This essay will explore theoretical concepts associated with loss, grief
and bereavement around end of life care.
Supporting this the writer will critically explore evidence based
holistic care for the dying person and their loved ones. This essay also aims
to highlight the impact and difficulties a paramedic may have in a palliative
care situation; with mention of existing care pathways and how a paramedic in a
pre hospital setting may utilize them.
Evidence shows that around one third of Paramedics attend at least one
End of Life (EoL) patient per shift (Munday and Gakhal, 2011). Brady (2014)
states paramedics are now caring for EoL patients, who may have complex
physical, social, and psychological needs. Additionally they are often called
in times of distress, acute pain, deterioration, and nearing death itself
(Brady, 2014). The National End of Life Care Programme (2012) stated there are
unique issues that need improvement to help paramedics to provide quality End
of Life Care (EoLC). Some of these are poor paramedic EoLC education, lack of
compliance with advanced directives and a lack of sharing information (The National
End of Life Care Programme, 2012).
NHS Choices (2015) states that different health and
social care providers may be involved in patients EoLC depending on the
patients needs. Palliative care teams consist of different health care professionals
such as district nurses, GP’s, hospice carers etc. As specialists they advise
other health care professionals (paramedics) on palliative care (NHS Choices,
2015). However the availability of specialist palliative care depends on the
health care system in place, the funding and political support of these
services, (Seymour and payne, 2008).
The World Health Organisation (WHO) (2017) define Palliative care, as an
approach that improves the quality of life of End of Life (EoL) patients and their
loved ones through the prevention and relief of suffering. Of which is done through the identification,
assessment and treatment of pain and other issues, whether physical,
psychosocial, social or spiritual (WHO, 2017). Similarly Brooker and Waugh (2014) have defined holistic care as providing
patient centered care; which is focused on the patients existing needs and
looks at them as a whole, and recommends that psychological and spiritual needs
must also be considered. It has been suggested by Roberts (2013), that health
care professionals must make their relationships with their patients a focus in
providing effective holistic care.
Pain management can be one of the
physical aspects of a paramedic’s job when dealing and treating EoL patients
(Hjermstad et al., 2016). The research by Hjermstad et al, (2016) suggests
a specific need for a pain-scoring tool for palliative patients who live with
pain day to day. Barnard and Gwyther, (2014) recommend that an assessment of the
patient’s pain is required including, establishing the level of pain, looking
for potential non-pharmacological intervention such as, spiritual support,
patient positioning and then considering drug therapies. Ramezani et al, (2014) stipulates that
spirituality has many positive attributes for patients such as healing,
psychological adaption and spiritual well being. As well as promotion of
spiritual awareness for health care providers (Ramezani et al., 2014). However this
may be difficult for Paramedics as they may have just met the patient and
family; and may be unfamiliar with the patient’s specific needs whilst
potentially having to make time critical decisions, (Brown, Kumar and Millins, 2016).
When providing care to palliative patients religious
and cultural factors are considered an important aspect of care, as these are
known to influence decision making at EoL (Bain et al,. 2017). However Bain et al. (2017) also goes on to
say there is still a lack of literature explaining attitudes towards life
sustaining treatment and care across religious and cultural groups,
specifically in a EoL care situation.
Pettifer and Bronnert, (2013) state that the
appropriate care and place of care for the EoL patient may be decided by
different factors; such as their own preferences, clinical needs and the
ability to provide the appropriate care in the right setting (community,
hospice or hospital). Another aspect of patient care paramedics must consider
is documentation and information about their conditions, (Pettifer and Bronnert, 2013). It could
potentially be very distressing for all if paramedics are not aware of predetermined
plans like Advanced Directives (ADs) or Do Not Attempt Cardio Pulmonary
Resuscitation (DNACPR), (Pettifer and Bronnert, 2013). If a DNACPR is not in place or not presented to health care professionals
when treating a patient, it is their decision whether to begin resuscitation (Resuscitation
Council, 2015). ADs are a legal
document that allows a patient, to make an advanced statement of their wishes
regarding medical treatment or intervention in the event they lack mental
capacity in the future, (Coleman, 2012).
A part of the paramedic’s role can be breaking bad news, (Brown, 2016).
Health care professionals may find it difficult to give bad news to a
deceased’s family or loved ones, as it is hard to predict how the bereaved will
react to death, (Warnock, 2014). Seymour and Payne, (2008) state that communication is
essential to effective health care; they emphasize that emotional support and
providing information is required to be seen as effective, and go on to say
that ineffective communication may also cause stress, lack of job satisfaction
and burnout for health care professionals.
Burglass (2010) recommends when dealing with EoL patients and their loved ones,
paramedics should be aware of theories relating to loss, grief and bereavement.
Kübler-ross, (2014) suggests that grief
can be outlined in five stages (denial and isolation, anger, bargaining,
depression, and acceptance). Kübler-ross (2014) proposes that denial works as a
“buffer” after unexpected news, which may allow the patient to come to terms
with bad news after time; she regards it as a healthy way of handling a painful
The second stage of
grief outlined by Kübler-ross (2014) is
anger; she goes on to say that different from denial, anger is very difficult
to deal with by the patient’s family and health care professionals. Furthermore
the reason for this is because anger is directed in all different places,
(Kübler-ross, 2014). Patients can provoke rejection and anger, and are yet the
most vulnerable, (Kübler-ross, 2014).
follows anger; Kübler-ross (2014) suggests this is an attempt to postpone
death, and may try to bargain
with the health care professionals or if they are religious, attempt to ask God
for more time.
The fourth stage of grief is depression, (Kübler-ross, 2014). It is stated that the patient should be allowed to
be sad; if they are allowed to express their sorrow they may find the final
stage of acceptance easier, and will be grateful to those who are with them
through this stage of depression, (Kübler-ross, 2014).
final stage is acceptance; this
is where bereaved have had time to mourn and are able to accept the forth
coming, (Kübler-ross, 2014). However acceptance
should not be confused with a happy stage, the family will need more help and
support than the patient themselves usually, (Kübler-ross, 2014).
to the previously mentioned theory, Worden (2013) suggests a four part task-based theory of dealing with loss, grief and
bereavement. The first task is to accept the reality of loss Worden, (2013).
This implies the bereaved should be ready to begin the healing process, (Worden
2013). This differs from Kübler-ross (2014), as
acceptance is the last stage in her theory of grief.
Secondly Worden (2013)
states the person needs to process the grief and pain, and stipulates there is
no way to overcome this other than to confront these feelings and emotions head
on. Adjustment to life
without the deceased and moving on is the third task of mourning, (Worden,
2013). Taking on the tasks the deceased would carryout in day to day life and
adjusting to doing things and living life without them may help the bereaved
cope, (Worden, 2013). Finally the bereaved need to find a
lasting connection with the deceased while moving on with life, (Worden 2013). According
to Worden (2013) failing to accomplish this task is not to live.
A different model to the above theories is suggested by Stroebe
and Schut (1999), in which
the grieving person “oscillates” between a process where the bereaved at times
confront and then can avoid the different stages of grief. Stroebe and Schut (1999) propose that adaptive coping
is composed of stress avoidance and confrontation. It also argues the need to
take rest from dealing with these stresses, as an important part of coping, (Stroebe and Schut, 1999).
It is important for
paramedics to be aware that reactions to grief will be different each time they
are faced with it (Warnock, 2014).