Nursing Roles in the End-of-Life Decision Making
Todays health care profession is progressively extending services to better serve the community and the people. Nursing as a profession that’s delivering primary health care to individuals, families, and the communities with compassion and respect for the patients. There are various areas of healthcare delivery where nurses can deliver care to patient and the families that includes providing palliative care. Palliative care means that identifying early the needs of patient and family, so they can live with dignity and higher quality in the end-of-life process; the nurse will assist them during the death process. The nurses’ roles in palliative care is complex and unique. The nurse functions as an integral part of a multidisciplinary team, providing evidence-based practice assessment and nursing care, supporting the patient and the family by encouraging patient to make decisions about their care towards the end of life.
Nursing Role as Information Broker
The nurse plays an important role in facilitating communication between family members and between family members and the health care team. The nurse roles include, “giving information to the physician, to family members as a mediator” (Luce, 2014). As stated in the journal article of Luce (2014), found that nurses were described as “information brokers” (pp.1), in which the nurse relay information about the patients and families to physicians (Luce, 2014). As described in a study of Nursing Research and Practice (2013) nurse as “nodal points for exchange of information” where nurses obtaining information from many sources and incorporate that source and use it to create a comprehensive assessment. The nurse is enacting the role by providing team members with information about the patient’s “clinical status, patient and family’s emotional and psychological state, and families expressed wishes” (Adams et al., 2013, para-11). The study demonstrated that nurses are an important source of information to help physician in deciding for the end-of-life of a patient.
The nurse takes a huge responsibility when giving information to family members about the patient’s condition and diagnosis. It is vital for the nurse to translate medical information in a simple form as possible when explaining education and clarifying meanings of terms such as DNR. When the nurse used “technical information without analyzing and interpreting the meaning of the information, can promote family’s false hope” Adams et al., 2013, para-5). As for example, as described in Nursing Research and Practice (2013), a family member shared that nurse relays information that patient has intracranial pressure (ICP) and had come down, family member was delighted with the hope that the patient was getting better. But, the truth was that patient condition was declining where ICP reading was significant to the prognosis (Adams et al., 2013, para-12). This study conducted based on family members experience where the nurse delivered a vague report in providing correct details and not information about prognosis.
So, the roles of nurses in end-of-life situation, as Adams (2013) cited in his research that nurses enact the role of “information broker by bringing people together to exchange information directly and facilitating communication among family members as well as between the family and the team” (Adams et al., 2013, para-13). Furthermore, the nurse job is to facilitates family meetings where the nurse will act as a third party. As per family wishes, the nurse “may also request other disciplines such as chaplains, or social workers to meditate the end-of-life discussion or request a physician to speak to family member for questions that only a physician can provide” Adams et al., 2013, para-13. As described in a research mentioned above that there is a strong evidence that nurses play an integral part in mediating information among family members and the health care team in facilitating communication about end-of-life decision making.
Nursing Role as Supporter, Building Trust, and Empathy
The nurse also acts as the supporter in the end-of-life care by building trusting relationships with the family members as they go through decision-making process and by demonstrating empathy for patient and family members. One of the nurses’ role as a health care provider is to provide support to families by taking time to develop trusting relationship. Establishing rapport with patient and family is very important in providing patient care. In the same study described by Adams (2013) nurses who allowed family members to “take part in daily care and important rituals is way of supporting the family and finding out what is important to them” (Adams et al., 2013, para-14). This is a method of helping family to maintain a sense of hope, accepting family’s decision as they prepare for the death to come. The nurse main responsibility is supporting family during end-of-life process through empathy, the understanding of what the family has been through during difficult times. Being present, taking time to listen and allowing family to process and acknowledging feelings is the best method of showing support. According to a researched by Silveira (2016) that nurses enact the role of supporter in many strategies to build trust and demonstrate empathy during end of life period and the family members value this support” (Silveria et al., 2016, para-11). However, study results described that there’s lack of evidence of whether family members find this support as helpful in the decision-making process.
Nursing roles as Advocate, Advocate to Family, and Physician,
One of the most important roles of nurses is a patient advocate where nurses will speak to healthcare care team on behalf of the patient or family and to communicate to the family on behalf of the patient. The nurse action helps the patient to expressed patient wants for effective treatment plan, in which steers the medical team decision for patient preferred care. In the study by Schwartz (2013) an evidence suggest that patient requires support to ensure their expressed needs are taken seriously and their interest promoted (Schwartz, 2014, para.3). Schwartz (2013) explained in his study that patient “may need extra support to express and secure their own choices for treatment, especially where the patient’s choice may seem bizarre or not preferred by the clinical staff” (Schwartz, 2013, para.10). The nurse clarifies the issue and keep patient informed and to ensure that the patient wishes are heard. Other reasons that patient need advocacy, is when patient is frightened, vulnerable or incompetent. Since, the nurse has more knowledge on the patient’s needs, the nurse will advocate and properly represent the issue to the health care team (Schwartz, 2013, para.12). The study by Schwartz (2013) shows that great nurse described “taking very assertive role in the end of life decision making process with families” (Schwartz, 2013, para.12). For instance, in one scenario presented in a research study where the nurse explained to patient family that the ventilator was not helping to patient COPD to breathe easier. With that, patient family member approved to stop the ventilator, so will die peacefully. In this situation, the nurse facilitated decision making by illustrating a realistic picture of possible outcome cuing the family to make decisions and helping them to accept the end of (Adams et al., 2013, para-23).
The research illustrated quantitative data for nurse enacting advocate role in end of life. In a study by Adams (2013), found that “53% nurses advocated for their patients, whereas other studies found that 78% of nurses in ICU were actively involved in end of life decision making, and 42%-54% active nurses discussed end of life decisions with the patient or family” (Adams et al., 2013, para-52). It was also reported that 81% of nurses involved in DNR orders based on the ICU and oncology study. In a study about nurses’ “attitudes in end of life, the decision shows 95%; and 98% believe that nurses respect patient’s wishes, 98% of nurses talking to physician if a patient wishes are violated, and 96% nurse help inform patient or family of the condition and treatment options” (Adams et al., 2013, para-29). Also, the study shows result that “98% of nurse counseled the patient and family about advance directives and 85% initiated the discussion of advance directive” (Adams et al., 2013, para-29).
In the final analysis, evidence shows the importance of the roles of nurses in the end-of-life process to patient, family and physicians. The nurse plays an important role in sending and informing messages between patient, family members and the physician to ensure messages are being communicated. Also, the nurse must show support to the patient and family’s decision as well as showing an empathy to patient and family members and building rapport with patient. Study shows that the nurse has responsibility in promoting patient care preferred by family members.
Nursing Roles in the End-of-Life Decision Making