Quality of Life and Functioning What does the phrase “quality of life” mean? Does it have an actual definition? The answer may not be as clear as one would expect because the concept of “quality of life” can vary from one person to the next based on the values of the individual in question. The purpose of this paper is to examine the quality of life of a patient with a cancer and describe an appropriate nursing care plan based on the patient’s values.
Personal Perceptions Personal perceptions about quality of life and health promotion can greatly influence an individual nurse when attempting to create a plan of care for a patient with a lingering illness. I have worked in home health care setting as a visiting nurse and have experienced this scenario firsthand. I believe that one of the hardest parts of nursing is being able to put personal perceptions behind you in order to accommodate the needs and desires of patients. Understanding my own personal perceptions on quality of life was a lesson I learned quickly as a new nurse. I was caring for an elderly woman who recently suffered a stroke and needed several surgeries on her right shoulder due to a fall. The woman was no longer able to care for herself and was receiving assistance from her daughters. The family had cultural concerns and beliefs that their mother should not receive any narcotic pain medication even after several doctors had recommended narcotics for pain management until the surgeries were complete. I would visit with this patient and her daughters several times a week and often saw her in excruciating pain. I remember her describing the pain as “the worst pain I’ve ever felt – even worse than childbirth.” Her blood pressure and pulse were consistently elevated and she often grimaced and moaned in pain while attempting to move. I just could not understand why the family did not want to relieve her pain and I started to feel myself resenting her daughters for causing her so much pain. I would never let my mother experience that level of pain, how could they just sit and watch her suffer? It was not until I sat down at spoke with one of the daughters that I started to understand their concerns and reasons why they would not allow narcotics. Not only did the family have cultural concerns regarding pain control but they had lost a family member due to an overdose of narcotic pain medication and they feared the same would happen to their mother. I slowly started to understand how my own perceptions negatively influenced my ability to give care to my patients. I started listening more to underlying concerns and really digging deeper to find out how to best care for the patient. I had to learn to remove my own personal beliefs on things such as pain management while still being able to get my concerns across. I have found that one of the toughest parts of nursing as a career is being able to respect an individual’s concept of quality of life even when I do not agree with it. Another early lesson I learned as a new nurse was that I could not define quality of life for anyone but myself. I took care of an elderly man slowing dying of end stage renal disease. He had undergone a kidney transplant but it was unsuccessful. The patient lived alone, he was widowed, and he refused to attempt dialysis. I looked at the case as he was giving up. If that was me, I would fight. I would try dialysis or another kidney transplant. I would not give up. But I was not the patient. The patient was a man who stated he “already lived a full life.” He raised four successful children, he married the love of his life, he made a living doing what he loved, and he refused to “become a vegetable in a nursing home.” He wanted to live the rest of his expected four-to-six months at home; the same home where he married his wife and raised his children. I learned a lot about life from him and I realized that he influenced my own personal views. I often offered a home health aide to assist him with his bathing needs or activities of daily living and he always refused. He never could give me an actual reason for why he did not want an aide to assist him but I learned that he did not need to give me a reason. We were dealing with his life, his illness and his care plan based on his definition of quality of life, not mine. Being able to understand how my own personal perceptions influenced my nursing care was something that nursing school simply could not teach me. I could identify my own personal values on controversial topics such as abortion, drug use or rape but it was not until I started actually caring for patients in their homes that I started to understand what quality of life and level of functioning meant to an individual. I no longer argued over the need for a home health aide, increased pain management or tried to convince an individual that they needed placement in a nursing home. I started listening to my patients and often began conversations by asking them what they wanted out of their life. In nursing school, I learned to create a care plan based off of diagnosis. In real life, I learned to create a care plan based off of an individual patient.
Strategies
Before any strategies can be developed in the case of Mr. and Mrs. Thomas, the patient and her husband must identify their own definition of quality of life. By finding out what these two individuals value a better nursing care plan can be created. The scenario given does not identify if Mr. and Mrs. Thomas have any specific religious beliefs. A community health nurse evaluating the case should identify this and determine if religion is something that could help provide some comfort to the couple. If religion is identified as a potential relief measure for the couple the nurse could collaborate with a pastor or other religious members to see if this could act as a positive coping mechanism for the couple giving the terminal nature of Mrs. Thomas’s cancer. The nurse should also identify and create an acceptable pain management plan based on Mrs. Thomas’s values regarding narcotic use. Mrs. Thomas previously said she “did not want to become addicted to drugs” and has been enduring most of the pain without using her prescribed Vicodin. The community health nurse should first assess the patient’s understanding of the medication use and potential side effects and identify if this influences Mrs. Thomas’s concept of quality of life. Perhaps Mrs. Thomas has been avoiding narcotic use because it is too sedating, in which case the nurse could collaborate with the physician to find a more suitable medication. The nurse could also suggest alternative pain management techniques that do not involve medication such as deep-breathing exercises, acupuncture, aromatherapy, massage therapy or relaxation therapy. The community health nurse should also assess whether Mrs. Thomas has an advanced directive or living will in place. While these topics will be challenging for the nurse to discuss with the family, it may bring some comfort to Mrs. Thomas if she knows that her wishes will be followed. If Mrs. Thomas does not have one of these already in place the community health nurse could assist the patient in doing so and potential alleviate this additional burden that Mrs. Thomas could be procrastinating. Another strategy that the community health nurse might chose to do is look at bringing in a social worker to the case. A social worker could help the family develop more positive coping mechanisms, identify some community social resources for the couple to participate in and bring Mrs. Thomas’s children closer to the family. The nurse might also case conference with the social worker to identify support methods for the Thomas’ children. The Thomas’ children might be more willing to participate in care of their parents if they felt more supported and had a better understanding of their mother’s illness. Mr. and Mrs. Thomas could also potentially benefit from identified social supports within the community as they have been isolating themselves at home. Additionally, the case identifies that Mrs. Thomas recently lost her clerical job and while Mrs. Thomas is receiving a small disability check, the couple is still struggling to make ends meet. The social worker and nurse may be able to identify any appropriate financial supports that could be available to the couple or suggest a long-term insurance plan that is affordable to coverage additional expenses.
Holistic Nursing Action Plan The community health nurse should try to incorporate a holistic approach to nursing as much as possible to improve the quality of life and functioning for Mr. and Mrs. Thomas. Holistic nursing encompasses the total human being including the mind, body, spirit, emotion, and environment of the patient. Furthermore, holistic nursing care treats a person’s physiological, psychological, and spiritual needs. Mr. Thomas already has a diagnosis of chronic depression and his disease is showing clinical signs of exacerbation related to several stressors. The community health nurse needs to address the stressors that Mr. Thomas is facing at home and at work. Mrs. Thomas has displayed signs of stress and anxiety related to her husband’s condition. The nurse needs to teach both patients several alternative positive coping skills to address the psychological concerns of this case. Identifying an appropriate pain management plan based on Mrs. Thomas values and concerns over narcotic pain medications needs to be immediately addressed by the nurse in order to relieve the physiological needs of Mrs. Thomas. For example, the nurse could suggest and implement alterative pain management such as teach Mr. Thomas massage therapy techniques to use on his wife or by teaching the couple deep-breathing methods and relaxation therapy. Mrs. Thomas should be able to identify a pain level within her personal comfort scale within a reasonable time frame. Also, the nurse needs to address if there are spiritual or religious concerns of the couple. By helping the couple to cope with a terminal illness in an appropriate manner, the nurse can expect to increase Mrs. Thomas’s quality of life. The nurse needs to anticipate and prepare Mr. and Mrs. Thomas for the current and expected needs of management in a terminal illness. At the current stage of Mrs. Thomas’s illness she appears to need significant pain management techniques implemented. The scenario does not suggest that a home health aide is present in the home so the nurse might be able to refer an aide for Mrs. Thomas when she is no longer to complete her personal hygiene regimen without assistance. The nurse could also refer Mrs. Thomas to a home care physical therapist or occupational therapist for evaluation regarding safe bathing techniques and the need for any assistive equipment. By allowing Mrs. Thomas services of a home care multidisciplinary team, the nurse is able to maintain the integrity of the patient’s wishes to stay in her own home as long as possible and without feeling as those she is burdening her children with her illness. As the cancer progresses, Mrs. Thomas will require additional services. The nurse will need to evaluate and change the nursing care plan based on the level of disease progression. For example, if the nurse notices that Mrs. Thomas is long longer able to cook for herself or her husband the nurse may suggest the services of a homemaker or an alternative food source, such as Meals on Wheels. As the cancer progresses, Mrs. Thomas may also need transportation assistance, such as Med-Cab, to attend medical appointments. The nurse should identify a long-term plan early on in the treatment of the Thomas family or when self-care is no longer possible. The nurse needs to identify when hospice care should be referred to the patient, if the patient desires nursing home placement, or if the couple decides that Mrs. Thomas prefers to stay at her own home during end-of-life care. The nurse should be able to outline a potential plan of care based upon the patient’s values and personal definition of quality of life and maintain independent functioning as long as possible. However, the nurse also needs to be able to be flexible in managing the patient’s plan of care and be willing to alter the plan as dictated by the patient’s wishes.
Chronic Depression The scenario given suggests that Mrs. Thomas is experiencing distress related to her husband’s chronic depression. Mr. Thomas has been showing signs of increase depression because of issues at work and because of his wife’s illness. The Thomas couple has also been isolating themselves at home and has identified a limited support system. Additionally, Mr. Thomas has been forgetting to take his medication regularly due to stress. The community health nurse should start by identifying any immediate concerns of safety by assessing Mr. Thomas’s mental status. The nurse should determine if he possess any immediate threat of harm to himself by questioning any previous suicide attempts, thoughts of suicide, intent to harm himself or plans to harm himself. The community health nurse may also need to refer Mr. Thomas to a behavioral health specialty nurse for a further evaluation of his mental status and personal safety. A behavioral health nurse would be able to identify any disease exacerbations of depression, medication effectiveness due to missed doses and concerns of safety. Also, the behavioral health nurse might be able to recommend alternative depression screening methods and suggest different ways of medication management, such as an alarming medication box to remind Mr. Thomas to take his medication. Mrs. Thomas is obviously concerned and frightened at her husband’s behavior and increased depression. By treating Mr. Thomas and his depression the community health nurse would be able to treat both patients by relieving some of the stress Mrs. Thomas is currently experiencing and allow her to enjoy the rest of her time.
Conclusion
Quality of life can greatly differ from one patient to the next. Nurses experience a heightened level of connectedness with their patients and are granted a special insight into the values and belief systems of their patients. Patients often trust nurses with this exclusive information and look to the nurse for guidance in the dying process. Nurses must be able to look past their personal perceptions of life and understand that only the patient can identify their personal standards and measurements of quality of life.