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Paper Topic:

Role of the Nurse




Scientific and social changes of the 21st century have brought a radical change in the Health care delivery system . Nursing is an important component of the health care delivery system and the role of a nurse in patient welfare has no boundaries for praise . The nursing profession has evolved through time to establish a firm role in the medical domain based on strong ethical , moral and professional principles . That is to say , a nurse has a more active role to

play in the health care delivery system than the past and the nurse , as a professional , is `accountable ' today and nurse is often a patient advocate who represents the patient wishes


According to Mc skimming , one of the most difficult situations in health care practice is that , despite the best efforts , some patients will die The death may be due to the diseases like cancer and HIV or various other factors (Mc Skimming et .al , 1997 . The patients who have to die are called terminally ill patients . These are those `nothing more can be done patients ' who need the comfort and care of everyone until their death and have a right to safeguard their dignity . Problems pertaining to `End-of -life ' care are on the rise especially when concepts of euthanasia and physician assisted death are trying to find legitimate positions in the society . The state of Oregon in U .S .A already has a legal backing and the bill introduced by Lord Joffe in U .K parliament recently has stirred a chain of debates on the ethical aspects of assisted death of the terminally ill . In fact , the concepts of Palliative care and Hospice have primarily evolved only to meet the needs of these terminally ill patients . Kubler-Ross opines that denial on the part of the patient and family members about the seriousness of terminal illness has been a barrier to discuss about end-of treatment options (Kubler-Ross , 1969 . Research studies by McSkimming have confirmed that patients went information about their illness and end of life choices (McSkimming et .al , 1994 . According to Cardozo ,the decision to limit care for critically ill patients is not uncommon , and most deaths in the intensive care unit are now preceded by do not resuscitate s , which are regarded by some as a way to make death more humane and respect patient autonomy (Margaret Cardozo ,2005

The patient in this case study is a one who had developed a form of cancer called post transplant lymphoproliferative disease on his small and large intestines after he had a kidney transplant . This type of cancer is mainly caused by the immunosuppressive medications a patient takes for his body not to reject the new kidney . As a result this patients become immunosuppressed , making them at risk of getting this form of cancer . It is through bone marrow aspiration and biopsy that this disease is diagnosed . The situation is critical with the patient at the end of his life and the treatment options centers around a time frame of two night shifts from 9 :00pm to 8 :00am . The argument in this case study , thus , centers on the withdrawal of treatment to let the patient die and the nurse acting as a patient advocate expressing the patient 's wishes to withdraw his treatments to let him die . While looking after this patient there was a lot of conflict going on between the patient , family and the doctors . The patient had lost his will to live as his body got weaker and due to the infections and constant bleeding brought about by the cancer . And he therefore wished to withdraw the treatment such as close monitoring , Intravenous infusion antibiotics , etc .in such a state . However the family wanted to carry on for with the treatment since he was only in his mid fifties . Another conflict has been with the medical team in this case . This disease not being very common at all and there being only one incident reported case about this in the past 20 years or so , the medical team were trying to use this patients ' case to explore and explain links of renal transplantation and cancer malignancy . He was bleeding from his abdomen intermittently , needing a lot of blood transfusion . He was bed bound Unable to meet his nutritional demand therefore was being fed with TPN (scale insulin because of him being a diabetic . A various antibiotics and intravenous medications were being given to him every day and night . The Central Line he has for us to use to give his intravenous infusion got badly infected , oozing exudate . But since his peripheral vein weren 't good enough to be cannulated - the doctor insisted to keep this central line in

This patient 's quality of life was poor . He wasn 't given a chance to properly decide for his own welfare . And a nurse - acting as patient advocate was over ruled . Each time the nursing staff was with this patient he expressed his wishes to withdraw everything but when the doctors are around , they said to him that this ongoing treatment is best for him - leaving the patient to have no choice but get the treatment he didn 't want . On the second night , he became very poorly . He bled more and the infection got worst . It was up until then the decision was taken to withdraw treatment and End of life care initiated . He was having a sub cut infusion of syringe driver with diamorphine injection in it to keep him comfortable . After 6 hours , he passed away . But if only his decision was taken into consideration , then his dying process would have been easier to bear


But the existing laws in UK do not permit the patients to request for withdrawal of treatment to end their lives . The best example of a patient with a terminal illness in U .K . fighting for her right to die is Diana Pretty with a motor neuron disease . Her request was turned down by the Government and she then went to the British Courts and the European Court of Human Rights to fight for this right to die . All the Courts refused her request (Mc Skimming et .al , 1997

There is no proxy consent for an adult in UK as in USA . Thus , no close relative of an adult can influence the treatment options in UK . Thus the treatment options are decided on the best interests of the patient by medical professionals . The nurse under such circumstances should judge the options clearly and be prepared to defend her decisions . In case of litigations on account of such medical decisions , the court will decide based on the findings whether the treatment was given in the best interests of the patient . The Bolam test is used to determine the best interest standards , which confirms if a responsible body of medical opinion , would affirm that the treatment was in the best interests Although In Scotland , the Adults with Incapacity (Scotland ) Act 2000 says that competent individuals over 16 can appoint someone to make decisions about medical treatment on their behalf if they become unable to do so , the English law demands that no-one can consent to medical treatment on behalf of an adult patient and the patient 's relatives cannot demand treatment they consider is in the best interests of the patient . When a patient is temporarily incompetent , following an accident or medical event like being unconscious or in the terminal stages of life , the healthcare professional should do only what is necessary in the circumstances . The patient 's close relatives are reliable sources who can help in this regard . But , in case the patient when competent issues an advance refusal of treatment under certain circumstances , the doctors should abide by the same

A code of practice under the new Mental Capacity Act for doctors and others who deal with people who cannot take decisions for themselves was issued recently in draft for consultation . The draft code applies to England and Wales . It sets out how patient capacity should be evaluated and how these advance directives on treatment will function and how treatment modes should be decided . The act is expected to be in force from April 2007 . Living wills are already binding on doctors even under common law (Dyer , 2006 . These advance directives helps sort out two types of legal situations .1 .These directives help a competent adult to choose his treatment and 2 .These helps a competent adult to choose his treatment options when he becomes incompetent under circumstances of a disease or accidents

But under no circumstances , the patient can request to withdraw treatment to end his life and no doctor can take a request to do so . If a doctor does so , He will be punished under murder charges . According to Hezebrok , In UK and most of the countries removing or denying treatment from the patient is seen as clear murder (Hazebroek et al , 1993 . For example , Madison County authorities charged Dr . James Bischoff with murder because he gave 85-year-old Kathryn Dvarishkis a lethal drug to let her die . She was administered two doses of fentanyl in a 10-minute interval and she died moments later . Thus , decisions at the end of life are always difficult ones to make creating a conflict of morality Ethics , and the law . The management of terminally ill patients who are unable to maintain their own hydration , or who express a wish to discontinue artificial hydration , is a significant controversial among healthcare professionals , patients and families . Evidence-based research suggests a number of medical and nursing indications and contraindications for dehydration (Lesley-Ann Maxwell ,2005


The Case of 70 years old Mrs . Sparza , is classic case of a competent patient 's legal right in giving informed consent . Mrs .Sparza was admitted for eye surgery by her sons in a NHS Health care center in London . After administration of pre-operative muscle relaxant medication , she was rolled into the operating room . Upon entering the operating room , Mrs . Sparza was greeted by Nurse Johnson who asked Mrs Sparza to sign the surgical consent form . The form was in English and identified the procedure as surgery of both eyes . Mrs . Sparza was told that she was scheduled for surgery of both eyes and asked to sign the consent . Mrs . Sparza objected and refused . She informed Nurse Johnson about her wish to have only one of her eyes to be operated upon in spite of her sons wishes to have both of her eyes to be operated upon . Nurse Johnson took the role of a patient advocate and had a lengthy argument with Dr . Pinnate about Mrs . Sparza 's wishes . After a few minutes of conversation , Dr .Pinnate agreed to her wishes and Mrs . Sparza signed the consent form and was placed under general anesthesia to be operated upon


In UK , before any terminally ill person receives his chemotherapy or an invasive procedure , he or his health attorney should give a well-documented informed consent . Informed consent means that tests treatments and medications have been explained to the person , as well as outcomes , possible complications and alternative procedures . But utilizing this patient as a medical case study amounts to tort according to law . Even taking the organs , parts of tissues without patient 's consent is illegal in UK . This includes Kidney , Liver and other organs and tissues including blood samples for genetic tests . This is as per the recommendations of The Joint Committee on Medical Genetics of the Royal College of Pathologists and British Society for Human Genetics But if a tissue is taken in the larger interests of the population where the competent patient is also a beneficiary , the doctor should be able to prove the best interests in the court of law


Dorothea Orem in 1971 ( HYPERLINK "http /www .ncbi .nlm .nih .gov /entrez /query .fcgi ?db pubmed cmd Search itoo l pubmed_AbstractPlus term 22McFarlane EA 22 5BAuthor 5D " \o "Click to search for citations by this author " McFarlane , 1980 ) defined nursing with emphasis on client 's self-care needs . Self-care , according to the theory , is a learned , goal-oriented activity directed towards the self in the interest of maintaining life , health , development and well-being . The ultimate emphasis of Orem 's theory is on client 's self care . Accordingly , nursing care is needed when the client is unable to fulfill biological , psychological , developmental or social needs and the nurse determines by duty why a client is unable to meet the needs or what must be done to enable the client to meet them . Thus , Orem defines the goal of nursing as to increase the client 's ability to independently meet their needs i .e , the self care of the client . The role of nurse as a patient advocate is lucid in the case no .1 where the patient has expressed his wishes to withdraw his treatment to his nurse so that he shall die at peace and in case no .2 , the nurse has spoken on behalf of the patient to the Health care team to express her legal right . Skilbeck et .al opine that the Clinical Nurse Specialists (CNS ) play a major role in UK . The care focus is primarily on the emotional aspect of care . A study has investigated the CNS patients interactions and has shown that such interactions involves a complex process of `Knowing the patient through effective use of communication skills (Skilbeck et .al , 2003

Thus , the role of the nurse as an advocate of the patient depends on

1 ) The Nurse 's Communication with the patients

2 ) The Nurse 's communication to the doctor and Health care workers about the patients

This requires active self-introspection of the events , assessment of the events , psychological understanding of the patients and above all a genuine concern for the ill . The communication cannot be universal in the sense that every patient differs and has different attitudes on various issues of life and has varied levels of understanding and withstanding capabilities . A critical issue of debate in nurse - patient relation ship with reference to patients is that the patient 's contribution is always neglected . Literature reviews point out that nurses are seen to be controlling and restricting the conversations with the patients . `Assumptions ' have been seen as an important factor which formed the basis of nursing communication without taking the views of the patients at all . Thus , Nurse-patient communication is not a series of isolated conversations , but a vital component of the care comfort concept (Jarret , 1995


The nurse as a client advocate ' protects the human and legal rights of the patient under her care , based on his /her cultural and religious affiliations . The changing role of nurses as significant members of the health care team has brought about radical change in Health Care delivery system . The nurse-physician collaborative model is a model which shows a radical shift from the past . In such a model , the health care organizational structure is decentralized and the nurses and physicians function collaborately to make clinical decisions

Nursing discipline should study narrative communication to understand the connectivity of expressiveness in sickness with the importance of personal presence listening and narrative communication as a patient advocate . In terminally ill nurse relationship , communication should be effective in expressing interest and concern for patient and the family Thus , a nurse needs insight , sensitivity , effective communication skills and strategies to give what the patient needs and uphold the values of nursing care . A nurse should look for ways to improve the relationship between the family and the supporting health care of terminally ill patients (Astudillo , 1995


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