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I'm caring for a 60-year-old patient with diabetes who was admitted for a hip fracture and has developed an infection. Her complex medical history includes a kidney transplant and foot amputation due to gangrene. She's been admitted to our unit four times over the last 3 years and she's also been admitted twice to the hospital's psychiatric unit for depression.
During past admissions to this unit, she seemed depressed one day and cheerful the next. This time she's been only semiconscious, and she has no advance medical directives.
Her family insists that "everything be done because she's going to respond sooner or later-she always has in the past." We've not had a formal care conference, but many staff members believe what we're doing is medically futile. Yet nobody's broached the subject with the family. I don't think the hospital will go against the family's wishes. Our facility doesn't have an ethics committee. What should we do?-S.S., S.C.
The ambiguity of this situation presents many ethical problems. The result? Moral distress for everyone involved. In this case, the meaning of patient advocacy isn't clear because in the past, the patient herself has been conflicted, and now she can't express her treatment choices. Her family sounds strong and united, which at times may seem overbearing and even threatening to staff.
The most unethical response to this situation would be to assume that nothing can be done in these distressed circumstances. In fact, this is a great time to bring people together to share concerns.
You say there's been no care conference, so how about holding one? Along with family members, invite several nurses who have good rapport with the family, a primary care provider (such as her nephrologist or an infectious disease expert), and a social worker or chaplain skilled in facilitating communication. Let the family know you're concerned about them as they try to cope. Keep the meeting positive and family-focused with no specific agenda-simply a time to share thoughts, feelings, and questions. Talk about "what ifs" and ask open-ended questions, such as:
* "How can we at the hospital help you most at this time?"
* "What do you hope for in the coming week?"
* "What should we plan for if that hope isn't met?"
* "What's the best way for us to all work together?"
The responses will guide treatment decisions and help you provide ethical and compassionate care to the patient and family in the difficult days ahead.
An Hispanic patient came to the clinic where I work complaining of anxiety, insomnia, and listlessness. He told me that he hadsusto,which he defined as "fright sickness." I documented this, but the physician dismissed it as nothing but folklore.
Recently I read thatsustois a cultural illness. Now I'm concerned that we didn't give this patient culturally competent care. How should I address this issue in the future?-S.U., ALA.
The signs and symptoms he described are all characteristic of susto, a cultural illness that has roots in Latin America. The word susto comes from Spanish and Portuguese words for sudden fear. Some severe forms of susto have been associated with a patient's death.
Susto is believed to be related to the soul leaving the body, which may be brought on by psychological trauma, such as witnessing a violent death. It's traditionally treated with herbal teas and prayer ceremonies. Some researchers consider susto akin to posttraumatic stress disorder.
Acknowledging and respecting your patient's cultural background is essential to therapeutic nursing care. This includes assessing his belief system and asking about self-medication practices; many folk remedies contain substances that could cause adverse reactions, especially if they interact with prescribed medications.
The more information and greater understanding you and your colleagues have about susto and other folk illnesses, the better prepared you'll be to provide effective and culturally sensitive care.
Reference: Willies-Jacobo L. Susto: acknowledging patients' beliefs about illness. Virtual Mentor. 2007;9(8):532-536.
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