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Overt Cognitive Distortion
An analysis of the application of
The care needs of patients are often complex and may involve a range of issues. During the process of caring nurses have a responsibility to understand and explore these broad issues and plan care to make a difference to the patients experience. To do this nurses need the skill of critical analysis, application and evaluation. Nursing also requires the use of refection -on experience that allows us to draw insights to ensure that our future practice is informed in a positive way and in turn improves the patients experience of care. Introduction.
This essay is based on an experience that I had when working on a General medical ward. It provided a major learning opportunity for me and my reflection on the issues involved have subsequently helped me to modify and adapt my practice when encountering this type of situation after the original event. The lady involved will be refered to as Mrs. G.
The clinical situation
This case revolves around Mrs. G. a lively lady in her late 50s who was admitted onto a general medical ward for investigation of back pain. On arrival she was sprightly and always in movement, never sitting still. She made a point of going from bed to bed in the ward talking animatedly to the other patients. It was quite noticeable however, that she always deflected questions about herself.
Over the first few days she had a number of different investigations. On the fifth day, the consultant came onto the ward specifically to see her. She went into a side room to see him and when she came out she was more motivated and animated than she was before arranging flowers on the ward and talking loudly to the other patients. The consultant told the nursing staff that Mrs. G. had been diagnosed with a malignancy of the pancreas and had multiple bony and pulmonary secondaries. He had just told her that she had a maximum of four weeks life expectancy.
I was amazed at her behaviour and went to talk to her. I asked what the consultant had said, she replied that it really was amazing how such an educated man could clearly be so wrong and not get the results of the tests right. She was firmly of the opinion that there had been a mistake or a mix up with the results and that her results would turn up shortly. She refused to answer any other questions on the issue and talked loudly and animatedly about inconsequential things happening on the ward.
It became clear that Mrs. G. was probably all too well aware of the diagnosis, even before she came into hospital. Both then, and after the consultant had told her directly, she was indulging in overt cognitive distortion and frank denial as coping mechanisms. Her animated persona was nothing more than a coping strategy so that she would not have to either face or dwell on the important issues that clearly confronted her.
My subsequent dealings with her on the ward over the next four days before her discharge showed that she kept this front up for the length of time that she was in hospital. I went along with this subterfuge in order to keep her spirits up. In the course of a subsequent discussion during a chance meeting with her community nurse, the nurse told me that, after discharge, she became profoundly depressed and died only two weeks later. I felt that I had not handled the situation as well as I could have done and resolved to make it a learning experience.
The nursing issues
For me, this was an important learning experience as I had never experienced such frank denial as a coping mechanism before. I reflected on the issue (Dewey, J. 1933) and resolved to consider the literature on the subject to become better informed. In retrospect and after a period of reflection, it seemed to me that the most significant nursing issue here was to manipulate the situation in an empathetic and humane way so that Mrs. G. found herself in a situation where she could come to terms with the diagnosis in a calm and considered way and where she felt supported and empowered. (Hogston, R et al.2002). Rather than simply colluding with her I feel that I should have spent more time trying to allow her the time and opportunity to talk openly about her fears and worries.
Literature review
A brief examination of the literature on the subject showed that the issues here were complex and well researched. Denial of a terminal prognosis can either be because the patient wishes to maintain a positive faade to bolster their family or because it helps them to remain optimistic (Dobrantz 2005).
From a nursing perspective one should consider the excellent article by The (et al. 2000) in which he examined a range or responses that patients exhibit after being given bad news. There is one section in the paper where the authors examine the issue of collusion between healthcare professionals and the patient. The patient presents the healthcare professional with an overtly optimistic picture and the healthcare professional will play along with the deception in order to avoid the necessity for the patient to confront the truth. (Kuhse & Singer 2001)
One has to question the appropriateness of this behaviour as, on the one hand, one can clearly see such interaction as a kindness to save the patient undue emotional trauma, but on the other it is clear that in order to allow the patient to make appropriate decisions relating to their end of life care, it is not a kindness to allow an indefinite postponement of the time when they must take a practical view of their situation. (Williamson C 2005).
Any person should ideally be allowed the time to order their life and to make whatever decisions they need to tell family or friends of their predicament and their wishes. This clearly cannot be accomplished if they are still in denial of the diagnosis.
The paper by Jennings (et al 1997) gives a clear and concise overview of the behaviour trajectory adopted by many patients in this type of situation. The typical patient who is facing a terminal prognosis either overtly or, as is the case with Mrs. G. covertly, will be in a situation which is completely new to them and stressful to the point that is rarely experienced in other circumstances. He describes the emotional turmoil as wide-ranging across a range of emotions and producing typical reactions including depression, denial, false optimism and then occasionally, acceptance.
Mason T and Whitehead E (2003) advise that the professional nurse should recognise these phases as part of the normal spectrum of illness behaviour. They should be seen and understood as such, and the concerned healthcare professional should be prepared for them and be empathetic to them.
A number of other papers embark on a similar theme and explore the frequency with which patient enquires about the ability of the medical staff to cure them. Meredith (et al 1996) False optimism is a common ploy that is adopted by both sides. The medical and nursing staff may be unduly optimistic as they do not wish to depress the patient and the patient may be unduly optimistic not only for the obvious reason that they find it easier to cope with than bad news, Costain (et al 1999) but also for the less obvious reason that they feel a deference to the professional staff and do not wish to be seen to question their ability to nurse and treat than back to health.
(Lynn 2001)
In specific reference to Mrs. G. we can also consider the paper by (Leydon et al 2000) who studied the situation where patients are overtly told bad news by healthcare professionals and then will deny that they have been given the news when questioned about it shortly after.
With regard to the nursing implications of this situation we should perhaps look in greater detail at the paper by Lynn, mentioned earlier. There is a particular twist in this paper where patients will often collude with their doctors about the chances of medical science being able to cure them and appearing overtly optimistic during the consultation. The same patient may well also be able to talk in a far more realistic and frank way to other healthcare professionals such as the nurse, who is perceived, in the caring role rather than the curing role, and therefore the patient does not necessarily feel that they are questioning the nurse's professional integrity by talking openly about matters pertaining to failure of treatment and death (Dean 2002).
This is a very important and sometimes overlooked role of the nurse who may, through pressure of work or even a feeling of embarrassment not actually make the time to allow the patient to express their fears and worries.
Implications for practice, specific and general
In patient management it is often useful to consider and adopt a particular nursing model. There are many to choose form. They are all variations on the basic theme of Nursing Process of assessment, planning, implementation and evaluation but each analyses the patient situation from a different aspect or in different terms. (Fawcett J 2005)
The Roper Logan Tierney model (Roper, Logan and Tierney 2000) is primarily concerned with the activities of daily living and dealing with them on a problem solving basis. This model is very useful for problems which are primarily physically or disability orientated. In the case of Mrs. G. although she undoubtedly did have physical symptoms, they did not feature in her daily life as she largely chose to ignore them and her major problem was one of facing her immediate prognosis which this model is not particularly useful in describing.
The Roy adaptation model (1991) describes the ability ( or in this case - inability) of the patient to adapt to the pattern of their illness. In this case, this model is also not particularly useful as Mrs. G. 's refusal to face reality does not show any degree of adaptation to the illness role. Her degree of cognitive distortion allows her to regard herself as well when in reality she is not far from death. In short, she is not adapting to the situation at all she is choosing to ignore it.
The Johnson Behavioural System ( in Wilkerson et al 1996) is certainly useful in tackling the denial features of Mrs. G.'s behaviour but is not helpful in describing the eventual adaptive processes that will inevitably overtake Mrs. G. as she is forced to confront reality when her physical symptoms rise to prominence.
This particular case is of the type described by Wadensten (et al 2003) who concludes that in cases of multifactorial aetiology there is not one satisfactory nursing model to account for all aspects of care
Because Mrs. G. has received a terminal diagnosis, one should consider the writings of Seale particularly the paper in which he explores the concept of a good death (Seale et al 2003). In short, this comes down to good holistic nursing care. In this context, it is care that recognises the spiritual and psycho-social elements of health as well as the overtly physical (Wright et al 2001)
The application of good holistic care is dependent on a firm understanding of the circumstances in which the patient lives. In the case of Mrs. G. she had a husband at home but, for reasons which were never disclosed, she made many excuses as to why he never visited her at the hospital. In the widest sense this could also be seen as part of her process of denial.
Lynn (2001) suggests that the holistic approach to healthcare, and specifically end of life care, calls for a recognition that patients need more than the specialists and technicians can normally offer. As nurses we are progressively becoming enmeshed in the technicalities of healthcare and can sometimes loose sight of the human qualities needed. To take this point further, one can consider the work of Cecily Saunders (quoted in Brignall I 2003). Her underlying belief was that patients should be allowed to come to terms with the spiritual values (as distinct from religious ones) in the time before death and to a large extent this was the guiding principle of the hospice movement.
It was part of the hospice management strategy to try to get all of the involved or concerned parties (patient, carers and healthcare professionals) to actively confront the prognosis, together with all of the uncertainties or insecurities that were associated with it. One could assume that it was probably these insecurities and uncertainties that made Mrs. G. 's situation intolerable for her.
This concept of confrontation of the prognosis places a large burden on the healthcare professionals and the lay carers. They have to make a judgement on the issue sensitively and carefully. As we have examined, a misjudgement can have major repercussions for the patient, but as Lynn (2001) points out, a good judgement can allow the patient and their carers to reap untold benefits that might otherwise have been denied.
Mrs. G. 's particular situation illustrates the difficulties experienced in these circumstances. The healthcare professional is put, by her actions, into a no-win situation. Sometimes it can be extremely difficult to break the deadlock. We have mentioned the paper by The earlier and in these specific circumstances he suggests the utilisation of a treatment broker who can bridge the gap and negotiate the patient's pathway to acceptance of the situation
Analysis, conclusion and discussion
The case of Mrs. G. both surprised and intrigued me. Having reflected on the problem and researched the literature on the subject, it would appear that the reaction shown by Mrs. G. is clearly not unusual. There are a great many references in the literature to various theories relating to a patient's coping mechanism with illness together with a number of academic studies that have attempted to both evaluate and to quantify the response.
The nursing challenge in this instance is how to both recognise and to manage the problem so that the best possible outcome can be obtained. It would seem that the concept of empowerment and education of the patient is particularly helpful in this case (Gilbert T 1995). If circumstances can be manipulated so that Mrs. G. was made able to feel that she can confront the issues relating to her illness then there would have been little doubt that whatever time she had left would have been more profitably spent.
The recognition of the problem should not represent too great a challenge as, having consulted the literature, it appears that Mrs. G. exhibited all of the major symptoms of both cognitive distortion and overt denial. She clearly was constructing situations of manufactured and unnecessary activity together with forced conversations with the other patients, so that she did not have time to quietly sit and face the reality of the situation.
The major question to be answered is Do healthcare professionals actually help the patient by not forcing them to confront the issue directly (Sugarman J & Sulmasy 2001). It would appear that the majority of informed opinion is that the patient should always be told the truth, but it is a matter of professional judgement and negotiation as to how overtly that truth is presented.
This illustrates one of the real dilemmas for the healthcare professional, of this type of situation Just how truthful should one be?. In practical terms the truth can be presented to the patient simply by the expedient of truthfully answering their questions. It is often the case that the patient will only ask the questions that they are ready to hear the answers to.
The creation of a non-threatening and relaxed, empowering atmosphere where Mrs. G. can bring herself to face reality should be the goal of professional management. This should be ideally followed by a supportive atmosphere when Mrs. G. will clearly find herself emotionally labile and vulnerable. In most cases the nurse is arguably ideally placed in the health care team as they are perceived as caring and typically have more time to talk to patients. Patients expect to find nurses in a supportive role and therefore will more readily accept the situation when it is presented. The role of the Treatment Broker (as advocated by The) is slowly gaining acceptance and is yet another option for the healthcare professional to consider in trying to resolve difficult situations such as the one presented by Mrs. G.
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