Week 11 discussion
Discussing End-of-Life Care
There is a human tendency to postpone uncomfortable or
â€”Nancy Kummer, geriatric patient
This human tendency to avoid the unpleasant makes
end-of-life care and hospice decisions difficult for many patients to discuss
with their families. Kummer is a former social worker who used to counsel
patients with terminal illnesses, yet she avoided discussing her own
end-of-life wishes with her children. While many Americans, like Kummer, agree
that these discussions need to take place, few have actually had these
conversations with their families (Lazar, 2012). Although initiating
conversations about end-of-life care and hospice might be difficult for
patients, as an advanced practice nurse, facilitating these conversations is an
integral part of your geriatric nursing practice. For this Discussion, consider
how you would facilitate care conversations with the patients and families in
the following case studies:
Case Study 1:
Mrs. Sloan, a 69-year-old widow, is about to enter the
hospital for an elective cholecystectomy; she is being medically cleared by her
primary care provider. During the
discussion, she requests to be placed on a no code status during her
hospitalization. Mrs. Sloan claims that besides her gallbladder problem, her
general health status is good. She wishes to have the surgery to avoid any
further attacks, which have been very painful. She states, however, that if
during surgery or her postoperative period, she undergoes a cardiac arrest, she
would prefer not to be resuscitated. She has read about the chances of
successful resuscitation, and has determined that the risk of brain damage is
too high. For this reason, she is requesting a no code status.
Case Study 2:
Ms. Stearns is an 83-year-old nursing home resident with
hypertension, coronary artery disease, arthritis, renal insufficiency, hearing
impairment, and a previous history of stroke. She also has a foot deformity
from childhood polio. She is disoriented
at times. She has lived in the nursing home for 10 years and rarely leaves the
chair beside her bed. She has recently developed urinary incontinence, but has
refused a bladder catheterization to determine postvoid residual urine or
possible bladder infection. She does not have a diagnosis of dementia; however,
current testing reveals that she performs poorly on a standardized mental
status examination. She can, however, identify all the staff in the nursing
home, and she can describe each patient who has been in the bed next to hers
over the past 10 years. When asked to explain why she does not want bladder
catheterization, she gives several reasons. She states that the incontinence
does not bother her, and that she has always been a very private person. She particularly
dislikes and objects to any examination of her pelvic organs; in fact, she has
never had a pelvic examination nor has she ever had sexual intercourse. She
realizes that she has a number of medical problems and that any one of them
could worsen at any time. She states she is not willing to undergo any
treatment for any of her current problems should they become worse.
Case Study 3:
Mr. Marley, age 91, is admitted to the intensive care unit
following a stroke. The stroke progressed from mild hemiparesis and difficulty
speaking to complete unresponsiveness and an inability to swallow. His daughter
feels certain, based on prior explicit conversations with her father, that he
would not want to have any treatment that would prolong his life and leave him
in a severely disabled state. Mr. Marleyâ€™s oldest son disagrees with his
sisterâ€™s assessment of their father. The son claims that their father still has
a strong desire to live, and that he has been very active in his church until
this stroke. Because Mr. Marley cannot swallow, he cannot be fed. The family is
asked about insertion of a feeding tube. It is explained to the family that
without food and fluids, their father will die fairly quickly. There are no
existing advance directives or a designated health care decision maker noted
for Mr. Marley.
Review Chapter 14 of the Holroyd-Leduc and Reddy text.
Reflect on the role of the advanced practice nurse in
facilitating the discussion of end-of-life care with patients and their
Think about how you, as an advanced practice nurse, would
approach a family who wants â€œeverythingâ€ done for a patient with only a limited
time to live.
Consider when it is appropriate to involve hospice and how
to approach patients and/or families who refuse hospice services.
Select one of the three provided case studies related to the
end-of-life care of the frail elderly. Reflect on potential patient outcomes
and how you would facilitate the discussion of care with this patientâ€™s family.
Post on or before Day 3 an explanation of the role of the
advanced practice nurse in facilitating the discussion of end-of-life care with
patients and their families. Explain how you would approach a family who wants
â€œeverythingâ€ done for a patient with only a limited time to live. Then, explain
when it is appropriate to involve hospice and how to approach patients and/or
families who refuse hospice services. Finally, explain potential outcomes of
the patient in the case study you selected and how you would facilitate the discussion
of end-of-life care with this patientâ€™s family.
Read a selection of your colleaguesâ€™ responses.
Respond on or before Day 6 to at least two of your
colleagues on two different days who selected different case studies than you.
Based on the site of care, suggest strategies for establishing the role of
advanced practice nurses in end-of-life discussions with patients.
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