Nursing Plan: Quality of Life

As a nurse assigned to provide care for Mrs. Thomas, I know that my first task, long before I began providing any actual care to her, would be to assess my feelings as they relate to the quality of life and health promotion and how those feelings might affect my care of Mrs. Thomas. On the topic of “quality of life,” I know that this topic is one that has been discussed time and time again in my training so far. As nurses-to-be, we are told repeatedly that one of our main jobs, especially in palliative care cases, is to increase the quality of life as much as possible. I believe firmly in this principle; if a patient is not likely to live, it seems that the least I can do as a nurse is to make his or her remaining time on earth more pleasant and enjoyable. I think it’s important for me to remember, however, what “quality of life” really means. Calman (1984) says that “quality of life must include all areas of life and experience and take into account the impact of illness and treatment” (p. 124). In other words, quality of life is something that will vary from one person to the next, based on his or her life experiences, expectations, and the illness he or she is experiencing. Keeping this in mind, it will be important for me, not just in my work with Mrs. Thomas but in all of my work with future patients, to remember that quality of life cannot be determined or supplied on a “one size fits all” basis. I have to take into account all of the factors affecting and relating to Mrs. Thomas’s case, and I have to also consider what is best for her versus just what she wants, something that I feel may be difficult for me. I have to learn to put those difficulties aside, however and to focus on what I know is right and how best to provide care to the patient based on the training I have received. With that said, however, I still have to determine what my feelings are and to work to combat those feelings. Even if I know they are “wrong,” they still exist and must be dealt with.

For example, as a new nurse, I often have to remind myself that “quality of life” is not just about making the patient “happy” or giving in to his or her wants and desires. It is not about those things at all; it is about actually, literally increasing a person’s quality of life and overall health, which may often mean not giving into certain desires or wishes, especially when they would be unhealthy or unbeneficial to the patient in the long-run. I think I would have to steel myself to always think of the “big picture” in terms of health and life quality because I would be tempted to feel sorry for the patient and to give in to everything she desired. Not only could these actions potentially be unhealthy for Mrs. Thomas, but they could also be detrimental in terms of the level of care I provide her and to Mrs. Thomas’s feelings about her. No one likes to be pitied, and being pitied could lead to negative self-image and to a feeling of “giving up” on Mrs. Thomas’s part, which could hinder her from making further progress and even speed up the progress of her illness. Since that is the opposite of what I want for her, I must take care to, in some ways, treat her just like any other patient, one who is going to get better. Even though I know that Mrs. Thomas is not going to make a recovery from her illness, I must act, in some ways, as if she is, while, at the same time, preparing her and her family for what is to come. That is a difficult line to walk, but I find that remembering that we are all approaching death and that we all go on with our lives despite it helps to put how patients like Mrs. Thomas should be treated into perspective.

In terms of health promotion, I must remember to take a holistic approach to the patient’s health. Not only do I need to keep her physical health in mind at all times, but I also need to consider her emotional health and the fact that her assessment of her quality of life is important. Calman (1984) says that “quality of life can only be described and measured in individual terms and depends on present lifestyle, past experiences, hopes for the future, [and] dreams and ambitions (p. 124). He suggests having the patient set goals for herself, working toward those goals, and then, once they are met, setting new goals, positing that continually striving for, reaching, and setting goals will enable a patient to feel happy, productive, and to perceive her quality of life positively (p.124-126). When a patient does perceive her quality of life as “positive,” she may be able to enjoy life more and perhaps even to live longer than she would have otherwise.

To this end, the very first strategy I would employ with Mrs. Thomas would be this goal-setting strategy. I would work with her to determine the goals she has for herself and to develop a plan for how to meet them. Then, together, we would work toward those goals, and, once met, would set and work toward new goals. These goals would not have to be large. They could be something as simple as engaging in one specific health-inducing activity per day. We might also consider contacting her children for their support, getting personal affairs in order, and planning special activities with a loved one. It may also be beneficial to get her family members, including her husband, involved in the goal-setting process, allowing everyone to focus on something other than Mrs. Thomas’s death and thereby allowing them to focus on enjoying the time they have left together as a family, rather than worrying and stressing about the situation and Mrs. Thomas’s impending death. The point would not be making or meeting the goals themselves, however, but the fact that Mrs. Thomas would be working toward something that would still allow her life to feel meaningful and purposeful. Again, this could potentially affect not only quality of life but the length of her life as well.

My second strategy would also be focused on improving emotional and mental health. I would strongly suggest that Mrs. Thomas and her husband receive some kind of counseling to help them to come to terms with the situation. And, to that same effect, I would have my third strategy focus on Mr. Thomas and alleviating some of the stress he is feeling as a caregiver. I would work with him to find out the times when he feels the most stressed and what caregiving tasks are the most difficult for him and would then develop a plan, one that would likely involve securing supplemental care, to reduce some of his responsibility. I believe that this would be important to improving Mr. Thomas’s health and wellbeing, and, as a result, Mrs. Thomas’s health and wellbeing. Since much of Mrs. Thomas’s stress is related to guilt over how her illness is affecting others, minimizing the effect on her husband would affect both her and her husband positively. As Oberst (1989) found in her study on caregiver strain, it is important for there to be “frequent reassessment of demands on family caregivers throughout the course of treatment” (p. 76), so I would need to continually assess his stress levels and work out ways to lighten his load, thereby helping both him and the patient.

I know that, in addition to implementing these strategies, I would also be responsible for helping Mrs. Thomas to improve and optimize her functional abilities for as long as possible. Based on suggestions from Palmer (1995), I would attempt to limit her bed rest, improve mobility through exercise, ensure proper nutrition, create a “friendly” environment in which she feels comfortable, and be aware of the signs of functional decline so that they could be addressed as the need arose (p. 120-122). I know that I would have some freedom to determine what each of these categories means and how they should be implemented into Mrs. Thomas’s life. For example, exercise, for her, might start as something as simple as walking around the home with assistance two times. I would need to monitor her progress carefully to determine what’s working and what’s not and would need to be amenable to change up what I was doing as needed.

By that same token, part of my job would be figuring out a way to assist Mrs. Thomas as her functional abilities inevitably declined. I would be much better equipped to do that if I could predict the likelihood and rate of functional decline. Fortunately, Palmer (1995) provides strategies for doing that. He suggests monitoring such factors as “pressure sores, cognitive impairment, functional dependency, and low social activity levels” because the presence of any or all of these things indicates a propensity toward further and imminent functional decline (p. 119). Simply by being able to better predict the rate of functional decline, I could better implement care plans to meet her changing needs. The exact nature of those plans, of course, would be entirely dependent on her rate of decline, but by knowing what to expect, I would be “ahead of the game,” so to speak. Having preparations in place for functional declines would make the transition process easier on Mrs. Thomas and her husband, further reducing stress and improving the quality of life.

The last matter that must be addressed is Mr. Thomas’s depression. It is my hope and belief that, by minimizing his levels of caregiver stress and improving his wife’s mood and outlook, his depression symptoms would be reduced. However, I understand that depression is a mental illness and usually requires professional care to overcome. As such, even if his depression symptoms seemed to be improving, I would still encourage him to seek professional care for his depression. This care would be in addition to the counseling he would hopefully be receiving, at my encouragement, to handle his wife’s illness and her impending death, but the two types of counseling could reinforce one another, creating a holistic sense of wellness for both him and his wife.

As a community health nurse, it is my job to help everyone involved in the situation at hand to improve in every possible way, and through the strategies and techniques I have outlined here, I believe that would happen and would lead to a better quality of life for all parties involved. Palliative care cases are never easy since they are not expected to have a “happy” ending in the way one might expect. However, these cases are a lot more positive than most people think, especially if they are done correctly. In the end, they are not about preparing the person for death but are instead about helping the person and those who love and support him or her to make the most of the time that is left.

References

Calman, K. C. (1984). Quality of life in cancer patients: An hypothesis. Journal of Medical Ethics, 10, 124-127.

Oberst, M.T., Thomas, S.E., Gass, K.A.,& Ward, S.E. (1989). Caregiving demands and appraisal of stress among family caregivers. Cancer Nursing, 12, 76-97.

Palmer, R.M. (1995). Acute hospital care of the elderly: Minimizing the risk of functional decline. Cleveland Clinic Journal of Medicine, 62, 117-128.