Client Based Care Case Study: Elderly with Diabetes

Client Based Care Case Study: Elderly with Diabetes 215479 Client Based Care Study Introduction In this essay, the author will explore the care of a single patient, encountered in clinical practice, examining the impact on quality of care, and on the health and wellbeing of the individual, of key aspects of care. Case studies allow nurses to reflect on practice, examine critical elements of case and of clinical decisions made and actions taken, and to examine areas of care in more detail. This essay will explore the care of one patient, who shall be called Molly, an older, community dwelling adult with Type 2 diabetes, who was admitted to a medical admissions ward having been found unconscious at her home by neighbours. The essay will examine the aspects of her care that relate to the management of her condition, the assessment and management of her social, care and personal needs, and the planning of her future care and support needs. Reference will be made to governmental guidelines and policies, and to interprofessional working as a fundamental component of meeting patient needs in this case. Discussion Diabetes is a chronic disease which is known to impact significantly on the health, wellbeing and prosperity of individuals, of families, and of society as a whole[1]. More than 1.4 million in the UK are affected by diabetes[2]. Because of the great impact that this disease has on public health and on the use of NHS and social care resources and services, the Department of Health has published a National Service Framework for diabetes, which not only sets standards for management and diagnosis of the disease, but outlines best practice in the light of the latest available evidence on the condition[3]. There are two types of diabetes, Type 1 and Type 2, both of which are signified by a persistent high level of circulating blood glucose, due to a lack of insulin or a significantly impaired response to insulin, or to a combination of both factors[4]. Type 1 diabetes is due to the insulin-producing cells in the pancreas, called the Beta Cells, located in the Islets of Langerhans, failing to produce insulin, because the body’s own immune system has destroyed them[5]. Type 2 diabetes is usually caused by a reduced amount of insulin production by these cells, and by a degree of insulin resistance within the body, wherein the body’s metabolic responses to insulin are not as sensitive[6]. Type 2 Diabetes is the condition which Molly, the patient in this case study, has been affected by. Molly is a 66 year old woman who has had Type 2 diabetes for 17 years. She is treated by twice daily insulin, and, living independently still in her own home, she is visited once weekly by a district nurse to monitor her glycaemic control and check her insulin stocks and her general wellbeing. Molly has a BMI of 35, and also has a history of hypertension which is controlled by medication. She has her blood pressure checked weekly as well. Molly lives alone, never having married, and has no children. She has an active social life, attending a local book group, taking part in a local history and re-enactment society, and volunteering at a community library. She is known by the district nurses to be competent in administering her own insulin and measuring her own blood sugar, but she does not always adhere to her regimen and her recommended diet, because it can interfere with her social life. Molly was found unconscious by one of her neighbours at 9 pm, and the ambulance was called. Paramedics attending were told of her history by her neighbour, who waited with her, and suspected either Diabetic Ketoacidosis or hypoglycaemia. Diabetic ketoacidosis is a condition which can be life-threatening, and is usually due to a lack of insulin, which means that the cells of the body are unable to use glucose for energy, and so instead convert fat reserves to energy, which can produce ketone bodies which can adversely affect brain function[7],[8]. Hypoglycaemia can be caused by an overdose of insulin, or inadequate carbohydrate intake in a person who is taking insulin, or by the patient taking too much exercise, thus using up glucose, or by a combination of these Paramedics found her blood sugar to be 1.1 mmols, and administered glucagon to reverse the hypoglycaemia. She recovered consciousness quickly once her blood sugar improved, but was also given facial oxygen, and had full observations taken. Molly remained confused after insulin administration. She was taken to the medical admissions unit for a full assessment and, if necessary, in-patient admission and review of her diabetes. According to emergency care principles for the diabetic patient, the priorities are to save the patient’s life, alleviate their symptoms, prevent long-term complications of the disease and their current risk factors, and then to implement care that will help to reduce risk factors for their health, such as hypertension obesity, smoking, and hyperlipidemia, along with providing ongoing education and support for self-management of their condition[9]. In Molly’s case, the team evaluated her condition, because although the initial diagnosis was hypoglycaemia, suggested by her self-reported history of missing meals that day and being very busy, the differential diagnosis was diabetic ketoacidosis, which can be precipitated by physical or biological stress, including changes in endocrine function or other diseases, such as myocardial infarction[10]. Molly is pale as well, a finding suggestive of hypoglycaemia, along with her elevated blood pressure and dilated pupils[11]. As Molly was conscious, her Glasgow Coma Score was 13, and she had responded well to glucagon, according to established diabetic protocols, she needed to be stabilised and undergo a range of investigations to determine any other disease or factors precipitating her condition[12]. Blood pressure, temperature, pulse and respiration rate were monitored recorded via continuous telemetry, and an ECG was carried out, which ruled out myocardial infarction. Molly had blood sent for Full Blood Count, Liver Function Tests, Urea and Electrolytes and Glucose, as well as insulin levels, prothrombin time, clotting factors[13]. Prothrombin Time and Clotting Factors may also be tested, due to the risk of disseminated intravascular coagulation. Bloods were also sent to test HbA1c; Fructosamine; Urinary albumin excretion; Creatinine / urea; Proteinurea; and Plasma lipid profile[14]. Urine was dipped with reagent strips to test for glucose, protein (suggestive of kidney problems) and ketones. Because of her presentation, Molly was put on a continuous IV infusion of insulin, titrated hourly using a syringe driver against blood glucose, with an infusion of 5% glucose running in a different IV port. IV fluid therapy, and fluid balance, were also monitored closely[15]. Diabetes can cause kidney damage and impaired urinary function, so monitoring kidney function was an important part of care[16]. Once Molly was stabilised, ongoing care related to supporting her health and wellbeing, and minimising complications of her diabetes, became an important part of care. Diabetes is a significant public health issue, because it is not only associated with the ‘social’ disease of obesity, but also because as a disorder it is associated with a number of serious health implications[17]. These complications include macrovascular complications, including atherosclerosis and cardiovascular disease[18], [19], [20]; diabetic retinopathy and sight loss due to vascular damage which weakens the walls of the blood vessels in the eyes, causing microaneurysms and leakage of protein into the retina, vascular damage and scar tissue [21], peripheral neuropathy, peripheral vascular disease and gastrointestinal dysfunction, gomerular damage, and kidney failure[22]. The impact of this disease on public health relates to the fact that many people of working age are diabetic, and because the co ndition is chronic as well as serious, with acute exacerbations and so many complications, it presents a serious drain on health and social care resources. Therefore, it is imperative that individuals with diabetes are identified as early as possible, and are educated and supported in good self-management, and provided with ongoing care to maintain good glycaemic control[23]. Molly’s status as an older adult is also a public health issue, because older adults constitute the largest patient group in the UK, and the ones which consume the biggest proportion of healthcare services[24]. However, it was also important to avoid stereotyping Molly as an older person, and making assumptions about her needs and her health. Although she was obese and hypertensive, and had Type 2 diabetes, she was very active and had a very important social life, and was usually independent and self-caring. It was important to consider the social support that she had, and to ensure that she was aware of any services or support she might be able to access if she felt it necessary. However, some members of the multidisciplinary team, in particular, some of the medical staff, did appear to act in a way that suggested they were stereotyping Molly based on these factors (age, weight, health) and were discussing her case without really making clear reference to her as a whole perso n. This leads on to the need to evaluate the multidisciplinary input in Molly’s case, and the quality of the interprofessional working that took place, which is discussed below. As can be seen from the list above, diabetes can affect the individual and the body in complex ways, and so requires an holistic approach to care[25]. Care should also be based on evidence based, collaboratively agreed care pathways[26], as suggested by the NSF for diabetes[27]. Molly may need a comprehensive review of her management and her lifestyle, the patterns of care and the ongoing monitoring of her condition[28]. The National Institute for Clinical Excellence recommends a patient-centred approach to ongoing patient education and management, and also suggests a number of options for patients who might require different forms of insulin administration, such as continuous sub-cutaneous insulin[29], [30]. This, however, was not suitable for Molly, because it is usually for people with Type 1 diabetes. Health promotion and education is an important part of Molly’s care at this point, which is related to the fact that her current hospital admission is due to mismanagement of her condition herself. It was important to determine what factors about her lifestyle and behaviours had led to the lapse and the serious hypoglycaemia. Ongoing care, health promotion and education involved multi-professional collaboration and integration of care into a complex, detailed care plan. The aim was to provide Molly with the information, support and guidance that would allow her to view her diabetes management as a means of achieving a better quality of life, rather than viewing her diabetes as something which interfered with her quality of life. It was also important to view Molly in terms of supporting her to continue with her normal social activities. Research shows that making changes in lifestyle, and providing good, effective health education, helps to contribute to reducing rates of diab etic complications[31]. However, the kind of health education and support used is important, because different approaches have different levels of effectiveness. Some research examines the differences between health education that tries to persuade patients to be compliant with regimes and activities designed by health professionals, approaches which are usually generic, and health education that is client-centred[32]. Client centred approaches are usually more effective, as they are individualised. Research shows very clearly that patients with diabetes need to understand their disease fully, and be supported and empowered to make the lifestyle and behavioural changes that will enhance their wellbeing whilst enabling them to control their condition[33]. In this case, a diabetic nurse specialist was involved with Molly’s case, and a plan for health education and support drawn up, with clear guidelines and a tailored plan for managing her social life around her diabetes. Diabetes UK recommends a struc tured, tailored education programme for people with the condition[34]. Interprofessional and multidisciplinary working is a fundamental component of care for a patient with diabetes like Molly[35]. This means that diabetic patients should experience seamless care, addressing all needs, with access to all the professionals necessary to support her care[36]. Specialist involvement, including diabetic nurse specialists, was a feature of this care, and helped with a client centred focus[37]. The literature suggests that it is important for a lead professional to take charge[38], but in Molly’s case, her lead nurse was not present for the majority of her inpatient stay, and there was a lack of effective coordination of the complex number of professionals involved. In relation to multidisciplinary, interprofessional working Molly was referred to ophthalmic services for a check-up, to ensure that there was no diabetic retinopathy or glaucoma. She was referred to a dietician to support her in managing her dietary intake. She was also referred to a social worker. Diabetic specialist doctors were involved, and a report was sent to the diabetic nurse at her local surgery, as well as to her GP. Molly ended up staying in hospital, however, on a medical ward, for two weeks, even though her condition was stabilised rapidly, and she experienced no further complications. In this case, interprofessional working was not effective, because although the said referrals were made, or were recorded to have been made, Molly was not seen by the dietician or a social worker for over a week, and only when she began to threaten to take a discharge against medical advice did the dietician and social worker arrive and get involved. The doctors in charge of Mollyâ€℠¢s case however appeared to make judgements about plans for discharge and ongoing care without involving the nursing team and without considering some aspects of her social situation and Molly’s own preferences and wishes. It is apparent, from this case, that while Molly’s immediate medical needs were met, the interprofessional working element of her ongoing care failed in some way. There are a complex range of professionals and support workers who provide healthcare[39]. Because of this complexity, interprofessional education has become part of healthcare education programmes[40]. Interprofessional working is supposed to help with the provision of true patient-centred care, and the highest quality of care[41]. However, experience in this case, and some of the literature, cites ongoing problems with interprofessional working in a number of contexts. Some of this is to do with the professional boundaries and hegemonies which persist in healthcare professions, which continue to be defended rigorously by each profession[42]. Some literature shows that elitism, professional isolationism and professional defensiveness can have negative effects on health professionals themselves as well as on the qual ity of care delivery[43]. Yet there is ample government guidance, particularly from the Department of Health, which aims to improve service provision, and the NSF for Older People[44], identifies the most important elements of care and service provision which must be improved upon. Standard 2 of the NSF, ‘Person-Centred Care’, requires that health and care services are designed around the needs of the older patient (and their carers)[45]. However, this kind of needs-based care then demands . â€Å"an integrated approach to service provision†¦ regardless of professional or organisational boundaries, [which is] delivered by clinical governance, underpinned by professional self regulation and lifelong learning† .†[46] In Molly’s case, the fundamental role of the nurse in providing leadership and coordination for her care was not acknowledged or supported. Some researchers suggest that this can be due to medical hegemony[47]. Current approaches to offsetting such ingrained hierarchical thinking are very much focused on initial education of healthcare professionals, overcoming historical professional boundaries[48], [49], [50]. The research shows that there is a difference between multiprofessional working, which does not transcend the traditional hierarchies and boundaries , and inter-professional working, which is built on the desire to share care, support each other, and value each others’ expertise[51]. Government drivers continue to underpin strategies for better, ‘joined up working.’[52],[53]. The failures which occurred in Molly’s care were clearly linked to poor communication between the healthcare professionals, a lack of joined up working, and a lack of recognition, perhaps, of the importance of the social aspects of Molly’s case, and the health-education aspects, based on her individual needs. On reflection, the author believes that had there been better, collaborative working, then none of these needs would have been overlooked and they would have been dealt with more speedily. But another aspect of her care that could be improved upon was related to her own involvement in her case. Molly was not fully involved in her case discussions and in the medical decisions made about her care. While this can be a product of the medical hegemony mentioned before[54], it constitutes a serious oversight and is not in line with governmental guidance[55]. Research shows that the patient voice is the most important one in terms of collaborative care planning and manage ment[56]. Conclusion This case study has identified the case of Molly (a pseudonym), an older patient with Type 2 diabetes who received good quality clinical care in meeting her acute care needs and managing her medical condition and its potential consequences, but for whom interprofessional working failed in relation to ongoing care and multi-discinplinary involvement. Diabetes is a significant public health issue, and a range of governmental guidance and research evidence informs care for patients with the condition. The public health issues surround the serious morbidity and mortality associated with diabetes, and the fact that good management and glycaemic control can minimise these complications. In this case, the patient’s needs were prioritised medically, but interprofessional communication broke down. While the appropriate referrals were made, proper joined up working did not take place. Similarly, Molly was not fully involved in her case, and should have been. 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Department of Health, (2007) Creating an Interprofessional Workforce: An Education and Training Framework for Health and Social Care. Available from www.CIPW.org.uk accessed 5-1-09.. Diabetes UK (2006) POSITION STATEMENT Structured Education for people with diabetes www.diabetes.org.uk/good_practice/education/recommend accessed 6-1-09.. Edge, J.A., Swift, P.G.F., Anderson, W. Turner, B. (2005) Diabetes services in the UK: fourth national survey: are we meeting NSF standards and NICE guidelines? Archives of Disease in Childhood 90 1005-1009. Funnell, M.M. (2004) Patient Empowerment Critical Care Nursing Quarterly 27 (2) 201-204. Gordon, F. Ward, K. (2005) Making it real: interprofessional teaching strategies in practice. Journal of Integrated Care 13 (5) 42-47. Greenwood, R., Shaw, K. Winocour, P. (2005) Diabetes and the Quality and Outcomes Framework British Medical Journal 331 1340. Guthrie, R.A. Guthrie, D.W. (2004) Pathophysiology of Diabetes Mellitus. 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(2004) Collaborative learning for collaborative working? Initial findings from a longitudinal study of health and social care students. Health and Social Care in the Community 12 (4) 346-358. Pollom, R.K. Pollom, R.D. (2004) Utilization of a multidisciplinary team for inpatient diabetes care. Critical Care Nursing Quarterly 27 (2) 185-188. Price, B. (2006) Exploring person-centred care. Nursing Standard 20 (50) 49-56. Reinauer, H. (2002) Laboratory Diagnosis and Monitoring of Diabetes Mellitus. Geneva: World Health Organization. Robinson, F. (2006) Community programmes promote healthier living. Practice Nurse. 10 32 (8) 11, 13. Scott, A (2006) Leadership in diabetes nursing: Where is it? Journal of Diabetes Nursing 10(9) 324 Skinner, T.C., Cradocl, S., Arundel, F. Graham, W. (2003) Four theories and a philosophy: self-management education for individuals newly diagnosed with Type 2 diabetes. Diabetes Spectrum 16 (2) 75-80. Snow, T. (2006) A breath of fresh care in diabetes Nursing Standard 20 (37) 14-15. Soedmah-Muthu, S.S., Fuller, J.H., Mulner, H.E. et al (2006) High risk of cardiovascular disease in patients with type 1 Diabetes in the UK. Diabetes Care 20 (4) 798-804. Stanley, D., Reed, J. Brown, S. (1999) Older people, care management and interprofessional practice. Journal of Interprofessional Care 13 (3) 229-237. Suman, S. Lockington, T. (2003) Generic care pathways for acute geriatric care and rehabilitation as a tool for care management, discharge planning and continuous clinical audit. Journal of Integrated Care Pathways 7 (2) 75-79. Turina, M., Christ-Crain, M. Polk, H.C. (2006) Diabetes and Hyperglycaemia: strict glycaemic control. Critical Care Medicine 34 (9) 291-300. Watkins, P.J. (2003) ABC of Diabetes (Fifth edition). London: BMJ Publishing Group. 1 Footnotes [1] Department of Health (2002) [2] Hilton, L. Digner, M. (2006) p 89. [3] Department of Health (2002). [4] Department of Health (2002). [5] Watkins, P.J. (2003). [6] Watkins (ibid) [7] DoH (ibid) [8] Hankin, L.(2005) p 67. [9] Watkins (ibid). [10] Turina, M., Christ-Crain, M. Polk, H.C. (2006) p 291. [11] Guthrie, R.A. Guthrie, D.W. (2004) p 113. [12] Edge, J.A., Swift, P.G.F., Anderson, W. Turner, B. (2005) p 10005. [13] Hankin (ibid) [14] Reinauer, H. (2002) [15] Guthrie (ibid) [16] Guthrie (ibid) [17] DoH (2002); Department of Health, (2001). [18] Guthrie (ibid) [19] Bloomgarden, Z.T. (2006) [20] Soedmah-Muthu, S.S., Fuller, J.H., Mulner, H.E. et al (2006) [21] Guthrie (ibid) [22] DoH (2002). [23] DoH (2002) [24] Department of Health, (2001) [25] Collis, S. (2005) [26] Pollom, R.K. Pollom, R.D. (2004) [27] OBrien, S.V. Hardy, K.J. (2003) [28] Snow, T. (2006) [29] NICE (2003) [30] Diabetes UK (2006) [31] Anthony, S., Odgers, T. Kelly, W. (2004) [32] Skinner, T.C., Cradocl, S., Arundel, F. Graham, W. (2003) [33] Antony (ibid) [34] Diabetes UK (2006) [35] DoH (2002) [36] Keene, J., Swift, L., Bailey, S. Janacek, G. (2001) [37] Keen, H. (2005) [38] Scott, A (2006) [39] Masterson, A. (2002) [40] Pollard, K.C., Miers, M.E. Gilchrist, M. (2004) [41] Kenny, G. (2002) [42] Colyer, H.M. (2004) [43] Price (ibid)

Analysis of Biff in Death of a Salesman

Camilla Tanzi Year 12 An analysis of the character of Biff. Biff Loman is portrayed as the root of Willy’s mental illness and instability. He is also the only member of his family who acknowledges his own failures in life. On the whole, Biff Loman stands out as the most intriguing and strong character in â€Å"Death of a Salesman. He is not a successful man and never will be, he is however able to admit this, even in a harsh society as the one of the 1960s America. Biff knows he is a â€Å"nothing† and tries to make his father see that he is â€Å"no good.I am a dime a dozen, Pop, and so are you. † He begs for Willy to communicate with him and accept him for who he is. Although Willy is forced by Biff to see some of his own failures, he never accepts that Biff will turn out the same way. At the end of the play, Biff seems to have developed a strength of his own; he has faced and accepted the truth about himself and his father. Now that he acknowledges his proble ms, there is a hope that he will be able to reach his potential. If â€Å"Death of a Salesman† offers any hope, it is only through the character of Biff. Also read: Expressionism in Death of a SalesmanMiller implies there is a chance that he will one day be able to live a normal life, away from the shadow of Willy Loman. Biff stimulates reactions out of his father’s lunacy and is portrayed as the main cause of Willy’s problems. We understand that Willy has been a bad influence on his son and in spite of this; he has big ambitions for Biff and does not want to admit that he will never reach the goals he wishes for him. Being Willy’s oldest son, Biff seems to be the perfect child to his father.However, as the play develops and especially when it shifts from Willy’s dreams to the reality, we see a change in his attitude towards his son. When Biff was the star rugby player, the only thing that mattered to Willy was his success in the sport. As a matter of fact, when Bernard informs Willy and Biff about the possibility of him being â€Å"flunked in math†, Willy’s reply is stiff and arrogant:  "Don’t be a pest, Bernard! (To his boys) What an anaemic! † The use of the word â€Å"anaemic† is a perfect example to show what the man’s morals are; he considers Bernard a teenager who lacks vitality, boring.The author could possibly be implying that Willy is actually envious of Bernard and even though he doesn’t want to admit it, his is just jealousy when he shows aversion towards him. Willy has different ambitions for his sons’ futures than most people had for theirs at the time; he believes that sport will be enough to help Biff succeed in the business world, make him rich and notorious; â€Å"That’s just what I mean, Bernard can get the best marks in school, y’understand, but when he gets out in the business world, y’understand, you’re going to be five times ahead of him. Arthur Miller provides us with a lot of evidence that Willy has been a bad influence on Biff. While Biff is in some ways desperate to impr ess his father, he is also conscious about the fact that Willy has failed his attempt to be successful in his career. He considers his dad’s dreams materialistic and unreachable. As a matter of fact, in the Requiem, even after his father’s death, Biff says: â€Å"He had the wrong dreams. All, all wrong. † Unlike Happy and Willy, Biff is self-aware and values facts; Willy never was a successful salesman and he never wanted to face the truth.On the other hand, Biff is conscious about his failures and the weaknesses of his personality. During an argument with his father, Biff admits that his dad made him â€Å"so arrogant as a boy† that now he just can’t handle taking orders from a boss. I think this is what truly differentiates Biff from the rest of his family; he is honest and sincere about himself and would rather work on a ranch than try to be successful in a work field that he knows will never accept him. Biff is also the only character that acts as a reminder that the American Dream is not an every man’s dream.Bernard has become a successful lawyer as his father Charley, Willy and Happy try to pretend they have too, but Biff is the only one who surrenders to his destiny. Rather than seeking success and money, he wants a basic life working on ranches. He does not try to push into the crowd of people aiming for a good job and a wealthy life-style, but instead wants to be seen for who he truly is: â€Å"Happy: The only thing is- what can you make out there? Biff: But look at your friend. Builds an estate and then doesn’t have the peace of mind to live in it. In a way, Miller is trying to tell us that Americans are made victims of the country’s success. â€Å"Death of a Salesman† seems to argue that America as a whole does not value people who look for simple pleasures such as working in the countryside, and the American Dream pushes people to only aim for jobs in the industry. It is ironic how Ber nard turns out to succeed as a successful and well-known lawyer. It is ironic because during high school Willy used to mock him for studying hard and always praised Biff for not studying at all.Bernard is presented as a weak and shy character and Miller wants us to believe that Biff will turn out to be successful rather than him and not the contrary. However, things turned out differently to how both Willy and Biff expected them to. Bernard’s success irritates Willy because his own sons’ lives do not measure up to Bernard’s: â€Å"(after a pause): I’m- I’m overjoyed to see how you made the grade Bernard, overjoyed. It’s an encouraging thing to see a young man really-really- Looks very good for Biff- very (He breaks off, then) Bernard- (He is so full of emotion, he breaks off again). Once again, Biff is the cause of his father’s despair; he does not want to pursue Willy’s dreams, he wants something other than material things fr om life, and this destroys the man. Biff has learnt from his father that to be â€Å"well-liked† and attractive are the most important ingredients for success. Up to now, I have only analysed the differences between Biff and Willy, however, it is also very important to highlight the few similarities between the two characters. When he was a teenage boy, Willy’s authority on Biff was evident.We find that when the three Loman men are talking about Bernard, Biff echoes small bits of his father’s view on life when he says that his friend is â€Å"liked but not well-liked†. This implies that Biff once used to have respect towards Willy; he admired his strong personality and approved his view on the business world. Biff Loman is aware that he will not succeed as a salesman or any other job without his maths degree. On the other hand, his father is convinced he will and does not what to face the reality of facts. However, towards the end of the play we see a cha nge in both the men’s attitudes.As a matter of fact, they have switched opinions; â€Å"Biff: (horrified, gets down on one knee before Willy): Dad, I’ll make good, I’ll make good. (Willy tries to get to his feet. Biff holds him down. ) Sit down now. Willy: No, you’re no good, you’re no good for anything. † Biff is now desperate and is obviously worried for his father’s mental health and tries to encourage him to be positive in any way he can- even if this involves lying to himself about his potential. As I previously mentioned in my introduction, Biff seems to be the only character that offers any hope whatsoever in â€Å"Death of a Salesman†.At the beginning of the play, he tells the audience about his dreams of living in the south: â€Å"What the hell am I doing, playing around with horses, twenty-eight dollars a week! I’m thirty-four years old, I oughta be makin’ my future. That’s when I coming running home. And now, I get here, and I don’t know what to do with myself. † This clearly shows that biff aspires to better things, but does not know what to do in an industrial city as New York. He wants to succeed and build a future, but at the same time he enjoys the pleasures of living in the countryside and not having any stress.Here is where we understand that Biff is fundamentally lazy. He would like to have a nice and wealthy life, but he just does not have the strength or the motivation to work for it. On the whole, through the illusions that Willy believes, he cannot see Biff as a â€Å"nobody† and cannot accept that he won’t be successful as he hopes. Eventually, Biff finally sees the truth and realises that he is â€Å"no great leader of men†. He also comprehends the delusions that Willy lived on. Biff is destined to no greatness, but he no longer has to struggle to understand what he wants to do with his life; â€Å"I know who I am, kid. â₠¬ 

Speech The Power Of Speech - 1770 Words

The Power of Speech Speech is a powerful tool, if used correctly. Speech can do many things, but there are two main things that speech is the best at. It can create and embellish as it pleases. Well-spoken words can also twist the truth and manipulate. Richard the Third is an excellent example of both these attributes. Richard uses the power of speech to gain what he wants. He shows the success that this tool can bring if used carefully. Richard makes himself a saint, a simple disabled innocent who is wronged by everyone. He also shows the failures it brings when overconfidence and haste spoil it. He loses his charm as he no longer treads carefully and simply drives his way through conversations. Richard is a good example of the power of speech as he uses his persuasion to accomplish his goals. From the very beginning, Richard is shown as being a highly persuasive individual. He is very careful to show himself as one who only speaks sweet words making him a very compelling character. He flatters his way to his goals and pulls the wool over everyone’s eyes as he does so. There are several scenes throughout the play where Richard has done this. In his attempt to woo Lady Anne, Richard is speaking to the enraged woman, noting on that it is â€Å"wonderful when angels are so angry† (1.2.72). Richard’s response to this seething rage is to create a beautiful angry angel of her. Another attempt at this flattery is made when he responds that â€Å"your [Lady Anne’s] bedchamber† would beShow MoreRelatedPower of Speech1450 Words   |  6 Pagesa better future. â€Å"‘Who controls the past’†¦ ‘controls the future: who controls the present controls the past’† (Orwell 37). If the United States’ history was altered and no one remembered the history before it changed, the government would have the power to make any regulations they desired. The government would be able to do as they please becaus e if the people do not have any history to tell them that the new regulations are out of place or wrong, people would not question it. Much like in GeorgeRead MoreFreedom Of Speech : The Power Of Freedom Of Speech1860 Words   |  8 Pages Freedom of speech would be easy if words did not have power. Guaranteeing people, the right to say and print whatever they wanted would be easy if we could believe that words had no real effect. But unfortunately, Americans tend to believe that words do have power and that they can anger and inspire, cause people to rise up and act out in harmful ways. Americans celebrate speakers like James Otis, Abraham Lincoln, and Martin Luther King, Jr., whose words inspired people to fight for independenceRead MoreSpeech Is Power Of Speech Changed The Course Of History Essay1613 Words   |  7 PagesRalph Waldo Emerson expressed the importance of speech in one short sentence: â€Å"Speech is power: speech is to persuade, to convert, to compel.† In 2008, the power of speech changed the course of history; the first African American president was elected, transcending years of racial inequality. For many blacks in the U.S., and many around the world, Barack Obama’s presidency was a step closer to righting America’s 400-year-old wrong: slavery and subsequent discrimination toward the black race. Obama’sRead MoreThe Power Of Speech By Janie1957 Words   |  8 Pages The Power of Speech. Throughout her life, Janie has always been told what to do. She could not express herself without being criticized. She is not given the chance to make decisions for herself because she is a woman and women were to expected to obey and not talk back. It is deemed wrong anytime she tries to stand up for herself. Throughout Janie’s life seems to be is controlled by others, first her grandmother, then Logan Killicks, and Joe Starks. Janie’s first husband Logan, thinks a JanieRead MoreJulius Caesar Power Of Speech921 Words   |  4 PagesMarissa Cheslock Mrs. Satchwell Honors English 9 B3 9 October 2017 The Power of Loyalty William Shakespeare, one of the most profound writers in all of history, skillfully used the character of Mark Antony in his play, Julius Caesar, in order to verify true the theme that loyalty and respect are two of the most extremely convincing tactics. He demonstrates the power of speech as he is manipulating words in order to prove a certain point in the speaker’s favor, whoever that may be. Mark Antony wasRead MoreThe Power Of Peace Speech Summary767 Words   |  4 Pages The Power of Peace During his Nobel Peace Prize acceptance speech, Martin Luther King Jr. declared, â€Å"I believe that unarmed truth and unconditional love will have the final word in reality. This is why right temporarily defeated is stronger than evil triumphant.† As a model for the Civil Rights Movement, Martin Luther King Jr. attested to the effectiveness of a nonviolent approach to difficult situations. Cesar Chavez urges the importance of a peaceful approach to every situation, and emphasizesRead MorePersuasive Speech : Solar Power1022 Words   |  5 Pages SOLAR POWER General Purpose: To persuade Specific Purpose: To persuade my audience to use more solar power, to save money and help the environment. Introduction Attention Getter: We are 90 million miles from the sun, but in merely ten minutes light travels all of that distance to the earth. This extraordinary speed and natural light can help us to power homes and businesses with the use of solar panels. Reason to Lister: NaturalRead MorePersuasive Speech : Girl Power 1448 Words   |  6 Pagesthe concept will make society appear friendly. - - - Innovative invention for decades have by habit woken up our youth culture from their hormonal apathetic doldrums - I confess, it has been a durable sleep since Britpop and that exhaustive Girl Power message which energised youth culture to fever pitch. Youth culture overtax surely, I recall watching our youth culture engaging in Spice mania thinking, you ll better stop, or you will burn yourselves out by the time you are a young adult...Read MoreInformative Speech On Nuclear Power753 Words   |  4 Pagescivilization. And hydroelectric and thermal power plants are not as clean and economical for the modern rhythm of life. Thesis: One of the solutions is nuclear power. The basis of nuclear power are nuclear power plants. The use of nuclear energy in the modern world is becoming so important that if we woke tomorrow and the energy of nuclear reaction disappeared, the world, as we know it, would probably cease to exist. Preview: so what is this nuclear power, how does it work? And is it that safe asRead MorePower Tactics, Power Speech, And Power Nonverbals Used In The Movie1075 Words   |  5 Pages 6. How are power tactics, power speech, and power nonverbals used in the movie? Give one example of each from the movie Power tactics are defined by the Forsyth text (p 254) as â€Å"specific strategies used to influence others, usually to gain a particular objective or advantage.† People will vary in their use of tactics to get there way, especially depending on where they stand in a group. Tactics are utilized from the time deliberations begin in the film. The garage owner engages in expertise tactics

The Fall Of The House Of Usher Analysis - 1696 Words

The Merriam-Webster Dictionary defines fear as â€Å"an unpleasant, often strong emotion caused by anticipation or awareness of danger†. Despite this feeling being extremely unpleasant for most, both authors and readers alike love the feeling that fear can give a person. Authors, especially those of different types of Gothic literature, particularly enjoy using transformation in their work to provoke feelings of fear in their readers. It helps them to draw readers in and keep them invested in their reading. Two examples of pieces of literature that use transformation to scare are â€Å"The Fall of the House of Usher† by Edgar Allan Poe and â€Å"Where is Here?† by Joyce Carol Oates. â€Å"The Fall of the House of Usher† is about a man who goes to visit his†¦show more content†¦Roderick Usher specifically can be seen reaching his total breaking point and losing his mind over the supposed death of his sister, Madeline. The reader eventually learns t hat Madeline had never actually died and that Roderick had buried her alive. The reader sees his complete mental breakdown with him screaming, â€Å"We have put her living in the tomb! Said I not that my senses were acute? I now tell you that I heard her first feeble movements in the hollow coffin. I heard them—many, many days ago—yet I dared not—I dared not speak!† (Poe 46). At this point, Roderick has gone from being somewhat mentally unstable to being absolutely broken inside. Any person who would willingly bury their own sister alive can not be in the right state of mind. When he starts yelling and repeating himself, the reader can tell that he is not okay. Those reading the story have no idea what Roderick could possibly be thinking and are worried about what he may do. The fear of not knowing what is going to happen can affect the readers and cause fear to rise up inside them. Another example of when characters transform is when characters change e motionally. â€Å"Where is Here?† is a story about a man who comes to visit his childhood home. While he is there he starts to go from a seemingly polite person to losing control of all of his emotions. He was in the son’s room, showing him a math riddle, and â€Å"after several minutesShow MoreRelatedAnalysis of The Fall of the House of Usher1122 Words   |  5 Pages In The Fall of the House of Usher, Edgar Allan Poe writes of a sickly brother and sister that live in an old estate, and a narrator’s account of the Ushers’ final days. The story is scary on two different levels. The first and most obvious that is noticed just by reading on the surface is the creepy atmosphere of the house and death of the main characters. Poe makes this level of scariness very accessible by the diction and imagery that he uses. The second level of scariness is the psychologicalRead MoreThe Fall of the House of Usher Analysis1277 Words   |  6 Pagesâ€Å"The Fall of t he House of Usher† - Review â€Å"The Fall of the House of Usher† is a short story written by Edger Allan Poe in 1839. Almost everything about the story is very gloomy, dark and depressing. For example, the house is described by the narrator as â€Å"the melancholy House of Usher† and the description of Roderick Usher himself makes you think of a corpse. This theme of dreariness and sorrow pervades the story and is done to a very chilling effect, which really draws in the readerRead MoreLiterary Analysis Of The Fall In The House Of Usher884 Words   |  4 PagesInto the Mind of Fear: Literary Analysis â€Å"...Madman!- he sprung to his feet, and shrieked out his syllables, as if in the effort he were giving up his soul†(Poe 277). The short stories, The Fall in the House of Usher by Edgar Allan Poe, and The Minister’s Black Veil by Nathaniel Hawthorne explore fear in a deeper context. Fear is a very common emotion. Fear is the result of encounters with the unknown. The Fall in the House of Usher, shows a very anxious Roderick Usher sending for a childhood friendRead MoreThe Fall Of The House Of Usher Analysis821 Words   |  4 Pageshuman beings aren’t used to seeing or recognizing. Fear is like an illness that will never go away no matter how hard we try everybody is afraid of one thing or the other so either way we will recognize it. Like in the story â€Å"The Fall of the House of Usher† ,the Ushers are known to have a mental illness that causes them to go psychological, and crazy ideas go into their head just so they can get rid of it. â€Å"The br eaking of the hermit’s door and the death cry of the dragon, and the clangor of theRead MoreA Critical Analysis of The Fall of the House of Usher Essay914 Words   |  4 PagesA Critical Analysis of The Fall of the House of Usher There are three significant characters in this story: the narrator, whose name is never given, Roderick and Madeline Usher. The narrator is a boyhood friend of Roderick Usher. He has not seen Roderick since they were children; however, because of an urgent letter that the narrator has received from Roderick which was requesting his assistance in alleviating his malady, the narrator makes the long journey to theRead MoreAnalysis Of Bipolar Disorder In The Fall Of The House Of Usher1536 Words   |  7 Pagespsychological disorders including bipolar disorder. Edgar Allan Poe was one of many who were diagnosed with this disorder, and it is prevalent in many of his works. The Fall of the House of Usher by Poe clearly depicts the symptoms of bipolar disorder, and he translates his feelings on the topic as well. Through the use of Roderick Usher and his sister, Madeline, Poe depicts the transference of bipolar disorder within a family, and more specifically with twins. Deciphering a story centered around a psychologicalRead MoreThe Fall Of The House Of Usher Literature Analysis826 Words   |  4 Pagessuperior or lasting artistic value. In the short story, â€Å"The Fall of the House of Usher† written by Edgar Allen Poe, Usher is a senile middle aged man who invites an old friend to his gothic mansion. While arriving the narrator notices mysterious events beginning to happen. Also, in â€Å"House Taken Over† written by Julio Cortazar, siblings find themselves in post WWII Argentina trying to avoid a dangerous entity manifesting and taking over their house. Gothic Style uses the power of suggestion and implicationRead MoreFall of the House of Usher Literary Analysis Essay1325 Words   |  6 PagesLiterary Analysis As with many of Edgar Allan Poes pieces, The Fall of the House of Usher falls within the definition of American Gothic Literature. According to Prentice Hall Literature, American Gothic Literature is characterized by a bleak or remote setting, macabre or violent incidents, characters being in psychological or physical torment, or a supernatural or otherworldly involvement (311). A story containing these attributes can result in a very frightening or morbid read. In all probabilityRead MoreAnalysis Of Poe s The Fall Of The House Of Usher 3197 Words   |  13 PagesTanner Hakert Introduction to the Short Story Final Paper December 10, 2014 Poe’s â€Å"The Fall of the House of Usher† Edgar Allan Poe is an American poet from the early 1800s who has been regarded in many literary handbooks as â€Å"the architect of the modern short story† (Poetry Foundation). Since his death in 1849, Poe has become world renowned for his critical theories as well as his many haunting poems and short stories. But Poe s work hasn’t always been as popular as it is today. In 1827, Poe publishedRead MoreThe Fall Of The House Of Usher - Literary Analysis Essay1196 Words   |  5 Pagesï » ¿The Fall Of the House Of Usher is a short story written by Edgar Allen Poe in 1839. The short story is complexly written, with challenging themes such as identity and fear. Poe utilises many elements of the Gothic Tradition such as setting and supernatural elements to create a more mysterious story, and uses language to his advantage, employing adjective filled descriptions of literal elements that also serve as metaphors for other parts of the story. In The Fall Of The House of Usher, Poe explores