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Table 7.3 The DECIDE model
Process Action from
D Define the problem Firstly the ethical issue needs to be identified. Is the individual involved competent or incompetent? What are the patient’s rights? In this case the problem is the issue of withholding or withdrawing nutrition or hydration in a terminally ill individual
E Ethical review What principles are relevant to the case? Which principles should be given priority? Is the patient autonomous? Apply beneficence, nonmaleficence to uphold the best possible outcome for the patient.
Are the patient’s best interests the precedence?
C Consider the options What options are available? What is the alternative? What is the potential for beneficial outcomes for this patient? What is the potential for producing distressful side effects in this patient? Have the essential facts about the disease process and the likely outcome of the
proposed treatments been explained to the patient and family? What are the patient’s goals and values? What is the impact of the proposed treatment on the patient or family members?
I Investigate outcomes What are the consequences of the action? Which is the most ethical thing to do? What are the benefits and the burdens of the treatment?
D Decide on action Having decided on the best option available, establish a specific plan, act decisively and effectively
E Evaluate results Having withdrawn, withheld or initiated a course of action, monitor the results of the decision
Reproduced from Thompson, I.E., Melia, K.M., Boyd, K.M. (2003) Nursing Ethics, 4th edn, with kind permission of Elsevier.
healthcare are more complex than those concerning the decision to withhold or withdraw life- prolonging treatment. The difficulties pertaining to the decision of whether to withdraw or withhold artificial nutrition or hydration in patients approaching the end of life are influenced by the patient and their family, together with the ethical and moral values of the healthcare professionals involved. The benefits and burdens of artificial nutrition and hydration ought to be evaluated in terms of short-term and long-term goals, and further ethical deliberation may be required depending on the outcome of these goals.
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Conclusion
End of life care is complex. Death can be a long protracted process that requires a comprehensive range of knowledge, skills and competencies that can address the needs of the dying person and their family members. Understanding the nature of the dying process as presented from a theoretical perspective can assist nurses and care-givers to initiate effective caring interventions so that the quality of life of those patients can be enhanced, particularly as the dying process progresses to ultimate death. The most common symptoms that present at the end of life include dyspnoea, a death rattle and pain. The multidisciplinary team may potentially initiate appropriate interventions so as to facilitate a good death for the dying person.
Communication with the dying person can cause much concern for healthcare professionals, but the use of a sensitive approach can enhance the healthcare professional’s skills in addressing sensi - tive issues. Families experience a range of emotions as they witness their family member dying. The
‘transition of fading away’ framework provides a comprehensive approach to addressing these con- cerns. It is not uncommon for family members to express concern with regard to the withdrawal of nutrition and hydration at end of life; using an ethical decision-making framework can assist members of the multidisciplinary team to address this ethical dilemma.
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References
Bausewein, C., Farquhar, M., Booth, S., Gysels, M. & Higginson, I. (2007) Measurement of breathless in advanced disease: a systematic review. Respiratory Medicine, 101:399–410.
Becker, R. (2010) Fundamental Aspects of Palliative Care Nursing, 2nd edn. London: Quay Books.
Bennett, M,. Lucas, V., Brennan, M., Hughes, A., O’Donnell, V. & Wee, B. (2002) Using anti-muscarine drugs in the management of death rattle: evidence based guidelines for palliative care. Palliative Medicine, 16:369–74.
Botes, A. (2000) A comparison between the ethics of justice and the ethics of care. Journal of Advanced Nursing, 32(5):1071–5.
Buckman, R. (1992) How To Break Bad News: A Guide for Health Care Professionals. Toronto: University of Toronto Press.
Chan, K., Tse, D., Sham, M. and Thorsen, A. & Thorsen, A. (2005) Palliative medicine in malignant respiratory diseases.
In: Doyle, D., Hanks, G., Cherny, N. & Calman, K. (eds), Oxford Textbook of Palliative Medicine (pp. 587–618).
Oxford: Oxford University Press.
Clayton, J., Butow, P. & Tattersall, M. (2009) Telling the truth. In: Walsh, D. (ed.), Palliative Medicine (pp. 620–4).
Philadelphia: Saunders Elsevier.
Copp, G. (1999) Facing Impending Death: Experiences of Patients and their Nurses. London: Nursing Times Books.
Corner, J. & O’Driscoll, M. (1999) Development of a breathlessness assessment guide for use in palliative care. Pallia- tive Medicine, 13:375–84.
Craig, G. (2008) Palliative care in overdrive: patients in danger. American Journal of Hospice and Palliative Medicine, 25(2):155–60.
102
Daly, B.J. (2000) Special challenges of withholding artificial nutrition and hydration. Journal of Gerontological Nursing, 26(9):25–31.
Davies, B. & Steele, R. (2010) Supporting families in palliative care. In: Ferrell, B. & Coyle, N. (eds), Oxford Textbook of Palliative Nursing (pp. 587–618). Oxford: Oxford University Press.
Dudgeon, D., Kristjanson, L., Sloan, J., Lertzman, M. & Clement, K. (2001) Dyspnoea in cancer patients: prevalence and associated factors. Journal of Pain and Symptom Management, 21(2):95–102.
Dunlop, R.J., Ellershaw, J.E., Baines, J.M., Sykes, N. & Saunders, C.M. (1995) On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far? A reply. Journal of Medical Ethics, 21(3):141–3.
Farrelly. M. (2009) Families in distress. In: Walsh, D. (ed.), Palliative Medicine (pp. 63–9). Philadelphia: Saunders Elsevier.
Gilbert (2006) The last days of life. In: Cooper, J. (ed.), Stepping into Palliative Care: Care and Practice (pp. 148–56).
Milton Keynes: Radcliffe Medical Press.
Glare, P., Dickman, A. & Goodman, M. (2011) Symptom control in care of the dying. In: Ellershaw, J. & Wilkinson, S.
(eds), Care of the Dying: A Pathway to Excellence (pp. 33–61). Oxford: Oxford University Press.
Glaser, B. & Strauss, A. (1965) Awareness of Dying. Chicago: Aldine.
Heaven, C. & Maguire, P. (2003). Communication issues. In: Lloyd-Williams, M. (ed.), Psychosocial Issues in Palliative Care (pp. 21–47). Oxford: Oxford University Press.
Hughes, A., Wilcock, A. & Corcoran, R. (1996) Management of death rattle. Journal of Pain and Symptom Manage- ment, 12(5):271–2.
Kass, R. & Ellershaw, J. (2003) Respiratory tract secretions n the dying patient: a retrospective study. Journal of Pain and Symptom Management, 26:897–902.
Kedziera, P. & Coyle, N. (2006). Hydration, thirst and nutrition. In: Ferrell, B. & Coyle, N. (eds), Textbook of Palliative Nursing (pp. 239–48). Oxford: Oxford University Press.
Kinder, C. & Ellershaw, J. &. (2011) How to use the Liverpool Care Pathway for the Dying Patient (LCP). In Ellershaw, J. & Wilkinson, S. (eds), Care of the Dying: A Pathway to Excellence (pp. 11–41). Oxford: Oxford University Press.
Korner, U., Bondolfi, A., Buhler, E. et al. Ethical and legal aspects of enteral nutrition. Clinical Nutrition, 25:196–202.
Kravits, K. & Berenson, S. (2010) Complementary and alternative therapies and palliative care. In: Ferrell, B. & Coyle, N. (eds), Oxford Textbook of Palliative Nursing (pp. 545–65). Oxford: Oxford University Press.
Kristjanson, L., Hudson, P. & Oldhan. L. (2003) Working with families in palliative care. In: O’Connor, M. & Aranda, S. (eds), Palliative Care Nursing: A Guide to Practice (pp. 271–83) Milton Keynes: Radcliffe Medical Press.
Kübler-Ross, E. (1969) On Death and Dying. New York: Macmillan.
Lawrey, H. (2005) Hyoscine vs glycopyrronium for drying respiratory secretions in dying patients. British Journal of Community Nursing, 10(9);421–6.
Maillet, J.O., Potter, R.L. & Heller, L. (2002) Position of the American Dietetic Association: Ethical and legal issues in nutrition, hydration and feeding. Journal of the American Dietetic Association, 102(5):716–25.
Mak, J.M.H. & Clinton, M. (1999) Promoting a good death: an agenda for outcomes research – a review of the litera- ture. Nursing Ethics, 6(2):97–105.
Mathes, M.M. (2001) Withholding and withdrawing nutrition and hydration by medical means: ethical perspectives.
Medsurg Nursing, 10(2):96–9.
Muller-Busch, H. & Jehser, T. (2009) Death rattle. In: Walsh, D. (ed.), Palliative Medicine (pp. 956–60). Philadelphia:
Saunders Elsevier.
O’Brien, T., McQuillan, R., Tighe, P. & Smullen, H. (2001) Artificial Hydration in Terminally Ill Patients. A Position Paper by the Irish Association for Palliative Care. Dublin: Irish Association for Palliative Care.
Pollard, A., Cairns, J. & Rosenthal, M. (2002) Transition in living and dying: defining palliative care. In: Aranda, S. &
O’Connor, M. (eds), Palliative Care Nursing: A Guide to Practice (pp. 5–20). Melbourne: Ausmed Publications.
Slevin, O. (2006) The experience of illness. In: Cooper, J. (ed.), Stepping into Palliative Care: Relationships and Responses (pp. 45–57). Abingdon: Radcliffe Medical Press.
Smith, S.A. & Andrews, M. (2000) Artificial nutrition and hydration at the end of life. Medsurg Nursing, 9(5):233–42.
Thompson, I.E., Melia, K.M. & Boyd, K.M. (2003) Nursing Ethics, 4th edn. Edinburgh: Churchill Livingstone.
Twycross, R. & Wilcock, A. (2009). Symptom Management in Advanced Cancer. Oxford: Radcliffe Medical Press.
Wade, R., Booth, S. & Wilcock, A. (2005) The management of respiratory symptoms. In: Faull, C., Carter, Y. & Daniels, L. (eds.), Handbook of Palliative Care (pp. 160–83). Oxford: Blackwell Publishing.
Watson, M., Lucas, C., Hoy. A. & Back, I. (2006) Oxford Handbook of Palliative Care. Oxford University Press: Oxford.
Wells, N. (2000) Pain intensity and pain interference in hospitalised patients with cancer. Oncology Nursing Forum, 27:985–91.
103
Wilders, H. & Menten, J. (2002) Death rattle: prevalence, prevention and treatment. Journal of Pain and Symptom Management, 23:310–17.
Wilders, H., Dhaenekint, P., Clement, P. et al. (2009) Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. Journal of Pain and Symptom Management, 38(1):124–33.
Woodroof, R. (2004). Palliative Medicine: Evidence-based Symptomatic and Supportive Care for Patients with Advanced Care. Oxford: Oxford University Press.
World Health Organization (1986) Cancer Pain Relief. Geneva: WHO.
Principles of
perioperative nursing
Joy O’Neill, Bernie Pennington and Adele Nightingale
Faculty of Health, Edge Hill University, Manchester, UK
8
Contents
Introduction 105
General issues and anaesthesia 105
Patient safety 107
Anaesthesia 108
Roles of circulating and scrub practitioners 113 Aseptic technique/infection control 113
Accountability 114
Patient positioning 115
Surgical sutures 116
Surgical needles 116
Surgical dressings 116
Surgical drains 116
Surgical instruments 116
Surgical specialities 117
Recovery 117
Postoperative nausea and vomiting 121
Pain management 121
Conclusion 122
References 123
Having read this chapter, you will be able to:
•
Gain a broad understanding of the knowledge underpinning the skills of a perioperative practitioner•
Demonstrate an understanding of the care delivered to patients in the perioperative environment•
Understand the role of risk management within perioperative careLearning outcomes
Fundamentals of Medical-Surgical Nursing: A Systems Approach, First Edition. Edited by Anne-Marie Brady, Catherine McCabe, and Margaret McCann.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
105
Introduction
This chapter on perioperative care has been written for student healthcare professionals who may or may not experience a perioperative placement within their training. It provides basic information regarding the role of the theatre practitioner spanning three areas of perioperative practice (anaesthet- ics, scrub and recovery) and the delivery of effective patient care. The role of a perioperative practi- tioner (nurse or operating department practitioner) is multifaceted as it encapsulates clinical care, advocacy, risk management and quality assurance. Maintaining a safe perioperative environment ensures that patients are provided with competent and high-quality care.