Accident and Emergency department

This reflective assignment is based upon a recent experience on a clinical practice placement within a busy Accident and Emergency department in the local general hospital. Whilst at the department many diverse situations were experienced which may be reflected upon. For the purpose of this assignment an incident which occurred causing me to question the moral and ethical underpinning of practice within the department will be discussed. The incident in question happens within the department on a regular basis.

The issues that this reflection have raised include, sudden death within he Accident and Emergency department, the dignity of a patient in death and western societies views of death. To assist in this reflective account Gibbs Reflective Cycle (1998) will be followed which allows for personal beliefs to be explored and addressed. The reflection also allows for the acknowledgement that some practice, which my personal belief feels is wrong cannot be changed. Main Body This assignment is based upon an experience encountered where a patient admitted to the Accident and Emergency department died suddenly and was later transferred to the mortuary.

By reflecting upon the incident it is cknowledged that, although the practice witnessed in my opinion is undesirable, it is performed to prevent distress for the general public. John’s (2000) describes reflection as a window through which the practitioner can examine oneself in relation to their own lived experience in ways that allows for understanding towards resolving the contradictions within their practice between what is desirable and actual practice. To protect patient confidentiality as stated by the Nursing and Midwifery Council (2000) the patient concerned will be referred to as David throughout the assignment.

David was a married man in his early seventies, he had enjoyed good health until recently when he started to suffer with hypertension and angina. David was at home with his wife when he started to feel unwell, he was complaining of chest pains and nausea, despite using his glyceryl trinitrate nitrolindual spray this continued for some hours before his wife phoned their general practitioner, he advised that an ambulance was called for immediately. Whilst in the ambulance, on the way to the hospital David suffered a cardiac arrest. The ambulance crew notified the department of this so that the appropriate team were available immediately.

David arrived at the Accident and Emergency department within minutes and was immediately admitted to the resuscitation room. David was accompanied by his wife and next door neighbour, they had followed the ambulance to the hospital by car. A member of staff had been assigned to meet David’s wife when she arrived in the department to ensure that she was provided with all information regarding her husband. David’s wife was shown to the relatives room together with her neighbour, the nurse had informed her that David was seriously ill and that he had suffered a cardiac arrest in the ambulance.

She was informed hat the team were trying to revive him and was given the chance to witness this, she declined as she was understandably too upset by the situation. She was kept updated by the assigned nurse on David’s condition. It is important that when it is recognised resuscitation may be unsuccessful the family are made aware of this fact. This provides the family with time, even though it may be only minutes to come to terms with the seriousness of the situation (Alexander, Fawcett & Runciman, 2000).

The team tried to revive David for some time, unfortunately their efforts were unsuccessful, he was pronounced dead approximately 30 minutes ater. His wife was immediately informed and given the chance to say goodbye to David, this was a difficult situation for her as the suddenness of her husbands death had left her in a state of shock. The staff were very sympathetic and caring towards her. The assigned nurse did not leave her side and was very supportive towards her, she was encouraged to stay with David for as long as she felt she needed.

After spending some time with David his wife expressed a wish to leave but requested to return later to view him in the mortuary. The porters were contacted to remove David’s body from the department nd to deliver it to the mortuary, the staff nurse in charge requested that I accompany them. Having never been required to do this task before, as on previous occasions the porters have collected the deceased in a mortuary trolley, I enquired as to why they needed to be accompanied. The explanation received produced feelings of shock and disbelief within me. My initial thought was that somebody was playing a practical joke upon me.

Hospital protocol states that the deceased remains upon the trolley with a sheet folded down over the shoulders. An oxygen mask is applied to the outh, this procedure apparently assures the general public within the department that the patient on the trolley is alive and being transferred to a ward or another department. I questioned why the deceased is not removed in the traditional way of the mortuary trolley and was told it would upset too many people in the department who viewed it. To transfer David to the mortuary we had to go through the Accident and Emergency department and then through the main foyer of the hospital.

Both were busy with large numbers of the general public being present, the main foyer was especially busy as it was visiting time within the hospital. My experience of the whole incident has evoked both positive and negative feelings within me. As a student nurse in an emergency situation such as this I felt the need to take a step back and learn by observing the team in action during the attempted resuscitation. Every member of the team had their role to perform, the way with which they all worked together whilst remaining calm left me awestruck. They were all extremely professional in the way with which they dealt with the situation.

David’s death had been unexpected and sudden, the staff nurse assigned to care for his wife communicated with her in a caring and sympathetic anner. Wright (1996) describes bereavement as a traumatic event but suggests that sudden death is the most traumatic experience of all. Within the Accident and Emergency department effective communication and interpersonal skills are imperative in order to avoid maladaptive grief. The ability to break the news of a sudden death requires skill and sensitivity as the grief process commences immediately after the announcement (Fontaine, 2001).

David’s wife was offered the chance of being present during the attempted resuscitation of him but she declined. It has been identified that family members who witness cardiopulmonary esuscitation may be more accepting of the death of their loved one, it may also improve the grieving process for them (Kidby, 2003). The way in which the staff treated David’s wife was exemplary, they offered her adequate support in a sensitive and caring manner and encouraged her to stay with him for as long as she needed.

Reflecting on this incident caused me to question whether the situation would have been treated differently if there had been other patients present in the resuscitation room. It would not have been an ideal environment for David’s wife to see him after his death, in my opinion there should be a oom allocated within the department for this purpose. The relatives would then be able to stay with their loved one for as long as they needed after a death, especially when the death occurred as suddenly as David’s did.

The negative feelings which were aroused within me was caused by the way David’s body was transported to the mortuary. The explanation received as to why David was transported on a trolley in the way that he was caused me to become indignant, why was the dignity of the deceased forsaken so members of the public were not upset by the sight of a mortuary trolley. Sewell (2002) argues that the removal of the deceased in a mortuary trolley, although a protective gesture, secretes the body from public view.

He suggests that this method of removal furthers the perception of death as a subject to be avoided by society. The nurse should continue to be the patient’s advocate in protecting their dignity even after death when they are unable to do so for themselves. According to Hill (1997) nursing care does not end when the patient dies, although the focus of care is transferred to the relatives. The deceased should still be treated in a dignified manner with all the solemnity which s usual in the family’s culture.

The family expect their loved one to be treated in in an effective, sensitive and efficient way. The subject of death is taboo within our society, Kubler-Ross (1970) suggests that society views death as a fearful, frightening happening, and that the fear of death is a universal one. Western culture maintains a social avoidance of death and expels the idea of death from both its language and daily life. Death is inevitable and it is essential that Western society confirms the humanist element of death and bereavement rather than delegating it to the status of social taboo (Fontaine, 2001).

Although my own personal thoughts on the way with which David was transported to the mortuary were that is was wrong, I did agree to participate, my refusal to participate would have perhaps been viewed as inappropriate and not abiding with hospital protocol. The transfer to the mortuary was swift, I became conscious of the fact that people were staring at David, this aroused feelings of apprehension and anger within me which in turn caused me to feel protective towards him. My thoughts were if David’s wife was aware of the situation it may have produced unnecessary anguish for her.

It was also a possibility that a member of the public may have recognised David and approached me to ask after his welfare, that would have placed me in a difficult position. For the remainder of my time at the department I was able to discuss with several members of staff the procedure of transportation of deceased to the mortuary. Many of them showed indifference to the subject and could not understand my thoughts and feelings, whilst others displayed concern of the suggestion of a body being removed from the department in a mortuary trolley.

They felt that the general public would loose faith in heir ability to cure and heal if they were to witness a mortuary trolley leaving the department. None of the staff spoken to seemed concerned about the fact that the deceased was exposed, and in my opinion treated with lack of dignity. I did feel hostility from certain members of staff when questioning this procedure and felt that the explanation given was inadequate. The method of transferring the deceased to the mortuary is hospital protocol, however, the department did not have a copy of that protocol, my mentor informed me that it was an unwritten ruling which had become a ritual.

Walsh and Ford (1989) intimate that the care of the deceased may be compromised because of lack of forethought or rationale due to recurrent practice being ritualised. Although my personal feelings on the transportation of the deceased to the mortuary is that it is inappropriate, the design of the hospital adds to the problems. The hospital therefore adopts the belief that it is acting in the interests of the general public. It must be acknowledged that caring for the dead is a unique feature of nursing as the deceased will never be aware of the care they have received (Sewell, 2002).

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