inservice teaching porfolio

In-Service Teaching Portfolio

One of the most pressing issues in nursing care is the development of protocols and standards for how to communicate with palliative care only patients the need to demonstrate rational end of life choices to the medical community. Nurses are often the first line in the development of such dialogue between the medical community and individuals or families, in triage and/or long-term care. The close proximity to the emotional and physical needs of the patient frequently requires the nurse to approach individuals and family members with these concepts. A current trend in medical care has been to adopt strategies that help nurses and other medical personnel approach such conversations so the issue of others making decisions for the individual is less likely to occur. Such documents were once called living wills, but now they are more frequently referred to as advanced directives This work will outline a strategy for teaching the approach of advanced directives conversations to a group of nurses in long-term care.

Part a Research Base

The older document, titled the living will is important but does not always demonstrate the whole scope of medical care that might be offered an individual if he or she is faced with a specific medical care decision and may need to be amended to include the determination of a proxy for the individual, before such time as one is needed. (Burnell, 1993, p. 219) as such stand alone Advanced Directive documents tend to be more reflective of patient rights (Galambos, 1998, p. 275) as well as very specific medical treatment plans that the patient might opt into or out of given his or her current state of health and his or her personal beliefs and/or desires regarding end of life. (Mcnamara, 2001, p. 19) (Shannon & Walter, 2005, p. 651) (Hardwig, 2000, p. 28) Recent legal decisions as well as universal and institutional protocols have stressed individual rights for end of life decision making, yet there are significant issues with cognitive impaired patients, often suffering from deteriorating diseases making decisions, at different stages of disease process. (Kunkel & Wellin, 2006, p. 6) (Lacey, 2006, p. 189)

In our country's health care institutions, decisions are made every day regarding the use of life-sustaining medical treatment. It is estimated that 80% of deaths occur in a hospital or nursing home setting, and that for 70% of these individuals a decision is made either not to start or to terminate medical therapy (Hawkins, Ballard, & Blaisdell, 1995, p. 3)

The decisions made can mean inhumane lingering of the individual in an advanced care setting, simply because there has been no medical directive communicated with the family and/or attending physician that stopped terminally dependant treatment. The multiple specialties that often become protocol, (Burnell, 1993, p. 32) as well as the current medical dependence on life saving highly technical treatment regimens can also complicate the issues by creating multiple communication opportunities and confusing medical procedural options. (Hawkins, Ballard, & Blaisdell, 1995, p. 3) in long-term care one of the biggest problems is the facility protocols that demand patients without advanced directives but in need of advanced care be transferred to an all too willing hospital when their condition deteriorates (Hickman, Hammes, Moss & Tolle, 2005, p. 26) where they are then potentially isolated from their social and emotional network and face confusing medical decisions without such support. (Walter, 1994, p. 61) (Saunders, 1996, p. 89)

In other work, Zwahr, Park, Eaton, and Larson (1997) examined the comprehension of middle-aged and older adults regarding information presented to them about advance medical directives and power of attorney for health conditions. In 1990, Congress passed the Patient Self-Determination Act which required all health facilities receiving Medicare or Medicaid to offer patients, at the time of admission, information about advanced directives and the opportunity to prepare a living will or advanced medical directive. (Park, Morrell & Shifren, 1999, p. 9)

It is clear that the current situation is difficult for both patients and nurses, as conversations are difficult and even more difficult to start. With such difficulty, to face and even despite the legal and institutional ramifications of not doing so, nurse and other health care professionals that assist patients in filling out and signing advance directives documents often rush through such documents, as they are afraid of the conversations they will start and/or they are unaware of the patient and/or families understanding of the ramification of the patients condition, or they are simply overloaded with work and do not feel they have the time to begin difficult conversations.

One of the most difficult situations health care professionals face when caring for elders and other patients is how to assist patients and families with decision making about whether to start, continue, or stop life-sustaining treatments for critically ill patients and those who cannot communicate their treatment preferences. Of the 2.4 million deaths in the United States in 2001, 1.8 million deceased were 65 years of age or older (USDHHS, 2001; Administration on Aging [AOA], 2002); thus, end-of-life treatment decisions are more prevalent among this group. Yet only 20% to 25% of the adult population in the United States have executed some kind of advance directive,...Making end-of-life decisions can provoke conflict among nurses, physicians, social workers, and families. Decision making can be especially difficult when care providers barely know the patient, have little knowledge of what treatments a patient would or would not want, or there is no one available to speak for the patient. (Mezey, Fulmer, & Abraham, 2006, pp. 265-266)

The development of protocols and time allotment to assist patients is essential to the development of real change in the system. Simply adding additional documentation to the pile of already confusing documents will not solve the problem for even half the patients involved.

Presentation Plan

Outline of presentation

The different types of Advanced Directive Documents

Community outreach protocol

Plan for discussing or breaching topic with patient/family

Plan for providing patient with directives

Suggestion of family planning meeting(s)

Observable outcomes of understanding and completion of documentation

Evaluation tool

In-service Format

The in-service will begin with introductory information about the nature of the problem. It is likely that many nurses in the in-service will express understanding of the concerns associated with the phenomena of dealing with end of life decision issues, and this situation will lead to a brief discussion about individual anecdotal involvement in resolving such conflicts.

This subsection will lead to a discussion of a plan for breaching the subject with individuals and families. The most crucial step of which is determining the patient and families understanding of the terminal condition he or she is experiencing and then explaining options.

Providing patients and families with Advanced Directives documents and then thoroughly explaining them, collectively with all members of the family involved. This section of the presentation will include a demonstrative explanation and Q&a session with nurses present to detail understandings of each section and type of forms, and conclude with nurses describing ways in which they field direct such information, including what aspects of the forms give patient / or nurse the most difficulty. The close of this subsection will be a reading of the below document.

There are two types of advance directive documents: the durable power of attorney for health care (DPAHC) and the living will. The DPAHC allows an individual to appoint someone, called a health care proxy, agent, attorney-in-fact, or surrogate, to make health care decisions if the individual loses the ability to make decisions or communicate his/her wishes. The person appointed has the legal authority to interpret the patient's wishes on the basis of the medical circum- stances of the situation and is not restricted to only deciding if life- sustaining treatment can be withdrawn or withheld. Thus, the proxy can make decisions as the need arises, and such decisions can respond directly to the decision at hand rather than being restricted only to circumstances that were thought of previously. Designating a proxy is preferable to completing a living will because it appoints one person to speak for the patient. Although most states have family consent laws that designate the order in which family members can make decisions for an incapacitated patient who did not complete an advance directive, disputes between family members who bear the same relationship to the patient are not uncommon and often very difficult to resolve. A proxy's decision legally supersedes a family wish or decision, and the Family Consent Law is not applicable in that case. The presumption is that the patient and proxy have discussed the patient's treatment wishes; however, a minority of states require that the proxy sign the directive as an attempt to assure that the proxy is put on notice and has accepted the role as proxy. This is not to say, however, that a proxy's decision is always easy and conflict-free or that the burden is light. It has been suggested that the patient-proxy relationship is a covenant built on trust, relationship, and fidelity (Fins, 1999). For elderly patients who have no one to appoint as their proxy, completing a living will that outlines their wishes is preferable to not providing any information at all about care preferences. This is equally so for patients who want to provide their proxy with some guidance about their treatment preferences and end-of-life care wishes, including artificial nutrition, ventilator support, and pain management. A living will (LW) provides specific instructions to health care providers about particular kinds of health care treatment that an individual would or would not want to prolong life. Living wills are often used to declare a wish to refuse, limit, or withhold life-sustaining treatment when an individual is unable to communicate. All but three states (New York, Massachusetts, and Michigan) have detailed statutes recognizing living wills. The usefulness of LWs is limited, however, to those clinical circumstances that were thought of before the person became incapable of making decisions. If a situation occurs that the LW will does not address, providers and families may not know how to proceed and still respect the patient's wishes. Assuming that an individual completes both the LW and DPAHC, the proxy/agent may not be obligated to follow the wishes outlined in the LW; those instructions serve as a guide.

(Mezey, Fulmer, & Abraham, 2006, p. 268)

The nurses will then read the Nina Case Study as a lead in to the family meeting suggestion:

To respect Nina's right to self-determination and to insure that her future welfare is protected, a goodness-of-fit process of obtaining ethically acceptable advanced directives should include a series of information sharing sessions among Nina, her children, and the medical scientists during which: (a) the physicians provide Nina and her family with information about the anticipated course, nature of, and potential risks and benefits of the experimental treatment; (b) Nina provides the practitioners and her children with information to help them understand her value system, the way she evaluates physical or emotional pain, her views on the altruistic value of research participation, and other personal perspectives that would allow her children to make future decisions from her perspective; and - Nina's children share their moral philosophies on consent-relevant dimensions so that Nina and they can decide whether or not the advance directives can be carried out in a manner that honors everyone's value orientations. (46) This last step recognizes that Nina is also obligated to respect the values and welfare of her children. (Fisher, 2002, P. 159)