Palliative Care Essays - Hospice, Palliative Medicine,

Palliative Care The role of the expert palliative care nurse is complex and unique. The nurse functions as an integral part of a Multidisciplinary team, providing expert skilled assessment and nursing care, supporting the patient and the family to make informed choices thereby encouraging the patient to continue to make autonomous decisions about their care towards the end of their life. However, often the nurse will find herself dealing with difficult family dynamics with family members having differing expectations of the type of care that the patient should be receiving, staff conflict over treatment methods or strategies and high workloads. These issues can only compound the stresses on the Palliative Care Nurse and to cope with the many dilemmas she must be well armed. The complex needs of the terminally ill patients and their families make the multidisciplinary team approach the most effective method of care Staff from a range of disciplines including medical, nursing, social work, dietitian, physiotherapist, pharmacist and others bring diverse and unique skills. As a team they provide an excellent sounding board for ethical dilemmas thereby hopefully- enhancing ethical practice. (Latimer, 1998) The Nurse in her role is required to act as patient advocate and ensure that the patients rights are respected. Unfortunately this advocacy is sometimes perceived negatively as a threat or implied criticism of medical care. Doctors need to listen to the nurses more accurate perspective of patient concerns. Consistency across the team leads to better outcomes for patients. Reinforcing the same information by both medical and nursing staff help to allay patient anxiety far more than conflicting views on such things as symptom control. (Jeffrey, 1995) The members of the Multidisciplinary team sometimes make decisions. regarding treatments, which they may perceive to be of the most benefit to the patient whilst in fact the patient, does not perceive the benefits in quite the same way. Nurses have more prolonged contact with the patient than most other members of the team due to the hands on patient care that they do. They often establish a close rapport with the patient and the family and are most likely to be aware of the patients likes, dislikes, hopes and dreams and are privy to often delicate and very private details of the patients life. The very fact that the nurse spends so much time with the patient makes them more likely to have knowledge of this kind of information. Doctors rounds in a Palliative Care Unit enable the doctor to spend perhaps 30minutes maximum per day in talking to the patient. In the community, appointments times with Doctors are restrictive and Home Visits limited. Patient Nurse dependency ratios in hospitals and palliative care units mean that Nurses are spending approxi mately four hours per day on one to one patient contact. Again, other team members are very limited in the amount of time they spend with patients due to the number of clients/patients they may have. A dietitian for example may spend 15 minutes with a patient twice during their six-week stay in a Palliative Care Unit or 30 minutes as an outpatient during the course of the Terminal illness. Social workers often spend long periods at a time with patients and/or their families in lengthy discussion however these discussions may only take place a couple of times over the period of the illness. Therefore the Nurse is far more likely to be aware of issues affecting patient care. There can be many difficulties for the Nurse expert providing high quality care to palliative patients whilst respecting their right to autonomy In the setting of the Palliative Care Unit, the role of the Nurse is to painstakingly assess the needs of patient and family. These needs may be constantly changing and there is no room for the Palliative Care Nurse to become complacent in her patient care. Symptoms may be physical such as pain, nausea, and dyspnoea or psychosocial or spiritual. In identifying care needs the nurse must be able to determine who is the most appropriate team member to refer to provide optimum management of these needs. E.g. although the expert nurse will have counselling skills, she must be aware of her limitations and refer on where appropriate to counsellors, psychologist

Analysis of Feathers, a Short Story by Raymond Carver

Analysis of 'Feathers,' a Short Story by Raymond Carver American poet and author Raymond Carver (1938 - 1988) is one of those rare writers who is known, like  Alice Munro, primarily for his work in the short story form. Due to his economical use of language, Carver is often associated with a literary movement known as minimalism, but he himself objected to the term. In a 1983 interview, he said, Theres something about minimalist that smacks of smallness of vision and execution that I dont like. Feathers is the opening story of Carvers 1983 collection, Cathedral, in which he began to move away from the minimalist style. Plot of Feathers SPOILER ALERT: If you dont want to know what happens in the story, dont read this section. The narrator, Jack, and his wife, Fran, are invited to dinner at the home of Bud and Olla. Bud and Jack are friends from work, but no one else in the story has met before. Fran is not enthusiastic about going.   Bud and Olla live in the country and have a baby and a pet peacock. Jack, Fran, and Bud watch television while Olla prepares dinner and occasionally tends to the baby, who is fussing in another room. Fran notices a plaster cast of very crooked teeth sitting on top of the television. When Olla enters the room, she explains that Bud paid for her to have braces, so she keeps the cast to remind me how much I owe Bud. During dinner, the baby begins fussing again, so Olla brings him to the table. He is shockingly  ugly, but  Fran holds him  and delights in him in spite of his appearance. The peacock is permitted inside the house and plays gently with the baby. Later that night, Jack and Fran conceive a child even though they had not previously wanted children. As the years pass, their marriage sours and their child demonstrates a conniving streak. Fran blames their problems on Bud and Olla even though she saw them only on that one night. Wishes Wishes play a prominent role in the story. Jack explains that he and Fran regularly wished out loud for things we didnt have, like a new car or the chance to spend a couple of weeks in Canada. They dont wish for children because they dont want children. It is clear that the wishes arent serious. Jack acknowledges as much when he describes approaching Bud and Ollas house: I said, I wish we had us a place out here. It was just an idle thought, another wish that wouldnt amount to anything. In contrast, Olla is a character who has actually made her wishes come true. Or rather, she and Bud together have made her wishes come true. She tells Jack and Fran: I always dreamed of having me a peacock. Since I was a girl and found a picture of one in a magazine. The peacock is loud and exotic. Neither Jack nor Fran has ever seen one before, and it is much more dramatic than any of the idle wishes theyve been making. Yet Olla, an unassuming woman with an ugly baby and teeth that needed straightening, has made it a part of her life. Blame Though Jack would place the date later, Fran believes their marriage began to deteriorate precisely on the night they had dinner at Bud and Ollas, and she blames Bud and Olla for it. Jack explains: Goddamn those people and their ugly baby, Fran will say, for no apparent reason, while were watching TV late at night. Carver never makes it clear exactly what Fran blames them for, nor does he make it clear exactly why the dinner gathering inspires Jack and Fran to have a baby. Perhaps its because Bud and Olla seem so happy with their strange, squawking-peacock, ugly-baby lives. Fran and Jack dont think they want the particulars - a child, a house in the country, and certainly not a peacock - yet perhaps they find they do want the contentedness that Bud and Olla seem to have. And in some ways, Olla does give the impression that her happiness is a direct result of the particulars of her situation. Olla compliments Fran on her naturally straight teeth while she herself had required braces - and Buds devotion - to fix her crooked smile. At one point, Olla says, You wait until you get our own baby, Fran. Youll see. And as Fran and Jack are leaving, Olla even hands Fran some peacock feathers to take home. Gratitude But  Fran seems to be missing one fundamental element that Olla has: gratitude. When Olla explains how grateful she is to Bud for straightening her teeth (and, more generally, giving her a better life), Fran doesnt hear her because she is picking through the can of nuts, helping herself to the cashews. The impression is that Fran is self-centered, so focused on her own needs that she cant even hear someone elses expression of gratitude. Similarly, it seems symbolic that when Bud says grace, Olla is the only one who says amen. Where Happiness Comes From Jack does note one wish that came true: What I wished for was that Id never forget or otherwise let go of that evening. Thats one wish of mine that came true. And it was bad luck for me that it did. The evening seemed very special to him, and it left him feeling good about almost everything in my life. But he and Fran may have miscalculated where that good feeling was coming from, thinking it came from having things, like a baby, rather than feeling things, like love and appreciation.