex, traumatic, be healthy or unhealthy biochemical, environmental) and psychological The critical care nurse, as caregiver to both the (ex, emotional, vocational, social & cultural.) patients and family, should be aware of the use of coping mechanisms by the family as a means of STRESS, CRITICAL ILLNESS, AND THE maintaining equilibrium. IMPACT ON THE FAMILY A sense of fear, panic, shock or disbelief is sometimes followed by irrational acts, demanding A critical illness is a sudden, unexpected and behavior, withdrawal, perseveration or fainting. often life-threatening occurrence for both the The family attempts to obtain some sense of patient and the family. control over the situation, often demonstrated by it can be an acute illness or trauma, an acute refusing to leave the bedside or, alternatively, by exacerbation of a chronic illness minimizing the severity of the illness through family members of patients in critical care unit denial. (CCU) may experience stress, disorganization, and In an event of an acute exacerbation of a chronic helplessness, which result in difficulty in but life-threatening illness brings with a different mobilizing appropriate coping resource, thus set of stressors, reminding the family of difficult leading to anxiety, and painful times in the past when they have faced In response to a stressor, the fight or flight similar circumstances. mechanism activated. Prolonged critical illness can present emotional Catecholamines, norepinephrine and difficulties for the family, which may increase the epinephrine are released in sympathetic likelihood of crisis. Quality of life issues such as nervous system. prolonged mechanical ventilation may occur and Responsible for the increased heart rate, increased should be approached with empathy and blood pressure, and vasoconstriction that make up understanding. the physiologic response to the alarm stage, the Research has shown that the top needs of families initial stage of the general adaptation to stress of critically ill patients are the need for syndrome. information, the need for support from the hospital The alarm stage is followed by the stage of staff, and the need for hope. resistance, which attempts to maintain the body’s Families of critically ill patients have other needs resistance to stress. that should be addressed frequently, including the If the person is unsuccessful at adaptation, or if the following: stressor is too great or prolonged, alarm and To feel that there is hope. resistance are followed by the stage ox exhaustion which can lead to death, the result of wearing down To feel that hospital personnel care about of the human body. the patient. After the initial fear and anxiety over the critical To know the prognosis illness and possible death of the family member, To receive information about the patient at other family issues become evident, including least once a day shifts in responsibilities and role performance, To see the patient frequently unfamiliarity with the routines of the CCU, and a lack of knowledge concerning the course and THE FAMILY AND THE NURSING PROCESS outcome of the disease. These issues can develop and persist over the duration of the patient’s stay in NURSING ASSESSMENT the CCU. Nursing assessment by the critical care nurse Having little or no time to prepare for such an involves primarily, but not exclusively, an event, the family is overwhelmed with a massive appraisal of the patient. It also includes an amount of unmanageable stress and can be thrown assessment of the members of the family. into crisis. Accurately, assessing the needs of the critically ill When allowed to visit in the CCU, the family patient’s family allows for nursing interventions observes sophisticated, intimidating equipment to reduce the family’s stress and strengthen family that causes additional fear. Such stress often can members’ ability to interact positively; it manifest itself as anger toward the caregiver. increases family satisfaction with care and The caregiver, absorbed with the physical care of promotes trust and confidence the patient, frequently has limited or inadequate NURSING INTERVENTIONS crisis are highly receptive to an interested, caring, It is important to make every interaction with the and empathetic helper. family as useful and therapeutic as possible. When first meeting the patient’s family, the nurse Compassion and respect, which include treating must demonstrate the desire and ability to help. the patient and family with kindness and listening Help that is specific to the family’s needs at that to special requests. time demonstrates the nurse’s interest in their comfort and well-being. Nursing interventions should address cognitive, This process then allows family members to affective, and behavioral domains and should be believe the nurse when the nurse conveys feelings designed to help the family of hope and confidence in the family’s ability to cope with whatever is ahead. Learn from the crisis experience and move toward adaptation PALLIATIVE CARE ISSUES IN CRITICAL Regain a state of equilibrium. CARE Experience the normal (but painful) feelings associated with the crisis, to avoid delayed The prevention and relief of suffering by means depression and allow for future emotional of early identification and impeccable assessment growth. and treatment of pain and other problems, Allow the family to share in the care of their physical, psychosocial and spiritual. family member. Caring for a patient’s family at any point during Provide active participation and a sense of the dying process encompasses three major control for the patient and family. areas: access, information and support, and Make sure that the patient remains the focus of involvement in caregiving activities. care and that intervention are performed for the good of the patient. PROBLEM SOLVING WITH THE FAMILY Assess the impact the medical and nursing interventions have on quality of life and sense DEFINING THE PROBLEM – being able to state the of well-being. problem and acknowledge the difficulty or threat it Determine family burdens resulting from poses reduce the family’s anxiety by helping family critical illness members realize what they have achieved some sort of understanding of what is happening. PROVIDING CARE FOR THE CRITICALLY ILL IDENTIFYING SUPPORT – asking family members OLDER PATIENT to identify the person to whom they usually turn when Respect the dignity, intelligence, privacy and they are upset and encouraging them to seek assistance maturity of the patient at all times. from that person. Maintain the patient’s right to make decisions as Family member of dying loved ones should be long as possible/ allowed more liberal access in both visiting Avoid paternalism in patient care. hours and number of visitors allowed. Integrate the physiological and cognitive changes of aging with the assessment and care of the Ensuring that a family can be with their patient. critically ill loved one will be a source of comfort. VISITATION ADVOCACY Access to information has been identified as a crucial component in the family’s coping, and Visiting hours in CCUs have been restricted for support in the form of the nurse’s caring many years, with the rationale that rest, quiet, and behaviors is influential in shaping the critical an undisturbed environment were therapeutic care experience for both the patient and family. nursing interventions. Family involvement in caregiving, in tasks as However, patients have a need to receive comfort simple as being physically present as well as and support, and families appreciate a caregiving those as complex as assisting with postmortem supportive role. care, may help families work through their It is not the duration of the visit, but rather the grief. flexibility of the visit and how appropriate it is for the patient, that is important. CULTURAL ISSUES RELATED TO CRITICAL ILLNESS USE OF THE NURSE-FAMILY RELATIONSHIP Nursing interventions for the critically ill patient Initiating nursing interventions and establishing a include recognition and appreciation of the cultural meaningful relationship with the family tend to be uniqueness of each person. easier during crisis than at other times. People in  Nurses must recognize the uniqueness of each END-OF-LIFE CARE person in this diverse, multicultural population and The final phase of life is difficult to define and realize the ways in which that uniqueness affects may last hours to years. Any care focused on the the care of the patient and the needs of the family. issues surrounding this phase may be termed end- Culture is important influence on the patient’s attitudes about approach to suffering and beliefs of-life care. about life prolonging treatments, palliative care Palliative care is appropriate at the end of life and advanced directives and health care proxies. but is not exclusive to this stage. HOSPICE CARE NCM 118: NURSING CARE FOR THE Hospice is a philosophy and a system that DYING provides palliative care for a patient with a terminal illness THE 5 STAGES OF GRIEF AND LOSS Hospice care is typically initiated when the 1. DENIAL patient’s life expectancy is six months or less. 2. ANGER 3. BARGAINING HOSPICE CARE 4. DEPRESSION Hospice focuses on dying pain-free and with 5. ACCEPTANCE dignity. Care may be provided in: Death can be frightening. This can be especially The patient’s home true for patients in terminal stages of chronic A hospice center disease. A hospital These patients often wish for a “good death.” A long-term care facility However, they often fear that they will die alone, in pain, abandoned by their caregivers. Nurses must provide excellent end of life care HOSPICE AND PALLIATIVE CARE INVOLVE: to all dying patients. Team oriented approach’ Pain and symptom management in these ways, healthcare providers can: Emotional and spiritual support to the person Help patients have a “good death” and his or her loved ones. Calm the fears of dying patients THE GOALS OF PALLIATIVE CARE AT THE Support the patient’s family END OF LIFE You will learn about: Comfort, not to cure Increase quality of life PALLIATIVE CARE, END OF LIFE CARE, HOSPICE CARE The goal is to give the patient the highest possible Guidelines for providing end of life care quality of life during his or her final days, weeks, or according to a patient’s wishes for a “good months. death” Comfort means: Ethical and legal considerations at the end of life Controlling pain and other physical symptoms Guidelines for helping loved ones when a patient Treating the patient with dignity is dying. Respecting the patient’s cultural beliefs around death and dying PALLIATIVE CARE Respecting the patient’s wishes not to receive life- Palliative care is appropriate at any stage of sustaining treatments that do not improve the illness, be it early or late. In addition, it may be quality of life provided: Meeting the patient’s psychological and spiritual In conjunction with therapy aimed at prolonging needs life Meeting the patient’s social and interpersonal needs When curative therapy has been discontinued Palliative care ideally begins with the diagnosis In short, palliative care treats the whole person. of a serious illness and continues until it is cured, or death occurs. Remember: Palliative care treats the whole person “Palliative care focuses on quality of life” Members of the care team may include: Physicians  Nurses In addition, oxygen therapy may also be ordered in Pharmacists certain cases, especially COPD. Social workers Related to these losses, anxiety, depression, Counselors delirium and anticipatory grief may all be present. Clergy Physical therapists SOCIAL ASPECTS OF CARE Dietitians The patient’s family’s and social needs should be Volunteers identified and addressed as needed. This may include family relationships, social GUIDELINES FOR CARE OF THE DYING support, work and school situations, finances, caregiver availability and ability. PATIENT Particular attention needs to be paid to children and this includes the interdisciplinary care team, their needs, whether they are patients or loved ones physical aspects of care, psychosocial and of a patient. emotional support, and cultural aspects of dying. SPIRITUAL CARE PHYSICAL SYMPTOMS The end of life often brings about spiritual Pain is a common problem in patients experience in a concerns. This may include life review and life-limiting illness. thoughts about meaning and purpose, as well as beliefs about afterlife and what comes next. Guilt Pain level is sometimes called the fifth vital sign, and forgiveness are common themes. and regular assessments of pain status should be An appropriate professional, such as chaplain or performed. clergy member, should be available for the patient These should be repeated on a regular basis, if and his or her loved ones to address these issues as there is a complaint or appearance of pain, and necessary. after any treatment for pain. IMMINENT DEATH NONPHARMACOLOGIC PAIN TREATMENT Signs and symptoms of impeding death should Heat and or ice be recognized and communicated with respect Massage to family preferences. Distraction: music, art, movies, reading, audio, An active dying patient may: books. Lose interest or ability to eat or drink Sleep more PHARMACOLOGIC PAIN TREATMENT Develop delirium Nonsteroidal anti-inflammatory drugs Become difficult to arouse (NSAIDs) Have an altered breathing pattern with irregular Opioids (codeine, tramadol) breathing and periods of apnea Morphine sulfate Have pooling of oral secretions creating noisy, rattled breathing PSYCHOLOGICAL CARE Run a fever Psychological issues are commonly brought about by Slip into a coma the losses and stress associated with a life-limiting Show mottling of the extremities illness. Have glassy, unseeing eyes Have a lowered heart rate and blood pressure PATIENTS AT THE END-OF-LIFE MAY EXPERIENCE LOSS OF: Develop cool, clammy skin Health This stage may last a few hours or as long as 2 weeks. Independence Relationships ADVANCE DIRECTIVES Money Bladder control Patients often do not explain what they need and Appetite want near the end of life, because they think that Weight their family, friends and doctor already know. Control In fact, family members and physicians often do not know what patients need and want. DYSPNEA Therefore, encourage all adult patients to complete At the end of life may be effectively treated with an advance directive. This could be a living will or opioids, as ordered a healthcare power of attorney.  An advance directive helps ensure that the patient's NON-MALEFICENCE wishes for end-of-life care will be respected, Avoid causing undue pain and suffering or harm to whenever the time comes. another “Do not do harm” IMMINENT DEATH avoid unnecessary physical or bodily harm as well At this point it is appropriate to consult the position in as psychological or emotional distress. regard to discontinuing anything that does not contribute to comfort, such as: VERACITY pulse oximetry Veracity or truth telling is foundational to the IV lines nurse patient relationship Antibiotics Clients have the moral right to determine what will Frequent vital signs be done with their own person; to be given accurate information, and all the information necessary for Laboratory tests making informed judgements. DEATH FIDELITY Death is often heralded by what is thought to be the last The duty to be faithful to one’s patients by breath followed by one or two long spaced breaths. The keeping promises and fulfilling contracts and absence of cardiac and respiratory activity signals death. commitments. AFTER DEATH CONFIDENTIALITY Post-death care should be undertaken in a respectful Is an aspect of fidelity that is an essential component of trusting relationships. Patients manner allowing the loved ones their freedom to have the right to know who has access to their respond according to their cultural and religious beliefs. personal healthcare information, and assurance Some activities that may be appropriate include; that it will be kept confidential. Providing a quiet room But confidentiality is not absolute and in certain Bathing the body circumstances can be overridden, such as when there is imminent danger to the patient or a third Changing linens party. Providing time and space to grieve JUSTICE Is often discussed in terms of distributive justice, NCM 118: ETHICAL ISSUES IN CCN or how 1 allocates scarce or finite resources. A daily basis in intensive care and emergency WHAT IS ETHICS? settings is the need to prioritize care. Ethics is the study of morality or standards of conduct and critical reflection and evaluation of WITHHOLDING AND WITHDRAWING moral choices. TREATMENT: Nurses help critically ill patients, and their families To withhold or withdraw treatment for critically ill make moral choices every day and intensive care or injured patients can be stressful for all involved environments. families and for healthcare providers. When a patient cannot speak for himself, nurses ETHICAL PRINCIPLES can help talk with families about their loved one’s wishes and present timely information about the AUTONOMY patient's plan of care with up to date, clear, and The right to make decisions about one’s own honest expectations about the situation at hand. body or actions free from interference or coercion from others MEDICAL FUITILITY Protecting patient’s rights and informed consent to When the healthcare team believes an intervention treatment procedures. has no prospect of helping the patient, they may The right not to disclose information describe the intervention as futile. This can create conflict if family members hold out BENEFICENCE hope of recovery and seek to pursue all aggressive Avoid the harm and promote benefit for their measures. patients. “Do good to your patients” Promote health, welfare and safety of the client.