, 2005, p. 375). With regard to the patient's quality of life and treatment the above study notes that; "We have observed that some older dialysis patients experience considerable difficulties with this treatment regime. Apart from physical discomfort, some patients have difficulty complying with treatment, or repeatedly express the wish to give up dialysis" (Tyrrell et al., 2005, p. 375). These and other problems emphasize the fact that the treatment regime can be arduous for elderly patients and, if not in administered and managed correctly by the nurse or caregiver, can radically decrease the quality of life of the patient and his or her family.

Another issue that is reiterated in the literature is the degree to which the elderly patient understands the treatment. This is an area where the philosophy of care and the holistic approach to nursing praxis comes into play; and where the nurse can help in the process of explanation and understanding. Related to this are the various psychological issues that can inhibit the treatment process. These may have a significant effect on the quality of life but as Tyrrell et al. note they "… are not routinely assessed in dialysis patients" ( Tyrrell et al., 2005, p. 375).

Therefore, the purpose of the above study was to evaluate levels of cognitive impairment, depressive mood and self-reported quality of life in older dialysis patients. A total of 51 outpatients receiving dialysis were assessed with, among others, a quality of life questionnaire (NHP). It was found that, "Sixty percent of the patients were depressed, and between 30 -- 47% had cognitive impairment. Almost half of the depressed patients were also cognitively impaired" (Tyrrell et al., 2005, p. 374). The study therefore suggests that "Regular assessments of depressive mood, cognitive ability and quality of life are recommended, given the prevalence of problems in these domains for older dialysis patients" (Tyrrell et al., 2005, p. 374). This study and others also note the relative paucity of research into the area of emotional well-being and its importance in the treatment of these patients. For example, "…Kimmel et al. (1998) also found that rates of hospitalization for dementia and organic disorders were "…much higher in patients with chronic renal failure, compared with those suffering other chronic diseases" (Tyrrell et al., 2005, p. 375).

In terms of the central focus of this paper, studies such as Renal dialysis abatement: lessons from a social study (2005) by Ashby et al. investigates"… the reasons why some people chose to abate & #8230; renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families" (Ashby et al., 2005, p. 389). Significantly it was found that, "The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis" ( Ahsby et al., 2005, p. 389). Ashby et al. also note that cultural and language factors as well as communication play a role in ascertaining the quality of life of these patients.

Importantly, a number of studies stress that the quality of life should also be considered from an experiential and existential point-of-view. This has a bearing as well on the nursing management of these patients and is an aspect that has been relatively neglected in contemporary treatment. For example, Ashby at al.( 2005) state that some elderly patients withdraw from dialysis treatment as a result of difficultly in discussing their fears and doubts with medical staff and family. Some have deep religious convictions that they feel are not appropriate to share in a medical and nursing context. This means that a more inclusive and interpersonal methodology is necessary in many cases.

This also relates to the issue of faith and religious perceptions in the treatment process. Studies such as Faith by James Dette ( 2008) emphasize the importance of this dimension and its relationship to a more integrated and holistic approach. An article entitled Developing a renal supportive care team from the voices of patients, families, and palliative care staff ( 2008) explores the concept of a Renal Supportive Care Team, which is "… designed to elicit and provide for the needs of dialysis patients and their families throughout the trajectory of their illnesses"( Berzoff and Swantkowski, 2008, p.133). The results of this study provide insight into the more integrated and humanistic approach which is the central focus of this paper.

Respondents agreed that there needed to be greater education of both patients and families regarding all aspects of the disease process, open communication, on-going support...

Identification of gaps, implications for nursing practice and evidence-based recommendations
From the above brief overview of the literature it is clear that there are a number of pertinent and essential issues that are of significance in dealing with these patients. This also applies to the particular patient under discussion. These include issues such as cognitive impairment, psycho-social aspects and communicative aspects that relate to the question of quality of life; for example, "…the presence of unrecognized psychopathology can complicate the management of this patient group" (Tyrrell et al., 2005, p. 378).

Therefore, best treatment practices include the routine screening of these patients in order to determine whether there are cognitive impairments or signs of depression. In other words, "The health-related quality of life of elderly dialysis patients also needs to be monitored, preferably using self-report measures such as the NHP, and semistructured interviews" (Tyrrell et al., 2005, p. 378).

In terms of quality of life the issue of good communication is imperative, as well as positive relationship factors. This applies to the relationship between the patient and medical staff as well as family. In this regard the implementation of a Renal Supportive Care Team is a very useful method of ensuring that quality of life is optimized for the patient. This is an aspect that relates particularly to the patient in this case study.

However, as has been suggested in the above review, the area of existential and religious perceptions that have been relatively neglected. To this end I would suggest the theories such as Jean Watson's Theory of Human Care should be implemented in this case.

Donna Bednarski ( 2009) states the following with regard to the Caring approach to treatment. Caring is an intentional intervention which involves "…Establishing a relationship and being present with patients " and "meeting their emotional, psychological, physical, social, cognitive, and spiritual needs" (Bednarski, 2009, p. 261). From a nursing perspective this involves certain core concepts that have been established by Jean Watson.

Watson's Theory of Human Caring (1985) is based on the principle of responsiveness to the patient as a unique individual and the perception of the feelings of others (Bednarski, 2009, p. 261). This theory suggests a holistic and integrated view of caring and its place in healing. It is closely linked to aspects of phenomenological psychology and philosophy of Carl Rogers (Ingalls and Tourvile, 2003). The central trajectory of this theory is a phenomenological and holistic view of the issue of treatment and healthcare. This relates to the inculcation of conscious compassionate skills in nursing that can assist the patient in achieving a healthy state of mind, body, and spirit (Norred, 2000).

In terms of this theory, healing and treatment of a patient like Mrs. E.S. should focus not only on practical medical procedure but also on developing interpersonal relationships with the patient and interacting with the family to improve quality of life. The patient is not 'objectified' in a scientific and technological way but is dealt with in a compassionate and interactive manner that also takes cognizance of the deeper and more intimate levels of her individuality and to issues such as faith and religion.

A central concept that is used in this theory and which will be applied to the case in question is the concept of "life space." This is described by Childs (2006) in the Complex Gastrointestinal Patient and Jean Watson's Theory of Caring in Nutrition Support. Childs describes the relationship between the nurse and patient as a "life space" in which nursing interaction takes place on a spiritual level (Childs, 2006). This particular form of connectivity provides the healing "space" or opportunity for both the nurse and patient. (Childs a. 2006). In other words, this suggests that the improvement in quality of life takes place not only on a physical or material level but on a psychological and spiritual level as well.

5. Conclusion

The issue of quality of life in the patient in question and in all elderly patients with this condition is dependent on a wide range of factors and issues. Among these are of course medical and practical elements that should be attended to. These include the…