DANA IERACI

16220873

NSG3INT

THE TRAGEDY OF WATCHING

Communicating effectively and therapeutically is a skill that requires extensive experience. This
is especially true when dealing with the family of a loved one suffering from a terminal illness.
The foundations for this dialogue are openness, honesty, empathy, and active listening. The
strength of any good nurse is being able to tease out a client or families understanding of the
illness they are suffering from whilst being able to facilitate them through the transition of
grief. This dialogue and counseling does not stop when the loved one is gone, but continues
through their transition with the overall goal of allowing them to move on with their lives. The
stage of grief which I was involved with was anger. The aim of this critical reflection is to
promote ideal communication techniques, and to understand the feelings and emotions at play.
Provided is critical reflection aimed for personal strategies of improvement regarding the
therapeutic use of self.

Critical Incident

Some say that the grief after death can be the most painful experience felt for those involved.
However sometimes the grief felt by watching a disease consume a person can be almost
unbearable. For many in this situation, the five stages of grief appear in this period. This is an
encounter following a clinical experience at a palliative care experience in Melbourne during
October, 2010.

This is a recall of a conversation, or more accurate of a family breaking down. They were all
sitting in a beautifully lit room bathed in sunlight. They were scattered around the bed. It
looked like most of them had been there for days. The son looked as if he had 4 days worth of
unshaven growth. The daughters eyes were sunken and red, as though she had been crying for
days and that there were no tears left. They were mourning the upcoming death of their
mother. I remember I walked in as I had done several times that day. Our goal was comfort.

Mrs. X was 56 years old and was suffering from breast cancer. She was in the end stages of her
illness. She had a daughter Simone 31, and a son Alex 27. Her husband Owen was 59, only
spoke in short sentences. He never held a conversation long enough for me to get a good feel of
the person.
On this particular encounter though, Owen looked at me after I had provided his wife with
some oral care. She was heavily sedated and was quite tired. He looked up and asked, 'why is
this happening? What have we done to deserve this'. It may sound unconvincing but I was not
prepared for this question, but what I was more shocked at was the fact that I could not answer
it. I had no idea what to say. Owen was aware that I was a student nurse. When I didn’t provide
an answer his tone turned to one of anger. "We took the treatments, did the chemotherapy,
had the mastectomy, and took the pills. Why?"

I said the only thing that came into my head, 'I know how you're feeling, and I had my
grandmother pass away not long ago'. Big mistake. The flash of anger I had seen escalated,
'How the hell would you know what I'm feeling, and what I'm losing'. Thinking that the
encounter could take on a more violent tone I turned away and walked out of the room, and
did not return. I swapped patients' with another nurse and continued on with the shift all the
while knowing that I had made a real mess of things due to not knowing how to deal with this
complex situation.

Body

The key issue surrounding this discussion was death, and the anger and confusion it caused for
the family involved. As a student I felt disempowered, untrained, and at points ill equipped to
deal adequately with the situation. Whilst there was no correct answer to make the husband or
children feel better, I did however cause further damage through both miscommunication, and
a lack of understanding regarding death.

According to Elizatheth Kubler Ross there are five stages of death. These are denial, anger,
bargaining, depression, and finally acceptance. From the scenario which I have discussed it
appears that the family had moved through denial, and on to anger. Unfortunately I was unable
to help them facilitate them through the stages. As stated I felt ill-equipped to therapeutically
deal with the ongoing situation.

Anger is the second stage of grief according to this model. This period is defined as the
individual or family ‘recognizes that denial cannot continue. Because of anger, the person is very
difficult to care for due to misplaced feelings of rage and envy’.

The perspectives of patient and family experiences of the dying process have been extensively
researched in many cultural settings. Families of dying people have assumed the role of primary
caregiver. With this role, families not only manage daily practical care giving tasks, but also are
faced with the emotional challenge of watching their loved one progress towards death
(Hudson 2006). It is the palliative care nurses role to not only care for the terminally ill patient
but also their families as well. This is what I was unprepared for. It was my role to help facilitate
the family through the grieving process and to help them understand their own emotions
associated with anger, loss, feelings of helplessness, and to try and help alleviate some of the
anxiety, worry, and hurt which comes with the process of watching a loved one die. We have
been taught the stages of death, but when you are actually confronted with this by a family it is
totally different from being in a lecture theatre.

Zerwekh’s (2006) family care giving model of core competencies for hospice nurses was used to
guide this analysis. The role of the hospice nurse, whether classified as an expert or not, is to be
with the patient and family during the dying process and provide honest, supportive and
compassionate care in the midst of an emotional transition. This helps to guide the family in
letting go of their loved one. Letting go is a progressive event which can encompass forgoing
material possessions, relationships and finally life itself (Zerwekh 2006).

What was important within my communication with the family was to provide this overall
facilitation, however from reflecting on this I can clearly see that I failed in the encounter. This
was due to a multitude of reasons including my own concept of death and grief. As well a lack
of awareness of the socio-cultural issue which were relevant to the family involved. In order to
learn from the situation than it will be imperative in my future nursing that I develop my
therapeutic use of self, and incorporate it into my nursing actions to help facilitate both the
families a patients involved in palliative care.

In order for the encounter to have been therapeutic it would have been necessary as a nurse to
facilitate the family through these stages of grief. It is vital to acknowledge the husbands
feelings and explore the depth of their knowledge of the situation surrounding his wife’s illness.
This could have been achieved through asking questions such as, 'what is your understanding of
your wife’s illness? To foster more therapeutic communication it would have been better to
actively and openly listening. However when encountered with the wife dying and the husband
asking why this has happened it is clear that the husband is stuck in the stage of anger. The goal
is to help facilitate him through the other stages and eventually to acceptance. Only then can
he find peace. In order for this to occur I should have asked:
-Tell me what you're thinking?
-What are your views?
-How can we help?
It is also very important to discuss the options available to help assist both the wife and family.
In the end the anger this client was feeling was not directed at me but just a projection of
powerlessness. They feel as if they have no control over the situation. Whilst there is nothing
he can do in order prevent his wife from dying it is vital to instill some control over the situation
through treatment options and preventative pain management. I should have allowed the
husband to reflect on the situation.

When the question was put to me, 'why is this happening?' my response was totally
inappropriate given the literature analysis that I have gone through. Whilst not meaning to do
this I was very patronizing should not have said, 'I know what you're feeling', as this only fueled
the situation and escalated it to a level that it didn’t need to be. After careful consideration and
extensive research the appropriate answer should have been, 'I don't know, I wish I did, but I
don't have an answer. My role is to help you here in this situation. How can I help you?' This
approach is honest, truthful, and aims at getting between the issues through exploration, and
to encourage questions.

The aim is to not foster false reassurance. Validate the client’s feelings because they are real.
This was an extremely delicate and volatile stage and it required my skills to be more developed
and mature to this particular skill. For this is what it is. This isn't something you can go blindly
in. Sadly I did, and I felt this way and because of that the situation escalated to where it did.
However through reflection, research, and practice I have been able to understand what is
appropriate and what is not.

While the nurse works on developing communication skills with the dying patient and their
family, the goal should be to build an understanding of the patient and their family's needs and
goals. Cultural and ethnic differences can occur and further complicate the process of
communication; nurses should approach the communication forum with the family as a new
and unique experience. Because no death is ever the same, no family is ever the same.
Research suggests that families want open and honest dialogue (Barclay, Blackhall, and Tulsky,
2007). There are several methods that can be utilised when deal with the family of a dying
patient. The cornerstones of this dialogue as previously stated include openness, honesty, and
understanding. These techniques will help facilitate the grieving process."Thoughtful
communication is based on awareness that life does not last forever, and the end is drawing
near".

My training has been based upon fixing the medical problem. When it occurred that I was
unable to facilitate this I avoided the situation of communicating the dying process (Weigel,
Parker, Fanning, Reyna, & Gasbarra, 2007). This apprehension and lack of experience in
palliative care left me lost for words.

Honest communication is integral in family dealings (Heyland et al., 2006). The barrier to
communication can likely be that the nurse is unaware of what has been communicated by the
treating doctors regarding, prognosis, treatment options and other things. When this occurs the
family can be frustrated about this (Schirm and Sheean, 2005). I should have briefly viewed the
progress notes about what has been communicated with the family.

The anger the husband displayed is not projected at me but at an overwhelming sense for
information and support. A lack of experience led to increasing the families’ frustration. To be
supportive I should have asked, 'what is it your understanding of your wife’s illness. A good
nurse will focus on support and clarification of issues important to the patient and family. It is
important to understand what the husband knows and it is important to not to assume that
they have real knowledge surrounding their illness.

The key to this situation was to acknowledge feelings, seek clarification with open ended
questions, and using silence with active listening (Perrin, 2001). Silence indicates empathy and a
willingness to stay engaged; it allows a person to listen to the answers, paying attention to
language content and non-verbal communication (Mauk, 2003). If the husband or family has
any questions write them down and let us get you the information you require (Perrin, 2001).

Honesty is an invaluable tool when a family asks why, respond, 'I don't know, I wish I had
answer as to why you are ill but I don't'. The problem with this situation was that the family had
been given different prognosis’s from treating doctors who fuelled anxiety and confusion
(Lorenz, et al., 2008).

The aim should be to build an understanding of the family’s needs and goals. Therapeutic
communication lays the foundation for a care path for the family, it is crucial that nurses
understand that each path will be different.

Some of the ideas which should have been adopted would have been to listen more and talk
less (Mauk, 2003). Key questions would have included, "what do you think your wife would
want now if she was able to talk, what would be important to her?”

Avoid such comments such as 'There’s not much more we can do for your wife", it leaves the
family helpless and feel that they are being abandoned (Ngo-Metzger, August, Srnivasan, Liao,
& Meyskens, 2008).The goal is to help facilitate understanding for the family and patient in
regards to what is going to occur, and how nurses can help. A nurse communicates caring
through open commitment to personal care.

Listed here are non-therapeutic statements, which I was guilty of drawing upon due to a lack of
education and experience surrounding death and dying.

She/He is better off now.

I know just how you feel.

You don't need to worry.

Everything will be all right.

It could have been worse.

Let me tell you what happened to me.

Source: Perrin, 2001.

Compared to what I know now, I am able to draw upon the experience and have a better
developmental understanding of my therapeutic self. Whilst the wife was still alive the grieving
process had already started for the family. To them their mother was slowly fading away.
Drifting between consciousness, and confusion.
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