Showing posts with label culture. Show all posts
Showing posts with label culture. Show all posts
Thursday, June 17, 2010
Pallimed Case Conferences (cases.pallimed.org) is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
For active posts on these cases and new cases go to www.pallimed.com.
By Julie Childers, MD
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center
Vol 10, No. 6 - June 2010
Case: Mrs. L was a 95 year old woman who was admitted to the acute care hospital from her nursing home with decreased mental status. She was found to have pneumonia, and though her infection improved with antibiotics, her mental status did not recover and she continued to be only slightly responsive to her family, unable to eat or interact On the sixth day of Mrs. L’s hospitalization, palliative medicine was consulted to help the family with decision-making. By the time the palliative care consultant saw the patient, a temporary feeding tube had been placed, and the family had reached consensus on a trial of artificial feeding to give her a chance to regain strength, though they acknowledged that her prognosis was poor.
The next day, the patient was still unable to communicate, but was moaning and grimacing. She repeatedly tried to cough weakly to clear the copious secretions in her upper airway. The palliative care consultant recommended low doses of intravenous morphine to treat pain and shortness of breath, with a medication to clear secretions. However, Mrs. L’s attending physician was concerned that treating pain with opioids would cause respiratory depression and lead to Mrs. L’s death. The next night, the bedside nurse charted several times that Mrs. L was screaming, but they were only able to give her Tylenol for pain; she required wrist restraints to prevent her from pulling out her feeding tube. The palliative care physician was haunted by the image of the dying 95 year old woman, tied down and denied treatment for her suffering.
Discussion: Moral distress occurs when the clinician knows the appropriate action to take, but is unable to carry it out, and feels forced to give care contrary to her values. It is more often described in the nursing literature, but is beginning to come to the awareness of physicians as well. Moral distress often occurs in end-of-life situations when the decision is made to provide aggressive life-sustaining treatments that are felt to put excessive burden on patients and families.
Clinicians who see patients at the end of life may be particularly vulnerable to moral distress. For those of us who serve as consultants, our involvement in a case is at the discretion of the attending physician. In cases such as Mrs. L’s, we feel constrained by our role as advisors to the consulting physicians and the expectation of professional courtesy towards other physicians’ decisions. When we serve as attending physicians ourselves, our ability to relieve patient suffering may be limited by the family’s preference that every possible life-sustaining measure be taken.
Moral distress is also a common problem in the nursing field, particularly critical care nursing. For clinicians in any of these roles, moral distress arises when the system or other people interfere with our ability to relieve a dying patient’s suffering.
In the nursing literature, moral distress has been shown to contribute to decreased job satisfaction and to burnout. The American Academy of Critical Care Nurses recommends addressing moral distress with a four-step process:
- Ask: You may not even be aware that you are suffering from moral distress. Signs of moral distress may include physical illnesses, poor sleep, and fatigue; addictive behaviors; disconnection with family or community; and either over-involvement or disengagement from patients and families.
- Affirm: Validate the distress by discussing these feelings and perceptions with others. Make a commitment to caring for yourself by addressing moral distress.
- Assess: Identify sources of your distress, and rate its severity. Determine your readiness to act, and what impact your action would have on professional relationships, patients, and families.
- Act: Identify appropriate sources of support, reduce the risks of taking action when possible, and maximize your strengths. Then you may decide to act to address a specific source of distress in your work environment.
In Mrs. L’s case, the consultant discussed the case with the interdisciplinary team, receiving support for her concerns. Despite fear of negative repercussions from the primary service, she called the patient’s son herself and gently explained the signs of suffering that Mrs. L was showing. He agreed that his mother should have low-dose morphine. The primary team added this order without any expressed objections to the consultant stepping over her boundaries. Mrs. L died a few days later.
References
1. Weissman, D. Moral distress in palliative care. Journal of Palliative Medicine. October 2009, 12(10): 865-866.
2. The American Association of Critical Care Nurses. The 4 A’s for managing moral distress. (free pdf)
Thursday, June 17, 2010
Thursday, January 1, 2009
Pallimed Case Conferences (cases.pallimed.org) is closed to comments and new posts as of April 25, 2013.
This site will stay online as an archived source, but will no longer be updated.
For active posts on these cases and new cases go to www.pallimed.com.
By Erin Hedden, Music Therapy Intern
Originally posted at the Institute to Enhance Palliative Care, University of Pittsburgh Medical Center
Vol 8, No. 10 - November 2008
Case:
Ms. Z was a middle-aged Colombian woman with pulmonary hypertension and was awaiting a double lung transplant. Her presenting symptoms included extreme shortness of breath with minimal exertion, tiredness, and chest pain. A palliative care consult was requested for support and symptom management for anxiety and depression. She was also very concerned about her bills. She had trouble concentrating, was unable to watch TV or use her laptop, and was constantly tearful. Through palliative care, a consult was obtained for music therapy. In the context of music therapy, her anxious and depressive symptoms were significantly diminished by using music that was specific to her native culture.
Discussion
Music therapy has consistently been demonstrated to help alleviate symptoms of anxiety and depression, especially when the implemented music is a type of music that is preferred by the patient. In fact, a study researching the effects of subject-preferred music found that subjects who listened to their preferred music exhibited an increase in positive mood if their pre-music mood was negative. It also found that subjects listening to preferred music maintained a positive mood if the subjects’ pre-music mood was positive (Wheeler 1985).
Since Ms. Z was a Colombian immigrant, there were many times that she had family members and friends with her to both support her and translate some of the more difficult conversations that were in English. Though this author did know rudimentary Spanish, and did successfully implement short phrases, it was the music that became the common language throughout each session.
The first music therapy session was met with much enthusiasm and laughter from Ms. Z’s family and friends. Ms. Z was visibly anxious and nervous as she sat in the corner, but as she began to watch those around her enjoying themselves, her face softened and she smiled from behind her oxygen mask. The two attending interns closed the session having played some of the requested music, but with the momentous assignment to learn many more songs. Countless hours were spent learning songs by one of her favorite artists, Juanes, who is famous in Colombia and other South American and Spanish-speaking countries.
The second session was filled with a myriad of their favorite Spanish songs. They sang every song along with the attending interns, laughing and crying at the same time. Ms. Z was visibly relaxed and at peace. She continued to enjoy music therapy after she got her double lung transplant. Through the implementation of music therapy, her anxious and depressive symptoms were significantly diminished through singing, the use of percussion instruments, and by using her preference of cultural-specific music.
Through singing, she used her lungs—both before and after her double lung transplant. Even when Ms. Z was only able to whisper, she was still stretching her new lungs while “mouthing” the words she knew from memory. It distracted her from the monotony of being hospitalized, from the bills she couldn’t pay, and from her constant medical problems. It fostered a deeper and more meaningful socialization with her loved ones, and helped her to find cultural familiarity within someone else’s culture. Singing also gave her choices: she could participate or watch; she could choose which song she wanted to hear; she could choose which artist she wanted to hear; and she could choose the language with which she wanted to surround herself. It also gave her a sense of ownership and pride that the attending interns learned these songs specifically for her.
Using percussion instruments had its own benefits: it was a less threatening way to participate in the music-making experiences; it gave another series of choices for her to make; and because there was a wide array of South American instruments, it was a physical and tangible connection to her cultural heritage.
Music can help patients to appreciate the beauty and wisdom of their own cultural backgrounds and promote positive feelings within them that can be tapped into when celebrating and coping with life’s highs and lows (Chase 2003). By validating Ms. Z’s culture and bringing it into her hospitalization, music therapy fostered a sense of normalization and familiarity within the hospital walls which to her had previously represented feelings of anxiety and depression.
References:
1. Chase, Kristen M. "Multicultural Music Therapy: A Review of Literature." American Music Therapy Association Music Therapy Perspectives 21 (2003): 84-88.
2. Wheeler, Barbara L. "Relationship of Personal Characteristics to Mood and Enjoyment After Hearing Live and Recorded Music and to Musical Taste." Psychology of Music 13 (1985): 81-92.
Ms. Z was a middle-aged Colombian woman with pulmonary hypertension and was awaiting a double lung transplant. Her presenting symptoms included extreme shortness of breath with minimal exertion, tiredness, and chest pain. A palliative care consult was requested for support and symptom management for anxiety and depression. She was also very concerned about her bills. She had trouble concentrating, was unable to watch TV or use her laptop, and was constantly tearful. Through palliative care, a consult was obtained for music therapy. In the context of music therapy, her anxious and depressive symptoms were significantly diminished by using music that was specific to her native culture.
Discussion
Music therapy has consistently been demonstrated to help alleviate symptoms of anxiety and depression, especially when the implemented music is a type of music that is preferred by the patient. In fact, a study researching the effects of subject-preferred music found that subjects who listened to their preferred music exhibited an increase in positive mood if their pre-music mood was negative. It also found that subjects listening to preferred music maintained a positive mood if the subjects’ pre-music mood was positive (Wheeler 1985).
Since Ms. Z was a Colombian immigrant, there were many times that she had family members and friends with her to both support her and translate some of the more difficult conversations that were in English. Though this author did know rudimentary Spanish, and did successfully implement short phrases, it was the music that became the common language throughout each session.
The first music therapy session was met with much enthusiasm and laughter from Ms. Z’s family and friends. Ms. Z was visibly anxious and nervous as she sat in the corner, but as she began to watch those around her enjoying themselves, her face softened and she smiled from behind her oxygen mask. The two attending interns closed the session having played some of the requested music, but with the momentous assignment to learn many more songs. Countless hours were spent learning songs by one of her favorite artists, Juanes, who is famous in Colombia and other South American and Spanish-speaking countries.
The second session was filled with a myriad of their favorite Spanish songs. They sang every song along with the attending interns, laughing and crying at the same time. Ms. Z was visibly relaxed and at peace. She continued to enjoy music therapy after she got her double lung transplant. Through the implementation of music therapy, her anxious and depressive symptoms were significantly diminished through singing, the use of percussion instruments, and by using her preference of cultural-specific music.
Through singing, she used her lungs—both before and after her double lung transplant. Even when Ms. Z was only able to whisper, she was still stretching her new lungs while “mouthing” the words she knew from memory. It distracted her from the monotony of being hospitalized, from the bills she couldn’t pay, and from her constant medical problems. It fostered a deeper and more meaningful socialization with her loved ones, and helped her to find cultural familiarity within someone else’s culture. Singing also gave her choices: she could participate or watch; she could choose which song she wanted to hear; she could choose which artist she wanted to hear; and she could choose the language with which she wanted to surround herself. It also gave her a sense of ownership and pride that the attending interns learned these songs specifically for her.
Using percussion instruments had its own benefits: it was a less threatening way to participate in the music-making experiences; it gave another series of choices for her to make; and because there was a wide array of South American instruments, it was a physical and tangible connection to her cultural heritage.
Music can help patients to appreciate the beauty and wisdom of their own cultural backgrounds and promote positive feelings within them that can be tapped into when celebrating and coping with life’s highs and lows (Chase 2003). By validating Ms. Z’s culture and bringing it into her hospitalization, music therapy fostered a sense of normalization and familiarity within the hospital walls which to her had previously represented feelings of anxiety and depression.
References:
1. Chase, Kristen M. "Multicultural Music Therapy: A Review of Literature." American Music Therapy Association Music Therapy Perspectives 21 (2003): 84-88.
2. Wheeler, Barbara L. "Relationship of Personal Characteristics to Mood and Enjoyment After Hearing Live and Recorded Music and to Musical Taste." Psychology of Music 13 (1985): 81-92.
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Thursday, January 1, 2009
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