Nursing

Module Eight: Suffering, Quaternary Prevention, Ethics in Chronic Illness Situations

This module introduces quaternary prevention and addresses the role of nurses in situations where individuals and families may be suffering. Principles of ethics are revisited as related to suffering and the nursing role.

Module Objectives

1. Discuss types of suffering.

2. Address the role of nursing in situations of suffering.

3. Introduce quaternary prevention as it relates to nursing practice.

4. Apply the Code of Ethics for Nurses with Interpretive Statements in situations of suffering.

5. Consider informed risk, autonomy, beneficence, and nonmaleficence in difficult situations.

Required resources and reading assignments:

Required videos linked into this module

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.).

(available free through the SMSU McFarland Library e-books: https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nlebk &AN=2935865&scope=site Focus on Standard 8

American Nurses Association (2015) . Code of ethics for nurses: With interpretive statements. Silver

Spring, MD: ANA.

http://ssuproxy.mnpals.net/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk& AN=1021757&scope=site

Martins, C., Godycki-Cwirko, M., Heleno, B., & Brodersen, J. (2019). Quaternary prevention: an evidence based concept aiming to protect patients from medical harm. British Journal of General Practice, 69(689), 614–615. https://doi - org.ssuproxy.mnpals.net/10.3399/bjgp19x706913

Martins, C., Godycki-Cwirko, M., Heleno, B., & Brodersen, J. (2018). Quaternary prevention: reviewing

the concept. European Journal of General Practice, 24(1), 106–111. https://doi org.ssuproxy.mnpals.net/10.1080/13814788.2017.1422177

Nagano, H., Chida, K., & Ozawa, T. (2022). Can We Be at Peace With Unsolvable Suffering? A Qualitative Study Exploring the Effectiveness of Supportive Communication and Resilience Building. Journal of Hospice & Palliative Nursing, 24(3), E76–E82. https://doi -

org.ssuproxy.mnpals.net/10.1097/NJH.0000000000000852

Norman, A. H., & Tesser, C. D. (2019). Quaternary prevention: a balanced approach to demedicalisation. British Journal of General Practice, 69(678), 28–29.

https://doi - org.ssuproxy.mnpals.net/10.3399/bjgp19X700517

Palliative and Supportive Care at the End of Life: Reducing Suffering, Enhancing Meaning, and

Improving the Quality of Life. (2021). Journal of Oncology Navigation & Survivorship, 12(10), 360–361.

https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm& AN=153038018&scope=site

Potter, M.L., & Wynne, B.P. (2015). Loss, Suffering, Bereavement, and Grief. In M. Matzo & D.W.

Sherman (Eds.), Palliative care nursing: Quality care to the end of life (4th ed., pp. 205 - 234).

Springer Publishing Company.

https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=e680s ww&AN=801728&lang=en%2cen&scope=site

Tarzian, A.J., & Schwarz, J.K. (2015). Ethical Aspects of Palliative Care. In M. Matzo & D.W. Sherman (Eds.), Palliative care nursing: Quality care to the end of life (4th ed., pp. 33-60). https://ssuproxy.mnpals.net/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=e680s ww&AN=801728&lang=en%2cen&scope=site

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles &

Practice, 30(1), 17–28. https://doi -o rg.ssuproxy.mnpals.net/10.1159/000509119

OPTIONAL readings

Alber, K., Kuehlein, T., Schedlbauer, A., & Schaffer, S. (2017). Medical overuse and quaternary prevention in primary care -- A qualitative study with general practitioners. BMC Family Practice, 18, 1–13. https://doi - org.ssuproxy.mnpals.net/10.1186/s12875 - 017 - 0667 - 4

Bolton, L. E., Seymour, J., & Gardiner, C. (2022). Existential suffering in the day to day lives of those living with palliative care needs arising from chronic obstructive pulmonary disease (COPD): A

systematic integrative literature review. Palliative Medicine, 36(4), 567–580. https://doi org.ssuproxy.mnpals.net/10.1177/02692163221074539

Derrington, S. (2021). Justice and the Ethical Response to Suffering. American Journal of Bioethics, 21(1), 73–75. https://doi - org.ssuproxy.mnpals.net/10.1080/15265161.2020.1850910

Duffee, C. (2020). What really is the nature of suffering? Three problems with Eric Cassell’s concept of distress. Bioethics, 34(7), 695–702. https://doi - org.ssuproxy.mnpals.net/10.1111/bioe.12748 .

Hofmann, B. (2021). How to Draw the Line Between Health and Disease? Start with Suffering. Health

Care Analysis,29(2),127–143. https://doi - org.ssuproxy.mnpals.net/10.1007/s10728 - 021 - 00434 - 0

Lee, E., & Kim, Y. (2021). Caregivers’ psychological suffering and posttraumatic growth after patient

death. Perspectives in Psychiatric Care, 57(3), 1323–1330. https://doi org.ssuproxy.mnpals.net/10.1111/ppc.12693 (this addresses suffering of nurses)

Seng Beng, T., Ting Ting, T., Karupiah, M., Xin Ni, C., Li Li, H., Chong Guan, N., Ee Chin, L., Chee Loong, L., & Maw Pin, T. (2021). Patterns of Suffering in Palliative Care: A Descriptive Study. Omega:

Journal of Death & Dying, 84(2), 512–524. https://doi org.ssuproxy.mnpals.net/10.1177/0030222820903221 Takla, A., Savulescu, J., & Wilkinson, D. J. C. (2021). A conscious choice: Is it ethical to aim for

unconsciousness at the end of life? Bioethics, 35(3), 284–291. https://doi org.ssuproxy.mnpals.net/10.1111/bioe.12838

Graded Assignments: Focused reflection assignment

After viewing the videos by Dr. Gwande and a minimum of two Finding Hope videos (the videos are linked into the module and most videos are less than seven minutes long), and reviewing required resources (you may certainly find more evidence if you wish), respond to the following questions, adhering to the rubric found in Appendix C. Submit your responses to the assignment box.

1) Reflect on what nurses can do when individuals and families are living with suffering. Include a minimum of two citation/reference pairs in your response.

2) Review Standard 8 in the ANA: Nursing Scope and Standards of Practice. How does the role of advocacy fit with Quaternary Prevention?

3) Reflect on quaternary prevention. How does quaternary prevention 'fit' with Dr. Gwande's views?

4) How does 'informed risk' fit with decision making?

5) Reflect on the ethical principles of autonomy, beneficence, and maleficence. How to they 'fit' in situations of chronic illness?

For the future

Dr. Atul Gwande is a prominent neurosurgeon whose perspective on death and dying changed when his own father was diagnosed with cancer. Dr. Gwande's work has been very well received and recognized over the last few years. When you have a bit of free time (maybe between semesters), I strongly recommend reading his book titled Being Mortal: Medicine and What Matters in the End - well worth your time!