Reflective practice enables nurses to critically review their actions through a process of thoughtful deliberation about past experiences, in order to learn from them (Tickle 1994; Atkins and Murphy 1995; Bailey 1995; Spalding 1998). Reflection is important since it provides opportunities for learning and continuing professional development (Hinchliff et al. 1993; Spalding 1998). Furthermore, it allows the nurse to better handle future situations and deal more ably with challenging events in everyday clinical practice (Jarvis 1992; Smith 1995). A number of models of reflection have been developed. Gibbs cycle considers the process of reflection as six key stages: (1) description of the event, (2) feelings, (3) evaluation, (4) analysis, (5) conclusion and (6) development of an action plan (Gibbs 1988). In this paper, Gibbs cycle will be used to reflect on an clinical incident that I have experienced which focuses on communication in palliative care and specifically, breaking bad news to a patient and his family.
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Palliative care is the care of any patient with advanced, incurable disease (Urie et al. 2000). Palliative care involves the management of pain and other disease-related symptoms, and aims to improve quality of life using a holistic approach that incorporates physical, psychological, social and spiritual aspects of care (Urie et al. 2000). Effective communication between nurses and other healthcare professionals, patients, and their families and carers forms a key component of palliative care, particularly when breaking bad news. Research has shown that healthcare professionals cite a number of challenges in communicating effectively, including cultural factors, deciding on the best process of communication and information to deliver, and the difficulty of conveying hope to patients and their carers (de Haes and Teunissen 2005).
The NHS Cancer Plan published in 2000 states that: “the care of all dying patients must improve to the level of the best”, with good communication between healthcare professionals and patients as central to achieving this goal (Department of Health 2000). The Gold Standards Framework (GSF) is a framework designed to ensure a gold standard of care is provided for all patients who are nearing the end of their lives (NHS 2005). There are three stages in this framework: (1) identify, (2) assess and (3) plan, with effective communication a key goal underpinning each of these stages. National Institute for Health and Clinical Excellence (NICE) guidelines on improving supportive and palliative care for adults also stresses the value of good face-to-face communication both between healthcare professionals and patients and also inter-professional communication (NICE 2003). This guidance supports the use of the Liverpool Care for the Dying Patient Pathway (2004) which provides a framework for improving communication. It is therefore important that nurses develop the required skills to enable them to communicate effectively with patients and carers, and also with other healthcare professionals within the multidisciplinary care team.
Reflection using Gibbs cycle
(1) Description of the event
Mr Smith is a 39 year old father and company director who discovered a testicular swelling. He chose to ignore this, initially because he misinterpreted it as a sports injury, and later because he felt embarrassed about discussing this with a doctor. Nine months later he presented to the emergency admissions unit as he was becoming breathless far more readily than usual, and suffered a constant backache. These symptoms were found to be due to lung metastases and referred pain caused by metastases in the para-aortic lymph nodes. His prognosis was poor and his family were called so that they could be there when he received the diagnosis to help support him. The consultant delivered the news to Mr Smith and his family in a quiet room, with both myself and another staff nurse present. Understandably, both Mr Smith and his family were devastated.
This case has had a huge impact on me. As this was the first time I had attended a case where bad news of this nature had to be broken to the patient and their family, I was naturally apprehensive prior to the event. On seeing the reactions of Mr Smith and his wife to the news, I was unprepared for the strength of my own emotions and found it hard not to cry. Initially, I felt helpless and unable to do anything to help relieve their suffering. I also felt awkward and as if I was intruding at a time when they should be allowed to grieve together privately. However, these feelings quickly passed and were replaced by a desire to do my best to make Mr Smith’s end-of-life care the best possible and provide as much support to both the patient and his family as I could.
The consultant broke the news to Mr Smith and his family very well and was able to draw on his considerable experience to handle the situation in a professional manner while showing empathy and sensitivity. The choice of a quiet room rather than an open hospital ward provided an ideal environment which afforded Mr Smith privacy to receive the news. The consultant primarily focused on verbal methods to communicate effectively, but also used non-verbal methods, such as sitting down on their level, rather than standing while they sat down; maintaining eye contact with both Mr and Mrs Smith throughout the conversation; using open body language (e.g. not crossing his arms); and using a soft tone of voice. The consultant did not rush in breaking the news and took time to explain Mr Smith’s diagnosis and prognosis, ensuring that what he was saying was understood and providing clarification where necessary. He was also careful not to give unrealistic answers to any difficult questions that were asked and was as optimistic as possible, while still being open and honest. While the consultant was speaking, the other staff nurse observed the reactions of Mr Smith and his family closely to pick up on non-verbal clues to their thoughts and feelings and was quick to step in to place an arm around the shoulders of Mrs Smith when she began to cry which was clearly of great comfort to her. The only negative aspect of the incident was that I felt that having two staff nurses as well as the consultant present was excessive and initially unsettled the family, serving to emphasise the gravity of the situation.
As this was the first time I had been involved in a case like this, my role was largely one of observer. Nonetheless, this was still an excellent learning experience and provided me with the opportunity to develop my verbal and non-verbal communication skills through observation. On reflection, I feel that I could have kept my emotions more under control, but I was unprepared for the strength of Mr and Mrs Smith’s response to the news. The consultant played the key role with support from the other staff nurse, both of whom have considerable experience in palliative care. It was clear that hey had already gained the trust of Mr Smith during previous consultations. Trust has been identified as a major factor in establishing successful relationships between healthcare professionals, patients and carers (de Haes and Teunissen 2005), and this enabled more effective, open and honest communication.
In palliative care, it is important to relate to the patient on a personal as well as a professional level (Lugton and Kindlen 1999). There should be consistency between verbal and non-verbal communication in order for the healthcare professional to be perceived as genuine (Benjamin 1981). Evidence has shown non-verbal methods of communication to be more powerful than verbal methods (Henley 1973), with listening and eye contact among the most effective forms of non-verbal communication. Touch has also been identified as an important for nurses in certain situations. The consultant relied mainly on verbal communication which may reflect gender-specific differences in communication with men using verbal forms more frequently and women tending to rely more on non-verbal communication methods (Lugton and Kindlen 1999). Observing the other staff nurse readily use touch to comfort Mrs Smith helped the rest of the family to relax and lessened the tension in the room slightly, also breaking down the ‘barrier’ between the healthcare professionals and the patient/family. I observed that the family appeared to view the nurse as a comforter and more approachable than the consultant, a view that continued throughout Mr Smith’s end-of-life care.
Although not relevant to this particular case, it is important to acknowledge that effective communication between members of the multidisciplinary palliative care team is also essential. This can be challenging if, for example, team members have differing philosophies of care. One of the key recommendations of the NICE guidelines on palliative care is the implementation of processes to ensure effective inter-personal communication within multidisciplinary teams and other care providers (NICE 2003). During Mr Smith’s end-of-life care, I had to work closely with other members of the care team and there were instances where it was important for me to consider the perspectives of other team members in order to communicate effectively with them. Regular team meetings were beneficial in creating a forum where difficulties could be discussed and solutions to problems found.
Reactions to receiving bad news in palliative care
After breaking bad news to a patient, healthcare professionals may have to be prepared to deal with a variety of reactions including denial and collusion, and emotional reactions such as anger, guilt and blame. Denial is often a coping mechanism for patients who are unable to face the fact they have a terminal illness but patients will often begin to face reality as their disease progresses over time (Faulkner 1998). Family members and carers may encourage the patient to stay in denial, as this will delay the time when difficult issues have to be faced and discussed. Collusion between healthcare professionals and families/carers to withhold information from the patient is usually viewed as a way to try and protect the patient (Faulkner 1998). However, honest and open discussion with the patient themselves establishes their level of knowledge and understanding and can help to reassure them about their condition and accept reality.
Patients and their families and carers often show strong emotional reactions to bad news. Anger may sometimes be misdirected towards the healthcare professional as the bearer of this news, and it is important that the cause of the anger is identified and addressed. Patients may feel guilt, and that they are somehow being punished for something they have done wrong. Alternatively, the patient may serve to blame their condition on other people. While healthcare professionals are unable to take away these feelings of guilt and blame, ensuring the patient has the chance to talk them through and discuss relevant issues can help them come to terms with these feelings. Mr Smith’s reaction to the news was one of self-blame and guilt – he blamed himself for not visiting a doctor earlier and felt guilty that he was putting his family through so much. He appeared to accept his poor prognosis and asked a number of questions which demonstrated a full understanding of his situation.
Spiritual and cultural beliefs can influence an individual’s experience of illness and the concerns of both patients and their families or carers may need to be addressed either at the time bad news is broken or at a later stage during end-of-life care when individuals are facing death (Matzo et al. 2005). Incorporating spiritual care into nursing is therefore particularly important in palliative care; however, since neither Mr Smith or his family were particularly religious, this was not a key issue in this incident or in his subsequent care.
Control of cancer-related symptoms in palliative care
Patients with advanced cancer are typically polysymptomatic (Grond et al 1994). Common symptoms include pain, fatigue, weakness, anorexia, weight loss, constipation, breathlessness and depression. Effective control of these symptoms is essential for optimal quality of life during end-of-life care. As previously discussed, one of the main processes in the GSF framework involves assessing patients symptoms and planning care centred around these, to ensure that these symptoms are controlled as much as possible (NHS 2005).
Three symptoms that required effective management as part of Mr Smith’s care plan were pain, breathlessness and depression. One of Mr Smith’s greatest concerns was that he would suffer considerable pain during the advanced stages of his cancer. This is a common fear held by many cancer patients. Pain is a symptom experienced by up to 70% of cancer patients (Donnelly and Walsh 1995; Vainio and Auvunen 1996). Pain may result from the cancer itself, treatment, debility or unrelated pathologies, and accurate diagnosis of the cause(s) of pain is therefore important. The World Health Organisation (WHO) ‘analgesic ladder’ (WHO 1996) provides a system for managing cancer pain and has been shown to achieve pain relief in almost 90% of patients (Zech et al. 1995; WHO 1996).
Pharmacological interventions for pain management include the use of non-opioids such as paracetamol, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDS) for the control of mild pain. In Europe, oral morphine is the dug of choice for the control of moderate to severe cancer pain, but weak or strong opioids may also be used, either with or without non-opioids. Correct dosing of opioids and effective management of common side effects (e.g. constipation) are essential (Walsh 2000), and adjuvant treatment for specific pain may also be required. Non-pharmacological interventions include the provision of emotional and spiritual support, helping the patient to develop coping strategies, use of relaxation techniques, acupuncture or the use of a transcutaneous electrical nerve stimulator (TENS). Evidence from a meta-analysis of randomised controlled trials assessing nursing non-pharmacological interventions demonstrated these interventions to be effective for pain management but some trials showed minimal differences between the treatment and control groups (Sindhu 1996).
Breathlessness is a common symptom among cancer patients which can be difficult to control and may cause considerable distress to both patients and their carers (Davis 1997; Vora 2004). Appropriate management frequently requires both pharmacological and non-pharmacological interventions (Bausewein et al. 2008). Pharmacological interventions include the use of bronchodilators, benzodiazepines, opioids, corticosteroids and oxygen therapy (Vora 2004). Non-pharmacological interventions which have been shown to be effective include counselling and support, either alone or in combination with relaxation-breathing training, relaxation and psychotherapy (Bausewein et al. 2008). There is limited evidence that acupuncture or acupressure are effective.
Both anxiety and depression are common among patients with advanced cancer but both of these conditions are frequently under diagnosed (Barraclough 1997). Furthermore, these conditions are sometimes viewed as simply natural reactions to the patient’s illness. Pharmacological interventions such as antidepressants should be used if the patient show symptoms of a definite depressive disorder. Non-pharmacological interventions include relaxation, psychosocial therapies and massage (Lander et al. 2000). Optimal management of depression in patients with advanced cancer typically involves a combination of both pharmacological and non-pharmacological approaches (Lander et al. 2000).
Ethical and legal considerations in palliative care
There are a number of ethical and legal considerations in palliative care such as euthanasia and the right to withhold or withdraw life sustaining treatment. Those aspects which were of importance in this account address the patient’s right to know their diagnosis (i.e. autonomy). Evidence shows that the majority of cancer patients wish to know their diagnosis and the likely progression of their disease (Faulkner 1998). This may present a challenge for clinicians and nurses who may wish to try to protect the patient and convey an optimistic outlook even when the prognosis is poor. In the case of Mr Smith, he wanted to know as much information as possible about his diagnosis and treatment and the consultant and nurse answered his questions as openly and honestly as possible.
Reflective practice is important both as a learning process and for the continuing professional development of nurses. The use of a model such as Gibbs’s cycle enables the nurse to move logically through the reflective process and provides a structured approach. Effective communication is essential in palliative care. Nurses and other healthcare professionals must be able to communicate effectively both with patients and their families/carers but also with other members of the multidisciplinary care team. The nurse plays a key role in the provision of supportive and palliative care and must develop excellent verbal and non-verbal communication skills. Breaking bad news such as that given to Mr Smith is one of the hardest tasks for healthcare professionals, regardless of their level of experience, and it is essential that the situation is handled professionally, but also with empathy and sensitivity, taking full account of the ethical and legal aspects of the situation. The use of non-verbal communication by the nurse is as important as verbal methods of communication.
(6) Action plan
This incident provided me with a valuable learning opportunity and were I to encounter a similar situation in the future, I would feel much better prepared to deal with this. I have learnt that preparation is important, for example, selecting a suitable environment in which to break the news, and ensuring that chairs are placed correctly within the room. Rather than relying primarily on verbal communication, I would be more aware of the effectiveness of non-verbal methods, particularly touch, if this was appropriate. I have also developed a greater awareness of the ethical issues surrounding breaking bad news in palliative care, and the need to be open and honest with the patient and their family where possible.
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