“End-of-Life Decision Making” by Debra Lacey

Introduction

Nursing care for patients with end-stage dementia is one of the most complicated issues in nursing practice which requires special skills and knowledge of a nurse. Complex societal factors also have influenced the need for a comprehensive approach to chronic disabling conditions. End-stage dementia caused by brain damage is usually from Alzheimer’s disease. It develops among mature and older people due to the deterioration of specific parts of the brain. Education of the nursing staff dealing with the end-of-life decision is crucial because retarded people require special care and treatment during the last months of life.

Summary

The article “End-of-Life Decision Making for Nursing Home Residents” by Debra Lacey is a research work that examines and analyzes the professional skills and knowledge of nursing staff and their involvement in advance directive discussions. The aim of the research is to analyze the degree of consistency between social workers and medical staff and evaluate end-of-life decision-making practices. In the first (introductory) part, Debra Lacey gives an overview of the state of dementia and the role of the Nursing Homes in the life of such patients. The author states that mental retardation has been attributed both to genetic factors, and therefore is immutable, and to environmental factors, and therefore is malleable. The observed effects of Alzheimer’s disease and mental retardation on the elderly come most often from those involved in the caregiving role because an individual with cognitive disability most often is not aware of or cannot verbalize the problems. This part of the article is based on detailed literature analysis and evaluation, including such problems as artificial nutrition and artificial hydration, cardiopulmonary resuscitation, and antibiotics for infections. Caregivers cannot rush or hurry through procedures while providing care to the cognitively impaired patient since any sense of urgency is contagious and agitating to the patient. This can often result in an exacerbation of difficult behaviors. Advance directives are very important for nursing homes and require coordination of actions and joint consultation of all staff.

The second part of the paper is a research study provided in New York State. The study consists of three stages, earlier literature research, obtaining results from interviews and focus groups, and feedback from academic, social workers. The sample consists of 660 nursing homes in New York State, including both for-profit and not-for-profit nursing homes. The study is based on a stratified representative sample technique. Questionnaires are sent to nursing homes. In general, answers from 138 social workers are accessed. The data are analyzed using SPSS version 10.0. The sample is represented largely by medium and large nursing homes. Based on the results obtained, Debra Lacey comes to a conclusion that “almost all nursing home social work respondents are responsible for the introduction of advance directives”. Also, it is found that the majority of nursing staff use artificial nutrition and hydration on admission instead of antibiotic treatment. Many respondents state that a documented health care proxy simplifies the procedure and helps them with the end of life decision-making. The major differences are found between respondents’ attitudes towards withholding and withdrawing treatments. The main limitations of the study are ‘the sampling methods, and responses limit generalizability’ and ‘the lack of depth in content, and the limited statistical analyses”. Debra Lacey concludes that there is a need for nursing staff education in end-of-life care issues. It should include palliative care practices and ethical dimensions, communication with family members, and withholding or withdrawing treatment.

Critique

The article represents a detailed analysis of nursing care for patients with dementia. The advantage of the research is that it pays special attention to advanced directives, which help to define a common ground where the patient, family members, physician, and health professionals come to comprehend and understand the patient’s and family’s decisions regarding end-of-life issues. If the patient did not previously prepare an advanced directive, these decisions would rest with the legally empowered family member. The main strengths of the article are a detailed review and analysis of the literature. Also, Debra Lacey highlights that as the patient enters the final stage of the disease, family members are confronted with very difficult decisions. Among these are the placement of feeding tubes to maintain nutrition, resuscitation in the event of cardiopulmonary arrest, and the aggressive treatment of infections.

Continuous education is important for nursing staff because the truly difficult task is to provide care to the patient who, due to an illness and inability to understand, maybe uncooperative, resistant, or combative during the provision of care. Debra Lacey emphasizes that terminal care, palliative care, and chronic care are terms that are intermingled and often used interchangeably. This includes conditions in which death is imminent, as well as chronic and debilitating conditions from which there is no reasonable hope for recovery.

The article vividly portrays problems and weaknesses of the healthcare management faced by nursing professionals. Wherever the patient receives terminal care, the last management issue to be addressed is promoting quality of life. This, too, is an ethical consideration for all people and poses a particular challenge to caregivers of dying Alzheimer’s disease patients. Debra Lacey suggests that “newly admitted residents and family members who are overwhelmed during the admissions process should be targeted for follow-up discussions on advance care planning when these individuals are more emotionally prepared to discuss palliative care”. The main weakness of the research is a sample structure. The researcher did not take into account possible variations in the sample and its design. The author admits: “a broad cross-section of questions was posed to participants, with little depth in any specific areas”.

In sum, the value of the research is that it unveils problems and limitations of the current healthcare and highlights the main areas for further improvements. Much of what is known about the treatment and management of Alzheimer’s disease is the result of trial and error. No one has all the answers to Alzheimer’s disease. Educators must admit to themselves and to the caregivers that because of the nature of the disease, the solutions and management strategies offered are not going to work in every situation. The appropriate approach to the management of advanced Alzheimer’s disease minimizes patient suffering and provides a compassionate environment for those approaching death and for their families. Caregivers in long-term care facilities have special needs for education. Federal and state regulations require training which must include information on aging and working with cognitively impaired patients. In addition, staff must also meet requirements for annual continuing education and training on dementia and working with the patient with dementia.