What is the probable outcome or prognosis? Is it possible to eliminate the disorder? Can the disorder be prevented?
Are there specific populations, cultures, or age and gender features indigenous to the disorder?
Family Assessment and Intervention of the Rogers’
The purpose of this paper is to expand on the interview conducted with a selected family while using the Calgary Family Assessment Model (CFAM) to create a nursing diagnosis, teaching plan as well as strength-based nursing interventions based on Calgary Family Intervention Model (CFIM). The selected family was referred to the nursing student by a close friend and colleague. The initial meeting took place at the Roger’s home where informed consent was signed, and a relationship of trust was established by introducing myself, followed by a brief explanation for the meeting (Kaakinen, Coehlo, Steele & Robinson, 2018). A 15-minute interview using the CFAM (structural, developmental and functional assessment) as a data collection guide was used to gain a better understanding of the family’s story. The Roger’s family consists of Sandra, who is a single mother of two children, Ashton and Jordon. Since the estrangement of the children’s father, Sandra has a difficult time asking for help outside of extended family and close friends which in turn increases her stress levels and causes a significant impact on the family. Because of this, Sandra often struggles with the many disadvantages of single parenthood, despite the family’s strong emotional bond. With the help of the grandmother, Mary, the family can meet many of the daily challenges. Since Sandra’s recent diagnosis with Fibromyalgia (FM), she is struggling with her management of increased stress due to the disease process which is affecting her activities of daily living (ADLs) and the functioning of the family. Findings within this assessment represent a glimpse of this family and are subject to change. For confidentiality purposes, pseudo names were used throughout the paper.
Structural Assessment
The structural assessment, according to Wright and Leahy (2013), examines the members of the family, and their connections by reviewing the internal structure, external structure and family content.
Internal Structure
The Roger’s family internal composition consists of a self-identified heterosexual 41-year-old mother Sandra as well as her two children Ashton and Jordon. Ashton is a 13-year-old adolescent female just graduating grade 8 and Jordon is a 6-year-old boy graduating from kindergarten this year. Aside from Sandra, Ashton and Jordon have strong emotional ties to their grandmother, Mary, who is recently retired at 68 years of age and an integral part of their lives by assisting with childcare and accommodations when needed. In terms of gender, Sandra facilitates both mother and father roles since the birth of Jordon in 2014. During the interview, the differences in ages between the two children were noted. Also, to understand the families rank order and the impact on the children’s development, the family was asked if the difference in birth spaces between children were involuntary or were the pregnancies planned. Sandra indicated by verbalizing that “Her pregnancy with Jordan was accidental and the biological father, Michael, has been estranged since the announcement providing no emotional or financial support to the family until recently” (S. Rogers, personal communication, May 30, 2019). Within the past few months, 41-year-old father, Michael, has attempted to reconcile with his family. Sandra also explained how the unexpected estrangement contributed to the current subsystems within the Roger’s family by leaving Sandra to be the primary parental subsystem for each child and the grandmother, Mary, accepting the role when Sandra was unable to. This estrangement has also left Ashton to take on more of an adult role, at times, by assuming a surrogate-spouse subsystem in the absence of the father (Wright and Leahy, 2013). A long history of trauma has affected Sandra’s boundaries, both internally and externally. Over the years, Sandra has developed difficulties with establishing trusting relationships outside of her extended family and close friends, especially since the estrangement of the children’s biological father. Her boundaries are closed/rigid, and she has a difficult time accepting or asking for help, which often increases her fatigue and stress levels. The genogram for this family is in Appendix A of this paper.
External Structure
The external structure includes extended family and larger family systems (Wright & Leahey, 2013). Sandra is the youngest of three siblings, and unfortunately, their relationship has been severed due to its toxicity. Whereas Sandra’s ambiguous relationship with her father has been the cause of childhood trauma, and although she still has contact with him periodically, he has been absent for the majority of her adult life. Currently, her father resides within the same urban centre but will only contact Sandra and her children when he needs something. The remainder of the extended family lives in Ontario and have minimal contact with her and the children; however, Mary goes to visit them yearly. The lack of extended family in Sandra’s life often leads to her dealing with problems alone, especially when larger support systems are problematic and not accessible. Since becoming a single parent family, financial resources have drastically reduced. The previous unsettled battles with the Provincial Family Justice system regarding defunct child support payments were exceptionally frustrating. Combined with, Sandra’s battles with her family physician regarding her FM symptoms that were disregarded, prior to diagnosis by a new family physician helped to create hesitancy, resistance and distrust in our provincial/regional services provided to her and her family.
Additionally, the lack of understanding and work schedule discrimination that have been imposed by numerous employers because of her sociological status is relevant to the number of jobs Sandra has held within the past six years. Not to mention, the time and energy needed to ensure that Ashton and Jordon are in activities, spend time with their friends, and get homework done for school often leaves Sandra very little time for her wellbeing. Sandra stated that her “close friendships have been a saving grace and play a vital role in the comfort and emotional support” (Rogers, 2019). The ecomap of this family is in Appendix B of this paper.
Context
Sandra considers her ethnicity as North American culture, whereas her children’s ethnicity is deemed to be indigenous because of their fathers’ Cree ancestry. Sandra has taken the necessary steps to ensure that both children have been legally identified as indigenous and issued a status card, so they are recognized as aboriginal by society. Conversely, the children take taekwondo as their weekly activity attend a Catholic school; have chosen to learn French as a second language and know very little about their indigenous heritage. When asked about social class, Sandra responded that “there were times when money was tight and being a single parent everything has to count because you have to juggle your time, money and work” (Rogers, 2019). Sandra felt that she is often looked on by society as low to lower middle class due to her the education level, and her children’s ethnicity or race. However, she is always thankful to be able to clothe, feed and care for her children to the best of her ability thanks to the assistance of Mary and the various supports available to her within her community such as low-income housing. Michael’s efforts to reconcile with the family by upholding his financial obligations and finally paying his allotted monthly child support payments has lightened the financial burden on the family. Sandra considers herself spiritual; however, she does not choose to attend a place of worship. Sandra believes that spirituality has many perspectives. Her ideology of spirituality is that happiness, strength and blessings in life are gifts from a higher power that are unique to each of us.
Development Assessment
As previously indicated, Michael, has been estranged from the family following the announcement of Sandra’s pregnancy until recently. The complexities involved with childrearing by a single parent can be very challenging. According to Wright and Leahey (2013), single-parent families must accomplish most of the same developmental tasks as families consisting of two parents, with limited resources. Sandra has accepted the role of both mother and father; therefore left to tackle responsibilities involving the emotional, psychological and developmental growth of each child as well as her own.
Functional Assessment
The functional assessment, according to Wright and Leahy (2013), consists of two parts instrumental and expressive functioning. It looks at the interaction between family members and the operation of everyday life for the family.
Instrumental Functioning
This section covers family routine, activities of daily living such as cooking, cleaning, shopping (Wright & Leahy, 2013).
When asked how she manages the daily challenges, Sandra stated: “I am not sure how I do it, but every day is different, and some are harder than others.” (Rogers, 2019). On days that Mary, the grandmother is there to assist with the before and after school childcare, she does assist in household duties and prepares supper. As a single parent, Sandra has the sole responsibility for all day-to-day aspects, and although Ashton does help out, Sandra tries to avoid exploiting her efforts. In regards to family decision making, the family acknowledges having a shared responsibility consulting each other in many family decisions.
Expressive Functioning
The Expressive functioning of CFAM Models includes nine subcategories such as: “emotional communication, verbal/nonverbal communication, circular communication, problem-solving, roles, alliances and coalitions of the family” (Kaakinen et al. 2018, p124). Sandra admits to habitually finding herself unable to relinquish the self-destructive behaviours of not always discussing her emotions when needed in fears of being judged. These emotional barriers have increased stress levels and contributed to her health problems. Sandra has sought professional support to facilitate relief for her anxiety and stress caused by these behaviours.
Despite this, the interactions between the children and her demonstrate that they have strong communication skills and a good relationship. The children are affectionate toward Sandra, and Sandra frequently speaks about their feelings and opinions. Jordon has a mild form of ADHD (Attention deficit hyperactivity disorder) that requires Sandra to repeat instructions, and ensure her verbal and non-verbal communications are clear and directed, so Jordon remains focused. Jordon is encouraged to use his inside voice when speaking verses yelling. Also, lots of facial expressions, eye contact and gestures are often used when Sandra is busy and cannot give Jordon his required attention. Whereas, Sandra mentioned that more Therapeutic communication is used with Ashton because she is in her adolescent years. When youth experience circular communication as a result of increased, anger and defiance problems in family functioning occurs (Liermann & Norton, 2016). Sandra believes that is it important to try and maintain communication because with positive communication emerges positive relationships.
The family believes that they can solve problems with perseverance and communication. The challenges faced sometimes vary according to circumstances, but when in doubt, grandma, Mary is called to help. When considering the subcategory roles within the family, as mentioned previously, Sandra has maintained the roles of both mother and father within the family unit. Sandra also values Ashton’s contribution and assistance in preserving family function but does watch to ensure that she does not take on the parental role. Despite this family’s challenges, they function very well as a unit. Influence and power, as well as beliefs, were not assessed during the interview.
In terms of the family’s alliances and the coalition, they fall into a triangular alliance with Grandmother, Mary, deemed helpful and unhelpful at times when boundaries/ roles are being challenged because of intensified tensions.
Rogers’ Family Nursing Diagnosis and Interventions
According to Kaakinen et al. (2018), the family reasoning web is useful in analyzing data from the family assessment into meaningful data groups. The nurse asked the family to identify their strengths and weakness so that competent care could be implemented (Silva, Moules, Silva, & Bousso, 2013). The family determined that their strengths were respect and love for one another, and their weaknesses were poor knowledge of disease process, together with decreased activities of daily living (ADLs) which is affected by ineffective stress management. These recognized areas were used to collaborate with the family appropriate family-based nursing diagnosis and interventions based on the CFIM (Calgary Family Intervention Model). There was two family nursing diagnosis and two interventions identified.
The first nursing diagnosis identified is deficient knowledge related to lack of information related to disease process, as evidenced by patient’s inquiry about the management of daily challenges needed for health recovery, maintenance and health promotion (Gulanick & Myers 2014 p. 115). Education provided to patients and their families within this cognitive domain by healthcare professionals plays a substantial part in patients obtaining the best possible health outcomes. Patients with FM often rank cognitive dysfunctions such as memory and mental alertness high in terms of the disease process; however, they also experience pervasive pain and tender points, extreme fatigue, accompanied by anxiety, and sleep problems (Årestedt, Benzein, & Persson, 2015). By working with the patients to increase knowledge, deficient nurses can assist in health promotion and alleviate frustrations associated with the disease process. Setting goals and discussing management of symptom expectations with therapeutic communication by healthcare professionals not only establishes trust, but self-management strategies personalized to that individual enhances better quality of life (Wayne, 2016 p. 1).
The other nursing diagnosis is ineffective coping strategies related to her recent diagnosis of FM as evidenced by increased stress and anxiety (Ladwig, Ackley & Makic, 2019). Based on the CFAM assessment, Sandra is having a difficult time managing her stress levels. Sandra’s stress levels and decreased activities of daily living (ADLs) is directly related to FM and the vicious cycle of non-restorative sleep, pain and increased anxiety (Davis et al. 2017). By recognizing the need for appropriate strategies through active listening, commendations and empathetic communication, we established a supportive environment. Healthcare professionals can teach patients how to focus on the present, let go of any emotional barriers, and how to use available resources (Gulanick & Myers 2014). By doing so, Sandra will recognize her strengths, which can facilitate improved coping and reduce stress. FM is a very complex disorder with no apparent cause and no cure; I commended Sandra for her strength and perseverance in overcoming her daily challenges associated with this disease process.
Teaching Plan Rationale
The information attained from the CFAM (Structural, developmental and functional assessment) data collection we created a recommended teaching plan for the Roger’s family. Sandra’s FM symptoms are currently increasing because of the stress associated with her inability to complete ADLs. Because Sandra is stressed, the children will also be stressed based on the concept of the family system theory by (Kaakinen et al. 2018). The author believes that the family is a system, all parts are interconnected and what affects one area will ultimately affect the other parts of the system (Kaakinen et al. 2018). Once Sandra can achieve a state of wellbeing by managing her symptoms of FM, the family’s functions and processes will also benefit. The teaching will focus on Sandra reducing or maintaining her stress levels, which in turn will reduce symptoms associated with her illness and enhance the wellbeing of the entire family.
Mindfulness-based Stress Reduction Techniques
A Mind-body therapeutic approach called Mindfulness-based stress reduction (MBSR) will teach Sandra how to reduce her stress-related symptoms of FM. This practice integrates mindfulness meditation, in addition to, complementary Mind-body therapies such as body scanning, hypnosis, reflexology and several other relaxation techniques (Chadi et al. 2016). MBSR focuses on calming your emotional- related brain activity, which has been linked to the reduction of pain, stress and anxiety, through increased self-awareness and body sensations (Cash et al., 2015). According to Koçak & Kurt (2017), MBSR provides effective treatment for treating symptoms related to FM and is frequently recommended as an alternative approach to traditional remedial therapies. This teaching plan will teach MBSR techniques to Sandra and assist her in identifying stressful events, increasing her ADLs; by reducing symptoms of FM and the impact on the family. The Teaching Plan for this Family is in Appendix C of this paper.
Conclusion
In conclusion, the CFAM Model has been used to assess the Roger’s family. Although the family assessment and interventions in this paper are just a current snapshot of the Roger’s family the CFAM and CFIM has allowed the nurse to recognize, interpret and implement change strategies for the family to promote positive family outcomes (Wright & Leahy, 2013). The Roger’s family have a strong family bond based on good communication and an excellent relationship. The Roger’s family identified their strengths as respect and love for one another and their weaknesses as ineffective stress management and decreased ADLs related to Sandra’s recent diagnosis of FM. Nursing diagnoses were developed to address some of the family concerns. The nursing diagnoses were: deficient knowledge related to Sandra’s current diagnosis and Ineffective Coping Strategies, which exacerbates symptoms of the disease process. In the area of health promotion, the CFIM Model was used to develop family centred interventions. Both individual and family strengths were commended, along with therapeutic communication maintained. Finally, to assist in the family’s wellbeing, as well as a reduction in the symptoms of FM exacerbated by increased stress, a teaching plan was presented to Sandra.
References
Professional development Planning (PDP) is a structured and supported process undertaken by an individual to reflect upon their own learning, performance and / or achievement and to plan for their personal, educational and career development. The primary objective for PDP is to improve the capacity of individuals to understand what and how they are learning, and to review, plan and take responsibility for their own learning. It helps to ,
Become more effective, independent and confident.
Improve their professional skills for career growth.
Articulate personal goals and evaluate progress towards their achievement.
Encourage a positive attitude towards work throughout life.
1.1.1 What is Professional development plan:
A professional development plan is a set of guidelines used to improve or redirect a career. It improves self-knowledge and identity, develop talents and potential, build human capital and employability, enhance quality of life and contribute to the realization of dreams and aspirations.
PDP encourages individuals to think more deeply and more broadly about their discipline by getting them to reflect on what they’re learning and to draw deep connections between what is being taught and how they are synthesizing that knowledge.
A PDP helps you to think through, and lay out the following:
Where am I now?
Where do I want to get to?
How can I get there?
How will I know once I’ve got there?
1.1.2 Why PDP is Important?
A PDP important to highlight the goals you would like to achieve in your professional and/or personal life. It provides a format for you to plan and track your learning needs. Each PDP will be unique, as although you may have the same aims as another person, how you achieve them may be different.
It’s the best way for you to manage your own development. Evidence shows that the more time you take to identify, prioritise and plan your development needs, the more successful you are likely to be.
It helps you to identify what you want to try, observe, get feedback on, or learn in any given situation.
It provides a clear and structured way of working with others (e.g. colleague, mentor, supervisor)
Regularly updated PDPs are excellent evidence of Continuous Professional Development (CPD) for courses or programmes.
Regardless of whether you are in business for yourself, or simply work for a living, having a strategic plan covering your professional development is essential to your long term success or employability. Failure to plan is truly as we’ve heard “planning to fail!”
1.1.2 The Skills required to achieve the strategic goals:
Professional Skills are the foundation for success at every organization. As the work-place has also changed, with the result that employees are expected to have a wider range of skills. Since I am working in a Business process outsoucing (BPO) firm its imperative to have a wider range skills set to function effectively and to support to achieve organizational strategic goal. Below are the professional skills required to achieve organizational goals.
Communication skill:
Communication is the most important skill required when you are working in a BPO. In a day to day work we need to communicate with the clients for deliverables and reporting the results, this requires very effective communication to complete the work on time. Basically our work is all about risk assessment and risk management, in this case reporting those assessments plays the key role that requires a good communication skill. In my work i need to raise my concerns when there is an issue of control laps in risk mitigation. At the same time I have to communicate the concerns effectively in such a way it should be reasonably and understandable. This requires a good communication skill. On the whole it will satisfy our clients and satisfy our purpose of business and helps to achieve our organizational goals.
Interpersonal skill
Interpersonal skill helps to interact with the team members effectively and get the works done. This skill is all about how you move with others and helps to work as a team. I my work I have to work with the team and each member’s contribution is imperative to achieve the common goals. My interpersonal skill improves my productivity and my team’s performance too. Interpersonal skill that I possess helps me go up in ladder and my team and it encourage us to achieve the organizational goal.
Leadership skill
Leadership skill is very important to lead a team. In my work I hold the post of team leader, team leaders must possess the leadership skill as they have to lead the team. I have a good leadership skill that helps me to get the work done. It all about delegating the responsibilities and keep an eye on them, it makes lot positive energy to the team and that in return improves the productivity of the team and to achieve the organizational goal.
Time management skill
Time management skill is controlling time spent on various activities and managing it efficiently to increase the productive. The work I do in my process, we have to spend lot of time in assessing the controls placed to mitigate risk and I have to plan my time spent on this particular activity. If that particular acivity takes most of the time then I have to hurry on other activity. It will create error, hence I have manage my time properly to keep a balance. In that way we can csatisfy our clients and satisfy ourselves by a step towards achieving the organization goal.
I manage my time by,
Creating a task list
Prioritizing the activity
There are two techniques are shown below that way can assess our personal and professional skills-
As a manager, I…
1. Listen more than I talk.
2. Ask questions to ensure others understand my instruc-
tions.
3. Use positive language in my communications.
4. Am conscious of my tone and body language when talk-
ing.
5. Ignore all distractions when listening to others.
6. Practice active listening techniques.
7. Am seldom misunderstood when I talk to others.
8. Adjust my communication style to my audience.
9. Am comfortable giving presentations to groups.
10. Use a writing style that is professional and seldom misunderstood.
11.Work to ensure that my team is meeting or exceeding
Customer expectations.
12. Address and resolve customer complaints quickly.
13. Ensure staff members understand how their work affects the customer.
14. Survey customers to find out how we’re doing.
15.Work effectively with internal customers (other depart-
Ments) to accomplish tasks.
16. Find opportunities to reward and recognize staff.
17. Set goals with staff members and create action plans.
18. Conduct formal and informal coaching sessions with staff member
19. Regularly observe employee performance to determine
Potential challenges.
20. Conduct positive and effective performance valuations.
21. Use a consistent time management system.
22. An effective at delegating work.
23. Know how to use all the technology and tools that are
available to me.
24. Employ a standardized system for project plans.
25. Can quickly and easily locate any records in my office
26. Receive ongoing feedback and coaching on my position
27. Know the big picture and my department’s role in the organization.
28. Frequently participate in training and development al
opportunities.
29. Review my goals and action plans regularly.
30. Have completed an individual development plan (IDP) in the last year.
31. Understand all employment laws.
32. Know all the steps to handling harassment cases.
33. Am comfortable with disciplining an employee.
34. Conduct effective and legal employment interviews
35. Document all employees counselling sessions.
36. Monitor my employees’ assignments without microma-
naging.
37. Delegate assignments evenly throughout my department.
38. Follow up on all tasks that I have assigned to staff mem-
bers.
39. Solicit input from various resources before making decision
40. Make decisions easily and effectively.
41.Create
a positive atmosphere
in which
teams
Work
together effectively.
42. Work effectively with persons of diverse personalities and backgrounds.
43. Regularly solicit input from members of my department.
44. Ensure that my teams know their purpose and authority
Level on projects.
45. Create opportunities for others in my department to take
Leadership roles.
46. Am calm and unbiased when handling office conflicts.
47. Am able to solve most problems that arise among workers in my department.
48. Solicit input from those closest to the problem.
49. Investigate to ensure I’m addressing the real problem, not just a symptom.
50. Conduct evaluations to review decisions and results.
Conclusion
Based on the above assessment, I can conclude that I am comparatively more effective in Communication skill, Customer service, Organizational skill and Team work.Skills like problem solving shows moderate score. At the same time, there skills like leadership skill, Legal issues, performance management and professional development shows low effectiveness and I need to put more emphasis on these skills to develop myself for professional growth and to achieve organizational goal.
This questionnaire will helps you to identify the types of roles that you perform in the team. You may be tempted to think that your own preferred way of working is the `best`, and you may think much of the contributions from people whose personality is different. Belbin undertook some research which clearly demonstrated the need for a mix of people with a team, or else team performance can suffer. The performance of team can be enhanced if I learn to value the different contributions offered by the team members.
For each section, distribute a total of ten points among the sentences which you think best describe your behaviour. These points may be distributed among several sentences: in extreme cases they might be spread among all the sentences. Or ten points may be given to a single sentence.
Section I : What I believe I can contribute to a team:
I think I can quickly see and take advantage of new opportunities
A
I can work well with a very wide range of people
B
Producing ideas is one of my natural assets
C
My ability rests in being able to draw people out whenever I detect they have something of value to contribute to group objectives
D
My capacity to follow through has much to do with my personal effectiveness
E
I am ready to face temporary unpopularity if it leads to worthwhile results in the end
F
I am quick to sense what is likely to work in a situation with which I am familiar
G
I can offer a reasoned case for alternative courses of action without introducing bias or prejudice
H
I am not at ease unless meetings are well structured, controlled and generally well conducted
A
I am inclined to be too generous towards others who have a valid viewpoint that has not been given a proper airing
B
I have a tendency to talk a lot once the group get onto new ideas
C
My objective outlook makes it difficult for me to join in readily and enthusiastically with colleagues
D
I am sometimes forceful and authoritarian if there is a need to get something done
E
I find it difficult to lead from the front, perhaps because I am over responsive to group atmosphere
F
I am apt to get too caught up in ideas that occur to me and so lose track of what is happening
G
My colleagues tend to see me as worrying unnecessarily over detail and the possibility that things may go wrong
H
I have an aptitude for influencing people without pressurising them
A
My general vigilance prevents careless mistakes and omissions being made
B
I am ready to press for action to make sure that the meeting does not waste time or lose sight of the main objective
C
I can be counted on to contribute something original
D
I am always ready to back good suggestions that are in the common interest
E
I am keen to look for the latest in new ideas and developments
F
I believe my capacity for cool judgement is appreciated by others
G
I can be relied upon to see that all essential work is organised
H
I have a quiet interest in getting to know colleagues better
A
I am not reluctant to challenge the views of others or to hold a minority view myself
B
I can usually find a line of argument to refute unsound propositions
C
I think I have a talent for making things work once a plan has to be put into operation
D
I have a tendency to avoid the obvious and to come out with the unexpected
E
I bring a touch of perfectionism to any team job I undertake
F
I am ready to make use of contacts outside the group itself
G
While I am interested in all views, I have no hesitation in making up my mind once a decision has to be made
H
I enjoy analysing situations and weighing up all the possible choices
A
I am interested in finding practical solutions to problems
B
I like to feel I am fostering good working relationships
C
I can have a strong influence on decisions
D
I can meet people to agree on a necessary course of action
E
I can get people to agree on a necessary course of action
F
I feel in my element when I can give a task my full attention
G
I like to find a field that stretches my imagination
H
I would feel like retiring to a corner to devise a way out of the impasse before developing a line
A
I would be ready to work with the person who showed the most positive approach, however difficult he or she might be
B
I would find some way of reducing the size of the task by establishing what different individuals might best contribute
C
My natural sense of urgency would help to ensure that we did not fall behind schedule
D
I believe I would keep cool and maintain my capacity to think straight
E
I would retain a steadiness of purpose in spite of the pressures
F
I would be prepared to take a positive lead if I felt the group was making no progress
G
I would open up discussions with a view to stimulating new thoughts and getting something moving
H
I am apt to show my impatience with those who are obstructing progress
A
Others may criticise me for being too analytical and insufficiently intuitive
B
My desire that work is done properly can hold up proceedings
C
I tend to get bored rather easily and rely on one or two stimulating members to spark me
D
I find it difficult to get started unless the goals are clear
E
I am sometimes poor at explaining and clarifying complex points that occur to me
F
I am sometimes poor at demanding from others the things I cannot do myself
G
I hesitate to get my points across when I run up against real opposition
H
Transfer the point, allocated to each question, into the following table:
Section
IM
CO
SH
PL
ME
TW
CF
I
G
8
D
7
F
7
C
7
A
7
H
7
B
9
E
II
A
7
B
6
E
7
G
7
C
6
D
5
F
8
H
III
H
7
A
8
C
7
D
7
F
9
G
8
E
6
B
IV
D
9
H
7
B
4
E
8
G
6
C
6
A
6
F
V
B
6
F
6
D
6
H
3
E
5
A
7
C
8
G
VI
F
7
C
5
G
7
A
7
H
9
E
9
B
9
D
VII
E
5
G
8
A
7
F
6
D
6
B
6
H
3
C
Total
48
47
45
45
48
48
49
54
Conclusion:
Based on the above assessment, the Team Role”Complete finisher” got the maximum score and hence that would be my primary role. Based on that I would Ensure the job is properly finished and I have the qualities like Painstaking, Conscientious, anxious, search out error and delivers on time. And also I got comparatively high score in “Team worker” and that would be the secondary role.
PL
Generates ideas, creative, imaginative, unorthodox, solves difficult problems.
Ignores details, too preoccupied of communicate effectively.
Maintains awareness of resources is available outside the team. Extrovert, enthusiastic, communicative, explores opportunities, develops contacts.
Overoptimistic, loses interest once the initial enthusiasm has passed.
CO
Ensures internal resources and applied to the team objective. Mature, confident a good chairperson, clarifies goals, promotes decision making, delegates well.
Can be seen as manipulative, delegate’s personal work.
SH
Shapes the way the team operates. Challenging, dynamic, thrives on pressure, has the drive and courage to overcome obstacles.
Can provoke others, hurts people’s feelings.
ME
Asses team progress against the objectives and milestones. Sober, strategic and discerning, sees all options, judges accurately.
Lacks drive and ability to inspire others, overly critical.
TW
Involves everyone, looks after individual needs, and seeks to gain commitment by participation. Co-operative, mild, perceptive and diplomatic, listens, builds, averts friction, and calms the waters.
Indecisive in crunch situation, can be easily influenced.
IM
Turns the jobs into practical actions. Disciplined, reliable, conservative and efficient.
Somewhat inflexible, slow to respond to new possibilities.
CF
Ensures the job is properly finished. Painstaking, conscientious, anxious, searches out errors and omissions, delivers on time.
Inclined to worry unduly reluctant to delegate, can be a nit-picker.
Knowledge and skills which I consider to be important for my current voluntary activity
My Ability Rating (1-5) or strong / weak / somewhere in between
I try to view problems as challenges rather than major obstacles.
I can Communicate with the clients effectively.
I am interested in finding practical solutions to problems
I can lead the team and capable delegation and decision making.
I would like to keep on innovating new ideas for teams performance
4
4
5
5
5
Knowledge and skills which I consider to be important for my future career
My Ability Rating (1-5) or strong / weak / somewhere in between
I need to update myself with technical knowedge to function efficiently.
I need to develop a individual professional development plan and need to evaluate periodically.
I need to develop my team bonding skills and accepting ideas from others.
I need to be more professional and strictly in work place.
I need to know about legal issue in my work place.
4
4
3
3
2
Task 2.2
SWOT Analysis
STRENGTHS
Good Communication skills
Strong report writing skills
Strong interpersonal skills
Good rapport with clients and team members
Expert in subject matters and good knowledge of process.
Good in decision making.
WEAKNESSES
Limited knowledge in technical tools and system handling.
Lack of professional development skills
Need to develop skills in terms of managing conflict/difficult situations
Slow to respond to new possibilities.
OPPORTUNITIES
Won several awards and recognitions. Opportunity for promotion.
Huge business opportunity and opportunity to lead more people.
Opportunity to take up new roles and responsibilities.
THREATS
Lack of technical tools knowledge
Competition from peers
Lack of decision making that would lead to advantage other.
Source:
www.wisegeek.com
www.pd4me.com
www.managementconcepts.com
www.wikipedia.org
Demonstrate analitycal stance in relation to your understanding of the influence of health and social policy, legislation, guidance and code of practice in relation to accountable nursing practice. Demonstrate critical awareness of contemporary issues in nursing education or practice
– it has to be an essay on a contemporary national healthcare policy issued within the last 3 years. Any policy you can think within last 3 years. You need to summarize the key points of the policy and discuss the implications for your nursing practice
– you need to reference the policy using the current school referencing guidelines and provide a web link to the original document or web page. You will be expected to refer to the NMC code of 2015 during this assignment
Instruction
This project deals with euthanasia and different views about the legality and practice in different States of
the country. In my state Florida is illegal , yet controversial some are pro and others are against . I prefer to remain neutral although I favor that in the event of a chronic disease to avoid suffering is better as well as if the person involved is too old as well to avoid suffering and complication to proceeded with Euthanasia .
Also the fact of quality of life after coma and possible recovery might affect the decision if necessary.
I need
—-More than 7 references
—-5 have to be articles , 3 peer reviewed (nursing) and one can be from the legal aspect, the fifth might be from steps to solve ””medical ethical dilemmas (please cite the article as well as the method to be used
during the discussion).
—-APA
—-Development of the scenario using steps of Ethical dilemmas ( do not skip any of the areas.
—- # pages of development
Scenario
Serious accidents can leave people comatose for month and even years. The longer the coma last, the less chance the person to regaining consciousness. There are people who lives in that state, care for at considerable expense in hospitals or nursing homes, unable to relate to their love ones, and unaware that they are technically alive. Such cases inevitably raise the question of euthanasia. Merely by injecting poisonous substances into a vein, a doctor or nurse could spare people a limbo of near life and grant them a painless death. Would it be ethically justify able to do so in such a situation? Would it be justifiable in other situation?
This is an ethical dilemma. Use the step required to discuss an ethical dilemma and how you would defend your actions.
According to Margaret Shetland, the philosophy of public health nursing is based on which of the following?
A. Health and longevity as birthrights
B. The mandate of the state to protect the birthrights of its citizens
C. Public health nursing as a specialized field of nursing
D. The worth and dignity of man
PHI 208 Week 5 quiz (100% Answer)
Question 1. 1. According to Caroline Heldman, which of the following is a question that applies to her sexual object test? (Points : 1)
Does the image show people having sex?
Does the image show a person as something that can be bought or sold?
Does the image display a full image of a woman?
Does the image display violence against people in the image?
Question 2. 2. According to Gilligan, stages five and six of Kohlberg’s analysis of moral development involve (Points : 1)
an egocentric understanding of fairness
shared conventions of societal agreement
a logic of equality and reciprocity
a disposition of emotional affectivity
Question 3. 3. In Held’s article, a thinker named Annette Baier claims that the history of Western ethical thought does not take into account feminine aspects because (Points : 1)
The great moral theorists were men who had little intimate interaction with women.
The great moral theorists were often loving husbands.
The great moral theorists hated women.
The great moral theorists
Question 4. 4. What, according to Noddings, do male philosophers tend to say about death (as opposed to women)? (Points : 1)
Men are more brave in the face of death than women because of their natural courageousness
Death tends to be harder on men due to their attachments to the glory of this world
Women are more able to allow their faith in the afterlife overcome their aversion to death
Male philosophers often talk as though the world or reason and abstraction is superior to the physical world of the body
Question 5. 5. In Gilligan’s article, the example of Heinz involves which crime (Points ????
theft
murder
arson
racketeering
Question 6. 6. According to Held, the following have been aligned with femininity in the history of Western thought (Points : 1)
emotion
weakness
passion
all of the above
Question 7. 7. Gilligan claims that females tend to see relationships as these (Points ????
hierarchies
webs
rules
duties
Question 8. 8. According to Colin Stokes, in this film all the heroic, wise, and villainous characters are female (Points ????
The Little Mermaid
Star Wars
The Wizard of Oz
Les Miserables
Question 9. 9. Held claims that this abstract concept has guided the development of Western ethics (Points : 1)
The man of reason
The feminist woman
The child of love
The mother of care
Question 10. 10. What does Noddings say about women’s feelings about the death of the body? (Points : 1)
Women, more than anyone, just want to know that the soul of their child has gone to heaven
Women know the preciousness of the body because they create them and care for them
Women are happy not to have to deal with the messiness of dead bodies
Men tend to be more sensitive to the death of the body since they are the ones that have to risk their own lives in war
Question 11. 11. In the video “Sexism in the News Media 2012” some newscasters blame military women for this (Points : 1)
being killed in combat
being raped
being war heroes
not being able to have children
Question 12. 12. In Gilligan’s example, the child named Amy focuses on this aspect of the Heinz dilemma (Points ????
the logical nature of the problem
a utilitarian calculus that weighs the options
Kohlberg’s theory of moral development
the relationships involved in the dilemma
Question 13. 13. According to psychiatric studies, which of the following has been discovered about the relationship between criminal violence and childhood abuse? (Points : 1)
Criminal violence follows childhood abuse equally in males and females
Women are more likely to commit criminal violence if the childhood abuse was at a younger age
When criminal violence follows childhood abuse it is almost always in males
No correlation has been found at all between criminal violence and childhood abuse
Question 14. 14. What does Noddings have to say about essentialism about gender? (Points : 1)
It is the clearly false view that men and women have essences
It is problematic because it has been associated with creation and because it has always favored males over females
It wrongly assumes that God could not have made us in ways that were contrary to our ‘essential nature’
Culture is irrelevant; all of our behaviors are innate
Question 15. 15. This is the name of the female goddess to which young girls are dedicated and then forced into prostitution in India (Points : 1)
Vishnu
Krishna
Lakshmi
Yellamma
Question 16. 16. Held uses this example to talk about the political distinctions that separate men and women in the realms of the public and the private (Points : 1)
a business man going out for cocktails
a mother nursing her child
a city planner developing a building
a mother homeschooling her children
Question 17. 17. This is the name for prostitutes in India who have been dedicated to a female goddess (Points : 1
Hindus
Hiermala
Devadasi
Sangli
Question 18. 18. This is one way that men can contribute to the destruction of sexual objectification of women (Points : 1)
they can be kind to women
they can tell women that they are attractive
they can stop seeking attention
they can stop evaluating women based on their looks
Question 19. 19. Which answer best describes Noddings’s statements about how mothers frequently to feel about losing their children in war? (Points : 1)
Mothers rest assured that the deaths of their children was fully justified by the good they did in the war
Mothers often allow their desire to demonstrate patriotism to override their natural opposition to war and the death of their children
Mothers universally oppose war and the death of children that it inevitably brings
Mothers are generally more enthusiastic for war than anyone else because they know it will make the world safer for future generations
Question 20. 20. What does NelNoddings say about rates of violent crime among men and women? (Points : 1)
Men are naturally much more violence prone than women
Women commit nearly as much crime as men do; gender differences here are illusory
Men can be socialized not to commit crime, as seen in many eastern societies
There has been no clearly
Psychology homework help
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The management of chronic wounds is a significant part of the workload for any nurse caring for elderly vulnerable people since these patients are more prone to the conditions that can lead to chronic wounding.
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Chronic wounds like pressure ulcers demands a detailed and individual treatment plans depending upon the nature of the wound and the circumstances of the patient. The experience of having a pressure ulcer can result in the loss of a patient’s sense of self. Exudation and malodour may lead to social problems and this, along with skin problems, may decrease a patient’s quality of life. Hence Pressure ulcers need to be prevented as far as possible in all care settings.
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Pressure ulcer management involves treating infection, providing a moist wound-healing environment and choosing the appropriate dressing.
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Various studies on the topic have found that a multidisciplinary approach is the efficient mode for care of patients with pressure ulcers. This essay is a review of the various studies evaluating the best practices of nursing management of pressure ulcers. New nursing interventions and pressure-redistributing devices in intensive care units, and specific risk factors affecting critically ill patients, mean that different factors must be taken into consideration in preventing pressure ulcers.
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A pressure ulcer is an area of skin especially the areas of superficial or deep- tissue that has been damaged by pressure, friction shear or a combination of these factors There are many factors attributing to the risk of pressure ulcers and the major ones are obesity, immobilisation and malnutrition while old age, malignancy, venous insufficiency, diabetics and history contribute to delay in healing.
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Pressure ulcers are found mostly in bedridden patients with spinal injury etc pressure ulcers develop as a result of prolonged periods of immobility during unrelieved pressure which compresses tissues that overlie bony prominences.
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Once the pressure ulcer has developed, it tends to deteriorate owing to the patient’s physical characteristics, such as extreme bony prominence, and poor condition in general.
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(Sanada et al., 2008).
The nature of the excessive pressure is important in the development of pressure ulcers. The principal factor in pressure ulcer development is excessive tissue pressure that prevents the normal supply of blood to the affected area. The severity of skin and tissue damage will depend on how long the patient has been exposed to these excess pressures.
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In the words of Betsy Myers, prevention is the best intervention for pressure ulcers. By being aware of the risk factors for pressure ulcer development, assessing for changes in risk factors on an ongoing basis, and addressing risk factors, the incidence of pressure ulcers can be markedly reduced.
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Several risk factors have been identified for the development of pressure ulcers and are classified into extrinsic and intrinsic factors. Extrinsic factors include interface pressure, shearing forces, friction and moisture. Intrinsic factors are the nutritional status of the patient, patient age, immobility, incontinence, circulatory factors, and neurological disease. Three main mechanical factors are thought to contribute in the development of pressure ulcers: pressure, friction and shear.
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Pressure ulcers are present in patients with intensive immobility and recovery is delayed for these patients due to many reasons including the accompanying medical complications like infections extending the hospitalization period for patients. Methods to measure immobility are not generally available in clinical settings.
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A successful wound management should include assessment, planning, management, reassessment, admission, transfer, reporting and audit. As per EPUAP guidelines (2010), all patients with wounds should be reassessed and documented at least weekly and the treatment methods and any alterations to be discussed with the patient. Prevention of pressure ulcers helps reduce patient suffering. The first step in pressure ulcer prevention is to identify those patients at risk and a variety of risk assessment tools have been developed since the 1960s. It is important that an assessment tool is appropriate for the specific patient setting in which it is used.
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A study conducted by Ingela Henoch (2003) gives the following details on risk assessment tools for pressure ulcers. Accordingly, risk assessment tools are developed from nursing experience and research on the causes of pressure ulcers. An appropriate risk assessment tool should assess only necessary factors, facilitate the nurse’s work, be easy to use, require minimal training, have clear management guidelines and prevent pressure ulcers.
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The major assessment tools to study the risk factors of pressure ulcers are the Norton scale, the Braden Scale and the Waterlow scale.
The original Norton scale, used since the 1960s, includes physical state, mental state, mobility, activity and incontinence but excluded age and malnutrition since the scale was developed for use with the elderly and was considered a part of general physical condition (Norton, 1989). The Norton scale is revised and the modern version is known as the modified Norton scale. The Braden scale focuses on measuring intensity and duration of pressure, and sensitivity of the patient’s skin (Bergstrom et al, 1987). The Waterlow scale was compiled in Great Britain in 1984 and consists of two parts, one measuring pressure ulcer risk and the other outlining a prevention and treatment policy (Waterlow, 1991). The scale includes several factors particularly directed to acutely ill patients that are omitted in the Norton scale. In her study testing the various scales for their ability to detect differences between the patient groups with and without pressure ulcers, Ingela concludes finding the scale which became HoRT scale to be superior with regard to statistical significance and validity. Reliability was determined by comparing the scale’s predictions with the actual numbers of patients with and without ulcers.
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Sensitivity and specificity, and measures derived from these, are epidemiological tools in evaluating the predictive validity of diagnostic screening tests. The risk assessment tools are treated as if they are diagnostic screening tests, while in contrast with such screening tests, risk assessment scales are not intended to identify the existence of pressure ulcers, but to identify the risk that pressure ulcers will occur.
The old saying ‘prevention is better than cure’ is apt in the case of pressure ulcers and the very probability that a patient will develop pressure ulcer can be checked if proper preventive measures are used. Patients identified as being at risk will develop pressure ulcers only if preventive measures fail. As per Laat et al’s study, use of effective prevention will alter the sensitivity and specificity of the risk assessment scale. Laat et al finds that there is still no evidence for a valid risk assessment tool in critically ill patients. In general, Laat et al recommends prevalence and incidence studies to be designed and executed in accordance with the EPUAP guidelines and also call for a well-designed research on the epidemiological aspects, risk factors and risk assessment of pressure ulcers in critically ill patients to gain more insight into the nature and extent of this problem.
Depending on various characteristics, pressure ulcers are classified under the International NPUAP- EPUAP Pressure Ulcer Classification System. Accordingly there are 4 grades (stage or category) from 1 to 4 and their characteristics are as follows:
GRADE 1: Non-blanchable erythema of intact skin; Discolouration of the skin, warmth, oedema, induration or hardness can also be used as indicators, particularly on individuals with darker skin.
GRADE 2: partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
GRADE 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
GRADE 4: extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with/without full thickness skin loss.
Pressure ulcer grade should be recorded using the EPUAP classification system and all pressure ulcers graded 2 and above should be documented as a local clinical incident.
A failure to correctly assess and treat wounds will lead to a failure to heal. It is important that a competent practitioner undertakes the assessment process and plans the care.
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A successful wound management should include assessment, planning, management, reassessment, admission, transfer, reporting and audit. As per EPUAP all patients with wounds should be reassessed and documented at least weekly and the treatment methods and any alterations to be discussed with the patient.
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As Karen’s (2005) describes in her book, the previous practice of pressure ulcer management was called back round process which involved nurses washing and massaging the pressure areas of bedfast patients and applying a range of lotions, creams, powder, oils and spirits in an attempt to prevent breakdown of the skin. If a pressure ulcer were to occur then treatments varied. They included: lying the patient on their side to reduce pressure and administering oxygen, by placing an oxygen mask over the ulcer to maintain a dry environment; placing a dressing of egg white over the affected area, with the thought that it would heal the ulcer due to the protein content of the egg.
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The treatment needs of a pressure ulcer change over time, in terms of both healing and deterioration. Treatment strategies should be continuously re-evaluated based on the current status of the ulcer.
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All patients with wounds will need to have a holistic assessment, including environment, cause, location, site, dimensions, exudates amount and type, nutritional status, local signs of infection, pain, wound appearance, surrounding skin, undermining/ tracking, odour, assessment of the skin as a sensory organ and the patient’s knowledge and understanding of their wound and general condition. The wound assessment should be documented on an appropriate wound assessment tool, within 24 hours of admission to a hospital setting and within one week of referral to primary care.
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Cleansing and Wound Dressing:
Likewise, special care and research to be done before deciding on the cleansing agents to be used and the modes of wound dressing to be made and this differs in different cases. Wounds should only be cleansed when they are dirty, with either warm normal saline or tap water, and not on a daily basis. In the case of pressure ulcer the wound shall be cleansed if there are any visible signs of debris or if the ulcer is contaminated with bodily fluids. EPUAP recommends that antiseptics and antibiotics should not be regularly used, however they may be considered when bacterial loads need to be controlled or until inflammation is reduced.
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Positioning and Repositioning:
Zena et al’s (EWMA 2010) study agrees to the fact that repositioning is an important component and is advocated to be the best strategy in the management of a pressure ulcer patient. There are a number of interventions required for the management of a pressure ulcer patient like nutritional care, pressure reducing/ relieving surfaces and skin and wound care.
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Positioning of patients who spend substantial periods of time in a chair or wheelchair should take into account, distribution of weight, postural alignment and support of feet.
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Pressure-redistributing mattresses or other pressure redistributing measures in combination with body repositioning are the main preventive measures for general and critically ill patients. Routinely turning immobilised critically ill patients every two hours is the accepted standard of practice, yet it is not practical all the times and most critically ill patients are not repositioned according to this standard. In the case of patients with pressure ulcers, instead of the standard hospital foam mattress, Higher- specification foam mattresses should be preferred. In a detailed study conducted by Laat et al (2006), they could find no superior device than a higher specification foam mattress for Pressure ulcer patients.
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Pressure ulcers are a significant problem for hospitalised patients. Effective management of patients at risk of or with pressure ulcers is the key to achieving good clinical outcomes. While pressure-redistributing surfaces can help in the management of patients at risk of pressure ulceration, there is little available clinical evidence on which is most appropriate.
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The presence of a wound may cause psychological distress to some patients and hence effective communication with the patient is vital.
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Since pressure ulcers occur in patients who are immobile in majority cases of bed ridden patients, occurrence of the same is considered to be a nursing problem. Nurses are considered to be responsible for the assessment and prevention of pressure ulcers and the role of Doctors come only secondary to the role of a nurse in this particular case. All the reviews and detailed studies on the pressure ulcer indicates the need of an interdisciplinary approach for the management of a pressure ulcer participating almost all level of practitioners like doctors, nurses, therapists, dieticians, porters etc. It is the first and foremost obligation of a nurse to conduct ongoing, repeated assessment of risk factors of pressure ulcers since early detection and treatment are vital for the treatment procedure.
As Julie (EWMA 2009) points out that current nursing documentation of pressure ulcer prevention and management is not adequate and that risk assessment tools although not perfect do have a role to play in the identification of those at risk of pressure ulceration by raising awareness. Reporting and high quality documentation is essential to the process of reduction in the incidence and prevalence of pressure ulcers.
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In the words of Karen (2005), a crucial feature for the prevention of pressure ulcers is correct and early identification of patients at risk. Risk assessment tools are meant as a part of holistic assessment and not to replace clinical judgment. The majority of patients admitted to a care setting, including those patients who are being nursed in a community setting, should be assessed, regardless of their age, gender or weight, and the results documented. If a patient is assessed as being at risk, then preventative measures should be implemented immediately and documented. Failure to do so will be viewed as negligence in the part of the practitioner, as harming the patient and may be viewed as a breach of human rights.
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According to Irene (2010), goals for pressure ulcer prevention require the selection of a bed that has a pressure redistribution surface such as air bladders, high-density foam, or alternating pressure surfaces. Careful and frequent skin assessments, frequent repositioning, managing moisture, and maximizing nutritional support are common interventions for prevention of pressure ulcers. Progressive mobility techniques and repositioning techniques used to prevent pressure ulcers are designed to promote the best outcomes while preventing dangerous complications.
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Evaluating the Japanese Government’s new incentive system for taking care of high risk patients, Sanada et al (2010) is of the opinion that for an effective strategy on pressure ulcer management, we need to focus on human resources, not on materials and devices.
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Student Example :
It is with increasing frequency that physicians in the United States and throughout the world are asked to participate in ending the lives of their patients. Abortion and physician-assisted suicide are two issues that illustrate the expectation that physicians will participate in intentional life-ending activities. They differ, however, in the potentiality of the life in question. In the case of abortion, the early life of the embryo or fetus is destroyed by the will of the mother, though if given the proper environment and there are no abnormalities, the child has potential for a full, productive life. At the other end of life’s spectrum, an increasing number of states have enacted laws to permit physician-assisted suicide.
Stories of patients suffering with inadequate pain relief and fear of loss of one’s autonomy are drivers for support of physician-assisted suicide legislation. The medical specialties of palliative and hospice care have transformed care for those with chronic and terminal illnesses. Palliative care provides an excellent alternative to physician-assisted suicide to address concerns of the chronically and terminally ill.
A Biblical View of Illness and Death
Scripture speaks to life and end of life issues and the value God places on those made in his image. As Fedler explains, humankind made in the image of God is the central theme of biblical faith.
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The psalmist asks God the question, “What is mankind that you are mindful of them, human beings that you care for them?” (Psalm 8:4 NIV). The psalmist then exclaims, “You have made them a little lower than the angels and crowned them with glory and honor,” (Psalm 8:5 NIV). God has given humankind high standing and is watchful over us. The concept of God being “mindful” of man is further illustrated by the scripture, “…for whoever touches you touches the apple of his eye…” (Zach. 2:8 NIV). The eye does not like to be touched, and many reflexes are in place to prevent this sensitive thing from happening. Likewise, God is very sensitive to anyone “touching” one of those made in his image.
Does the time of our death matter to God? The earliest stories of man’s interactions with each other include Cain’s murder of his brother Abel. Though Cain thought the act was done in secret, God’s response was, “What have you done? Listen! Your brother’s blood cries out to me from the ground,” (Gen. 4:10 NIV). There are many verses that condemn one person putting another to death. One of those is, “Anyone who takes the life of a human being is to be put to death,” (Lev. 24:17 NIV). Our societal laws reflect the value of human life and severe consequences for taking another’s life.
The despair associated with severe infirmity is illustrated in the book of Job. One illustrative statement is, “…to those who long for death that does not come, who search for it more than for hidden treasure,” (Job 3:21). Job expresses a wish for escape when he said, “…I prefer strangling and death, rather than this body of mine,” (Job 7:15). Though he was great man of faith, he was suffering physically and psychologically. His condition seemed endless and without hope, but he did eventually recover. Even if he had not recovered, he was steadfast in maintaining his faith as evidenced by the statement, “I know that my redeemer lives, and that in the end he will stand on the earth, And after my skin has been destroyed, yet in my flesh I will see God;” (Job 19:25-26), so he had the moral courage to fight the battle of his illness.
The Hippocratic Heritage
The Hippocratic Oath has been the foundation for understanding the role and duty of a physician from the time of the ancient Graeco-Roman world until today. In the past decades, the principles of the Oath have come into question, specifically over the prohibition of participating in abortion and giving poison for taking one’s life. As Cameron explains, the Greek culture was pluralistic, and the Oath outlined a specific philosophy in favor of life that Hippocratic physicians would adhere to. It is also important to note that a standard was set that was different than marketplace demands.
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Some consider this paternalistic, as the physician was expected to stay true to the Oath, even if it contradicted the patient’s expectation.
The Hippocratic philosophy is still very instrumental in defining expectations of physician behavior. Though the oath establishes a sacred trust to maintain the patient’s secrets, it is understood that when a life hangs in the balance, protecting life trumps privacy.
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Examples include patients disclosing a plan for self-harm or for harm to another.
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The physician has an obligation to obtain care for the patient against the patient’s will or to notify authorities if someone is in harm’s way. Though the confidence of the patient is sacred, protecting life is a higher obligation.
The Discipline of Bioethics
There has been an evolution in medical care options since World War II. Advances in antibiotics, medications for numerous conditions, organ transplantation, and life-sustaining technologies such as ventilators, dialysis and organ transplantation revolutionized the practice of medicine. In the decades following the war, although physicians were able to treat the previously untreatable, the advances permitted those who would have died earlier to languish without cure. Physicians were faced with excruciating decisions on how to allocate scarce resources. Discussions on how to meet the new challenges in medicine included input from physicians, scientists, theologians, philosophers, legal experts and sociologists, and the discipline of bioethics was born.
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Religious influence was important in the initial framework of understanding bioethics, but this was followed by an “enlightenment period,” when a secular approach to bioethics was developed and became more prominent than a theological perspective. Ethical theories were primarily viewed from a deontological or utilitarian perspective and guiding principles were developed to address the types of situations faced by the medical community. Four primary principles to use in biomedical decisions were identified as follows: 1) autonomy; 2) non-maleficence; 3) beneficence; and 4) justice.
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Arguments in Favor of Physician-Assisted Suicide
The growing public support for physician-assisted suicide is evidenced by an increasing number of states that have passed or considered legislation permitting it. Oregon’s Death with Dignity Act was the first of its kind in the United States, passed in 1997. Patients must be able to ingest the medication themselves and qualify for consideration if they have a terminal condition with an estimated six months or less to live. Euthanasia is not permitted. Since then, the United States has a total of eight states with legislation permitting physician-assisted suicide, and one state that will not prosecute physicians participating.
Autonomy is one of the most important arguments in favor of physician-assisted suicide. Hollinger explains that for those who merely see physician-assisted suicide as a choice, morality is removed from the debate.
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For these individuals, autonomy the most important factor in a patient’s decision.
The philosopher Peter Singer has written extensively on life and death issues. He promotes personhood theory, believing that the value of human life varies
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depending on their ability to interact with their world and their intelligence. He believes there are animals that exhibit some characteristics of human beings more than some humans do, therefore should be considered persons and also have a right to life.
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Singer states, “The new vision leaves no room for the traditional answer to these questions, that we human beings are a special creation, infinitely more precious, in virtue of our humanity alone, than all other living things.”
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He believes we should respect a person’s desire to live or die,
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so supports full autonomy of the patient. He rejects the sanctity of human life arguments and believes there should be no reason to deny a request for physician-assisted suicide.
On the question of the appropriateness to hasten death actively, Rachels makes the case that there is no substantial difference between acts of omission (to let someone die) than allowing acts of commission (to provide active euthanasia). He states, “….once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse.”
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His greatest priority is relief of suffering, and if active euthanasia provides relief, then it should be permissible. Hulse agrees with the opinion that there are situations where killing someone is preferred over letting die, but only when the motivation of the physician (or those helping) is the good of the patient and not for the benefit of the “helper.”
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Death with Dignity is an organization with a mission “to promote death with dignity laws based on our model legislation, the Oregon Death with Dignity Act, both to provide an option for dying individuals and to stimulate nationwide improvements in end-of-life care.”
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The organization objects to the term “suicide” being used for legislation regarding end of life options because, “Physician-assisted dying isn’t suicide legally, morally, or ethically. Patients already are dying and therefore are not choosing death over life but one form of death over another.”
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The organization argues that semantics matter, and opponents to physician-assisted suicide agree on this point.
Another organization promoting physician-assisted suicide is Compassion in Choices. Their website makes this statement, “Medical aid in dying is a safe and trusted medical practice…”
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The website offers free consultations for patients exploring end of life options, and testimonials about why the authors or their loved ones have chosen or would have chosen to ingest a lethal prescription. In addition to physician-assisted suicide, it offers information on advanced directives and understanding end of life treatment options.
Both websites feature stories of patients who had intractable suffering at the end of their lives, or felt they were more aggressively treated than they would have wished to have been. Clearly, giving patients appropriate informed consent and having physicians who are ready to admit when care is futile is important to adequately care for patients with terminal illness.
Physician-Assisted Suicide: What Professional Medical Organizations Have to Say
Though proponents of physician-assisted suicide call it “safe” and “trusted”, most physicians will define safe medical practices as those which promote health and well-being, and unsafe practices those that lead to increased patient morbidity and death. It is not conceivable to declare a “safe practice” one that precipitates a patient’s death, nor does a conscientious physician “trust” a practice that causes loss of life.
The American Medical Association(AMA)reaffirmed its physician-assisted suicide policy at the AMA House of Delegates meeting in 2019, which includes this statement: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”
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The largest organization representing physicians in the United States, the AMA, remains opposed to the concept that facilitating death at the end of life is medical care.
Physicians spend many years and untold hours learning about the human body, dedicating themselves to promoting health and curing disease. It only takes minutes to learn how to write a lethal prescription to end a patient’s life. What qualifies physicians, in their training, to determine when it is appropriate for a patient to take their own life? Physicians are trained to fight disease and extend life, not to help determine the right time for a patient’s death. If one suggests that the patient should be the sole determiner of the time of their death, then why is the physician needed at all? If the physician is a contractor obligated to comply with the wishes of the patient under the principle of patient autonomy, then the many years of medical training to determine the best course of treatment are unnecessary. To call writing a lethal prescription “medical care” runs contrary to multiple millennia of medical tradition.
In 2017, the American Osteopathic Association (AOA) reviewed a resolution to change the Osteopathic Oath, which contains the phrase, “I will give no drugs for deadly purposes to any person, though it be asked of me.”
[18]
The resolution addressed a concern that osteopathic physicians may be asked to decide between following the Osteopathic Oath (not providing lethal prescriptions to terminal patients), or to follow laws of the states that permit physician-assisted suicide. The resolution to change the phrase to “I will give no illegal drugs though it be asked of me,” was defeated.
[19]
Official policy of the organization maintains the original phrase in the oath against the administration of deadly medications.
Both the AMA and the AOA, the professional organizations representing physicians with unlimited licenses to practice medicine in the United States, have recently taken action to reaffirm opposition to the practice of physician-assisted suicide as part of medical care.
A Case for Palliative Care
Hospice and Palliative Care are relatively new subspecialties in the practice of medicine, having received approval from the Accreditation Council on Graduate Medical Education (ACGME) to develop fellowship training programs in 2006.
[20]
Palliative care is defined as care for patients and families to provide relief from pain and other symptoms, and support quality of life for those with serious advanced illnesses. Hospice, on the other hand, provides palliative care to patients and families with limited life expectancy.
[21]
The goal of palliative care is to keep a patient living and able to enjoy those activities that mean most to them despite chronic or terminal disease, and is intended neither to hasten or postpone death.
[22]
This includes excellent pain management and partnering with the patient to determine how much pain relief is needed without compromising the patient’s ability to participate in the most important activities to them. Hospice’s more narrow focus of care during the last six months of a terminal condition may cause patients and families to resist committing to the services. Palliation, on the other hand, does not carry the same stigma.
Intractable pain is often used as an argument in favor of physician-assisted suicide. Appropriately applied palliative care addresses adequate pain relief in most cases. The use of opioids is considered appropriate and in doses higher than what would be acceptable in a non-terminal condition.
[23]
Concerns of the addictive nature of the drugs is not an issue in the terminal patient, though patients may resist the medications for that reason. Patient and family education to understand the appropriate use of analgesia is important. Sedation can be employed for intractable pain.
[24]
As the practice of palliative and hospice care continue to improve, and available services become better known, one would expect fewer people to choose physician-assisted suicide as their preferred option.
Autonomy:
An Absolute Right?
The bioethical principle of autonomy is a central point of debate on physician-assisted suicide. The State of Oregon has the longest record of physician-assisted suicide in the United States, passing their legislation in 1997. The state produces an annual report of the characteristics of those participating. It is noteworthy that in the most recent report the most commonly stated reasons to ask for a lethal prescription are: 1) fear of loss of autonomy (91.7%); 2) less able to participate in enjoyable activities (90.5%); and 3) loss of dignity (66.7%). Fear of inadequate pain control was only 25.6%,
[25]
though it is frequently cited as the rationale for physician-assisted suicide. Loss of autonomy is the single greatest driver of the request for a lethal prescription.
Depression is a common finding in patients with chronic disease, and patients who are depressed are more likely to want to end their lives. Depression is also common in the elderly, one article estimating the incidence between 34% and 38%.
[26]
Of the patients who died under the Oregon Death with Dignity Act, the median age was 74, so it can be presumed that a similar percentage had depression. The report tracks how many patients were referred for psychiatric evaluation. During 2018, 249 prescriptions were written, and 168 patients died secondary to ingesting lethal medication. Of those that died, only three were referred for psychiatric evaluation.
[27]
Given the incidence of depression in the elderly and those with chronic diseases, one would expect the rate of those who had depression to be significantly higher than the number referred. Patients with depression may have chosen another course had their underlying psychiatric conditions been appropriately treated.
The principle of liberty as understood by the United States founding fathers was not an unfettered right to do whatever one wants, but the ability to choose to do what is right, and that a liberal democracy can only function with a moral people.
[28]
Today, autonomy has “run amok” as individuals exercise their rights as absolutes without consideration for the impact on society or what should be done for the greater good.
[29]
Conclusions
For those who believe humans were made in God’s image, that humans have inherent value for this reason, and that the timing of one’s last breath is in God’s hands, physician-assisted suicide has no place in patient care. Death with dignity is always guaranteed, because all humans have dignity by virtue of having been made in the image of God, no matter what the circumstances of their last days.
Excellent palliative care can relieve the despair that may overtake even those with deep reverence for and faith in God. The modern practice of palliation allows access to pain relief and strategies that permit life to be lived to the fullest possible until the last natural breath. This includes supportive strategies to help patients live while they are dying, and help families better support their loved ones. Those who fear pain and loss of ability to enjoy life are less likely to choose physician-assisted suicide when excellent palliation is available.
For those who connect human dignity to their physical appearance or activities, excellent palliation is not likely to give them the control they desire. The temptation of original sin, “…you will be like God…” (Gen. 3:5) applies when individuals take upon themselves decisions that belong to God, like the timing of their own death. These individuals may not realize or value the contributions they can still make to their loved ones and society despite their condition, and how their lives contribute to the greater good. Advocates of physician-assisted suicide say that the term “suicide” is inappropriate, as one is just hastening inevitable death. The definition of suicide does apply as it is the taking of one’s own life before natural death. Giving it a different name does not change the intent or the action. By promoting the philosophy that for those near death the remaining hours, days, weeks or months still available are inconsequential, a class of people is created that are as good as dead, or those who have “lives not worth living.”
[30]
The desire for ultimate autonomy by those with this philosophy cannot be met with palliation.
The utilitarian argument that one’s value is based on perceived contribution to society has wreaked immeasurable havoc in the past, as evidenced by the atrocities committed by Nazi physicians during World War II.
[31]
As the 19th century philosopher Georg Wilhelm Friedrich Hegel stated, “But what experience and history teach is this, – that peoples and governments never have learned anything from history, or acted on principles deduced from it.”
[32]
As our culture moves further down the path of utilitarianism in measuring the value of human life, and as autonomy becomes out of control, we would be wise to take a careful look at where this path has led before.
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[1]
Kyle D. Fedler,
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[2]
Nigel M de S. Cameron,
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[3]
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[4]
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[5]
Albert R. Jonsen,
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[6]
Scott B. Rae and Paul M. Cox,
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[7]
Dennis Hollinger,
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[8]
Peter Singer,
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[9]
Ibid., 202–206.
[10]
Singer,
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, p. 183.
[11]
Ibid., 197.
[12]
Kuhse, Helga; Schüklenk, Udo; and Singer, Peter,
Bioethics
, p. 249.
[13]
Ibid., pp 257-259.
[14]
“About Us,”
Death With Dignity
, accessed August 4, 2019, https://www.deathwithdignity.org/about/.
[15]
“Terminology of Assisted Dying,”
Death With Dignity
, accessed August 4, 2019, https://www.deathwithdignity.org/terminology/.
[16]
“Medical Aid in Dying Is NOT Assisted Suicide,”
Compassion & Choices
, accessed August 4, 2019, https://compassionandchoices.org/about-us/medical-aid-dying-not-assisted-suicide/.
[17]
“Physician-Assisted Suicide,”
American Medical Association
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[18]
“Osteopathic Oath,”
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, accessed August 4, 2019, https://osteopathic.org/about/leadership/aoa-governance-documents/osteopathic-oath/.
[19]
“H332 – AOA HOD Osteopathic Oath Resolution Defeated.,” n.d.
[20]
“A Framework for Generalizability in Palliative Care- ClinicalKey,” accessed August 4, 2019, https://www-clinicalkey-com.proxy.pnwu.org/#!/content/journal/1-s2.0-S0885392408004387.
[21]
Committee on Approaching Death: Addressing Key End-of-Life Issues,
Dying in America:
Improving Quality and Honoring Individual Preferences Near the End of Life
(Washington, DC: National Academy Press, 2015), 7.
[22]
Ibid., 58.
[23]
Ibid., 415.
[24]
Ibid., 449.
[25]
“Oregon Death with Dignity Act Annual Report 2018,” n.d., https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf.
[26]
Yaeko Ozaki et al., “Depression and Chronic Diseases in the Elderly” (2015): 5.
[27]
“Oregon Death with Dignity Act Annual Report 2018.”
[28]
Rae and Cox,
Bioethics:
A Christian Approach in a Pluralistic Age
, 201.
[29]
Ibid., 198.
[30]
Cameron,
The New Medicine:
Life and Death After Hippocrates
, 71.
[31]
Ibid., 69–84.
[32]
Georg Wilhelm Friedrich Hegel,
Lectures on the Philosophy of History /
(London :, 1857), p 6, http://hdl.handle.net/2027/uc1.$b288580.
