End-of-Life Care Challenges for Nurse Practitioners

Introduction

The scenario for the nurse practitioner centers on a 55-year-old patient — referred to here as the patient — who suffered a stroke and was admitted after neighbors noticed unusually concerning behaviors. The situation was further complicated when the patient suffered a respiratory arrest requiring mechanical ventilation. A second CT scan revealed bleeding into the ventricles and brainstem, which may have caused irreversible brain damage. Her condition is critical, and a decision must be made about how to proceed with her care. It is likely that she will need long-term ventilation and a PEG tube, and the neurological team suspects that the brain damage is irreversible.

The most difficult aspect of this scenario is that there is no advanced directive, and the family is being indefensibly optimistic regarding the potential for recovery. The patient's two daughters have stated that they believe God will provide a miraculous cure and that their mother will somehow beat the odds through divine intervention. While some degree of optimism during a difficult period is understandable, it is equally necessary to temper these impulses with objectivity. As a nurse practitioner, it is critical to provide the family with an objective interpretation of the patient's situation and to guide them toward a consensus about treatment goals and their available options. This paper identifies the key themes a nurse practitioner should address in conversations with the family during this process.

End-of-Life Care

This case deals with one of the most important aspects of nursing. End-of-life care encompasses a broad and sensitive dimension of nursing practice in which the nurse must deal with death and the dying process. Generally, the family will be deeply emotional throughout this transition, and great care must be taken to comfort them during the grieving process. Yet it is equally important to be truthful and honest about the challenges that lie ahead. Mechanical ventilation and a PEG tube have the advantage of giving the patient more time, allowing the care team to continue assessing whether her condition might improve. However, when the patient's odds for improvement are extremely low, needlessly prolonging the inevitable leads to additional suffering. If there is no realistic hope of recovery, continuing aggressive interventions causes more pain for the patient without meaningful benefit.

Advanced directives are a set of instructions the patient has established beforehand in the event that she cannot speak for herself. Nurses can use advanced directives to guide the treatment plan based on the patient's own previously expressed wishes, made before she lost the mental capacity to communicate them. Having a set of advanced directives is the ideal means of deciding treatment options in such situations. Without them, the process becomes more complicated due to both the emotional factors at play and the many legal considerations that must be addressed.

Once a terminal diagnosis is established, the family can create a palliative and end-of-life plan to guide the care team through the patient's final phase of life. Patients who are terminal should have the ability to die with dignity, yet families sometimes unintentionally strip their loved ones of this right due to emotional factors. A comprehensive palliative care plan may include spiritual care providers, social workers, hospice care, and many other parties working to address the patient's fears, provide support, and honor any final requests. Nurses play a critical role in helping families navigate this process thoughtfully and compassionately.

Cultural Competence in Nursing Practice

The patient's family is deeply religious, and their faith is apparently driving their decisions about how to proceed with their mother's care. Although a nurse will not typically base a treatment plan recommendation on the expectation of a miracle, it is important to recognize and respect cultural differences in order to improve communication and increase the likelihood of reaching a consensus. One prominent model, Campinha-Bacote's model of cultural competence in health care delivery, defines the process as an ongoing effort in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client — whether that client is an individual, a family, or a community. This ongoing process involves the integration of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (Campinha-Bacote, 2002). Other scholars similarly propose that cultural competence is best understood as a nonlinear and dynamic process that is never fully completed, always expanding in its pursuit of greater knowledge and more developed skills (Burchum, 2002).

Despite the many different approaches and models devoted to cultural understanding, a common foundation underlying most of them is a commitment to humility. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient–provider dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals (Tervalon & Murray-Garcia, 1998). The first objective when discussing the patient's options with her family should therefore be to remain culturally humble and to build genuine empathy. On this foundation, the second objective is to truly understand the family's position and beliefs. Once their perspective is clear, the next objective is to design a communication plan tailored to the family's individual concerns as they relate to the treatment decision. Maintaining humility prevents professionals from making rash generalizations and positions them to engage in far more effective communication.

Conclusion

Therefore, it is also important in this situation to help the family establish a sense of empathy for their family member that is based upon objective factors. Any treatment plan that requires a miracle for the patient to recover does not represent an objective understanding of the situation. Furthermore, to help the family build an understanding of these circumstances, the nurse practitioner should enlist the head physician of the neurological team to explain the likelihood of the patient recovering brain functionality, as well as the physician who would perform the tracheostomy, so the family understands exactly what that course of treatment entails. It would also be reasonable, based on the family's cultural background, to recommend that they enlist a trusted member of their church for counseling and spiritual guidance through the process. By combining culturally humble communication, objective medical information, and spiritual support, the nurse practitioner can help the family move toward a treatment plan that honors both their beliefs and the patient's dignity.

References

Burchum, J. (2002). Cultural competence: An evolutionary perspective. Nursing Forum, 5–15.

Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 181–184.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility vs. cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal for Health Care for the Poor and Underserved, 117–125.