Table extracted from Price and Chalker (2000, pp 52).
As I move on to exploring my emotions I became aware that in the above situation which is the next step in Newham’s model is. I felt that the physiotherapist was interacting with the patient quite well even though there was no verbal communication. The reason I thought she interacted well was her tone of voice when talking to the patient, her caring manner, she maintained the patient’s dignity very well and the fact that she was talking to the patient when she got no response back (CSP 2000). The above situation made me realise that you have treat every patient the same whether they are responding to you or not. It also made me think about consent and how important it is to ask the patient before you do anything with them. In this situation verbal consent could not be given. As it was my first ever observation, I had not seen a patient in this way before. The situation of the physiotherapist talking to the patient who was not responding made me feel a little uncomfortable. I also felt quite upset to see the patient in this way. This may have limited my thinking in my understanding of what was going on as the situation did make me uncomfortable.
Following the Newham’s model I have began to analyse what made me feel the way I did. Although I did not have to make a decision which would have influenced the situation itself, but I made decisions that influenced my thoughts and feelings. The factors affecting my judgement may have been because the patient was not responding back. My understanding of communication may have had something to do with the way I was feeling as I believe that you communicate with people who talk back to you, and if someone who is not responding to you, you automatically stop talking to them. This may have come from my experience as a child where, when someone was angry or upset with me they stopped talking to me. My past experience therefore was a limitation to my understanding. Booth (2006) suggests that interpersonal communication serves many functions, a practical function (to complete life’s activities), a social function (for social belonging) and for physical well being, which are achieved through complex verbal and non-verbal processes (such as body language). This is what my understanding of why we communicate with people was. Therefore, when someone is not communicating with you, all of the above do not fit well with the physiotherapist talking to the patient. This perplexed me as I was still thinking about a two way interaction.
When I consider this further, the physiotherapist had a duty of care to the patient and to treat them as they would a verbally communicating patient according to the CSP (2002) guidelines. Patak et al. (2006) suggested that patient’s inability to communicate results in unrecognized pain, feelings of loss of control, depersonalization, anxiety, fear, distress, and frustration. Patients may become anxious when their needs are not met during periods of mechanical ventilation because of their inability to verbally communicate with family and health care providers (Patak et al. 2006). The physiotherapists own experiences may have led her to act the way she did as well, and thinking that the patient was not in a non responsive state may have come from her past experiences and this is why she may have been talking and interacting with the patient as she did which fits in with Patak et al.’s (2006) suggestion. As she stated that she did not think the patient was brain dead she must have thought that this patient was able to understand what she was doing, so this may have made the physiotherapist carry treating how she would a responsive patient.
I was also concerned by the patient’s lack of verbal response because it meant they were unable to actively give verbal consent and I have begun to realise how important this issue is in the physiotherapy literature (CSP 2002). The physiotherapist had to obtain consent and in order to obtain consent they had to communicate with the patient. The problem with this is that the patient was not responding verbally. This perplexed me about obtaining consent. My experience with consent was that patients had to either gain verbal or written consent, which was the idea I had got from my previous degree, where our client group were sports athletes who were able to give verbal consent and so we did not discuss gaining consent from patients who were non responsive. From the research I have carried out, I have found that “No other person can consent on behalf of another adult, even where that person lacks capacity. Although capacity is normally a requirement for valid consent, the law allows treatment to be given to patients who lack capacity on the basis that the treatment is in the patient’s best interests.(CSP 2004). Dubois (2005) suggests that “in a situation where a patient can no longer give informed consent, others can exercise that patient’s decision making authority for the patient”. To summarise this I believe that if the treatment is of benefit to the patient than the treatment can be carried out. However, conflict can arise when giving treatment to benefit the patient and a family member refutes the treatment. In this situation the case would have to be taken to the ethical committee, but in this situation this problem did not arise.
Before I went to observe the patient I had no understanding of patients who were brain dead (which was diagnosed by the doctors) and therefore I was already limited in my understanding of what to expect. From my previous experiences I have only seen treatment given to patients who have full capacity and understanding of what is going on. Therefore, in the situation given above, treatment was given to someone who was not participating in the treatment process and it was something that I had not seen before. From carrying out research on Brain death I have found the following: “Brain death is defined as complete and irreversible cessation of all brain and brain stem functions synchronously. It is characterized by complete apnea, absent brain stem reflexes, and cerebral unresponsiveness. Usually the brain dead patient is in a coma requiring a ventilator with a known cause of serious brain damage, such as traumatic injury” (Akrami, Osati, Zahedi and Raza 2004). Dubois (2005) suggested that a vegetative state is where patients cannot interact with the environment or develop as a human being. When I observing the physiotherapist giving treatment the patient was moving slightly and making noises. This would suggest that the patient on even a small level is interacting with the environment. However, some may argue that this is just a reflex response and the patient does not know what is going on. There is a lack of research regarding brain dead patients due to its complexity (Dubois 2005)
A study by Rocker, Cook and Shemie (2006) found that 10–20% of critically ill adults die in the ICU. Many of these deaths follow acute brain injury in the setting of clinical deterioration, life support limitation and brain death. The provision of compassionate high quality end of life care should be standard of practice for brain injured and all other critically ill patients who cannot survive.
I have begun to analyse how I could deal with the situation differently, which following the Newham’s model is the 7th point in reflection. From analysing and reflecting on the situation I hopefully now have a better understanding of the issues that arose from the situation and I will be able to apply what I have reflected upon when I am in that situation and I will hopefully be able to deal with and interact with the patient in the same dignified manner that the physiotherapist I was observing did. I have learnt about the issues regarding consent and how I should interact with patients who are not responding to me. However, until I am in that situation where I am treating a patient similar to the one mentioned I do not know how I will feel but I will have a better understanding of how to interact with them. From observing the above situation I have an understanding that all patients should be treated equally no matter what condition they have or what state that they are in and they should have an equal access to treatment. The last part I have analysed how this will effect my own practice, which fits in with the Newham’s model of reflection.
From following Newham’s model of reflection I have analysed the situation in detail and the steps that I have followed follow a logical order. However, it was difficulty following the steps without them overlapping. For example, when analysing what made me feel like the way I did, I was able to use research to back up my thoughts.
Reference:
Akrami, S.M, Osati Z, Zahedi F, and Raza M. (2004) Brain Death: Recent Ethical and Religious Considerations in Iran. Transplantation Proceedings, 36, 2883–2887.
Booth, L (2005) Observations and reflections of communication in health care-could transactional analysis be used as an effective approach? Journal of Radiography, xx, 1-7
Chartered Society of Physiotherapy (2002) Rules of professional Conduct. London: CSP
Dubois, M (2005). Ethical issues at the end of life. Techniques in Regional Anesthesia and Pain Management, 9, 133-138
Johns C (1995) Time to care? Time for reflection. International Journal of Nursing Practice, 1: 37–42
Patak L, Gawlinski A, Fung I, Doering, Berg L J, Henneman E A (2006) Communication boards in critical care: patients’ views B Applied Nursing Research 19 (2006) 182–190
Price A M. and Chalker, M (2000). Our journey with clinical supervision in an intensive care unit. Intensive and Critical Care Nursing, 16, 51–55 51
Rocker, GM,Cook, DJ and Shemie, SD (2006) Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury. Canadian Journal of Anesthesia 53:814-819