Patient Physical and Mental Health Care Decisions

INTRODUCTION

CASE STUDY: HISTORY OF SIMON

Simon Evans, a 32 year man has been diagnosed of schizophrenia at just 20 years of age and his illness comes with negative symptoms. Simon’s diet is poor; eating erratically, he is a chain-smoker and stays up all night. His symptoms are but not limited to auditory hallucinations, disorders of perception thought and affect. Earlier on in his illness, Simon experienced personal functioning deterioration entailing memory and concentration problems, unusual behaviour and ideas, disturbed communication and affect, social withdrawal, apathy and reduced interest in daily activities, which was followed by an acute episode of hallucinations, delusion, behavioural disturbance which included agitation and stress. He currently lives with his mother who although extremely worried about Simon’s behaviour, is very supportive and involved with every step of care given to him. His brother left home several years ago and is currently a teacher and he has very limited contact with his father. At the age of 16, Simon left school with no qualifications; he has been in and out of several jobs stacking shelves at the supermarket but cannot hold down his job due to his inability to concentrate, disturbed communication and social withdrawal due taunts and torments from youngsters because of his bizarre dress sense. Simone has Ketones in his urine and is currently on Clozapine (500mg/d) treatment which he tolerates well but has since gained weight and has also started cognitive behavioural therapy (CBT) in-patient treatment to be continued after his discharge.

In this essay, we will examine Simon’s physical and mental health needs. The structure of the essay will include a background which will look at the theories in decision making and an in-depth discussion of Simon’s issues above and conclude with recommendations.

BACKGROUND

Schizophrenia:

Schizophrenia is a term derived from the greek words ‘Schizein’ (to split) and ‘Phren’ (soul, spirit and mind), which was introduced by Eugen Bleuler in 1908, during a lecture of the German Psychiatric Association in Berlin where he separated the functions between personality, thinking, memory and perception (Ashok et al, 2012). Schizophrenia is a severe, long-term mental disorder that affects the way a person thinks, acts, speak, perceives reality, shows emotions and understands him/herself coupled with how he/she associates and relates to other people (Wilkinson et al, 2000). Schizophrenia is often associated with Psychosis which is the hearing of voices and delusional dispositions and can negatively affect a sufferer’s thought, functions and living a fulfilling life (WHO, 2018).

Statistical Facts:

As a nurse, understanding schizophrenia and having an in-depth knowledge on how to identify, diagnose and choose the right intervention is important because of the information below that shows the number of people suffering from the illness. Schizophrenia affects over 21 million people worldwide (WHO, 2015). Genetic defects account for around 80% of those with the risk of having schizophrenia. 1 in 100 people will suffer an episode of schizophrenia in their lifetime (Royal College of Psychiatrists, 2017) and one in two people living with schizophrenia only receive care for the condition (NHS, 2018). About 25% of schizophrenia sufferers will recover fully (Fuller, 2013). Schizophrenia often starts to occur in adolescence or early adult life, affecting both men and women equally. It however, tends to develop earlier in men at younger age than women across all cultures and climes (Barnes, 2004) There are 13% of people living with schizophrenia in the UK who are not in employment (Warner R, 2000). Schizophrenia sufferers have 5 – 10% chance of committing suicide within 10 years of diagnosis (Caldwell and Gottesman, 1992).  About 30% of NHS spending in adult mental health goes on the 220,000 sufferers of schizophrenia in the UK (NICE, 2014) and it is a major illness that puts a major financial burden on the UK economy costing the government up to £12 billion pounds a year (LSE, 2012).

DISCUSSION

THEORIES OF DECISION MAKING:

The Clinical Reasoning Cycle and The Nursing Process are two theories that nurses employ in the course of their decision making. Nurses have a vital role to play through building and initiating the nurse – patient relationship which is the most important issue in nursing, without which, any nursing actions will be ineffective (Kozier et al, 2008) and in assisting people with schizophrenia have a meaningful life by adapting the various developed nursing models, theories and processes and making sure that problems and triggers of patients are not deliberately overlooked or that those with acute care needs and risks aren’t poorly managed. Levett-Jones et al (2010), supports the use of a ‘clinical reasoning cycle’ as a detailed method for clinicians to gather cues, analyse or process information, a means to possessing full and detailed knowledge of a client’s situation, plan and implement tailored interventions, evaluate outcomes and reflect on or learn from the process.

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The Clinical Reasoning Cycle (CRC) is a process made up of eight (8) distinct stages that are systematically linked together. These stages do not necessarily follow a sequential route but are joggled through in a back and forth phase until the client’s assessment is precise. Bulson and Bulson, (2011), however, outlines the nursing process as a five (5) stepped process that can be used in solving challenges in nursing, namely: Assess, diagnose, plan, implement and evaluate. Both theoretical processes above share similar ideologies as they both address the gathering of information and using the information in a feedback mechanism.

In order to use the nursing model and theory to address Simon’s on-going health needs, the CRC will be used due to its 8 staged phase’s robustness as shown in Fig. 1. (Levett-Jones et al, 2010). The process does not automatically assume a clockwise flow depending on a patient’s situation but will help develop a patient care plan strategy and offer the best service to him and his family (Leung, 2000), which will be agreed by the health and social care professionals, Simon and his carer.

Figure 1: Clinical Reasoning Cycle (CLC). (Levett-Jones et al, 2010)

1^st and 2^nd Stages: Consider Patient’s Situation and Gather Information.

The first stage is for caregivers to collect data that will help them “get to know Simon” and understand his situation and condition. According to Fulder (2005), an integrated and holistic approach will help to give aspiration and direction to any possibility of achieving realistic health outcomes. Introducing a holistic approach that help to understand the patient will cover all areas relating to the patient’s physical, mental, emotional, psychological and social wellbeing that relates to the patient’s illness and how to meet their healthcare needs. (Margereson, 2010).

State of Simon’s Mental, Physical and Social Health

Mental: At the age 20, he was diagnosed with schizophrenia following deterioration in his mental health. His symptoms include auditory hallucinations, disorders of perception, thought and affect. He began deteriorating in personal functioning which includes memory and concentration problems, unusual behaviour and ideas, disturbed communication and affect, social withdrawal, apathy and reduced interest in daily activities. These were then followed by an acute episode of hallucinations, delusions, behavioural disturbances which included agitation and distress. He is currently undergoing treatment with Clozapine 500mg per day after being re-admitted and discharged from hospital due to a psychotic episode. Simon started CBT as an in-patient under MHA 2007. Fig. 2 highlights Simon’s situation, his vulnerability and symptoms puts him in the psychotic phase (Miret et al, 2016).

Physical: With so much focus by authorities on the mental health state of service users, now that Simon is under the care of healthcare givers after so many years of neglect, it is easy to lose sight of his physical health needs (helping him deal with his chain smoking, poor sleep pattern, hygiene, poor and erratic diet, ketones detected in his urine and clinical obesity of 30.5 BMI) as all focus being channelled towards implementing policies and best practices that only deal with his mental illness such that holistic care is overlooked. (Nash, 2014).

Social: He still lives with his mother upon whom he is very dependent and she has no one else to help out. He is socially isolated with no qualifications or prospect of getting a new job easily. He has no current skills haven not worked for about 12 years when he was diagnosed of Schizophrenia at age 20. He is a victim of bullying and is socially withdrawn. Simon has also previously been admitted in Hospital under MHA 2007.

Figure 2: Basic symptoms in schizophrenia (Miret et al, 2016)

3^rd Stage: PROCESS INFORMATION

The next stage is to process the data collected by analysing and comparing the past with the present, normal with abnormal, recognise gaps and inconsistencies the narrow the information that will help reach expert logical conclusions regarding his pathophysiological and pharmacological patterns (Levett-Jones et al, 2010). Clearly, Simon exhibiting negative symptoms of self-neglecting lack of self-care, withdrawal from daily activities, poor social functioning, showing apathy and lack of emotion, coupled with torment and bullying may be the reason why Simon refrains from leaving house, getting and holding down a job or forming and keeping relationships(Cook et al, 2010). Also, his experiencing positive symptoms such as auditory hallucinations, thoughts and affect as well as cognitive as evidenced by his memory and concentration problems (Rosen et al, 1984), could be the reason why prefers to keep to himself, has sleep disturbances and agitation and does not want to get a qualification. His clozapine medication treatment may also be a cause for his lack of sleep (BNF, 2018).

Simon’s weight and the ketones found in his urine may be triggers for diabetes (ketoacidosis – DKA).

4^th Stage: IDENTIFYING ISSUES and PROBLEMS

Then we come to the stage where we Synthesise facts and inferences to make a definitive diagnosis Simon’s illness as a schizophrenic displaying both positive and negatives symptoms. Mental health specialist risk assessments will be carried (NICE, 2014), out to assess the effect of his chain-smoking, poor erratic diet, lack of sleep and poor hygiene of his probably due to poor diet, lack of exercise and weight gain on his already poor physical health. Further assessments will also be carried out to check the side effects of his medication treatment on his weight and also check for any chances of diabetes (DKA) due to the ketones found in his urine. Continued Therapeutic Care will also be promoted to address any psychological complications, trauma and underlying problems that may have been experienced by family as part of the therapy, because this will help Simon more than managing risks during his recovery (NICE, 2009). Simon will also need to be constantly monitored by his GP while in recovery to keep an eye on his weight, psychosis, schizophrenia and general healthcare when he moves into secondary care.

5^th and 6^th Stages: ESTABLISH GOALS and TAKE ACTION

A Care Programme Approach (CPA) will be agreed with Simon where his target goals will be outlined with courses of action he needs to take within timed frames(Levett-Jones et al, 2010). McDermott (1998) introduced the CPA in April 1991 with the aim of providing mental health patients with a care plan and a care coordinator to support them through it. The royal College of Psychiatrist (2015) has adopted the CPA as a method of ensuring suitable care and support is provided for people with schizophrenia. A CPA is reviewed and updated for changes every 3 – 6 months with Simon’s approval, his care coordinator and all other MDTs involved in his care/support. The CPA will be clear and simple enough for Simon to understand steps he should follow in an emergency or when he becomes unwell again or run into difficulties. The care coordinator ensures that every stakeholder in Simon’s healthcare team, including his GP, has a copy of his care plan.

Simon’s Treatment Interventions would include physical Health/medication, social and psychological intervention, with him involved at every step of the way in his care. As Edvardsson et al (2008), outlined, person centred care as involving, recognizing personhood, preservation of their personality, personalizing their environment, collective decision making and behaviour interpretation from the service user’s viewpoint.

Interventions

Physical and Medication: Referral will be made to his GP for urine lab review regarding the ketones issues. According to Leslie and Rosenbeck (2004), Ketone bodies in the urine are an indication that the body is utilizing fats for energy instead glucose. Also, Robson and Gray (2006) recommends  annual checks for Clozapine users due to risk of developing DKA and keeping a close eye on Simon’s weight and metabolism.

{as well as his cardiovascular indicators as mental and physical health cannot be treated in isolation.Consider getting Simon’s GP to prescribe other medications to suppress the side effects of Clozapine, for example, using laxatives for constipation and regular rehydration to reduce blood acidity (NHS, 2018).}

Weight concerns, Drinking and Erratic eating: With a BMI of 30.5: Weight gain and dry mouth are possible side effects of clozapine (BNF, 2018), he needs more water intake to alleviate his dry mouth which is consistent with Diabetes mellitus. NICE guidelines (2014) encourages healthy eating combined with planned physical activities. Exercising and more walking can help release Endorphins which trigger a positive feeling in the body when released and absorbed, this will help reduce his weight and cut his risk of developing cardiovascular disease (Bender et al, 2007).

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Personal hygiene and Chain smoking: According to Baumeister (2017), schizophrenics are more than five times likely to smoke than non-sufferers (Minichino et al, 2013), Simon’s chain smoking habits adds an undesirable impact to his mental and physical health so he will be encouraged to kick the habit with the aid of Nicotine replacement therapy (NRT) so he can attain low levels of tar, carbon monoxide nicotine and other poisonous chemicals present in tobacco smoke (NHS, 2018). This could work in combination with his CBT to help his hygiene (Sykes and Marks, 2001).

Sleep hygiene:

Seidman et al (2012), says that when neurocognitive deficits of people living with schizophrenia deteriorates, it could result in conditions like: unusual behaviour, confusion in the mind, withdrawn emotions and lack of sleep which affects energy levels, concentration, relationships and mood swings (Kaskie, Graziano and Ferrarelli, 2017), psychoeducation to highlighting the importance of sleep and encouraging a record keeping of his sleep patterns in his CPA monitored by his care coordinator would benefit Simon. {A referral to The Sleep Council would be made through the CMHT.}

Social Interventions: It should be included in Simon’s CPA and agreed with him, issues like moving on into independent living, to get new vocational skills through employment or volunteering as these will help to boost his confidence, help restore his individuality, health and wellbeing on his way to recovery (NICE guidelines, 2016), social inclusion and engagement where he can go into day centres or activity groups will also be beneficial to Simon. Intervention for family should also be offered to help assess the needs of Simon’s carer (NICE,2014).

Bandura and Wood (1989), also suggests that positive behaviour motivates positive behaviour in others so the role of Simon’s brother in his life would help him see new possibilities, so spending more time together will help form better bond and relationship.

Psychological: Simon and his family would benefit a lot from Psychoeducation to give him and his family information and support on how to better understand and cope with schizophrenia. (Cochranelibraby.com, 2019). The use of printed and verbal materials will further aid Simon and his family’s understanding of his illness and treatment Zapata et al, (2015)

Cognitive Behavioural Therapy: According to Pontillo et al. (2016), Getting involved with CBT willhelp to reduce Simon’s sleeplessness, deal with positive symptoms of schizophrenia such as hallucinations and reduce his social isolation (Freeman et al, 2015). With CBT, Simon will identify his triggers in order to avoid them and cope with challenges and changes (Carroll, 1998). With CBT Simon can also improve on negative symptoms like self-neglect (Rethink Mental Illness, 2018).

through CBT, Simon will improve in his social interaction when he joins groups like Art Therapy where he can use his imagination and materials to create objects (NICE, 2010). Joining such groups will help his social interaction, build confidence, self-esteem and reduce anxiety (Hung & Ku, 2015).

7^th Stage: EVALUATION

This is the stage where care coordinators review the actions that Simon has been supported to take and weigh observed outcomes to determine the effectiveness of the process and see if Simon’s care has achieved desired goals (Hall et al, 2012) or heading towards possible success or whether to readjust, continue or stop any course of action (Levett-Jones et al 2010). We will mainly be concentrating on observed changes and feedback from both Simon and his mother also getting input from his care coordinator. The line of questioning will mainly be ‘what is getting better?’, ‘what is working well and what is not?’, ‘is the situation improving?’ etc.

8^th Stage: REFLECTION

The final stage in the process is where we reflect on what has been learned from this particular case. Reflecting on what had been done and how it could have been done better or a different way. How we can achieve a much better outcome or avoid any uncomfortable situations in the future (Levett-Jones et al 2010). A reflection on how using the CRC has helped in a holistic way to understand and provide an improvement to Simon’s wellbeing as a patient living with psychotic schizophrenia.

Even though Simon may have side effects of weight gain due to treatment with Clozapine, treating his schizophrenia with its accompanying complications was a case of benefit versus consequence to which in Simon’s case, the benefits out-weighs its consequences.

Also, this is where we reflect on how we can go further to provide help for the carer (Simon’s mom) and any other family in his circle of care and ask if they would need respite due to the physical and psychological distress they might have experienced. (NICE, 2015).

CONCLUSION

The CRC has been a valuable tool for healthcare professionals when analysing patients’ care. It is imperative for them to have thorough knowledge of the process as inadequate skills will result in the delivery of unsatisfactory healthcare and ultimately lead to incorrect diagnosis, poor medical treatments, poor risk assessment and poor management of medical complications. There is therefore need to practice and perfect the use of this tool so as to be able to achieve and deliver best healthcare practices.

• S. Zhao et al, (2015). Psychoeducation (brief) for people with serious mental illness Available at https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010823.pub2/full [accessed 04/09/2019]