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Cure versus care

Debbie Borron

Enrolled Nurse, 4 North, Sacred Heart Hospice

http://www.clininfo.health.nsw.gov.au/

ABSTRACT

The Sacred Heart Hospice is a centre of excellence in palliative care. I have been working there as an enrolled nurse for nearly 10 years. Our multidisciplinary team (MDT, meaning all members of staff who provide care to our patients) approach is of excellent quality and we pride ourselves on involving all members of our MDT equally. As enrolled nurses we are valued members of the MDT and as such I found myself presenting this paper to enrolled nurses at an enrolled nurses professional day last year.

The topic for that day was Idealism vs Realism. This topic in a palliative care setting was, I thought perfect, but only having 10 minutes to present what I do as an enrolled nurse was going to be hard. 1 decided to concentrate on a few well known symptoms and situations that enrolled nurses have to deal with at the Hospice.

Cure Versus Care

The Sacred Heart Hospice is a 73 bed purpose built palliative care facility, consisting of two 25 bed units, a 21 bed independent living suite and two beds in the Day Centre. The ratio of enrolled nurses to registered nurses is about 50:50 so our presence is very noticeable and we are very valued members of the MDT.

Each day our shift starts with a handover and allocation of patients. This is done by the registered nurse in charge of that shift, but often it is up to the individual nurse to request the patients they would like as the nurses prefer continuity of care to enable them to build up trust and friendships with patients and families. This is also to enable follow through with interventions the nurses may have instigated and would like to monitor.

At the Hospice we are lucky that we are able to have a good patient/nurse ratio. This is very important because all nurses at the Hospice are responsible for the total care of their patients.

The term 'Quality of Life' is often heard... and said at the Hospice to remind us of our main aim and purpose. As most of our patients have been diagnosed with a terminal disease, further treatment is often inappropriate and cure is not always an option. Symptom control accounts for many admissions, as does radiotherapy as a form of symptom control.

As CURE is not always an option, CARE is our main focus, and 'Quality of Life' is the ultimate goal.

When a patient is admitted to the Hospice, in a sense we admit the whole family, as often the emotional pain of relatives and loved ones is a major consideration in the treatment of the person being admitted. Our MDT approach means that the patient, family and others will be helped through this very difficult time.

The enrolled nurses role in the 'Big Picture' is very significant. Identifying and acting on problems associated with our patients is as much our responsibility as any other person in the MDT. As nurses. we are taught throughout our training and following years as registeredlenrolled nurses that cure is the ultimate goal. It is often hard to switch this focus off, but switch it off you must when considering the comfort of a palliative patient.

When looking at symptom control our aim is to relieve, not necessarily cure. When we look at pain, it can sometimes be relieved by increasing the patient's analgesia. Often this is a temporary measure as their pain may not be wholly physical - it could be emotional. We therefore have to be sure that increasing analgesia is the right option. We talk to the patients, we try to find out if there are any other problems worrying them. And as we all know - a change of position or hot pack may also help to relieve pain! If it is emotional because of physically not being able to tidy up loose ends, or not having made a Will etc,. the social worker is called upon. If it is more spiritual, pastoral care is called in. By using the MM all our patients needs are met by the most qualified members of our team - so I guess at times we do cure to a degree.

Bowels are another major cause for concern to our patients as most are on high and prolonged doses of morphine or the like. And we all know the side affects of that situation. We at the Hospice pride ourselves on our expertise in this area and have formulated a pretty much fool proof system to take care of this problem with very thorough documentation, follow up interventions and recording. This responsibility is as much the enrolled nurses as it is the registered nurses, and is mighty rewarding when success is achieved. So, yes Cure, you could say, has been achieved.

Wound management or prevention is another ongoing and difficult symptom for our patients, as most are in very debilitated states that we know are not going to improve. So when looking at a patient's wound, what is our aim? Is it cure or care?

Often we will start by taking the cure option, especially if the skin breakdown is in its early stages and we can call in the physios and their 'magic machine' that helps strengthen the skin by stimulating cell growth to the area being treated.

We have other options also - we have Spancos on all beds and if required, Roho mattresses and Therakair beds are available. These beds are fantastic! I have seen a patient lay on their back for more than 3 months without a pressure mark! Every bed should have one (but I guess the lack of money in health prevents this little luxury). So while we strive to prevent, even with all these options, the decreased mobility due to their disease, pain and other symptoms, it is always an uphill battle and cure is not always a viable option.

We do however, treat with all the latest dressing techniques on hand, and have had some successes, but for many of our patients, at some time, we as nurses have to sit back and assess the situation to see if the patient's 'Quality of Life' is our focus, or are our many years of being programmed to heal is what we are actually doing. This is often a hard decision for us, but nevertheless, with the MDT approach we can come to a decision and act, this is often by still treating the wound. A daily or twice daily dressing for example, may often cause more discomfort and pain to our patients than the actual wound does, therefore, a decision is made to optimise the comfort of the patient. This may mean if the wound is able to be dressed say PRN or 3rd daily, this is what we will do, reducing unnecessary wear and tear on already fragile skin. So what have we achieved? Not a cure as this is usually not an option. We have however managed care and comfort with our focus being our patient's 'Quality of Life'.

Nausea is another major symptom control problem as it is often caused by many factors, often like a 'merry-go-round' - one causes another that causes another and so it goes. Nausea may be caused by constipation, the disease process or medication etc, so if one symptom is eliminated it often relieves another. On many occasions this is the case with nausea. So often a cure is reached, but by the same token if it is not, we have to look at 'Quality of Life' by reducing the symptoms. So in this case, care and comfort is achieved.

The patient's family and others play a major role in the comfort of our patients. If they have difficulty dealing with the impending death of a loved one, this can cause extra stain on the patients themselves. So being able to identify this is very important, and knowing the appropriate person to call is a must. As. an enrolled nurse, this is also our responsibility and you are often asked some very tough questions by patients and their loved ones. Being able to answer them is essential. I often offer a shoulder to cry on, a cuddle or kiss and find this is a way of breaking the ice and gaining loved ones trust.

Often the question is asked, "How long does he/she have?" I guess we have all been asked that question, and are often waiting for those little words to be uttered, knowing we have no answer. Being able to talk openly about their loved one's 'quality of life' helps - how comfortable they are or look, that they seem to be painfree and that when it is time we will know, and that at this stage it is really up to the patients themselves as to how long they have. This often helps loved ones come to terms with this terrible waiting game.

Other ways of helping loved ones cope, is by suggesting they bring in special possessions of the patients. Reading the paper out loud or a book can help whileaway some time. Also, playing music that the patients like helps both patients and their relatives relax. Giving the patient's loved ones the option to help you with the daily care of the patient by letting them help you wash them or suggest they maintain mouth care also helps the patient's loved ones feel useful at a time when all else seems fruitless. So care and comfort has been achieved as cure is not an option.

When death actually happens, no matter how much counselling and preparing our patients' loved ones have had, that actual moment of death is still a shock, often filled with emotions of regret, elation, sadness, emptiness, pain, fear of the unknown and the realisation of being left to go on without one's partner. Some cry, some can't. Some feel so overwhelmed with all these emotions that trying to work through them is beyond comprehension, because where do you start?

As an enrolled nurse at the Hospice you are often right there, so you have to deal with their grief and, once again, I find a shoulder to cry on, a hug, a smile, even a tear from me is all that is needed. right then. This is also a time for pastoral care, so again we have achieved care and comfort, from within our MDT and our family has received only the best from us.

Following on from this, we have a wonderful bereavement followup program offered to all our bereaved families and significant others. Also at the Hospice we have a Memorial Service every three months which staff, families and friends are all invited to attend. Some find this a very helpful part of their grieving process and often look forward to seeing staff again. So once again care and comfort has been achieved.

Idealism versus Realism or Cure versus Care

What have we as enrolled nurses in a palliative care setting achieved? I would like to think for the most part I have helped patients, families and loved ones through probably the most difficult time in anyone's life. I think we at the Hospice see idealism as just that. But the realism is - we give care, comfort and support and when it is all added up we have looked after the whole patient, the whole family and others needs during this very special, emotionally packed time, and we have been lucky to have been allowed to share this with our friends.