A unitary view at end of life nursing.
|Subject:||Nursing (Personal narratives)|
|Publication:||Name: Visions: The Journal of Rogerian Nursing Science Publisher: Society of Rogerian Scholars Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Society of Rogerian Scholars ISSN: 1072-4532|
|Issue:||Date: Jan, 2011 Source Volume: 18 Source Issue: 1|
|Persons:||Named Person: Mezick, Nancy|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Martha Rogers' theory of Unitary Human Beings was the first to
define humans as energetic beings that should be treated in an
all-encompassing manner (Rogers, 1970). While simply stated, this theory
is quite complex and abstract. According to de Chesnay (2005),
Rogers' theory of Unitary Human Beings can effectively be divided
into three components of pattern appraisal, mutual patterning, and
When formulating the pattern appraisal, one should identify the patterns that encompass the whole person because the life process reflects its own unity intermingled with the surrounding environment. This comprehensive assessment involves cognitive and sensory input, types of language familiar to the patient, and intuition. The nurse's use of feeling and sensing can be quite valuable in understanding the patient more fully. This understanding should encompass the past, present and future. One's appraisal can be validated by correctly identifying the patterns and rhythms of the patient. "The goal of the nursing action is to bring and promote symphonic interaction between human and environment " (de Chesnay, 2005). The purpose of this interaction is to strengthen the coherence and integrity of the human field and adjust the patterning of the human and environmental fields as needed. This is an organic process and should continue to be so while caring for the patient.
Mutual patterning between the nurse and patient is multi-directional. It can include medication administration, therapeutic touch, visualization and imagery. These are to be used in the evaluation process to resolve the dissonance often found in those needing medical attention. This ongoing process of evaluation of pain, fear, and tension with caregivers and family should be addressed regularly in that the dynamics of each will often be in a state of change. The nurse can then share her assessment with the patient so that mutual patterning can continue and a more harmonic state can be present within the patient (de Chesnay, 2005). Cobb expands the understanding of this theory as a transformative process in a unitary system that is infinite and irreversible (Cobb, 2006). Every experience of a person impacts his or her level of health. The totality of the human is a "biopsychosociocultural spiritual being" that is much more than the sum of the parts (Wright, 2007).
Evaluation centers on the process of determining if the actions taken through mutual patterning activities have rendered harmony in place of dissonance. The nurse should also assess the fear, pain, and tension of the patient's loved ones. This is an ongoing process with changes in dynamics. Therefore the nurse should be aware of these variables and continue to address those issues that cause an interruption in the patient's energy field. These issues often will manifest in discomfort, fear, and pain (de Chesnay, 2005).
I am writing about an experience with a patient who has forever impacted me. I had the honor and privilege of providing nursing care for my father in his last days and being witness to and integrated with his transition from this life. I was not expecting to have such an intense and hands on experience this early in my nursing career, but I was put to the test in August of this year. My father was one of the most intuitive people I have ever known. He taught me to know and trust my own intuition. In some ways this made working with him in his altered state rather simple. In other ways it was very difficult in that the high emotion and pain that accompanies the loss of a parent can easily cloud judgment and hinder clear decision making.
On Friday July 31, 2009, I received a message from my sister that my father had been put in the last stages of hospice care. He had been courageously fighting Alzheimer's disease and its comorbidities for about 14 years. My family had witnessed the slow deterioration of his abilities to perform activities of daily living. After assessing the new needs of my father and being determined to keep him at home if at all possible, we had rearranged the master bedroom of my parents' home to accommodate a hospital bed, a twin bed, and newly needed supplies. At this stage he was able to ambulate with much assistance and was sporadically aware of his surroundings. When taking him into the newly arranged bedroom, he displayed a look of surprise at the condition of the room where he has slept for the past 30 years. I kiddingly told him that he had once again sold the furniture from their bedroom. He just chuckled and then a sense of calm familiarity came over him. As a middle aged man, he was owner/operator of a successful home furnishings business and more than once he and my mother had words as she would come home from work and find her bedroom suite had been sold and removed. This exemplifies the portion of Rogers' theory of integrating the past with the present to put one's energy field in a harmonic state (Rogers, 1970). Also vital to addressing the Unitary Being is the use of innovative and creative responses to the interaction between the person and their environment. This is said to reinforce harmony within a dissonant situation (Alligood, 1991). By suggesting a familiar reasoning to an unfamiliar situation, my father was put at ease.
His first night in the hospital bed was somewhat restless. We realized by his fidgeting that he must be uncomfortable. Also, the pillows used to cushion the metal rails were making him hot. We remedied this by adding an egg crate pad to the mattress and used a swimming noodle (a long, round floatation device made from styrofoam) we measured and cut to fit the rails. His restlessness ceased and his temperature became more normalized.
Another main goal for us was to keep the situation one of dignity. I instructed and reminded everyone when in the room to not refer to his adult briefs as diapers. I knew that he had always been a modest man. I asked everyone not directly involved in his care to leave the room when it came time for bathing, cleaning etc. When one of my sisters had a rather difficult time with some of the cleaning duties, I assessed this and would gladly trade duties with her. We all were focused on what was best for my dad, happily asked for help when we needed it, and allowed each other to use their own strengths. By addressing this, the overall environment of the room remained calm. My mother reminded us that in my dad's more active years he had always been very aware of good hygiene and personal care. We arranged for daily bathing and shaving with hair washing every two to three days. These grooming sessions left him pleasant and arousable for about one hour. The family relished these times of communication.
My father was a man who always enjoyed being outdoors. While still ambulatory, he would take a cup of coffee and sit out side in the sun with his dog. Daily, after he became bedridden, we moved the bed in front of the picture window. I bathed and dried the dog brought him in to be with my father. My dad reached up to touch him and puckered his lips as if to give a kiss. This was a sign he was comforted.
Throughout the time I was providing nursing care for my father, I was careful to use jargon familiar to him. I would refer to him by a silly nickname he used his whole life, Ellibow, when having to move him or give instruction for taking medication. He responded to this very well. When lifting him or turning him, I would tell him to give me a big hug. If we needed him to stand he would hug me and then we would sway slowly as if to dance. I would remind him to not try to jitterbug. Often he would pat my back and kiss my cheek. All of these actions, which integrated past behaviors, proved to bring harmony to the situation.
I was under hospice orders to administer medication based on my father's behavior. He had recently begun having seizures when his Seroquel was increased. At first the seizures were so brief that I questioned if they were true seizure activity or other neurological issues associated with Alzheimer's. But my mother, who has been his caretaker for the past ten years, later stated she knew something was just not right. The Alzheimer's specialist was called and told us that no one had ever reported having seizures from Seroquel. So going against her intuition, she continued the administration of the increased amount. Within 24 hours he had body stiffening and jerking and a bit of emesis that was undoubtedly a true seizure. The hospice nurse was called and we had new orders to stop the Seroquel and use an appropriate dosage of Ativan instead. In the first week, my father was able to swallow. I would crush the Ativan and mix it with applesauce for easy administration. I would gently hold his face, call him either Ellibow or daddy, and tell him I needed him to swallow just one time; this was the medicine that made him feel better. He would rouse slightly and concentrate on taking the medication. This proved successful as long as he could swallow. Once he was no longer able to swallow, I made a milky paste of the Ativan and water and told him what I was doing before I applied it to his buccal membrane. I would hold his face gently, rub his hair, and kiss his forehead. Even when he could barely muster the energy for movement, he would oftentimes pucker his lips as if to kiss me and occasionally stroke my face with his hand. He knew I was caring for him.
The hospice service gave us liquid morphine to use as his dehydration status increased and muscle pain intensified. My mother had dreaded using the morphine. I think she knew that administration of this drug meant we were so close to the end. She had always put his needs first and would never allow any of us to do otherwise. One night when I was sitting up with him through the night, I noticed he was grimacing slightly and fidgeting. I had given him his Ativan about an hour prior. When he was not resting well, I knew it must be time for the next stage. I was hesitant to administer the morphine simply due to my mother's dread. So I waited another 15 minutes and hoped he would become calm. When no relief was evident, I awoke her and we agreed together it was time for the narcotic. I felt it was important to have her at peace with this process and knew she would not hesitate.
Often reported at the end of life are visions of loved ones who have already died. My father was not different. When he would speak it was often unintelligible with the exception of select words. When my family or I would understand one of these words we would latch onto them to try and engage him. The hospice workers had told us that he would need our permission to die. I used visualization and imagery to assist with this process. When we could understand he was addressing his deceased mother and two of his deceased brothers, I was able to use this to talk about the party that was waiting for him on the other side. This was in line with his belief system and seemed to add to his comfort. I told him it was okay to go whenever he needed to and they were most likely looking forward to him getting there because he was always the life of the party. I would use the names he had just mentioned and address the specific things about them that I could remember. I reminded him we would all be fine and care for each other. I told him that I loved him and that we would all miss him but would be okay: he had taught us well. My sisters, mother and I all learned from each other how to do this.
My father died on August 14, 2009 at the age of seventy nine. I was with him and at the time of death I was helping him into an adjusted position to aid his comfort. I had been with him for the majority of the past three weeks. I had expected to feel his spirit leave. I did not. Each day prior, I could see a noticeable decline in his energy field. The transition to death for him was one of seemingly fading away. The day after his death, I was expecting a sign of some sort, but I saw nothing. On day three I was alone in my car, retuning from an errand for my mother. I spoke out loud to him telling him he was changing my view of the other side. No bird, no rainbow, nothing. Later that day, my sister told me that she had seen a yellow bird that made itself very obvious to her. "Yellow bird" is a song he frequently sang to us as children. Before nightfall, my nephew told us to come outside. Over the sky out of the front door was a vibrant full rainbow. While getting ready for his viewing, we saw a baby dear feeding from its mother a few feet in front of the window. The first weekend I was visiting my mom, a yellow bird was at the feeder. It was the first visit we had seen from this type of bird. The day the death certificates arrived in the mail, another rainbow was in the sky. Some may contribute all of this to coincidence. But intuitively we knew it was some sort of sign. Intuition, which is so valued in concrete circumstances, is often disregarded in areas that are more ethereal. Though often times Rogers' ideas and theories are viewed as "quackery" I can't help but give validity to much of it. I think we may get caught up in the jargon and fail to see that what she describes is really all around us. The idea of holistic nursing is as old as nursing itself. As humans in relatively good health we can endure some dissonance. In fact I think that is what different forms of stress are. But once our health is compromised, we can often become hypersensitive to those things we might not otherwise notice. We need more quiet and calm than usual. We need our energy and environment to be in harmony. We need loved ones to be sure we are cared for and comforted. It seems at the end of life it was so important to have children and spouse near and to be sure that the work of a father was done. Rogers' theory is more poignant today than ever. I have no doubt that we are unitary beings. As Unitary Beings, the human energy transforms and only the physical body changes in death (Malenski, 2006). Nothing in nature is ever lost; it only changes form. It has been said that healthcare providers should use Rogers' theory to be inspired to go beyond the ordinary line of vision and embrace the esoteric in order to more fully serve the individuals unique potential (Tordar-Francheschi, 2006). By going to a place that many may have found uncomfortable, I was able to focus on my dad and talk about painful things in order to assist him. I often cried and at times had to leave the room unnoticed when talking about his passing. The physical aspect was easier in that I was able to teach my family what I knew as a woman about to be a nurse how to care for him physically. He had absolutely no skin breakdown. I could slightly elevate the head of the bed to aid his breathing. I could float his heels and put a pillow between his knees. I taught my family how to log roll him and use a draw sheet. I followed his cues on how to deal with him emotionally. He reinforced what I have always believed: little things make the biggest differences in patient care. And he was gracious enough to be the first patient I have ever had to die. The relationship with my dad is not gone, only changed. Those we love always live in our hearts.
Alligood, M.R. (1991). Testing Rogers's theory of accelerating change the relationships among creativity, actualization and empathy in persons 18-92 years of age. Western Journal of Nursing Research 13(1) 84-96.
Cobb, C., Bean K. (2006). Unitary: a concept for analysis. The Journal of Theory Construction and Testing 10(2) 54-7.
de Chesnay, M. (2005). P. 54-56. Caring for the vulnerable perspectives in nursing theory, practice, and research. Sudbury Massachusetts: Jones and Barlett Publishers.
Malinski, V.M. (2006). Dying and grieving seen through a unitary lens. Nursing Science Quarterly 19(4) 296-303.
Rogers, M. E. (1970). An introduction to theoretical basis of nursing. Philadelphia: F. A. Davis Company.
Todaro-Francheschi, V. (2006). Studying synchronicity related to dead loved ones aka after-death communication: Martha, what do you think? Nursing Science Quarterly 19(4). 296-303.
Wright, B.W. (2007). The evolution of Rogers' science of unitary human beings: 21st century reflections. Nursing Science Quarterly 20(1) 64-67.
Nancy Mezick MM, CMT, CNMT, RN, BSN
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