NU435 Unit 10 personal reflection essay example

Two Beliefs About Death I Brought Into NU435, and What Happened to Each

[Student Name]

Purdue University Global

NU435: Hospice and Palliative Nursing Care

Unit 10 Assignment

[Instructor Name]

[Date]

The narrator and patients are composites. Claims about care carry citations; the voice is first person.

What

Last spring, a man with end-stage lung disease was readmitted to my unit for the fourth time in a year. He was short of breath, frightened, and asking when he could go home. In four admissions, as far as I could find in his chart, no one had asked him what he wanted from the time he had left. I had cared for him twice and had not asked either.

Two beliefs came with me into this course. First, that hospice meant stopping care: a family that chose it was giving up. Second, that morphine near the end of life shortened it, so giving it was a trade between comfort and time.

So What

Belief one met its evidence early. Hospice is not the absence of care but a different aim of care: symptom relief, support at home, and a team that includes the family. Palliative care, of which hospice is one form, can begin much earlier, and in one trial early palliative care alongside standard treatment improved quality of life (Temel et al., 2010). What I had called giving up was, in most of the cases I could remember, a family choosing comfort over another admission.

Belief two met its evidence in the literature on opioid use at the end of life. A review found no evidence that opioids given for symptom relief, in doses titrated to effect, shorten life in patients near death (Sykes & Thorns, 2003). This belief did not vanish completely. I still feel uneasy saying the word dying in front of families, and some of that unease was the belief in disguise: if morphine did not hasten death, then the death was coming anyway, and I would have to say so.

My grandfather's death shaped both beliefs. He died in an intensive care unit after a week on a ventilator, and when the family finally agreed to comfort care, he received morphine and died within hours. I concluded then that the morphine killed him. I now understand that he was dying before it was started, and that the week on the ventilator, not the last few hours, was the part of his care no one had chosen.

What the Course Changed in How I Work Now

Some changes have already started. Last week a woman with advanced heart failure told me she was "tired of all this," and instead of reassuring her that she would feel better soon, I asked what she meant. She meant the admissions. We talked for ten minutes, mostly her talking, and I passed what she said to her physician, who arranged a palliative consult. A year ago I would have changed the subject.

I have also noticed how often my unit treats readmission as routine. Patients with the same failing organs come back every few months, and each admission is handled as if it were the first. The course gave me language for what is missing: nobody is asking these patients about their goals, because each of us assumes someone else did. The man with lung disease was not an unusual case. He was the usual case, seen clearly for the first time, and there are several like him on my unit this week.

Now What

Three changes, each dated:

1. From [month], at every admission of a patient with advanced chronic illness, I will ask myself the surprise question, whether I would be surprised to see this patient's death within a year. The question has only moderate accuracy (Downar et al., 2017), so I will use it as a prompt to start a conversation, not as a prediction.

2. By [month], I will attempt one goals conversation using the Serious Illness Conversation Guide with a patient whose answer to that question is no (Bernacki & Block, 2014), with our unit's palliative nurse present.

3. I will complete the Professional Quality of Life scale now and again in six months (Stamm, 2010), since conversations like these take something from the nurse who has them.

Back to the Man on My Unit

If he were readmitted tomorrow, I would sit down and ask him what he understands about his lungs, and what matters most to him if his breathing gets worse. I do not know what he would say. The point is that, after four admissions, someone would finally ask. Rolfe and colleagues describe reflection as ending in action (Rolfe et al., 2001), and this is mine.

References

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. https://doi.org/10.1001/jamainternmed.2014.5271

Downar, J., Goldman, R., Pinto, R., Englesakis, M., & Adhikari, N. K. J. (2017). The "surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. Canadian Medical Association Journal, 189(13), E484-E493. https://doi.org/10.1503/cmaj.160775

Rolfe, G., Freshwater, D., & Jasper, M. (2001). Critical reflection for nursing and the helping professions: A user's guide. Palgrave Macmillan.

Stamm, B. H. (2010). The concise ProQOL manual (2nd ed.). ProQOL.org.

Sykes, N., & Thorns, A. (2003). The use of opioids and sedatives at the end of life. The Lancet Oncology, 4(5), 312-318. https://doi.org/10.1016/S1470-2045(03)01079-9

Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., Dahlin, C. M., Blinderman, C. D., Jacobsen, J., Pirl, W. F., Billings, J. A., & Lynch, T. J. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine, 363(8), 733-742. https://doi.org/10.1056/NEJMoa1000678