Community nurses work closely with patients and families as the end of life approaches. Many patients, as well as their families and friends, may come to realise that the end of their life is getting closer with each time their illness deteriorates. With this realisation comes the painful decision to abandon unrealistic pursuits and concentrate on what seems possible within the restrictions imposed by their illness. The pain comes from being torn between continuing with life but knowing this is no longer an option under their control and refocusing on other elements of their remaining life. In this moment, many people rearrange and reprioritise the various aspects of their life, which Gawande (2015) referred to as ‘shifting their perspectives’.
Gawande suggested that people engage in a shift of perspectives in response to how they perceive how much time they have left. Patients and relatives are often heard asking doctors and nurses: ‘how long have I got?’ or ‘am I dying?’. Very often, healthcare professionals misconstrue these as difficult questions, but when they are understood correctly, the realisation occurs that perspectives matter, and the responses provided often influence a shift in the questioner's future outlook.
Gawande used the hierarchy of needs proposed by Maslow (1943) to demonstrate shifting of perspectives among dying people. According to Maslow (1943), many people strive for the top position in the pyramid—self-actualisation. For self-actualisation, certain factors must be true: potential to achieve goals, time available, limitless energy and creativity and a horizon of infinity (Gawande, 2015). Success in these aspects is based on people having a potential for health. However, Gawande argued that when people perceive that these possibilities are no longer viable, perspectives shift to the here and now. In palliative care, patients tend to refocus onto those closest to them (family and friends) and want to share their remaining time with them. The point here is how community nurses can facilitate care that appreciates the shifting perspectives of patients. This would involve understanding that the shift in perspectives may not be easy to accept on a psychological level. For example, patients may feel they have let themselves and their family down by not accomplishing their goals. Not being there to see their children grow up or no longer being the bread winner could be sources of distress. It also needs to be recognised that deteriorating illness has a ripple effect in that it narrows patients' social horizons as their circle of friends diminishes—something that is out of their control. Essentially, the point is that individuals' perspectives are bound to shift with any uncertainty in life, but particularly with ill-health.
If the main goal for patients is self-actualisation in whatever form and deteriorating illness ‘forces’ them to shift their perspectives, it is crucial that healthcare professionals work with patients to refocus them on the here and now. From the perspective of Maslow's (1943) hierarchy of needs, this may mean ensuring that their basic needs are met; more importantly, the feelings of belonging and being loved are critical if community nurses are to help patients achieve a dignified death. The decisions regarding place of care and death become equally important and, where possible, patients should be afforded care and death in their chosen place. Institutions with palliative care beds and hospices should continue to care not only for the patient, but also those deemed important to the patient. Hospitals caring for dying patients need to review their visiting policies to provide more visiting hours for family and friends, with the recognition that time is limited. Where possible, patients should be discharged ‘home’ or to hospices where the environment facilitates the shifts in patients' priorities.
Community nurses and hospice staff witness numerous patients with shifting perspectives, and these experiences can be distressing. Therefore, these care providers will need support to debrief and emotionally renew themselves. It is also possible that healthcare professionals experience their own shifts in perspectives as a result of caring for and supporting patients who are dying. Therefore, healthcare professionals and community nurses, in particular, need self-care and regular support (clinical supervision) to recharge their caring batteries. While this may be costly initially, it can only be a prudent investment given the long-term benefits on staff health and wellbeing, with minimal absenteeism. Patients also benefit from continuity of the best care, and relatives are left with positive memories after the death of their loved one.