In the past, it may have been acceptable for doctors not to tell a patient they had cancer. There was a culture of silence around talking about death and terminal illness (Heyse-Moore 2009). In On Death and Dying (Kubler-Ross 1973) Kubler-Ross said it was often the wife or husband who was told the diagnosis and then had the burden of whether to tell the painful truth. However, the development of the Hospice movement and Palliative Care in the past 30 years has made it the duty of health care professionals to inform patients of their diagnosis. Now, there are General Medical Council guidelines (2006) that make it an ethical duty for the doctor to inform the patient of the diagnosis (Heyse-Moore 2009).

Parkes (Parkes & Markus 1998) discusses the importance of breaking bad news effectively and sensitively. Parkes sees this as an element in preparing for loss. He is specifically discussing how to care for the terminal patient, so this may be a limitation (Parkes & Markus 1998).He describes how the doctor should arrange and meet with patient. It is notable he does not provide exceptions and does not discuss involving family or speaking to a spouse first.

Parkes provides practical guidance possibly gained from clinical experience. He advises finding a “homely area” where everyone can be comfortable. This can be a place where everyone can sit and not be disturbed. The decor should be the opposite of clinical if possible. He discusses giving as much information as the patient can cope with, and suggests “bite sized chunks” of information (Parkes & Markus 1998, p. 8). He suggests inviting questions from the patient and using this to guide how to prevent information. The difficulty in talking about dying is where the patient becomes distressed and anxious, they may not take in what has been said, and may not fully understand the diagnosis or terminal nature (Parkes & Markus 1998).

If the dying person has a “thinking” coping style then the doctor can begin to help him/her focus on the feelings involved and expressing them; and vice versa for the person with a “feelings” coping style where the focus might be on the problem solving (Parkes 1996b).

In Bereavement: Studies of grief in adult life (Parkes 1996a) discusses the tendency for the family to conceal the truth from the dying person. He is clear that the patient should be told of the terminal illness. According to Hinton (1967) (see Parkes 1996a), dying people tend to know and value the chance to talk about their terminal illness. There is some evidence that older people contemplate the end of their life and possibly want to talk to others about it. In a small study of 20 older residents in care homes in the UK, only 2 residents did not wish to discuss dying and death and neither objected to being asked (MacKinlay 2006). Further, Parkes sees giving bad news as a process. It is the beginning of an anxious and stressful period. The doctor should take the time and with empathy help the patient to adjust to the psychological transition of terminal illness (Parkes 1996a).

In Speaking of Dying (Heyse-Moore 2009) Heyse-Moore discusses how it is possible to move the focus from the patient to the family if they are included in this initial discussion. Also it is possible for hidden or concealed barriers between family members to come to light while breaking bad news. She also writes of bad news as the beginning of a process that becomes part of the dying person’s life. She advises being honest with the patient, including saying “I don’t know”. There is an emphasis on balancing giving information and supporting the patient with his/her feelings and reaction to the news. The point is also made that an older generation of patients can react passively as they are used to “doing as the doctor tells them”.

There has been some research in communicating with the dying that agrees with Parkes. In a study in USA involving 137 individuals in 20 focus groups of patients, family members and health care professionals, there were some common themes identified around effective communication. The best communicators were suggested as being honest and using understandable language. Qualities elicited were being willing to talk about dying; being sensitive in giving the news; listening to the patient; encouraging questioning; being sensitive to when patient will discuss dying (Wenrich et al. 2001).

Information is necessary to cope and adjust in life in general. If the doctor fails to give correct information or even perhaps mislead the patient, this can cause confusion and distress as the patient may feel betrayed. The lie if told may not be consistent across teams and even silence can give information and be distressful to patients. This can undermine the trust implicit in modern health care (Parkes 1996b).

Parkes is speaking of the doctor as the professional who will break the bad news. This has probably been the sole duty and responsibility of the doctor in health care traditionally. Nurses and other professionals would face sanctions if they accidently gave information about the diagnosis. However, with the development of the multi disciplinary team; and professional roles for other health care workers it is possible for other members of the team including nurses to be involved in the meeting to discuss a terminal diagnosis (Heyse-Moore 2009).

Parkes however, conceives of the doctor as the agent of change for the patient. He argues that the medical profession should acquire the skills and knowledge to help the process of dealing with loss and with bereavement. He does not argue for a speciality role but instead argues that General Practitioners are ideally placed to facilitate this change process as they tend to build up a relationship with the patient over time and know the person well (Parkes & Markus 1998).

For Parkes the process that begins with breaking the bad news is not just about an ethical imperative to inform patients of their diagnosis. He believes that grief both for the dying person and the spouse and family involves “grief work” that is difficult and painful. For Parkes, breaking the bad news although this can be painful, allows the dying person and family to begin to prepare for loss (Parkes & Weiss 1983). He argues that anticipatory grief is less severe than grief due to unexpected death (Parkes & Weiss 1983).

This preparation can allow spouses to come closer together before death; and there is possibility of working through some grief prior to death (Parkes 1998) (Schaefer & Moos 2001). Kubler-Ross echoes this with her concept of unfinished business. She states that the dying person can share how she works through her grief and that this may allow the family to begin the process of grieving before death (Kubler-Ross 1973). Walter when examining the concept of unfinished business discusses the need to sort things out before death and if not attended to then this can lead to torment for the bereaved spouse and family (Walter 1999).

Death means a fundamental change to the person’s world. Distress and anxiety can result due to the difficulty in making sense of this seismic shock (Parkes 1997). A theoretical concept of Parkes is Psychosocial Transitions which he applies to losses in the broadest sense. He talks of a life changing event and an upheaval in the psychological internal world or assumptive world. Parkes view is that the dying and death of a loved one involves changes in meanings and relationships, status and roles and values which is why it can be so traumatic (Parkes 1993).

Parkes had done some research in one of his interview studies in Boston where he compared how two groups of bereaved spouses reacted depending on how much warning they had of impending death. In one group there was less than 2 weeks of notice and in the other there was over 2 weeks and even up to over a year’s knowledge of terminal illness. Parkes found that the long forewarning group fared better and more effectively in dealing with grief and this was consistent over significant period of bereavement (Parkes & Weiss 1983). Stroebe and Stroebe (Stroebe & Stroebe 1987) agree with this idea that forewarning can help deal with anticipatory grief and help spouses to share and resolve difficulties.

Parkes does not advise any exceptions to breaking the bad news. His approach is based on the universality of bereavement and the experience of loss. This may be a limitation for his work, if research suggests that grief and the process of bereavement is not universal to the human condition. Parkes, although he acknowledges concepts of pathological grief and mental illness, sees the process of loss as part of the human condition (Parkes & Markus 1998).

However, Heyse-Moore (Heyse-Moore 2009) provides a list of those who should not be given the bad news of a terminal diagnosis. Any patient who clearly states he doesn’t want to know his diagnosis or treatment options. The only caution here might be that often the dying person could change his or her mind and be ready to talk and discuss at some future point. Implicit in this example is the idea that the patient is autonomous and capable of making an effective decision regarding their healthcare and indeed their life.

Secondly, there is “demented person whose loss of memory means she has forgotten what you told her half an hour later” (Heyse-Moore 2009, p. 78). Thirdly, is the confused patient who cannot understand and fourthly, the psychotic patient who “are liable to incorporate the information you give them into their paranoid delusions” (Heyse-Moore 2009, p. 78).

The second example is the crux of the dilemma when dealing with Mr Brown in the incident in this essay. Together with the third and fourth examples about confusion and psychosis, the issue here is whether the patient has the capacity to make an informed decision about their treatment and ultimately, their life. Heyse-Moore argues that there should be a full discussion with the family and the multi disciplinary team with the aim of arriving at a consensus on how to proceed (Heyse-Moore 2009). This should also be done within the relevant health legislation framework, for example, in Scotland the Adults with Incapacity (Scotland) Act 2000 (Griffith 2006).

One example to illustrate this is sharing information with children. A study of a series of interviews with 20 social workers about their work with a total of 53 children of dying parents, revealed some guidelines in avoiding euphemisms with children and updating children regularly and giving information in “bite sized chunks” (Fearnley 2010, p. 453). However, one finding was that often the younger children were not given as much information and were not perceived by parents as understanding as much (Fearnley 2010).

A second example is with people with learning disability where withholding information about a dying relative can still be common. Read discusses several barriers to breaking bad news: such as lack of understanding about learning disability; some of sensory, behavioural and cognitive impairments of specific learning disabilities; and also, a continuing paternalistic attitude towards people with learning disability. This means treating people with learning disability as less than adult (Read 1998).

With dementia patients there is evidence that patients with Alzheimer’s are not told their diagnosis. Family members can be ambivalent towards disclosing diagnosis to their loved ones. However, in a study 69% of people experiencing memory problems stated they would like to know if further diagnosed with Alzheimer’s (Elson 2006). A systematic review suggested that disclosure of diagnosis with dementia is under researched. Euphemistic terms such as memory problems and confusion can be used. Clinicians reported difficulties in disclosing diagnosis to both patients and carers (Bamford et al. 2004).

On one level it is understandable that patients who perhaps lack capacity are not given full information about their own health or of those in their family or even details about death of loved ones. However, what is left if information is withheld but deception?

In a study of 112 staff working (in North East England) with dementia sufferers in care settings, 106 admitted to some form of lying to residents; 90% to ease distress; 75% to ease care givers distress and 60% to promote treatment compliance. Staff recognised both benefits and problems in using lies to help manage care (James et al. 2006).

In a further article, Wood-Mitchell et al (Wood-Mitchell et al. 2006) state that the most common reason given for a lie is when the dementing resident wants to see a deceased relative. Wood- Mitchell et al argue for a realistic stage response to such situations starting with sensitively imparting the truth; then trying meet the need by an alternative means; then trying distraction to some other activity; and finally using some form of a “therapeutic” lie. One of the problems care giving staff recognises in lying is inconsistency amongst the staff team and Wood-Mitchell et al argue that care planning should be considered to ensure consistency and also when lie should not be told.

A debate on the ethics of lying to dementing patients ensued in the Journal of Dementia Care in 2007, involving 6 separate articles for a variety of responses.

Walker (Walker 2007) argues that although lying to patients will happen but cannot be justified. She suggests finding alternate ways of interacting with patients using a Validation approach. She advocates being silence if the truth is judged too painful to give, though she emphasises staying with the person. The aim is to try and connect with the patient and workout the symbolic or hidden meaning.

Wood-Mitchell et al (Wood-Mitchell et al. 2007) then discuss the range of lies from outright lies down to not telling someone or not correcting them and so being deceptive. They argue against Walker’s Validation or symbolic meaning approach: describing dealing with dementia as problem solving where the sufferer has to sort cues out and find the correct behaviour. They argue that communication should be conceived of directly; else in the search for hidden meanings the nurse may ignore a basic need like going to the toilet.

Pool (Pool 2007) says the focus should be on emotions and feelings rather than factual information. She advocates using Rogerian principle of Congruence with person centred care for dementia sufferers and therefore cannot agree with Wood-Mitchell et al as this is fundamentally dishonest. While Muller-Hergl (Muller-Hergl 2007) describes care giving as being about integrity; and that suffering cannot justify lying or treating someone unethically. Fowler and Sherratt (Fowler & Sherratt 2007) does little but raise some further questions and acknowledge this in their article.

Bender (Bender 2007) makes a good case that the context is most important here. She argues that ethical absolutes are not useful for poorly paid and trained care staff. Bender advocates a realistic approach that accepts that in everyday life lies are tolerated and accepted and can even be valued to protect and care for someone. She suggests there is value in understanding a person’s life story and biography to aid communication and understanding. She also raises the question of new approaches to loss and bereavement around ideas of continuing bonds instead of accepting loss and moving on. Finally, she states the value of strong caring and therapeutic relationship that can withstand, if necessary the lie.

Health profile to identify health risk and promote the health and wellbeing of an individual living in Brent.

Introduction

Nursing health promotion can lead to many positive health outcomes, including compliance, quality of life, knowledge of patients about their illness and self-management (Bosch-Capblanc et al., 2009; Keleher et al., 2009).

Studies show that nurses have taken an individual approach and a shifting outlook on behaviour, and it seems that the development of the theory health promotion has not changed nurses ‘ realistic practices of health promotion (Casey, 2007a; Irvine, 2007). There has been some discussion on how to include health promotion in nursing programmes and how to redirect nurse education from being disease-orientated towards a health promotion ideology (Rush, 1997; Whitehead, 2003; Mcilfatrick, 2004).

Background

The World Health Organization is a specialized agency concerned with international public health. They defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. (WHO 2014) While this definition has been longstanding, contemporary critics have challenged its dimensions of absolute well-being. Huber and colleagues (2011) argued that with the emergence of chronic illnesses, the definition might not be suitable for the purpose and it might be useful to adjust the definition to entail the ability to cope.

Multitudes of factors combine to affect the health of individuals and population, which challenges their ability to cope. Some of these factors are geographical, biological, socioeconomic and political (NICE, 2007). While biological (age and sex) are fixed and some other factors such as behaviour are associated with individuals’ choice, educational, political and socio-economic factors beyond individual’s control can also determine their health. This is what makes the difference in the distribution of ill –health and mortality between the least and most deprived as detailed in documents such as the Black Report (1980) and Marmot Review (Marmot 2010; Office of National Statistics, 2017).

OVERVIEW OF INDIVIDUAL

For the purpose of this assignment the individual will be referred to as Mr Johnson to maintain confidentiality. Consent has been obtained from the concerned individual.

Mr. Johnson is a 56 year old unemployed individual who lives alone in a council flat in a council flat in Brent. He enjoys a take away 4-5 times a week. He’s very overweight and finds it difficult to get around and often doesn’t leave the house.

Epidemiology data of Brent

Brent is an ethnically diverse borough located in the north-west region of London. As of 2016, the population was approximately 328,800 people with projections to reach 345,400 by 2021 (Brent Joint Strategic Needs Assessment (JSNA), 2015) due to rapid population growth. Brent’s population is characterised by young people aged between 20 t0 39 years representing 35.1% of the whole population, while 11% of the population is made of older adults aged 65 years and over, which is growing at a higher rate than other adult age ranges (Office of National Statistics (ONS), 2011). In Brent, the white group are the majority with 33%, while 65% of the population distributed among the Black, Asian or other minority ethnicity (BAME). Brent has been ranked 15th of the most deprived areas in England. Parts of the borough have high levels of social and economic disadvantages (Brent JSNA, 2015). Socio-economic inequalities affect all aspect of health, ranging from risk factors to health outcomes and access to services (Marmot Review, 2010), resulting in a low level of social functioning in older adults with obesity. The borough has a gap in life expectancy between the most affluent and the most deprived areas. While overall life expectancy is similar to the rest of London, there are significant

health inequalities

within the borough with

mental health

as the largest cause of morbidity (Brent JSNA, 2015). This highlights the detrimental effect of social isolation and loneliness on the health and mental wellbeing of adults in this borough. Brent JSNA (2015) reveals that prevalence of overweight people (including obesity) in Brent was 28.5%. It was higher than England average of 22.4% (Appendix 1).

Determinants of health

Obesity and overweight adults are at higher risk of developing conditions such as type 2 diabetes. Type 2 diabetes rates in Brent compared to other parts of the UK is particularly high. In 2012/13, 7.8 percent of people on GP lists in Brent were recorded as having diabetes (Public Health England, 2014). Without intervention, 60% of men and 50% of women could be obese by 2050 (Wang et al., 2011). Further, according to the Health Survey for England (2015), adults between 55-64 years have the highest prevalence of obesity (37.3% men are obese and 34% women are obese) compared to other adult population age groups. Evidence demonstrates an increased impact of obesity on people with mental health issues (Gatineau and Dent, 2011; Bégarie et al., 2013). The relationship between mental health and obesity is bi-directional as illustrated in a study which found that adults suffering from depression are 58% more prone to becoming obese; while those who are obese are 55% more likely to develop depression (Luppino et al., 2010). Individuals living with depression eat excessively (The British Medical Association, 2014). The complex interplay of social determinants of health such as ethnicity, socioeconomic status, educational attainment, age and gender have all been suggested as possibly important risk factors that could affect the trend or strength of the association between both conditions (National Obesity Observatory, 2011).

In relation to Mr Jonathan there are many determinants that affect his health. Mr Jonathan is unemployed and is not financially secure and does not have disposable income. This affects his self-esteem and the value he holds of himself. His financial situation prevents him from participating in many things, therefore impacting on him social and emotional health. Being single impacts on Jonathan, he lacks interaction with other adults, preferring his own company. Mr Jonathan is overweight and does not think he has a problem. He doesn’t cook and orders take way most days. This aspect of his lifestyle is impacting greatly on his health. His emotional and social health is also being affected, he has low self-esteem, suffers depressive moods, he withdraws and isolates himself. Many of Mr Jonathan physical health troubles are genetic. He suffers from

hypertension

as does his father and brother, he also has a hereditary hypercoagulability disorder. He also has pre-dispositions to other illnesses. Heart disease and cancer are common in the immediate family as are diabetes mellitus and glaucoma. The medications that Mr Jonathan takes have contributory effects that add to the state of his overall health. Many of the determinants that evidently contribute to his health are within his control, given the appropriate support and advice of healthcare professionals Mr Jonathan can take steps to improve her health.

Impact of Health Policy

The Care Act (2014) has vital impact on people with multiple LTCs and complex care needs alongside their carers; and the mandate from the government to the NHS for people to be treated as individuals and not as a collection of conditions (DoH, 2014). Other policy include;‘ No health without mental health’(DoH, 2014) strategy document, which place mental health on the same level with physical health by guaranteeing the access to good-quality services, support, countering stigma and negative attitudes to mental health across the whole of society. The Brent local policy outlined key priorities informed by the JSNA (2015) and National Policy, one of which is concerned with working collaboratively to support the vulnerable adults. Specifically, the strategy for this group in Brent is to improve urgent care as well as integrate health and social care services to help identify vulnerable adults, provide support people with LTC and their carer and reduce rate admissions. Other strategies include care pathways/guidelines, case management and with a single named health or social care professional a care coordinator. (NICE, 2018).

Nurses and other Healthcare professionals are often identified as key contributors and agents of change in many health targets by the government. Making every contact count provides an opportunity to educate and empower individuals to make primary positive choices about their own health. They have a crucial role in understanding the health needs of individuals and population groups, the delivery of care and promoting change in behaviour using appropriate resources as prevention strategy that can empower, educate, and prevent avoidable disease (PHE, 2013; NMC Code, 2015, p.5).

Accessing Health Services

There are several influential factors that affects how health services are accessed by group of people similar to Mr Jonathan in Brent, these factors include; fear of future, stigma, environmental factors and cultural conceptualisation. A qualitative study in Southeast England by Memon et al. (2016) found two broad themes as perceived barriers to accessing mental health services: first, personal and environmental factors which include cultural identity, negative perception of and social stigma against mental health, lack of knowledge to recognise and accept mental health problems, impact of social networks and low economic status. Secondly, the factors influencing the relationship between health provider and service users; which included the effect of long waiting times for initial assessment, and ineffective communication between providers and service users. For strategies to improve greater engagement, additional thought needs to be given to solutions that cater for service users with poor functional and health literacy (NHS Outcome Framework, 2016), communication preferences (Leung et al., 2010, NICE, 2018) and exploring opportunities to encourage co-production (The Health Foundation, 2010). For the older adults in Brent, engaging health services becomes even harder with the bidirectional relationship between physical and mental health problems, whereby individuals with mental health problems are at an increased risk of developing physical health problems (Poblador-Plou, 2014). This suggests specialist support through the Home Treatment Team in Brent.

Role of Nurses

The Royal College of Nursing (2007) identified four nursing role functions as supportive, restorative, educative and life enhancing.

Nolan, Davies, and Brown (2006) suggest that therapeutic relationship should be built, which will allow for natural interaction between all involved in care delivery; carers, family, health and social care staff, and patients. While this requires substantial engagement time that can be a barrier, the nurse is required to prioritise care (NMC, 2015; Skaalvik et al., 2010). A strong Nurse-patient relationship and tailored communication skills facilitates accurate assessment and improved outcomes (Jenkins et al., 2016). Good communication and integrated IT system between and across services —primary, secondary and tertiary care, will allow appropriate management and treatment of any physical and mental deterioration that warrants urgent treatment. Research shows that poor communication can lead to poor care outcomes (Goldberg et al., 2011). Communication strategies should include engagement of patients, their carers and family in shared decision making about the escalation of their care.

Health Promotion

Physical inactivity and an unhealthy diet are closely linked to excess weight and obesity. In the document, ‘Making Every Contact Count’ NHS (2014), obesity was identified as one of the five main public health issues in the United Kingdom, suggesting the urgency in addressing the consequent likelihood of illness or preventable death.

Barry and Yuill (2008) highlight statistics that show that people living in poverty make bad nutritional choices and diets are often high in fat and sugar leading to heart disease and increased risk of certain cancers.

From the SF-36 questionnaire that was given out, it was discovered that there’s a lot of factors that contributes to Mr Jonathan being overweight. From the GP Physical activity questionnaire that was given out, question 1A, it was discovered that Mr Jonathan is unemployed. Mr Jonathan doesn’t do any physical exercise as he doesn’t leave his flat. In Brent, 30.5% of the adults living in Brent are physically inactive and in England, an average of 22.2% of the adults is physically inactive day’ (Public Health England (PHE), 2018) (Appendix 1).

Only 55.5% proportion of the adult population in Brent meets the recommended ‘5-a-day’ on a ‘usual day’. 2.54% average number of portions of vegetables is consumed daily by adults and 2.59% average number of portions of fruit is consumed daily by adults living in Brent (Public Health England (PHE), 2018) (Appendix 1). The UK Diabetes Diet Questionnaire (UKDDQ), question 1, 2, 3, 5 and 11 tells us that Mr Jonathan doesn’t eat any vegetables or fruits. However he often drinks fizzy drinks. He eats a lot of cake, sweets and fast food from restaurants. As a nurse, the advice to Mr Jonathan will be to have a good variety of healthy foods from the five food groups each day. His healthy diet should consist of fruits, vegetables, whole grains, low-fat dairy products and lean meats (Appendix 3). On top of eating well, Mr Jonathan must also minimize your consumption of sugar and saturated fat. Mr Jonathan should only occasionally eat sugary, fatty or salty food, and then only in small amounts. He should drink fresh, clean tap water instead of sugary drinks.

Regular exercise and the having a healthy diet can lead to a lot of benefits, including increased energy, happiness, health and even a long life. It can reduce Mr Jonathan risk of heart disease, osteoporosis, type-2 diabetes, high blood pressure and some cancers. Appendix 2 compares the prevalence of individuals living with Diabetes in England to individuals living in Brent. Exercise and diet are important to determining a person’s overall health, and making them a lifestyle can make a dramatic difference in how an individual look and feel. In Brent, there are 19 outdoor gyms. The outdoor gyms can be used free of charge, seven days a week. This will be suitable for Mr Jonathan. He is unemployed and won’t have to worry about having to pay monthly because it is free. The outdoor gyms have a wide variety of equipment to help manage weight, improve cardiorespiratory fitness, muscle strength and tone and flexibility (Brent.gov.uk, 2019)

Being overweight and depression often goes together. This is the case with Mr Jonathan. He’s overweight and because of this he has low self-esteem, suffers depressive moods, he withdraws and isolates himself. In Brent, Mr Jonathan can get psychological therapies, including CBT, on the NHS. The referral for this service can be done either by a GP or self-referral.

However the extent of waiting for specialist support is a problem. It’s possible that Mr Jonathan might have to wait weeks before he can access psychological talking therapies. There are private therapy sessions for those that can afford to pay for it. This will not be suitable for Mr Jonathan because he is unemployed.

The Therapy for Low Self Esteem will Involve Mr Jonathan discussing with the therapists about the beliefs that he holds about himself and how these affect how he feel and the choices that he make. The therapist will teach Mr Jonathan techniques to reduce self-criticism and doubt and help him learn to build a more accepting, positive and nurturing attitude towards himself. The therapist will help him to deal with any feelings of anxiety, anger or depression associated with his low self-esteem.

Conclusion

One strength to be considered in this resource is the fact that its development was informed by epidemiological statistics and relevant models and literatures. However, its effectiveness might be limited by the lack of involvement and inputs from the target population in its design. Though engaging in physical activities and eating healthy are important health seeking behaviours that can improve the health outcomes of Mr jonathan, but these does not address other determinants of health inequalities ingrained in socio-economic and political aspects of the environment where this individual live, work, and socialise.

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Appendix 1: Public Health Profile (2018)

Appendix 2: Brent JSNA Highlight Summary Report

Appendix 3: Five a day