Application of Perspective of Health and Illness to Case Study

1. How do the lenses provided by psychology, biology, sociology and the life course help you to understand your own healthcare practice in this case?

2. How did the multidisciplinary team working help in responding to the needs of those you were caring for?

3. What was exemplary about the response and what do you think should be done differently next time?

The aim of this essay is to discuss a case study from my practice placement who is at the midlife stage of the life course. I will use the pseudonym Joan to conceal her identity and the location and personal details will be changed to maintain confidentiality throughout (NMC Code of Conduct, 2018). Joan is a 58-year-old lady who is currently receiving palliative care as a result of end stage ovarian cancer. I have chosen this particular case study to highlight and explore the biological, sociological and psychological perspectives that shape our understanding of health and illness during this life stage. This essay will then discuss the role of the multi-disciplinary team and how they will address the holistic needs of the patient. The assignment will then evaluate what was exemplary about the response are what would need to change in order to achieve person centred effective care.

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Life transitions are critical times within a person’s life span. The life course perspective elaborates on the importance of time and the processes of human development and family life Bengston et al (2005 cited by Rogers 2019). The life course approach to health acknowledges key stages in people’s lives have relevance to their health. Midlife is a pivotal time and transition to midlife may result in change of status social identity and role involvement. Individuals may have to adapt are change their expectations are behaviour in response to needs or resources. Women in midlife are often referred to as the sandwich generation due to dealing with the responsibility of younger family members as well as older family members McFadden et al (2012, cited by Watson, 2019). It can be a stressful time as individuals come to terms with the fact, they are getting older and struggle with bodily changes that occur during this time. One of these changes is the menopause. The menopause transition is a universal milestone when women ‘permanently cease menstruating and lose ovarian follicular activity’ Rubinstein and Foster (2012, cited by Watson, 2019a). The NHS website describes the menopause as a natural part of ageing that usually occurs between 45 and 55 years of age (NHS 2018).

Joan is a 58-year-old lady who was in the late stages of ovarian cancer when I first met her. It was evident when I had read Joan’s notes which gives a detailed account of her life history that she had a difficult time during the menopause. Joan claimed that she had very rarely visited the doctor until she reached the age of 54. During this time, she became very down as she began to put on weight around her tummy and had difficulty sleeping at night, so she felt constantly exhausted. The GP had put it down to symptoms associated with menopause and prescribed Joan with Hormonal replacement therapy (HRT). The medical profession had contributed to a view of menopause as a ‘deficiency disease’ that could be ‘cured’ by prescribing  (HRT) Rubinstein and Foster (2012, cited by Watson, 2019b) Loppie and Keddy, (2002, cited by Watson, 2019) state that that menopause is a natural phenomenon and highlight the concerns of women who receive conflicting information and do not always feel that they are in control of their lives. This was the case for Joan she felt that the GP was always right and put up with the symptoms. It was a year later and after a private scan when she found out that her symptoms were in fact ovarian cancer.

From a biological perspective ovarian cancer is when abnormal cells in the ovary begin to grow and divide in an uncontrolled way, and eventually form a tumour (Cancer Research UK 2010). Joan experienced symptoms which were very symptomatic with the menopause. Most women attribute the nonspecific nature of symptoms to menopause or stress (National Cancer Institute (2014). She also had persistent bowel problems which required her to have a scan. It was very easy to mistake Joan’s symptoms with menopause as she was at middle age which is associated with menopause and ovarian cancer. According to NHS website about 8 in every 10 cases are diagnosed in women over 50 and are usually diagnosed after the menopause (NHS 2018).

Ovarian cancer is sometimes related to genes especially if you have inherited a faulty gene called BRCA1or BRCA2 these genes increase the risk of developing ovarian and breast cancer. Another way that you are defined biologically is through your genes, which, among many other things, are responsible for the inheritance of certain diseases such as some cancers Waugh and Grant, (2006, cited by Watson, 2019). Treatment of ovarian cancer consists of surgery and chemotherapy. (NICE 2011) recommends If performing surgery for women with ovarian cancer, the objective should be complete resection of all macroscopic disease. In Joan’s case when undergoing surgery, they had found that the tumour had spread to her stomach, bowel and spleen which resulted in Joan having to have extensive surgery. Joan disclosed that the hardest part was wakening up to find she had an ileostomy which was hard for her to come to terms with. Joan’s surgery had a major effect on her quality of life and physical appearance.

From a psychological perspective Joan faced multiple psychological issues. Joan had stated that before her poor health she was always upbeat and loved her job as a teacher which she talked about passionately.  She believes her poor health began with the menopause. Joan claimed during this time she suffered low mood and was always tired which influenced her home life and work. Joan’s husband had to work away from home a lot of the time so they both planned on taking early retirement to spend more time with each other and be a support to family. However, after this news their plans for the future changed significantly. Joan was referred to a specialist nurse for support during this difficult time. Pratt (2006) states that a cancer nurse specialist can provide a supportive link between the specialist cancer centre, hospitals and community to enhance the continuity of this support. Joan was a glamorous lady and body image had great importance, she found chemotherapy difficult and the fact that she lost her hair. She also had an ileostomy and couldn’t dress the same as she used to.  Rubenstein and Foster (2012 cited in Watson 2019c) commented that midlife was culturally associated with negative issues such as loss (of fertility, youth, beauty and sexual attractiveness), disease and illness. They claim that in today’s society women are under a lot of pressure to fit in with societal ideals about physical beauty, attractiveness and being skinny, and physical changes away from these ideals can be difficult to cope with. Joan had suffered a lot of anxiety and depression due to her diagnosis and poor quality of life. She said the only thing that kept her going was her strong faith in God. She said during her illness her faith increased and give her a deeper meaning to life. Her parish priest visited her regularly and she found great comfort in those visits. Health includes having a sense of purpose and meaning, having activities that transcend one’s self, or having a sense of spirituality Saylor (2004, cited by Watson, 2019a). Good communication and active listening are paramount in letting the patient express their feelings and will aid coping.

The sociological perspective aids our understanding of relationships and what support is available for the patient. Social support includes having the social interactions to obtain help, assistance, or relief Saylor (2004, cited by Watson, 2019b). A social model of health employs holistic definitions of health, taking into account a wide range of factors including social and mental dimensions (Hickman,2019). Joan was happily married and had 2 children and 1 grandchild. Joan’s daughter lived and worked in the south of Ireland and her son was in further education. She only had one sister and a brother who lived in England. Joan had been a very social person and had friends who were colleagues from the school she worked in. She enjoyed going out for meals with friends and going to the local gym. She also enjoyed spending time abroad with her husband during summer months.

 She said she had great support from friends and family and never really felt lonely. However, this all stopped when she became ill, she said body image played a major role in her social isolation. She found it hard wearing wigs and felt her baldness drew negative attention to her. She found her stoma hard to manage and was on a special diet. Body image involves considerations of how women view and monitor their own bodies and the extent of anxiety and body shame experienced Rubenstein and Foster (2012 cited in Watson 2019d). Joan had to give up her job which she loved which was emotionally and financially difficult. The specialist nurse gave Joan support with her finances and information on support groups with people in a similar position as her.

The multidisciplinary team plays a crucial role in Joan’s care and due to her complex needs, there are a variety of different health professionals working together to provide vital person-centred care at a very critical stage of her life. The term ‘integrated working’ covers multidisciplinary teams and is used as shorthand for a range of ways in which workers are expected to cooperate (Rogers,2019). Health professionals are encouraged to work collaboratively and form partnerships to ensure seamless delivery of holistic care. To achieve this goal a person-centred process is required that encapsulates the desires and goals of the individual. Saylor (2004, cited by Watson, 2019c) believes holistic health offers a more rounded view of how the mind, body and spirit integrate. The WHO (2002) also incorporates holistic health in its definition of palliative care stating palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

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 Joan was in the care of the specialist palliative care team all who have had specific training in dealing with patients with life limiting illness. This specialist team worked alongside the GP and district nursing team to provide a continuity of care from hospice to the community. Joan was also in the care of the stoma nurse. The stoma nurse was able to educate and teach Joan how to manage her stoma and empowered her to manage it independently she also offered her emotional support helping her to cope with this difficult transition.  The National End of Life Strategy (DOH,2008) sets out key standards for patients receiving palliative care which include a holistic assessment and coordinated care, good communication and a detailed care plan. They also claim that high quality care should be available wherever the person may be at home, in a care home, in hospital, in a hospice or elsewhere. Joan had been in and out of hospice for pain management and help with managing her nausea.

As an impatient in hospice Joan was able to avail of counselling services as she was a young woman and her diagnosis and prognosis came as a big shock to her which had a major effect on her mental health. One in three people with cancer will experience a mental health problem such as depression and anxiety which usually occurs towards the end of treatment when the patient expects to recover Mental Health Foundation (2018). Joan also availed of the chaplaincy service in hospice and became very friendly with the priest who visited her. She disclosed to the specialist nurse that she would like him to be present at her final moments. Nice (2011) Stipulates that people approaching the end of life are offered spiritual and religious support appropriate to their individual needs and preferences. Spiritually may be described as a vital essence of our lives that often enables us to find new meaning and purpose which can foster hope Speck (2005). 

Nurses can help to improve patient’s quality of life by coordinating timely referrals to other health care professionals. Joan was referred to the palliative care dietician as she had a problem with nausea and vomiting which resulted in poor appetite and fatigue. She was put on a special diet and her medication was changed which helped her get some quality of life back. Effective teamwork between different professions and agencies may lead to improved quality of care and be more cost-effective Lake (2009 cited by Watson 2019. When Joan was discharged into the community the district nurse was able to look up Joan’s assessments and input using the Paris electronic system. This system assists health professionals by enabling shared patient notes and giving staff access to patients records. It is really beneficial for the district nurse with regards Joan’s care because each professional records case notes and updated assessments which helps the nurse plan accurate and safe care. The (NMC 2018) stipulates that good record keeping is one of the most important aspects of communication and enhances patient care. Good communication is crucial in caring for patients who are palliative as it creates trust and ensures the patient that they are being heard and listened to, encouraging them to take an active role in their own care and wishes.

The district nursing team helped build a good rapport with Joan as they visited her daily towards the last few months of her life. Joan disclosed personal and critical information about how she would like to spend her final days at home with her family. The nurse’s role is to act as the patients advocate ensuring Joan’s wishes were respected however Joan had limited family support and her daughter and husband did as much as they could to facilitate Joan’s needs. Families play an active role as they are the primary care givers and spend most of the time with their loved one Payne (2013).  It is important for the nurse to act in partnership with family guide them through all the information that is needed to understand care options. RCN (2015) suggest that a key challenge for all staff is knowing how and when to open a discussion with patients and families about what they wish for as they near the end of their lives.

Towards the last few weeks of Joan’s life she had a lot of pain and the district nurse had given Joan a lot of breakthrough medication. The family were finding Joan hard to manage so the nurse specialist thought it was best to refer Joan to hospice to review and assess her medication. In hospice Joan’s health deteriorated and it was agreed that she was nearing the terminal stage of her illness. In order to facilitate Joan’s wishes to die at home assessments were carried out by both the physiotherapist and Occupational therapist to assess what level of help Joan required at home and to make sure the relevant equipment was ordered and in place. These assessments were given to the social worker to organise a package of care for Joan when she came home as family were not able to manage on their own. Due to Joan’s home address being so rural it was extremely hard to source a package of care. This caused great frustration for family and everyone involved in Joan’s care as they were very aware that it was her final wishes. Unfortunately Joan died in hospice but she lived in hope of getting home before she went unconscious. She was however surrounded by her family and the priest who she wanted to be with her was present during her last days.

The multidisciplinary team played a key role in the coordination of Joan’s care and she received exceptional palliative care both in the community and as an inpatient in hospice. This approach provided Joan with complex symptom management and holistic care at a critical stage of her life. Joan’s family were also offered advice and support so they could make informed choices and decision towards Joan’s end of life care. Assessments were done quickly to make sure the proper equipment was in place and rapid referrals were made to social work to source carers. The hospice had also set up a palliative care support service for people who choose to die at home. The only negative issue was the fact that because of Joan’s rural address a care package could not be sourced and Joan’s final wishes to die at home could not be met.  Local trust policy promotes choice and offers support for patients who choose to be cared for and die at home.  Statistics from the DOH (2008) show that despite 74% of palliative patients expressing a preference to die at home only 20% achieve this. There is evidence that location can have an impact on discharge and length of stay in hospital – an end-of-life care ’postcode lottery’ (Venkataslu et al, 2015).

 The palliative care team worked tirelessly with the social worker to try and source a package of care but because of the severe shortage in carers especially in rural areas left a distressing effect for Joan’s family. The health and social care workforce are passionate and capable, but to tackle demand it needs numbers and a proper government-led conversation about long-term planning for the delivery of end-of-life care to address these issues Torley (2019). The multidisciplinary team faces many challenges but the most significant challenge they face at present is a growing demand for carers to facilitate hospital discharges and the patients desire to be cared for at home. High vacancy and turnover rates have a major impact on the continuity of care. Age UK (2018) Claim that a dysfunctional social care market, unable to provide care for the people who need it, will have a negative impact across all of society.

In conclusion Individuals that are living through the midlife stage of their lives face many challenges especially women who have to cope with the menopause and all other physical changes to their bodies. This in turn has a significant effect on the psychosocial aspect to their health as well. The case study I chose to reflect on provided me with greater knowledge about the life course stage and the effect the three perspectives had on her living with a terminal illness. It also highlighted the work of the multidisciplinary team and the challenges they face daily. It was very sad Joan’s final wishes were not met but the family were extremely grateful for the care Joan received. There are very serious issues with regards lack of carers which is having a harmful effect on all of society as continued staff shortages will mean more people at the end of their lives will receive insufficient care.

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