Journal excerpt and associated resources for learning and teaching
Journal excerpt 1.1
Mary was on reception at the hospital when I went for treatment. I liked her immediately and eventually she agreed to go out. We courted, became close and I asked her to marry me. She said, “Speak to my father”. I did. He grinned and said, “Ask her mother”. We married, honeymooned in the mountains, and settled in the city until I finished my studies. We were very happy and so much in love. We asked ourselves, do good times like this last forever? Later she felt ill and consulted her doctor who told her she had miscarried. I was dismayed – would we ever have a family? Cheerfully she replied, “Of course, we will! Don’t worry – everything will be OK”. And so it proved to be. We reared four healthy children and enjoyed the journey. As the children matured, she build [sic] a career and travelled within Australia and overseas both professionally and socially. She led an active and rewarding lifestyle. We both looked forward to a satisfying retirement.
1.1 Points to consider
- How does a person’s life experiences and history affect their response to diagnosis with chronic or terminal disease?
- How may a diagnosis of chronic or terminal disease affect the relationships the person has with family and loved ones?
Journal excerpt 1.2
She drove to the medical centre for a routine visit. Her doctor, noticing she was disoriented, suggested further tests. Eventually, she was diagnosed with Lewy Body Dementia.
Our lives were to change dramatically. She was gradually to lose her cherished independence – could no longer drive, required assistance with personal care and other activities at home and in public. Luckily, she retains her cheerful nature, wry sense of humour and full recognition of people and places.
Upon becoming a carer, major changes took place in my lifestyle. –I’m not resentful – not much anyway – because I believed I owed much to Mary – a loving wife and devoted mother to our children for over 50 years. I wanted to repay her for her kindness and provide care to help soften the problems arising from her dementia.
Dementia has been described as a ‘long goodbye’. Tonight we will be close. We’ll talk, recall past experiences, sleep and dream. Tomorrow we’ll wake together to another beautiful day. We are so fortunate. We know now that good times do last forever.
1.2 Points to consider
- What type of psychosocial effects might a terminal diagnosis have on the patient?
- their immediate family?
- As an older patient/couple, how might Ed and Mary’s experience differ from a younger patient/couple?
1.2 Suggested activities
- Use a jigsaw classroom to explore:
- Psychosocial effects of a terminal diagnosis across the lifespan
- Dementia types
- Introduce concept of ‘reminiscence tools’
- Relate theories of grief and loss to the lived experience for patient and carers. In particular, consider the process of reconciling old expectations with new ones as limited by the diagnosis.
- Consider how your values, religious or cultural beliefs frame your understanding of death and dying, and how this may influence your response in a situation like Ed and Mary’s.
- In particular, consider the concept of ‘obligation’ and what it means to you. How may this be different to someone from a different background/culture/religion/social group to you? How does this change depending upon the role a person has within the family/group?
- How can life history be used positively?
- In what ways can family and friends gather memories with the person diagnosed with dementia?
Journal excerpt 1.3
Friday, 7 November 2008
Mary having a lot of delusions:
Wants to go home.
“Lewy’s” men (up to three in room) and watching her.
Asks at bed-time “Which bed is she going to sleep in tonight?” Pictures still being shifted about (by “Lewy”)
7 February 2009
Mary ‘sat down’ on way to shower. Going to use shower chair with wheels in future. Mary, Jess and I went to lake for walk and lunch.
1.3 Points to consider
- What behavioural management strategies and tools can be employed to support the patient?
- How can trust in service/s be engendered?
1.3 Suggested activity
Debate:
- Natural therapies
- Pharmacological management vs. behavioural management
Journal excerpt 1.4
8 February 2009
Using shower chair. Seems successful.
10 February 2009
Mary has reached ‘new’ stage in her decline.
26 February 2009
Mary very tired. Quieter and reflective. Appears to be ‘depressed’. Having more difficulty in speaking. Getting hard to understand. Mobility not good.
1.4 Points to consider
- Reflecting on the nurse’s attitudes and behaviour in response to change in the person being cared for what is the nurse’s role in fostering behavioural, emotional and environmental safety
- How might you approach someone to help with ALs?
Journal excerpt 1.5
Thursday, 12 March 2009
Collected (urine) specimen and tested at Doctor’s surgery. Positive – put her on antibiotics for 7 days.
Monday, 16 March 2009
New behaviour: Hallucinations all night and early morning. Up six times. Incoherent most of the time. Aggressive.
17 March 2009
Mary hallucinating again all night. One episode involved a snake and Mary inflicted a tear on her lower arm. Dressed in a waterproof cover. Mary [sic] hallucinations cover a wide field of imagination. Having great difficulty in swallowing tablets. Taking liquids OK.
1.5 Points to consider
Medication:
- How is it best administered?
- Is it appropriate for late stage care?
1.5 Suggested Activities:
With changed behaviour, consider:
- Positive behaviour management
- communication tools
- safety
- Swallow assessment.
Journal excerpt 1.6:
Tuesday, 28 April 2009
Agreed: Anti-biotics cease. Not having any effect and continuation could cause side effects and diarrhoea.
Discontinuing feeding by cannula, except potassium. Feed subcutaneously into muscle in mid-body. Continue oxygen but finish feeding in 1 to 2 days.
Mary not alert enough to feed by mouth. Monitor, and if Mary becomes more alert, feed by mouth. Move to single room. Unlikely Mary will leave hospital. End will come any time from days to weeks. Mary alert this evening – strong grip; trying to speak, moving arms, etc.
1.6 Suggested Activities
High-fidelity scenario:
- Simulation of nurse-led therapeutic communication with Ed and family
Journal excerpt 1.7
The Goodbye
We put Ma to bed as usual on the night of … April 2009. Ma walked slowly from the lounge room, down the hallway to her bedroom asking as she did ‘where am I going? Where am I sleeping tonight?’ We gave our usual reply ‘In your bedroom where you always sleep’. Satisfied, Ma snuggled comfortably between the sheets as we hugged and kissed her goodnight. She smiled and said ‘thank you’ and looking peaceful and contented she dozed off. Little did we know that these were to be the last words we would speak.
Next morning I prepared her medication, ‘Lewy medication’ she called it, and took it to her bedside announcing my presence with a cheery ‘Good morning, how did you sleep?’ Ma didn’t stir; she seemed to be sleeping soundly. I decided to let her sleep until S., the carer, arrived. We were unable to wake Mary and decided to give her a bed-wash and change of pull-up pants. Nurse visited and suggested Mary go to hospital by ambulance. I consulted Dr N. J. who agreed. In hospital Mary had various tests – blood tests, X -rays, urine etc and placed on drip and given oxygen. Further tests tomorrow. We advised family of Mary’s situation and then O., K. and M. – visited this evening.
A-A planning to come to Canberra from Sunshine Coast. I discussed further treatment with Dr D. E., including what action to take if any possibility of recovery passes. I expressed some surprise to be having this discussion at the time. Dr D. explained that this was routine as it was preferable for the medical team to know the thoughts of the family when commencing normal treatment regime. Dr D. explained that it could be days or even weeks before a decision needs to be made.
For the rest of April, Mary remained in Canberra Hospital under treatment but showed no signs of recovery. Many friends visited daily.
Journal excerpt 1.8
On Saturday, 2 May 2009 Mary passed away peacefully at 11 am. I was present and A-A., M, O., and K. soon arrived. We stayed ‘til 2 pm except M. who stayed longer. K. began funeral arrangements. As an organ donor Mary’s eyes were accepted for research purposes.
1.8 Suggested Activities:
Jigsaw classroom –
What does the research say:
- Legislation concerning organ donation and transplant
- Policies and procedures around organ donation and transplant
Role play:
Therapeutic communication:
- Broaching the subject of organ donation
- Dilemma
Discuss:
How is the family’s need/desire to say goodbye/stay with the patient balanced with the need to move forward with the donation/transplant procedure?
That is, who’s in charge of the end-of-life moment?
1.8 Points to consider
- What happens now?
- carer?
- family?
- care workers (paid and unpaid)?
- What kind of support will the family need?
- How would the nurse support a family through organ donation decisions?
- How would the nurse support a family through the organ donation process?
1.9 Suggested Activity
- What does the research say about mourning and grief?
- Develop some strategies to use in the clinical setting?
The Jigsaw technique is designed for cooperative learning in small groups. Students are provided the opportunity to become "experts" in a particular subject, and share that knowledge with their peers. Source: Institute for Teaching & Learning Innovation
See appendix for a short guide to the jigsaw classroom.
