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Dying Patients

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Analysis: Providing Good Care to Dying Patients: Paper 2
Jaime Holtgrewe
Chamberlain College of Nursing
NR 449 Evidence Based Practice
February 2013

Clinical Question
In my group, the focus of research is based on the following clinical question: What are the best practices for end of life care? Within the group, research is driven to focus on enhancing care for end of life patient, including collaboration with physicians and surrogate decision makers or a power of attorney (POA), as well as pain management policies. However, all aspects of care for end of life patients are taken into consideration when determining which facet is most important. The group’s research consists of quantitative and qualitative articles focusing on transitioning to hospice programs, new measures of care, acceptance of death and experience of caregivers for the dying patient.
According to the Journal of Health Politics, Policy & Law (2008), three of every four Americans do not fear death as much as they fear being in pain at the time of death. End-of-life care can be a challenge requiring the full range of a family physician's skills. Significant pain is common but is often undertreated despite available medications and technology. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. A considerable amount of research has compiled over time to aid in reducing the amount of pain in the dying patient (Health Care in America, 2004).
Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. The physical, psychological, social and spiritual needs of dying patients are best managed with a team approach. Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life. Proper end-of-life care requires an intimate knowledge of the dying patient and experience with a wide range of treatment modalities. Physicians may have conflicts with substitute decision makers of dying patients and need to identify the factors that may facilitate or hinder the end-of-life process decision-making process. (Tan & Manca, 2013).
The purpose of this paper is to analyze the information found in two articles that provide evidence to help support the group’s clinical question, while focusing on the prevalence of pain management policies and collaboration between physicians and surrogate decision makers for end of life patient care.
Description of Findings- Quantitative Article
An analysis of two relevant articles provided the research for this paper. The quantitative article analyzed for this paper was focused on answering the clinical question: Is pain management effective for end of life care? State medical-board policy adoptions were evaluated with an event-history analytical technique using Cox semi parametric regression. Over a fifteen-year period, nineteen states adopted all four positive pain-management policies, no state had adopted all four of the negative outcomes, and ten states adopted none of the eight outcomes. Refer to Appendix A for the matrix table. The quantitative article is a descriptive, non-experimental review, and considered a level III in terms of level of evidence.
There is no independent variable or dependent variable in this article. However, the variable of interest in the article is the pain management policies for end of life care. The purpose of the descriptive review was to establish the critical role played by state medical boards in developing state management policies and to apply an event-history analysis to identify the variables most critical to the formation of pain management policies for a dying patient.
The major findings of the quantitative research article included four positive and four negative pain management adoptions. The positive adoptions include pain management as part of medical practice, opiates as a legitimate form of professional practice; prescription legitimacy is not determined by dosage amount, and reducing physician’s fears of regulatory scrutiny. The negative adoptions include opioids only being used as a treatment of last resort, opioids falling outside the boundaries and legitimate medical practice, the limited amount of physician discretion in prescribing medications, and physicians being required to file a report each time they prescribe opioids for pain management (Imhof & Kaskie, 2008).
There are several questions that may gain a further understanding of pain management for end of life care. Examples of those questions would be how beneficial are the presumed pain management policies? Also, what are the expected outcomes of the implemented pain management policies for the end of life patient?
Description of Findings- Qualitative Article
The focus of my qualitative article based on my groups research is on the satisfaction of the collaboration between physicians and surrogate decision makers. The qualitative clinical question is: What do physicians and surrogate decision makers feel promotes a good death? A summary of this article can be found in Appendix A Matrix Table. This qualitative research study was a non-experimental, ethno-graphic, lived experience. The focus of the study was to illuminate lived experiences of family physicians who have collaborated with surrogate decision makers for an end of life client. This study consisted of 11 physicians, with saturated evidence occurring after eight responses. The variable of interest in this article were the perceptions of collaboration with substitute decision makers of dying patients related to a good death.
The major findings of the study include three key components in the process of facilitating a patient’s “good death”. The three key components are building mutual trust and rapport, understanding one another, and making informed, shared decisions. As each layer of the foundation is built, the process of finding common ground has fewer barriers to overcome (Tan & Manca, 2013). It is also suggested that caregivers provide sympathy and empathy, along with compassion throughout the end of life process.
The succeeding steps for our group include a meeting, giving each member time to present the research information established to support our clinical question: What are the best practices for end of life care? We have asked ourselves and each other: How can care be improved for end of life patients? What do physicians and surrogate decision-makers feel establishes good end of life care? What are nurses’ perceptions regarding obstacles and supportive behaviors in end of life care? How do staff introduce the topic of end of life care to the family? What are family needs for end of life care? How do patients make an optimal transition to hospice care? Is pain management effective for end of life care? After answering the preceding questions, our group will allow readers to see a holistic approach of the significance of the group’s research.
There are several questions that may gain a further understanding of collaboration between physicians and surrogate decision makers. Examples of these questions are: Do surrogate decision makers feel that the key components described above are the same key components needed to ensure a good death for their loved one? What do surrogate decision makers feel establishes a good rapport?
In the final analysis, the purpose of this research, which includes the group clinical question, has been addressed in this paper with the use of the two most relevant articles. What do physicians and surrogate decision makers feel establishes good end of life care? By meeting the three key components of building a rapport between physicians and surrogate decision-makers, they can better understand each other and make informed, shared decisions Tan & Manca, 2013). As described above, the question, is pain management effective for end of life care? States have adopted pain management policies in order to promote better end of life care. Many states have found that pain management during end of life care has promoted comfort for a better death (Imhof & Kaskie, 2008).

Health Care in America. (2004). CDC Health Care. Retrieved January 15, 2014, from
Imhof, S., & Kaskie, B. (2008). Promoting a "good death": determinants of pain-management policies in the United States. Journal of Health Politics, Policy & Law, 33(5), 907-941.
Reinberg, S. (2013). U.S. News & World Report. Too few Americans pass last days in hospice care. Retrieved January 16, 2014, from
Tan, A., & Manca, D. (2013). Finding common ground to achieve a "good death": family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study. BMC Family Practice, 14(1), 1-11. doi:10.1186/1471-2296-14-14

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