This essay will examine the Gypsies and Travellers community as a vulnerable group. It will also explore diverse subject matters around vulnerabilities in this group by indicating and describing some of the risk factors, and how these vulnerabilities affect their health and wellbeing.
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The rationale for choosing this particular group will be provided followed by the provision of prevention intervention and support by the multi-disciplinary team (MDT) and multi-agency team (MAT) to mitigate vulnerabilities, and also pointing out the role of nurses and essential social dexterities needed to successfully safeguard and protect the target population.
Also, a discussion on relevant laws and policies to safeguard the target population will be drawn, followed by a reflective account of my learning and how it will impact on my ability as a nursing student to identify vulnerability and working openly and sensitively with those affected. This essay will conclude to integrate all the key points to a conclusive statement.
The importances of protecting vulnerable adults have been acknowledged globally, and in certain communities, it seems more enhanced particularly with nations that have zero tolerance policies and legislations on abuse of vulnerable people (Bromley and Anderson, 2012). In the United Kingdom (UK), robust policies and legislations are protecting and safeguarding vulnerable people from categories of abuse and discriminations.
The Gypsy and Traveller community are a mixed group of individuals originating from parts of India, Romania and Egypt. They have a traditional background in trade illustrated in their nomadic culture and temporary accommodations such as caravans, temporary homes (within the housing) and unauthorised or illegal sites. In the UK, several scholars have studied the relationship between the Gypsy and Traveller community lifestyles and the impact on their health and wellbeing.
‘Vulnerability’ in this context is described as the diminished capacity of a person or group to foresee, cope, resist and recuperate from the impact of a natural or artificial hazard/harm (William, 2008; Penhale and Parker, 2008). For this target group, it is defined as the incapacity to fully achieve the psychological, socio-economic and environmental influences which may negatively impact on the health and wellbeing of the group (Wray et al., 2008). This notion is relatively dynamic and often linked with poverty. However, it could emanate as result of social isolation and insecurity from risk or trauma. Reactions differ when exposed to risk as a consequence of social status, gender, age, ethnicity, education, income et cetera.
Statistics reveals that over 70% of the Gypsy and Traveller community engage in a risky lifestyle and behaviour as a result of their culture, beliefs, values and norms and an estimated 20% live in temporary accommodations like caravans (Parry et al., 2004). This is supported by a government study which claims that these factors, as well as poor education, increases exposure to ill health and poor registration with health facilities. The overall health of the group is poorer compared to the general population and that of non-travellers residing in socio-economic deprived regions, (HM Government, 2011).
The 2011 statistics reported that an estimated 12% of Gypsy and Traveller children obtained 5 or more GCES in either English or Mathematics compared to National average (DCLG, 2012). NHS statistics also report that there were a relatively high prevalence and incidence of preventable ill health amongst the target group. These include high prevalence of neonatal deaths, miscarriages, maternal death (during and after pregnancy) and stillbirths (Parry et al., 2007; DCLG, 2012).
Parry (2007) also emphasised that the Gypsy and Traveller community has a relatively high prevalence of avoidable ill health such as low birth rates, sexual health issues, teenage pregnancy, smoking, and drug and alcohol abuse. It is also evident that their health outcomes are as a consequence of their lifestyle behaviours (Penhale and Parker, 2008; Okely, 2011). Arguably, the target population have a culture of early marriages and multiple celebrations (e.g. of birth, weddings, and christenings). Evidence suggests that the target population also have a reduced inclination towards education and have low records to GP registrations (Papadopoulos, and Lay, 2007). Academics have linked the above behaviours to the determinants of health and the existing inequalities in health.
Marmot (2010) stated that where we live, eat, who we socialise with, how much money we have and what work we do significantly have an impact on our health and wellbeing. Marmot’s argument implies that: individuals who come from poor socio-economic and environmental backgrounds are more likely to suffer poor health as opposed to affluent individuals.
In the light of this argument, the target population are viewed as a vulnerable group as opposed to other societies and communities within the UK. The UK government established several policies and legislation to ensure that this target group and other vulnerable groups enjoy enhanced health and wellbeing.
The Health and Social Care Act (HSC) was established in 2012 with several elements to amplify quality healthcare service provision and also protects vulnerable people such as the target population (DH, 2015). In order to achieve the aim of the HSC, it was important to use an integrative provision of health and social care services through local communities and especially communities of interest. Under the safeguarding policy that aims to protect vulnerable people, the HSC Act mandated several safeguarding measures that require healthcare providers to implement the policies and these are monitored by the Clinical Quality Commission (CQC). The CQC is a government body that ensures that health and social care providers follow the policies and the procedures of protecting vulnerable people under the HSC act on safeguarding policy (DH, 2015).
The Race Relation Act 2000 identifies the Gypsy and Traveller community as a marginalised group, but the 2002 amendment to the same act reiterates that these groups such as the Gypsies and Travellers are to be recognised as a fully established part of a community without discrimination or prejudice highlighting the need for the community to be recognised to foster equality and diversity. This made the letter G-in the word Gypsy uppercase as well as the letter T-for Traveller to show respect to this target group (HM Government, 2015). The UK government, therefore, has a statutory duty to ensure that delegated government and non-government agencies conduct equality impact assessments on every policy and ensure that there is the implementation of equality to all including the target group (HM Government, 2009).
The 2010 Equality Act also provides a legal framework to protect the rights of individuals and the promotion of equality regardless of age, race, religious beliefs, disability and gender. The Equality Act provides significant protection for the target population from discrimination. Policy makers and service providers use key points of the acts to augment the health and well-being of the target population regarding education, housing, employment, etc. (Department of Health, 2005).
The 1998 Human Rights Act is a legislation established to defend human rights and ensure all individuals are treated equally with fairness, dignity and respect regardless of age, sex, race, disability. The application of this right to the Gypsy and Traveller groups in the UK ensures that service providers have an obligation to improve the health and wellbeing of the target group respectively (HM Government, 2015).
The UK government under the Department of Health and especially in the HSC Act mandate several safeguarding interventions to protect vulnerable people and ensuring that they enjoy equal benefits as everyone (London Safeguarding Children Board, 2010). As such, many organisations and government departments have implemented successful interventions that directly benefit the Gypsies and Travellers group, e.g. promoting educational equality under the Department of the Community and the Local Government, provision of long-term and adaptable services to the target population, providing anti-racist health and social care services within the targeted communities and working collaboratively with other organisations to ensure that the target communities benefit from the planned interventions (Van Cleemput et al., 2007)
For educational equality, several interventions have been implemented within the Gypsy and Traveller communities aimed at ensuring they benefit from all educational service provided nationally; including the registration of all children who are entitled to school, providing services enhancing early year education in communities, and supporting families to ensure that their children receive government standard education. An example can be seen in the Barnet borough where several Gypsies and Travellers project provides specialist groups with the aim of safeguarding an early intervention. This includes the provision of available data to the government and providing training and policy implementation that benefits the target group. For social inclusion, several networking projects have been implemented at community levels to ensure the promotion of social inclusion within the target group and other communities at large (London Safeguarding Children Board, 2016).
With regards to promotion to behaviours change due to the risky lifestyle of the Gypsy and Traveller groups, several successful intervention groups have been implemented to provide good sexual health, housing and other facilities. An example is an intervention that is provided by the department of health under local authorities to provide one to one and focus group interventions on raising awareness and exposure to factors that influence ill health. Examples of this health education include the provision of leaflets on how to practice good sexual behaviours, good nutrition and better housing options.
By achieving safeguarding interventions, the Clinical Commissioning Groups (CCG) and the Joint Strategic Needs Assessment teams of all local authorities ensure that they conduct the Health Needs Assessment (HNA) of the whole population and priority is given to the Gypsies and Travellers to ensure their health and wellbeing needs are met. The Health Watch and Public Health England also ensure that health profiles of particular populations are obtained and interventions are planned accordingly. But, to attain all these importance of the role and responsibilities of nurses and other health professionals plays an important part.
Health care professionals like nurses have the duty of care to ensure that vulnerable people are always protected (Martin, 2015; NMC, 2015). Academics argue that professionals have an obligation to work conscientiously to improve the individual’s health and wellbeing; e.g. nurses need to adhere to the NMC code of professional practice and competencies to address inequalities in health that exist amongst the vulnerable people such as the Gypsies and Travellers. Nurses, therefore, have a responsibility to provide health promotion information, make referrals to other agencies; to ensure that effective interventions have been implemented and provide advocacy to tackle hate crime and discrimination amongst vulnerable people, promote social inclusion and above all to participate in community projects that aim to promote the health and wellbeing of Gypsies and Traveller groups.
As a prospective student of mental health nursing, I have learnt the importance in accurately identifying vulnerability; being sensitive, non-discriminatory, non-judgemental avoiding stereotypes and being cognisant of stigma and underlying factors correlated with mental infirmity or illness. I will also embark on a holistic approach and work closely with patients to promote dignity, confidentiality and professionalism and use current evidence-based practice as potential interventions that will enhance the health and wellbeing of vulnerable people (Larkin, 2009). I will also work efficiently as part of a team during my prospective placements; report concerns to my mentors or ward managers regarding safeguarding and protection of vulnerable people as outlined by health and social care legislations and policies and stipulated by the Nursing and Midwifery Codes of conducts.
Overall, health policies and legislations are likely to evolve fundamental changes in health inequalities; they are not drivable on their own. Effective implementation and evaluation are respectively essential to achieve the success of policies and legislations. The national government should support bottom-up initiatives and schemes to prompt community actions and engagement as well as community development. It is crucial that the Gypsies and Travellers population are engaged and supported to participate in every phase of health and social care project. However, according to Mechanic and Tanner (2007), it is evident that making changes or amendments in policy is more rapid than engagement and works with families and individuals within the Gypsy and Traveller communities. This may be time-consuming, entails tolerance and commitment to achieve the predetermined objectives.
The apparently the national strategy and implementation on Gypsy and Traveller health are essential, supported by devoted funding, for continual improvements, especially in the local projects. Although it has been documented that the Gypsy and Traveller communities relatively live in poor health conditions as opposed to the rest of the population, there are several factors that have been found to contribute and provide answers to the research on why they have poor health status (Van Cleemput et al., 2007).
The national government and the international organisations have come up with several policies and legislations to ensure that there is a reduction of inequality in health amongst the target group. Policies such as the Equality Act, the HSC Act and the Human Rights Act have all played a significant role in improving the health and wellbeing of the vulnerable people. However, several interventions have been implemented to tackle these challenges; the role of health professional especially nurses, by the whole, has played a major role in making sure that vulnerable people are safeguarded and protected from harm, abuse, and discrimination.
REFERENCES AND BIBLIOGRAPHY
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Her Majesty Government (2015) What to do if you’re worried a child is being abused Advice for practitioners. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf (Accessed 3/11/2016)
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Cite This Work
When words of Code Blue are announced through overhead speakers, my heart always skips a beat, and I will start my personal struggle again among professional, legal and ethic obligation: “did I take the right action on a right patient and did I do a right thing?”
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Code blue means a patient, who is in “Full Code” status, is suffering a event of cardio-respiratory arrest, and immediately needs a starting of full advanced cardiac life support protocol, including cardiopulmonary resuscitation (CPR), medication, and mechanical ventilation (Lewis, Heitkemper & Dirksen, 2006, p.166). I have been working in an adult inpatient medicine unit for six years. I can not exactly remember how many times I initiated a code blue call and have participated with the resuscitation team. Most of the patients that I have involved in code blue have died during the resuscitation process with a huge mess of blood, airway secretion, urine, bowel movement and medication on his or her body or survived less than 24 hours. After each resuscitation action, I felt emotionally drained, depressed, guilty, helpless and frustrated with the code status decision – “Full Code”. In this paper, by presenting a resuscitation scenario, I will conduct a discourse analysis about this clinical dilemma from both liberal-humanist and scientific-medical perspectives. Through analysis, I understood that clinical dilemma happens all the times, and it also will happen in the future. Nurses need to seek how to explore the contradictions or tensions from different discourses and understand them to grieve over. At the end of the paper, I discuss the implication of the future nursing practice based on the knowledge acquired from this discourse analysis.
It was my first year in an adult inpatient medicine unit after my graduation from a nursing school. Mr. D was a 97 years old widower. He was admitted to the hospital for congested heart failure, shortness of breath and also found to have pneumonia. He was intubated for respiratory difficulty in the intensive care unit then eventually developed multisystem organ failure, sepsis, and meningitis. Also, he was at the end stage of liver disease, and illustrated by brain damage signs from circulating toxins, hepatic encephalopathy. Arriving at my unit, he complained of shortness of breath and dizziness. His jaundiced skin glowed bright yellow. He showed delirium, repeated the same questions in slurred voice incoherently. He presented a marginal blood pressure, lungs were full of fluid, and oozed blood from his gums and injection sites was hardly to clot. All his limbs were extremely swollen. Nasogastric feeding tube was in situ. Oxygen was supplied at 4-liter by nasal prongs with saturation of 88 – 92%. While checking orders to create a Kardex, I realized his code status was “Full Code”, and physician’s progress notes indicated that decision of code status was discussed between health care team and family three times.
Two days later, I found Mr. D was not responding to my greeting and touch during my hourly round checking at 10:00 in the morning; no breathing sound heard, and no palpable pulse. I hit the code blue button on the wall at beside and started CPR. A “code blue” announcement automatically was delivered through overhead speaking system. Code team arrived in one minute. Night gown was stripped off; an aged body was totally naked. Deep suction via yankauer was made in rush, a tube was inserted down his throat, and then into his lungs in a harsh manner, and a ventilator took over his breathing, blood noted in his mouth; a cardiac monitor was hooked up to his chest; chest compression was made in a powerful manner to reach the depth of 5cm, rib and sternum bones broken noise was heard; a big needle-like catheter for getting artery blood gas by a respiratory therapist was poked into to several locations, blood contaminated his right upper arm and inner thigh; venopuncturing for intravenous cannula insertion by a nurse was re-poked four times on both extremely swollen arms and blood messed on forearms; isosource of nasogastric feeding came from his nose and mouth, foul odour smelled; epinephrine was injected two times; defibrillator was applied three times with strong electric shock. Twenty minutes later, the physician ordered to stop the resuscitation effort and give up. Mr. D was left naked in the bed, lying without moving, deadly pale on his face. Everybody was exhausted, leaving the room with disappoint on face, and huge mess on the bed and floor. Tears were running down in family’s cheek, too sad to say a word.
Analyzing Personal Struggle
Full code is permission for a code team to insert a ventilation tube into failing lungs, apply electric shock to a fibrillating heart, and unleash a extra blood of punctures, dissections, and exsanguinations on the human body. A resuscitation based on “Full Code” is supposed to be performed aiming in offering the patient a benefit. However, these interventions are marginally effective (Hiberman, Kutner, Parsons & Murphy, 1997; Perers, Abrahamsson, Bang, Engdahl, Lindqvist & Karlson, et al, 1999), lives saved and functioning restored only for a small number (15% worldwide average) of people (McGrath, 1987; Saklayen, Liss & Markert, 1995; Schneider, Nelson & Brown,, 1993). Subjecting a dying person to CPR who is believed there is virtually no hope of survival is a terrible way to practise health care; it is inhumane; and it is an assault. Despite significant improvements made in training, equipment, and drugs, the overall CPR survival rate has remained almost the same over the past 30 years (Beall, 2001). Findings from 33 studies showed that about 16% of patients under age 70 and 12% of patients aged 70 and older survived CPR only (Kaye & Mancini, 1996).
After participating in the resuscitation for Mr. D, I have been struggling over this real scenario at: (1) what is the quality of death; (2) who can decide the code status; and (3) what can I do for advocating my patient?
As a nurse, I have to deal with life-and-death decisions with each of my patients. With the participating in the resuscitation for Mr. D and witnessed his death, I am wondering: what is a “quality death”? What a kind of process is a “quality death”? Who defines it? What is the resuscitation doing? How much do patients in terminal life stage have to understand about what dying is like? How well patient’s dignity could be preserved and integrated into the resuscitation process? How well patient’s wish could be respected in the decision of code status? How does a patient want everything to be done to extend his life – “Full Code” in hospital parlance, or a patient wants to let his/her death happen naturally without interference – a “Do Not Resuscitate” order? Does the “Full Code” status really benefit the patient’s interest or just benefit a substitute decision maker’s/family’s interest? As for Mr. D’s scenario, is the “Full Code” status his real wish? Is the dying process his real belief about dying? Is the dying process his real value about the death? Did he image his death with broken sternum and ribs, massive blood mess and contamination? Did he image that, at the end of life, he was surrounded by the code team rather than by his family members? Unfortunately, I have no solution to seek the true answers yet; I felt the contradiction and tension between the resuscitation on behalf of a “Full Code” status and quality death: professionally, I have “duty of care” to participate in the resuscitation action and do whatever required for such a purpose, but ethically and morally, I do not want to do any harm on my patients during the resuscitation. It has become my clinical dilemma of struggle for many years.
The decision of code status is a complex and controversial topic. Theoretically, it seems simple and easy to declare either patient or patient’s substitute decision maker will be the subject to make decision about code status. However, in the real working environment, I noted that many patients’ indications on code status are blank, not checked yet; and sometimes they are left as blank for a long period; also, some patients’ code status has been changed reversely from “Do Not Resuscitate” to “Full Code” by their family; Mr. D was one of such examples. It tells me that the decision process in not a straight-forward linear procedure; it is organic or dynamic. The confusion for me is who is the real decision maker during this organic process, the patient own, patient’s family/substitute decision maker or a health care provider? As a regulated professional, a health care provider is rarely taking action as such decision maker; usually, either patients or their family will be. While the patient is capable, it is clear that the patient decides it for himself or herself. However, my wondering is that there are so many factors that will impact patients’ capacity when decision needed to be made on the code status, such as age, medical condition, the quality of life, religious views and overall wishes. Further more, like the perception on pain, capacity is really subjective; a sound judgement on patient’s capacity also is difficulty. Who can decide a patient’s capacity is either intact or impaired without any interest conflict? Like Mr. D’s scenario, due to his senior age and confused medical condition, his daughter was his decision maker from the admission; the reality of his condition was recorded as deteriorated daily, and he had been incapable to provide any input about his code status; the progress notes show us that his code status has been changed from “Full Code” to “Do Not Resuscitate”, and then back to “Full Code” again during a five-week period of hospitalization. Is there any interest conflict in the process while his daughter made decision of turning over on his code status for him, and does such change will really benefit him in relieving suffering, restoring functioning and improving his quality of life?
As a member of heath care team, what I can do to advocate my patients’ decision is really limited so that I am feeling helpless. Being a sick people in a hospital might be very stressful; in additional to physical symptoms, people may feel anxious, depressed and helpless. Also, family members might be place under a difficult time and position during a medical crisis; family members may disagree, emotions might be high and medical information can become confusing agent. In such a stressful circumstance, any possible irrational decision could be made without considering the reality and possibility. Perhaps, we can say nurses are knowledgeable to provide information, as well as nurses know more about the patients’ daily condition than a physician so that a nurse really can make some good input for health care team and family in decision-making to advocate patient’s benefit; however, the final decision is totally depending on patients’ or their substitute decision-maker’s understanding about the context of code status; they are legally granted the power. Like Mr. D’s case, his decision-maker alternatively requested change of his code status from “Do Not Resuscitate” to “Full Code” on his behalf that resulted in futile and miserable resuscitation, even if his most responsible physician could not apply any influence on it. Health care providers are not legally granted such a power, and ethically, we also can not apply our opinions, judgement or choice on patients’ or their decision-maker’s decision. So, I have been struggling over the relationship between power and knowledge; under such circumstance, knowledge is not and does not have the power at all. What we can do is through information providing to empower our patients or their decision-maker to use their power to make a right choice on code status to avoid such futile and miserable resuscitation happened on Mr. D without any benefit, but harm.
Exploring Discourse Analysis
The clinical dilemma as identified in the above scenario, the contradiction and tension are mainly triaged from respecting the patient’s own or their decision-maker’s choice on code status while providing our resuscitating intervention. In order to understand the issue, I did literature review on decision making on code status choice. I chose the patients’ or their decision-maker’s decision of choice on their code status and how to empower them in making a right decision by information providing to advocate for patients’ benefit in quality of life at the end of life as my focus. In the following sections, I will use Mr. D’s case to analyze this clinical dilemma from both liberal-humanist discourse and scientific-medical discourse perspectives.
Scientific-medical discourse: empower patients to make right choice on code status
According to Grant, Giddings & Beale (2005), the scientific-medical discourse is based on the biomedical mode of medical science. Its core concept is that a human body is a collection of different parts that are organically organized and form different systems that manifest as a set of symptoms (Brown & Seddon, 1996, a, b). It constitutes the scientific fundamentals and becomes the root of nursing science (Grant, Giddings & Beale, 2005, p.499). That is the reason I chose it as one of my discourse.
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Medical knowledge explicitly tells me that life maintenance must be under the control of homeostatic balance, which is maintained by normal functions of all organs; and homeostatic control mechanism can maintain only in a relative narrow constancy (Thibodeau & Patton, 2005, p.16). CPR is a desperate technique that is used on the people who are might be suffering cardiac arrest in order to deliver oxygen to blood stream and maintain a cardiac circulation to keep vital organs, such as such as the brain, be oxygenized to be alive, to delay brain death, and maintain the heart to remain responsive to defibrillation; in many type of patients, it virtually never works; for a patient with an advanced age and life-threatening illness who is dying of the underlying disease, there is very limited benefit because survival is rare (<1%); patients, even health care professionals, largely over-estimated its function as an global or universal resuscitation technique (Hayward, 1999). Dr. Bishop, Brothers, Perry and Ahmad (2010) also argued that patients in their final stages of their lives would finally reach the point of cardiac arrest, and CPR is a desperate, invasive medical intervention which for many patients has a remote chance of success. As for Mr. D’s case, my assessment tells me that his coming death is the normal human body deterioration related to his aging, irreversible function ability losing of multiple organs; the given resuscitation action driven by his “Full Code” will be futile and can not make any sense to bring him back to alive, but impairing on his quality of death into an indignity process. That makes me feel frustrated and helpless at not only the intervention I have to take without scientific rationale, but also the intervention will bring some harm on my patient for no benefit.
As articulated by Grant, Giddings and Beale (2005), “nurses had sound technical knowledge of bodily diseases, the associated symptoms, predisposing causes, and appropriate treatment” (p.499) from medical science. Under the influence of biomedical model ideology, the interventions of nursing care have been constructed as a set of tangible, specifically operate-able and measurable procedures that are implemented in a methodical manner – step by step, for example, nursing process. Reflecting on Mr. D’s case, by informing them the updated condition and possible prognosis through my careful and objective assessment, I can support my patient or their decision-maker to choose a right code status to avoid a violent death that occurs during an advanced cardiac life support and artificially prolonged life maintenance. It is not to apply my opinion or choice on them. It is to empower them to make right choice in a supportive manner to preserve patient’s dignity and quality of life, as well as death. In such a way, my professional integrity also will be benefited in maintaining, professional contradiction and personal tension will be avoided.
Liberal-humanist Discourse: Advocating Patient
According Grant, Giddings & Beale (2005), the liberal-humanist discourse of nursing care is a holistic approach; the patient is viewed as a whole person and a unique individual, not the collection of different parts only. Empathic nursing care does not only deal with patients’ biomedical issues, but also emphasize patients’ autonomy, rationality, emotions, understandings and dignity; it is characterized by respecting patient’s self-determination, free choice, and self-representation (Praeger, 2002). The ethic ideology of liberal-humanist discourse of nursing care is underpinned by two assumptions: nurses’ commitment to a trust therapeutic interpersonal relationship of care and having moral obligation to act (Dyson, 1997, p. 200) on behalf of patients (Grant, Giddings & Beale, 2005). Such a sound holistic approach becomes the grand rationale I choose it as one of my discourses. Also, it casts and shapes my best nursing practice by providing my patients and their family holistic caring.
However, it must be understand that such an universal or global ideology itself has an underlying contradiction and tension that I experienced in my patient Mr. D’s scenario, that is, under some circumstance or specific context, it is difficulty that empathetic nursing care must have commitment to trust interpersonal relationship by respecting the patient’s autonomy and at the same time, nurses also have moral obligation to act on behalf of the patient.
As for Mr. D’s case, health care team discussed the code status choice in multiple family meetings based on informed decision principle. The whole caring process demonstrated the empathetic caring by respecting family’s decision on the code status choice, taking appropriate and timely resuscitation action morally on behalf of the decision maker. However, the misery result was the violation of patient’s dignity and quality of death in the dying process, which is actually avoidable and it morally generates the ethic guilty and tension in health carer’s emotion, because health carer eventually does not have the legal authority to take action to morally prevent such an avoidable misery event to be happened. Such contradiction and tension in professional, legal and ethic principles basically contribute to my distress and confusion.
Implications for Nursing Practice
The discourse from either scientific-medical approach or the liberal-humanist approach, while people’s life reaches the end stage life-span, not only does the physical body, but also the person as a whole, become a vulnerable object. Being a ill person in a hospital can be terribly overwhelming with physical symptoms, anxiety, depressed and helpless, as well as invasive treatment, diagnostic interventions and a variety of information that is related to each procedure. A treatment is supposed to be of benefit if it relieves suffering, restores functioning and improves quality of life; it will become a burden if it causes pain, prolongs dying without offering a benefit or increases distress. When we emphasize that patients do have some control over what kind of treatments they do and do not want, but in how many cases patients really implement their control over the treatments? Taking Mr. D’s scenario as an example, being in his senior age and impaired cognitive status, it is impossible for him to be a host to get his treatment and care plan under the control of his wishes; his decision maker on his behalf, driven and masked by a general graceful desire that is often seen in the most of people, just wants “everything has to be done to remain alive” to save and prolong his physical life, even if a few more minutes, legally places not only his physical body, but also “a person as a whole” at the risk of vulnerable position unconsciously while choosing a “Full Code” status. As a nursing member of the code team, I have “professional obligation” to do some inhumane resuscitation actions on his vulnerable body and impair his dignity of death. So, putting myself into Mr. D’s shoes, if either my parents or I were in his age and health condition, I really need the preservation of self-determination, free choices and self-representation in decision making on code status choice – choose “DNR”, let me go naturally without pain, suffering and inhumane resuscitating effort.
Our patient-center nursing care philosophy always makes us be aware of that patients need to be supported, not blamed (Kammerer, Garry, Hartigan, Carter & Erlich, 2007). From the liberal-humanist discourse of nursing care views, committed to trust interpersonal relationship with patients, empathy and communication are two core concepts. When a person’s life is at the brink of death, a clear mind is a rarely existed. Often, it will be more difficulty to accept and respect a frail mind than a frail body. Terminally ill people may look differently, feel even worse and terrible, and think in another way. They need advocacy, protection and caring in humane, patient, and professional ways. Supporting their ability to get their lives under control is no less important than keeping their blood pressure under control. Communication in an empathetic passion is more conducive to doing the right thing than rigid legal documents. Nursing has moral, as well as professional, obligation to communicate our scientific-medical knowledge to support patients in determining what kind of code status they want to be and make their wishes known to their loved ones. Family is an integrated part of our clients, which are facing a difficult position during a medical crisis. Identically, we have above obligation to support patients’ family members in knowing what a loved one wanted that will help them get peace of mind that they are honouring the wishes of their loved one. In such a way, our professional development will be in growth, and our personal distress that is involved in the discourse tension will be released.
According to the learning goals of this course, discourse from scientific-medical approach and liberal-humanist approach on a real clinical situation is presented in this paper. Personal distress, frustration and confusion arisen from the clinical dilemma have been analyzed. Nursing care can be explored from different kinds of contradictory discourses. All these contradictory discourses might contribute to nurses’ feeling of distress, frustration or confusion when encountering different clinical situations. The liberal-humanist ideal of ethic of care focus on viewing a person as a whole and respecting patient’s self-determination, free choice, and self-representation, bur patients need advocates and support from scientific-medical approach in decision-making. Furthermore, for professional and personal development, nurses should learn to understand these different discourses in one situation and take effective strategies to solve the clinical dilemma. Committing to a trust therapeutic interpersonal relationship with patients will help nurses understand patients better, and it also helps nurses to find the meaning of the event so that effective solutions could be figured out to solve clinical dilemma.