End-of-life nursing mainly encompasses various characteristics of care, which includes symptom and pain management, assisting patients and culturally sensitive practice along with the families through dying and death process as well as ethical decision making. According to NICE (2013) EOLC for adults` quality standard, it is noted that people reaching the end of life stage and their carer and families are communicated with, which offers information on the sensitive way in response to the preferences and needs.
Stimulating patient`s values and preferences for EOL shared decision-making has central elements for advance care planning that drives with health-care professionals. However, the main objective is to empower patients by executing different opportunity for optimising the care that empowers autonomy and patients. In 2010, it is carried out in a study form that there is an existential issue that shares decision-making in a broader way, which asks nursing home patients with relatives by experiencing nursing home, which includes a conversation with the values and preferences related to participation with different forms of decision-making including attitudes. However, there are different experiences and attitudes with the use of oppression (Gjerberg et al., 2015).
NHS (2015) stated that it is a care of dying patient, which supports guidance for professional, which trust specialists palliative care team that are relevant for professional specifically working in all setting and the key aspect of care planning that is communication and delivery. Considering the aspects from NMC (2014), which is mentioned in RCN (2015) that NMC has updated the code of conduct specifically for nurses and midwives, which highlights the significance of delivering basic care for dying people since they expect to get a high standard of care afforded for other person needing nursing care?
Challenges often take place along with restrictions and limitation in nursing schools curricula on dying and death process, mainly under multicultural settings, practices, and differing policies within health care system and several interpretations of "end-of-life" legal language. The conceptual model for advocacy behaviours within the end of life nursing that offers the framework where nurses can become effective patient advocates. Forming effective communication abilities and active listening skills will lead to motivate and enhance the trust relationship of nurse patients and this further develops healing environment (Visser et al., 2014).
It is noted that primary care by physicians has the opportunity to maintain a trusting and long-term relationship with patients, therefore, it is well positioned to discuss such difficulties and certain issues like different terminal issues or newly diagnosed cancer. In this regard, primary care physicians may not feel equipped by discussing end-of-life care. Thus, such lack of physician training of patient and physician may fear that lead to discomfort while communicating bad news. Breaking such bad news specifically discussing forecast, needs a combination of disease-specific biomedical knowledge along with finest and effective communication skills. Hence, when the bad news is delivered in an incorrect way then it leads to long-term situations like the poor psychological adjustment for patients. Thus, suggestions are developed to help physicians in order to deliver bad news (Gjerberg et al., 2015).
Various studies found by Petriwskyj et al. (2014), which emphasised on trust as it is assumed as significantly essential in family involvement while decision-making. However, an environment of trust occurs when family perceives that staff is playing their best role with respect to the best interest of the patient. Hence, such kind of trust is mainly developed through interaction with staff.
Rationale of the study
It has been observed that there are so many clinical challenges, which is integral in the care of dying patient. However, there are different interventions, which clinicians are able to perform in order to treat physical and emotional symptoms of the patient at the end of life. It is further stated that patients and families appreciate doctor over and over again for listening to their concerns more than physical intervention. Moreover, such approval permits the doctor to offer care, which is better personalised to individual patient`s needs and concerns. There are many patients who are afraid of not understanding the process of dying, of pain and of being left alone with the end of lives. Hence, the clinicians who are involved in the process can offer a great deal of reassurance by explaining patients, which expects from dying process by treating pain and by promising that is not unrestraint at the end by making such promise.
Objectives of the study
The aim of the study is to develop quality indicators linked to End-Of-Life (EOL) decision making and communication.
Literature Searching Process
The chosen topic is communication, relating to the end of life care or palliative care. In this way, the researcher has used the contemporary literature that is primary research of different institutions and health centres that recorded the experiences and databases related to palliative care. Moreover, secondary researches in terms of different researches by different researchers are also taken in order to complete this research.
The search terms for this study are palliative care, End-of-life (EOL) care, and communication in EOL. These terms were used to find out the specific literature that explains specific information regarding communication-related to EOL care.
It is noted that the databases used for this study are CINAHL, Psycinfo, MEDLINE, EMBASE, ProQuest, and the Cochrane Register of Controlled trials (Central). High-quality peer reviewed journals are included from the mentioned databases, whereas, the advanced search option has been done through Boolean model.
Potentially, the relevant publications are identified and taken with the help of database searching. The search terms that were used in identifying the publications are palliative care, End-of-life (EOL) care, and communication in EOL. In this way, total 30 publications were identified from the database with respect to the key terms. These publications were selected by considering the criteria of the year of publication of last 10 years to date; to make sure that the literature is updated and still relevant to practice along with the understanding of past findings related to the same aspect. Among 30 number of publications, researcher excluded 9 studies because of their irrelevance as the publications were not relevant to the research that researcher wanted to know. Hence, the researcher found 20 articles as appropriate one in which 8 publications are excluded from research because of duplication as the publications were counted double because of the same content. Later on, the researcher selected 12 publications as the final research papers from which researcher has emphasised on these 12 studies. Moreover, the Boolean model has grasped the advance search option. It is found that the researcher has searched through the input of communication AND end-of-life care, which means that researcher, wants literature and studies from both the aspects. Similarly, the researcher identified with the concept of OR in which articles are found that will contain communication either end-of-life care or palliative care. Lastly, the articles will contain communication either end-of-life care or palliative care but NOT other than that. Considering the end-of-life care and communication during EOL mentions the common themes as these keywords are being searched specifically with respect to care during EOL.
Rationales for Decisions
The majority of the studies examine provider practices, patients and views of caregivers’ attitudes, knowledge and behaviour. As such studies are assumed as acceptable evidence related to interventions, screening and prognostic factors, which is applicable for such guidelines.
The definition of palliative care by the World Health Organisation (2014) stated as;
"An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual".
In contrast to conventional care, there is specialist palliative care service that enhances satisfaction of patients and caregiver, which offer better pain and symptom control that decreases the anxiety of caregiver, which also increases the likelihood of patient that is being cared for terminal phase, which is in place of choice. Hence, recommendations to palliative care service may suggest fears of impending death, abandonment, and helplessness in the patient if it is not communicated perceptively and effectively with the health care team (Krawczyk and Gallagher, 2016).
Because of the higher number of important deaths and events, moreover to the gradual and widespread deterioration of cognitive role, it is the greater challenge for making sure that the era leads up to end-of-life in conformism with nursing home patient`s values and preferences. This is applied to what patient needs to worry about their future life and health care for future along with the predilections for the end of their life. Therefore, the staffs of nursing home along with their skills and ability for dealing appropriately with the question is essential.
Provoking the preference and values of patients for end of life care along with shared decision making are an important aspect of what is known as "Advance care planning (ACP)", which is the method that is anticipatory decisions that are often derived from open discussions among patients, relatives, and health care professionals. The objective is to motivate and promote future care which reflects the values and preferences of the patient and this need to be offered when the patient is able to take part in decision-making process. Advance care planning is considered as an opportunity for optimising care, promoting autonomy and empowering patients. Applying diverse advance care types planning has currently expanded an increasing significance in various Western states (Almack et al., 2015).
Communication and Palliative Care
The quality standards for "end of life care" within hospitals are often developed under a partnership with interested parties and healthcare staff that include orphaned relatives. They leave a shared aim of end-of-life care that every person needs to have and what every hospital must aim to offer. The standards recognise what hospitals need to seek and how they could allow the important aspects and elements of constant quality approach to end-of-life care in place within the entire hospital irrespective of death is expected or unexpected. The standards must consider the reason that distribution of end of life care is often governed not just by individual`s recognition however also from their stated inclinations along with spiritual and cultural values. The fundamental message of standards is that "time is of the core and that provision of high quality care is supreme" (Visser et al., 2014).
There is an intervention for communication tool, which shows palliative care consultation with the reason of supporting decision-making may have the reason for offering emotional comfort, which controls symptom. The limiting review has some common type of intervention, which has become difficult for identifying the studies that includes; there are some difficulty, which seems possible for withdrawing and withholding the treatments that are commonly reported. The alternate measurements directly evaluate the patient`s wishes, which care for concordance between care plans and care for it is received. It is identified that the care plans have patient preferences, which shows advance directive that receives essential aspect (Oczkowski et al., 2016).
Wide range of Contemporary Literature
Back and Arnold (2005) offers a brief and perceptive discussion regarding the common pitfalls, which deals with the conflict by caring specifically for critically ill. They explain behaviours, which needs to be avoided by dealing with conflict that involves avoiding and denying conflict. However, by assuming the entire story, it repeatedly tries to convince other party for correctness the own perspective.
Meanwhile in a case study of a patient by (Tulsky, 2005) stated that trust can be built by using patient-centred and empathic style as good and common communication styles includes by using eye contact if it is socially suitable then there needs proper body language as well like open posture and by sitting close to patient, active listening to patient by nodding or by making sound of encouragement and agreement, which shows understanding, compassion by using warm, caring and respecting manner. However, patient-centred approach is seen with elicit greater expression of feelings, which is mainly compared with use of closed questions. Asking open questions during discussing prognosis or palliative end-of-life issues, the goals and values are determined. It is helpful in creating an atmosphere where patient is treated as a whole person, which feels that health care professionals are interested in and sensitive to different feelings and issues (concerns).
Similarly, a qualitative analysis has been done by (Walczak et al., 2015), which mentioned that it is appropriate to begin with an open question such as: "Tell me ..." Thus, the patient and / or his family will have the opportunity to start wherever they want and at the end of his story, if she complains of a symptom, such as pain, more questions focused on exploring the symptom will be made. How is the pain? How does it seem? Is it cool with anything? Does it increase with something?
In contrast, one qualitative meta synthesis found by Petriwskyj et al. (2014) stated that patient`s family has to build relationship with patient and communicate with patient. Hence, one of the situations that often faces is the so - called conspiracy of silence of the family, taking the paper, generally beneficent purpose, to safeguard the information on the patient`s clinical and prognostic situation. Keep in mind that the silence of the family and the patient may be adaptive or, but in any case, since the family is the primary caregiver of the patient, it should take care of the relationship with them, as members of the treatment team. You must understand and accept that the pace of adaptation to the situation may be different for each of the family members of the patient and they also are the subject of care and attention.
Impact of Chosen Topic on Clinical Practice
It is noted that EOL care leads to different challenges for clinicians, patients, and to their families like pain management and suffering. However, the care of dying patient needs to be considered while the setting of physical, social, and psychological experiences of person`s life. Notably, those who need end-of-life care are old age people who are susceptible to loneliness who regularly underreport pain and those who have a greater understanding of drugs and with drug-drug interactions. Inopportunely, clinicians are liable for treatment of patients at EOL generally with a lack of sufficient training, which helps in guiding end-of-life decisions that deliver bad news for families and patients (Almack et al., 2015).
Clinical communication takes place in the context of a human relationship, in which the protagonists are professionals and patients and their families. This ability to relate to patients is one of the core competencies of health professions; in that relationship, other clinical competencies are based on play in any act of health care. This relational competence is especially necessary in the most transcendent moments for the patient and his family, as a serious illness or end of life, where communication and emotional support allow to assemble the patient`s goals and his family and the media available to achieve them , whether diagnostic or therapeutic (including therapists themselves) (Visser et al., 2014).
Some of the researchers have found a deficiency and lack of some aspects of communication between patients and health-care professionals regarding discussion of end-of-life issues. There are many health professionals who are not confident and feel uncomfortable while addressing the issue with the patient or family. The prime reasons are perceived a lack of training, no time to attend patient`s emotional needs, stress, fear of upsetting patients and feeling of insufficiency of hopelessness related to unattainability of curative treatment. This kind of avoidance leads to poorer patient satisfaction with psychological morbidity as information provision is not honest that may perceive health care professionals that conceal terrifying information (Gjerberg et al., 2015).
The development and growth of sensitivity and emotional intelligence of professional self, which together with ethical sensitivity and communicative form the basis of professionalism, requires exquisite care in the choice and adaptation of relevant emotion in every situation along care of patients and their families at this vital time.
If patients and their families in any clinical encounter, even right now, expect professional emotional support, it must have a certain development of their emotional skills. Emotional support is the establishment of a therapeutic relationship in which the patient feels understood and helped to confront, from the reception and respect, their fears, desires, and needs. Requires professional accept the emotional impact, let the emotion is manifested in the patient, get the patient to feel and identify the emotion, help the channelled in one direction to facilitate the adaptation, help them discover their own adaptive strategies, help find and activate social and family support.
When talking with the patient and his family, at the end of his life, professionals tend to talk a lot and listen little. If tips are given directly, instead of exploring problems, only uncertainty will increase patient anxiety. Given the desire to speak and "confer" to quell the anxiety itself, to decrepitude and death, the "therapeutic silence" will be as indicated, pending the request for specific assistance by the patient and family or just sit with them and from the proximity ask What need me, or us at this time?
Hence, it is concluded that based on the knowledge on the basis of the therapeutic relationship (respect, honesty and empathy) petitions on the clinical setting by patients to the health system and its professionals, crystallised in the model of care focused on the patient are reviewed in the training in communication and emotional competence of professionals. Examples of real consultation intended to illustrate the application to specific cases in the field of care for patients at the end of life.