Week 11 Discussion

Discussion: Discussing End-of-Life Care: There is a human tendency to postpone uncomfortable or unpleasant tasks.

—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:

Discussing End-of-Life Care 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.

Discussing End-of-Life Care 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.

Discussing End-of-Life Care 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. Marley’s oldest son disagrees with his sister’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.

To prepare for Discussing End-of-Life Care:

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 families.

Think about how you, as an advanced practice nurse, would approach a family who wants “everything” 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 patient’s family.

Week 4 assignment 1: Assignment: Practicum – Week 3 SOAP Note

In addition to journal entries, SOAP Note submissions are a way to reflect on your practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Refer to this week’s Learning Resources for guidance on writing SOAP Notes.

Select a geriatric patient that you examined during the last 3 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list with the Beers Criteria and consider alternative drugs if appropriate.

Objective: What observations did you make during the physical assessment? What functional assessments were used?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority.

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for the patient? How would you offer caregiver support?

Reflection notes: What would you do differently in a similar patient evaluation? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?

Refer to this week’s Learning Resources for guidance on writing SOAP Notes.

By Day 7 of Week 4

This Assignment is due. You will submit this Week 3 SOAP Note along with your Journal Entries (from Weeks 1, 2, and 4) by Day 7 of Week 4.