In this essay I will reflect on a significant issue in practice using john’s model of reflection. This will clearly explain the choice of model for reflection and the importance of reflection. Going on to explain my experience which was of the controversial use of truth telling in terminally ill patients. I will then highlight the professional, ethical, legal principles which are effected due to this. Explaining Evidence based practice and why it is vital to the practitioner. Analysing the ethical decision making and the critical thinking behind the decisions and the accountability.
Johns (2006) model of reflection. I believe this model was most appropriate as it is a systematic and structured way of identifying which may be missed or areas where practice could be altered to make it more effective, this is reiterated by Taylor (2006) who agrees that this makes reflection more meaningful and useful. Haddock (1997) believes reflection is what people naturally by gaining insight in different ways and using the understanding to build and develop more and new ideas. Johns (2006) writes that the act of reflecting assists the understanding that a person has through experiences which are already learned and are reviewed in a structured way.
The Johns (2006) structured reflection begins with the descriptions of the experience or event and this will describes the here and now experience, the essential factors affecting the experience and the major background factors which affect the experience as well as the key processes of the reflections. The next stage involves a description of what happened, then what was achieved and why. This then leads on to the influencing factors both external and internal for the experience, after that the last two part of the reflection is the opinion of what could be done better in this experience. The final part of the reflection process is the findings of the experience and what changes will be made to promote best practice. Schön (1983) believes new ideas can be developed by using good reflection however does warn that reflection, is often used incorrectly due to lack of time and support in the clinical area. It is also important to reflect if the experience is a good one or a bad one.
In my experience a patient on an oncology ward who had metastatic cancer. Who was 88 years old and very adjusted and nervous and was having chemotherapy once daily. This was due to end in 2 days and discharge planning for when her white cell could came up to an appropriate level. The patient had a DNAR this was because the patient did t want to be resuscitated if they died. The scan was to see the progress of the disease and the results were that it had spread and would likely be fatal in a few days. The family explained to the doctors that if it had worsen to a point where the disease would be fatal that they would like to fast track her home and care for her in her dying days. They also requested that this was not told to the patient since it would only lead to making her worse and worry in her final days.
The issue was that the patient was not involved in the decision process that meant that the patient would not know about their diagnosis and would be blissfully unaware that they were dying. This is known as truth telling REF. It is very difficult for people to live with a long term condition. Muncey and Parker (2002) ref write how a long term condition can seem like a death sentence in some peoples view due to the sigma around disease like cancer, where the patient believes that their lives would be shortened while their quality of life reduced and sometimes they must live with the realisation that their condition has no cure. They explain that health care practitioner have to use a systematic planning process for their patient’s care which discusses the needs of the patient where by empowering them with the responsible for their own care which can lead to advanced directives which this patient had. The idea behind this aids the patient to live their lives to their full potential, happy within the constraints of their condition. This is supported by Miller (1992) who agrees writing how the main goal of care towards a person with a long term condition is to enhance their quality of life, enable them to cope effectively and help them to balance their dependence with independence. Which shows that assisting a patient home as soon as possible is important.
This was trying to achieve Happiness for both the patient and the family in their last few days together and allow the patient to be calm and with their family as stated in Ref to achieve the best end of life care as possible. So that they are not stuck in hospital but in their own home as per her wishes in her advanced directive. This made the family happy to have their wishes upheld. And this was evident in that they could return home together. Fast track ref
The consequences of this saw the health care staff avoiding the patients questions to avoid the truth being told. Code of conduct for a nurse Nursing and Midwifery Council. (2015).
Also this has consequences for the patient in that they are dying and they are not reasonably informed to make decisions on the future. However I believe this is for the best this is because it is allowing the family time together with end of life care, this decision is ethical even though it is something that is disputed. In future it would be important that I have further information on the truth telling. Ref This could be better handled by gaining the knowledge on if they wish to know if they have a terminal illness which is life threatening. Carpers (1976) talks about different ways of knowing empirical factual knowledge from science or external sources that can be empirically analysed. Aesthetic Awareness of the immediate situation and including awareness of the patient and their circumstances as a uniquely individual and of the combined wholeness of the situation
Personal is the emotion intelligence knowing derived from personal self-understanding and empathy. Ethical knowledge is Attitudes and knowledge derived from an ethical framework, including the awareness of moral questions and choices.
The professional issues which are involved with this kind of decision making is clinical governance Scally & Donaldson(1998) talk about the 7 pillars of clinical governance, these are clinical audit, patient and public involvement, risk management, clinical effectiveness, staffing and staff management, education and training and use of information. This covers the support of the patient and family this is backed up by the nice guidelines (2009) which agrees that involving the patient and looking at the clinical effectiveness to make sure that the patient is safe also the accountability of the decisions made. The professional accountability is vital to any decision made for a patient, this is to make sure that the patients’ rights and the health and wellbeing is at the centre of all decisions for the patient. The NHS ref is pushing to have all decisions Person centred and taking the patient’s wishes into account to avoid any harm or concerns.
It is in the nature of health care professionals that paternalism takes over and then the decisions are taken out of the patient’s choice. This is more common as stated in Gallagher (1998) which go on to say that paternalism is given by most patients because usually the health care professionals are expected to make the best decision for the patient. Although Gallagher (1998) goes on to say that this is not the modern way that its limitations these are found in the individuals lack of knowledge of both the patient’s personal choice and potential other options which could also be taken. Bennin ref
The law and legal perspective was that until recently was disclosure could be relevant in arguments surrounding truth-telling and collusion and focus on law relating to information disclosure, consent, capacity and confidentiality. This according to data protection act (1998) the information can be withheld if the information is relating to potential distressing information. Although this is changing in recent case law in that the ethical principle that the health care practisoner should answer questions truthfully to protect the patients’ rights to decide and reflect the principles of autonomy grubb (1998). Dimond (2005) agrees and discusses the duty of care, explaining that a nurse is obliged to provide adequate care to their patients as stated in the laws.
Confidentiality is part of the NMC code set out by the NMC (2015) and also is reiterated in the NICE guidelines (2015) this is vital in this situation so that the private information that the patient may not want the family to know the prognosis and may not want family informing of the situation. Although in this case it is implied that the family are fully aware due to their current involvement in the care of the patient.
Mental Capacity Act (2005) states that four key principles need to be taken in to account for assessing capacity, these are seen when the patient is able to understand and is reasonably informed to make their decision. It is imperative that they can communicate and retain the information that is needed to make the decision. In this case the practitioner is working in the best interests of a patient which according to the mental capacity act (2005) requires finding out the individual’s views on the matter and this will be identifying them through the patient’s wishes, feeling, beliefs and values. Also will need to take the circumstances in to account that the patient will be not discriminated against in any way. Under normal circumstances with a patient when assessing for best interest decisions encouragement of involvement and waiting till capacity in regained is vital but in this case it is not considered.
The duty of beneficence which Beauchamp and Childress (2001) stated generates a moral obligation to act in ways which promote the well-being of others. To act for the benefit and interests of others includes: Acts of mercy, Kindness, charity, Altruism, love, humanity, helping others, protect the weak and vulnerable. They goes as far to say to protect the rights of others while preventing harm from occurring. Constraints on when we act beneficently: Cannot always respect the wishes of the individual, Cannot always respect the needs, wants and rights of the individual and Sometimes the help is at too high a cost. Beauchamp and childress (2001) also Non-maleficence an obligation not to inflict harm intentionally and not to impose any risks of harm. Harm being – pain, disability, death, injury, violation and disrespectfulness. It is both physical harm and mental harm. They go on to explain that respect for Autonomy this is to allow and respect individuals to make their own choices through their own beliefs and values: Tell the truth, Respect the privacy of others, Protect confidential information, Obtain consent for interventions with patients, when asked, and help others make important decisions. If autonomy is to be respected it is important that valid consent be given before any treatment undergone to the individual. Respect for autonomy requires that an individual’s autonomous decisions should not be unjustifiably interfered with.
This kind of ethical decision making is important and requires to consider certain points such as the willingness to take risks, stress on both the staff and the patient, staffing levels, interpersonal skills, law and policy and authority with accountability. These factors are important so that the patient is not harmed in any way again by following Beauchamp and childress (2001). All stake holders should be considered when making ethical decisions so that no one is unduly harmed because of the decision made. This can be done by looking at who is effected by any decision made and how badly would it effect each party taking in to consideration that the patient should take priority providing a best interests resolution. It is important that the MDT analyse the known dialogue between the patient and the family so that a swift decision can be made which will not give conflicting information.
Using evidence based practice Sackett(1996) REF will allow for the patient to receive the most up-to-date and best care possible this will allow the option to be the best choice and best outcome trajectory as possible this is due to the research showing that this path is the best for the patient which has been done before and showed to work well. Polit & Beck(2008)agreed that evidence based nursing is vital for outcome for patients so that the health care practitioner is best equipped for the situation using the hierarchy of evidence.
It is important that accountability is taken in to account since this is a decision that can only be made by a senior member of the multi-disciplinary team (MDT) as stated by REF. Benna (ref) in her book talks about starting as a novice and gaining the necessary skills then to be a expert which can mean that the specialist knowledge gained will allow decision making in this type of situation easier and better for the most appropriate course of action for the patient and of course the family who also would be under great stress and be very saddened by the prognosis. Vivian (2006) agrees that someone who has the authority and understanding can make this decision to truth tell and allow the patient to spend the rest of their life at home.
Conclusion
This truth telling is important so long as it is a MDT decision so that this can be in the best interests of the patient and the family to improve the last few days of life for the patient. It is clear using Beauchamp and Childress (2001) principles that this kind of decision will be in the best interests of the patient and will be using beneficence and non-maleficence to make sure that these decisions are taken with the upmost care. Although the law allows truth telling as seen in the NICE guild lines ref. it is ethically questionable and this is shown to be infringing on patients autonomy and choices as stated by Beauchamp and Childress (2001) although following the old practices of an paternalistic outlook for the professional and the patient roles which is also effecting the basic human rights of the patient even though it is in the best interests. This kind of decision should be made using an MDT meeting and may even be discussed with the patient at an earlier intervention before the MDT is in this position to make the choice of truth telling using advanced directives to avoid affecting people autonomy. This seems to be a controversial topic which I believe to be good but only when used in the correct manner with full support of an MDT. The assignment has also discussed the importance on reflecting on ones practice whether it is a good or bad experience. Reflection is a fundamental aspect of nursing care.