Moments that shaped my philosophy of nursing: patients that fall through the cracks

Discussion board post for NURS608 Philosophical and Critical Foundations in Nursing, posted on May 7, 2022.

It was about a year into my nursing career in the emergency department when I learned an important lesson about how our patients' needs fall through the cracks in the fast-paced, efficiency-driven healthcare system in which we work. I took report in the morning on a patient that had come into the emergency department overnight by ambulance from her long-term care home. Her son had arrived to be with her at the bedside some short time later. The patient presented with respiratory symptoms after a likely aspiration, her breathing was difficult and labored, and she had many pre-existing health problems, was in her 90s, total care and non-verbal. The overnight ED doctor had prescribed antibiotics, bloodwork, and X-rays. In morning report, I was told, by a frustrated and aggravated nurse, that the patient's son was refusing any of the care that was being offered, so the doctor had marked the patient for discharge, but the son also refused to have the patient sent back to her care home.

At this point, I was confused and skeptical that I had the full story. A few minutes after shift change, the patient's son - upset, anxious, and worried - approached me at the nurse's station and demanded to know what the care plan was for his mom. I asked the son if he was aware that the doctor had ordered diagnostic and antibiotics for his mother, and he said yes, but then he continued to inform me that his mother appeared extremely uncomfortable and he was worried that she was suffering. He expressed his concerns that further testing would aggravate his mother's situation, and that she would not want any further treatment, that she just wanted comfort. As nurses, we understand this as palliative care, but it occurred to me in that moment that the patient's son may not have realized he was seeking an alternative care plan than the usual one expected in the emergency department.

After engaging the patient's son in conversation, I learned that he did not know anything about palliative options, and that no one had offered him a chance to revise the care plan or even contribute to it, nor had asked what the patient actually wanted us to do for her. I brought this new information to the emergency doctor, and he immediately consulted palliative medicine, which finally put the patient on the care trajectory that was better suited for her unique needs and desires.

While the emergency doctor brushed it off as out of his hands at that point, I sat with the situation and reflected because it did not sit right with me that this patient and her son should have had such a stressful experience with our healthcare system. I found it hard to believe that the other healthcare providers the patient's son had interacted with had not provided any education on palliative care options. I wondered how many other patients out there were accepting or declining treatment options simply because they were not aware of all of their options, or not being engaged and communicated with to contribute to and design their own care plans. I resolved, then, to ensure I ask my patients what their primary goals for their treatment are, and ask what is important to them in terms of their health and perceptions of quality of life.