In palliative care, where interactions cross clinical, pathological, psychological, social and spiritual considerations, it may be useful to take a minimal approach and avoid an overcomplicated or formulaic structure for the consultation. We will concern ourselves with points in the encounter where doctor and patient with or without family or carers need to be in agreement. Whether a consultation is based on a structured interview, a cue-based assessment or a narrative approach, the points of agreement or concordance need to cover four key areas; missing any of these has grave consequences for the clinical relationship. Without concordance, patients may be right to conclude that you don't know why you're all there (context), you don't know what's the matter (issues), you don't know what's going on (story) or you don't know what you're doing (plan). These four elements may serve also as a guide to the quality and effectiveness of an encounter among a doctor, patient and carers. We consider how this clinical method might integrate the nosological practices of doctors in palliative care services better, and we argue that finding concordance is likely to establish a better doctor-patient relationship at a human and professional level through empathy and trust rather than just a technical exchange.
Background Serious illness disrupts the narrative coherence central to maintaining our sense of self. In healthcare interactions, including palliative medicine consultations, paying close attention to patient narrative provides insight into the multi-dimensional impact illness has on the whole person, and can be therapeutic; helping a person make sense of their illness and engage in narrative repair. Co-construction of narrative in consultation reflects a shared understanding of a patient's problems and a plan for future action that is collaborative. This literature review is the first step in a study to develop and evaluate a narrative-based approach for palliative medicine consultations following the Medical Research Council guidance on development and evaluation of complex interventions. Aim To describe the scope and effectiveness of narrative interventions with patients in healthcare. Methods Literature was sought from three electronic databases, hand-searching of journals, citation lists and on recommendations. Sources include all types of papers from peer-reviewed journals and textbooks published in English that describe narrative practice in healthcare and evaluate narrative interventions with adult patients in healthcare settings. Results Of 1884 references initially identified 222 sources were included in the review. These were sorted into three categories: 1. Narrative theory applied in healthcare; 2. Biographical interventions; 3. Narrative therapy. Conclusions The application of narrative theory in healthcare has grown since the 1980s, has broad scope, and includes many different interventions with patients few of which have been evaluated. Biographical interventions in gerontology however predate this more general interest, and with regards to life review therapy have demonstrated benefit in emotional well-being and life satisfaction for older people. Life review interventions such as Dignity Therapy have been successfully adapted for use in palliative care.
cycle 1 (30%) to cycle 2 (55%). Additionally, there was a decrease in the mean length of time from recommendation to administration (213 minutes 1st cycle and 172 minutes 2nd cycle). Conclusion Initial interventions including educating ward staff and palliative care link nurses, plus the introduction of syringe driver board magnets to highlight patients with CSCI may have had some impact on CSCI practice at LRI. Continued work is needed to maintain the momentum of this project and sustain change. Incorporating CSCI alerts and reminders into the hospital electronic system represents an important next step, along with empowering and supporting wards to monitor their own practice routinely. The work is due to be replicated at other UHL sites.
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