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 patient’s 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. Doctor’s 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 approximately 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