Case Study on Death and Dying Assignment Papers.
The practice of health care providers at all levels brings you into contact with people from a variety of faiths. This calls for knowledge and understanding of a diversity of faith expressions; for the purpose of this course, the focus will be on the Christian worldview.Case Study on Death and Dying Assignment Papers.
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Based on “Case Study: End of Life Decisions,” the Christian worldview, and the worldview questions presented in the required topic study materials you will complete an ethical analysis of George’s situation and his decision from the perspective of the Christian worldview.Case Study on Death and Dying Assignment Papers.Provide a 1,500-2,000-word ethical analysis while answering the following questions:
How would George interpret his suffering in light of the Christian narrative, with an emphasis on the fallenness of the world?Case Study on Death and Dying Assignment Papers.
How would George interpret his suffering in light of the Christian narrative, with an emphasis on the hope of resurrection?
As George contemplates life with amyotrophic lateral sclerosis (ALS), how would the Christian worldview inform his view about the value of his life as a person?Case Study on Death and Dying Assignment Papers.
What sorts of values and considerations would the Christian worldview focus on in deliberating about whether or not George should opt for euthanasia?Case Study on Death and Dying Assignment Papers.
Given the above, what options would be morally justified in the Christian worldview for George and why?
Based on your worldview, what decision would you make if you were in George’s situation?Case Study on Death and Dying Assignment Papers.
Remember to support your responses with the topic study materials.
Prepare this assignment according to the guidelines found in the APA Style Guide. An abstract is required.Case Study on Death and Dying Assignment Papers.
This assignment uses a rubric.You are required to submit this assignment to LopesWrite.
1. Bioethics: A Primer for Christians
Read Chapters 6 and 12 in Bioethics: A Primer for Christians.
http://gcumedia.com/digital-resources/wm-b-eerdmans-publishing-co/2013/bioethics_a-primer-for-christians_ebook_3e.php
2. Called to Care: A Christian Worldview for Nursing
Read Chapters 10-12 in Called to Care: A Christian Worldview for Nursing.
http://gcumedia.com/digital-resources/intervarsity-press/2006/called-to-care_a-christian-worldview-for-nursing_ebook_2e.php
3. Defining Death: Medical, Legal and Ethical Issues in the Determination of Death
Read the Introduction and Chapters 1-3 of “Defining Death: Medical, Legal and Ethical Issues in the Determination of Death” by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1984).Case Study on Death and Dying Assignment Papers.
https://repository.library.georgetown.edu/bitstream/handle/10822/559345/defining_death.pdf?sequence=1
Rubric
Analysis of how the man would interpret his suffering in light of the Christian narrative and the fallenness of the world is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%Case Study on Death and Dying Assignment Papers.
Analysis of how the man would interpret his suffering in light of the Christian narrative and the hope of resurrection is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
Analysis of how the Christian worldview of the man might inform his view about the value of his life as a person with ALS is clear and demonstrates a deep understanding that is skillfully supported by topic study materials.12%
Evaluation of which values and considerations the Christian worldview focuses on when deliberating the option of euthanasia for the man is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
Evaluation of which options would be justified in the Christian worldview for the man is clear and demonstrates a deep understanding that is skillfully supported by topic study materials. 12%
Reflection hypothesis of which personal choices would be make if faced with ALS based on personal worldview is clear, relevant, and insightful. 10%
Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear. 7%
Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative. 8%
Writer is clearly in command of standard, written, academic English. 5%
All format elements are correct.5%
Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. 5%
Marjorie was a 60-year-old woman who came to the hospice after a long and arduous hospital admission.
She was a single woman who had enjoyed a rural farm life, including managing race horses and a large
rural property.Case Study on Death and Dying Assignment Papers.
Initially she was admitted to a NSW hospital with a Basal Cell Carcinoma that, despite initial surgical
intervention, had infiltrated her brain tissue. Following a second surgical intervention she had been in an
ICU, where she was intubated and suffering seizures. After a successful extubation and the use of anti
convulsants, she was finally released from ICU. Unfortunately following the surgery she also developed a
deep intracranial infection that was not resolving.
As her condition worsened, her brother requested palliative care consultancy input at the hospital. Marjorie
had become unresponsive at the hospital and it was agreed at that point she would be transferred to the
hospice for end-of-life care.Case Study on Death and Dying Assignment Papers.
Marjorie had a range of symptoms which were causing issues. These included ongoing seizure activity,
headaches, and a hyperactive delirium. Her pain medication, seizure medications and medications
associated with her history of anxiety and depression were reviewed and revised numerous times. Whilst
remaining very frail, dependent, and largely symptomatic, her condition stabilised.
Her family were her Enduring Power of Attorney and were clear that Marjorie was not for further
burdensome interventions, including cannulation, transfer to another acute facility, surgical options or
resuscitation. The hospice was the preferred place of death.
Her nursing care included; ongoing management of her worsening mobility and associated falls risk
issues. Our Physiotherapist and Occupational Therapist reviewed her mobility on a regular basis,
observing her with transfer use of the MRAT and the PCOC RUG ADL tools she was able to mobilise with
a wheelie walker for some time, until she was eventually bed-bound or utilising a sling lifter, lifted into a fall
out chair.Case Study on Death and Dying Assignment Papers.
Marjorie had skin integrity issues due to her increase frailty and continence issues her care needs were
modified as her condition deteriorated. Management of these continued to be integral to Marjorie’s comfort
and care. Her scalp wound was quite purulent and malodourous. Wound care had to accommodate these
issues, as well as addressing aesthetic issues and Marjorie being confused was constantly attempting to
remove dressing material. Nursing staff utilised a range of head wear to suit Marjorie’s needs.Case Study on Death and Dying Assignment Papers.
Marjorie’s family were initially quite relieved that she was in a facility and that her illness was coming to an
end, but after a week she awoke from her comatose state. This was challenging for the family. An early
CareSearch is funded by the Australian Government Department of Health.
family meeting was held to re-establish goals of care. These meetings continued throughout the course of
her admission as her issues changed.
As Marjorie’s condition stabilised, her delirium included some paranoia and Marjorie was ringing her call
bell a lot. It seems that Marjorie had a history of anxiety and depression, and throughout her life her family
had struggled to manage this background of illness.
Nursing staff grew tired of Marjorie, finding it increasingly difficult to manage her daily outbursts of fear,
panic, anger and stress. Her initial admission for end-of-life care was no longer in play.Case Study on Death and Dying Assignment Papers.
Marjorie’s symptoms, although challenging, were increasingly controlled effectively with medication, this
included bladder discomfort, constipation and xerostomia. Marjorie was now in a stable phase.
Senior nursing staff, including the CNC and educator became more involved in some daily care and role
modelling the use of firm but clear directions which were necessary for her care to be effective. This
included a genuine desire to connect with Marjorie’s love of her horses and dogs. It became clear that
Marjorie had a sense of humour and that it was possible to enjoy positive connections with Marjorie.
Education sessions were held to allow staff to have emotional and clinical support regarding her clinical
care. Many staff were perplexed that her condition had stabilised and concerned that a short term
specialist unit was not an appropriate long term strategy. Her care was rotated throughout the nursing
team so that staff were able to care for themselves and maintain a positive compassionate outlook on
Marjorie’s condition.Case Study on Death and Dying Assignment Papers.
The pastoral care team spent time with Marjorie, allowing her to talk about her fears around her dogs’
wellbeing and other issues that stressed her. Our trained volunteers became expert at making Marjorie a
coffee she liked, and assisting her with meals. They too were finding it increasing difficult to manage
Marjorie’s outbursts, and it became important for the CNC and volunteer coordinator to meet and discuss
appropriate strategies to support Marjorie and the volunteer staff.
Throughout the admission the social worker, who is also a trained counsellor, spent time with the patient
and the family. She assisted them with managing some of Marjorie’s sometimes complex affairs (including
selling one of the horses!), as well as supporting the issues that they too were experiencing. Medical staff
were patient and clear in documenting the short, medium, and long term goals of care for Marjorie. Each
issue that distressed Marjorie was addressed openly, clearly and with compassion. Ward rounds allowed
for the medical team to have an understanding of Marjorie and her changing needs.Case Study on Death and Dying Assignment Papers.
After a prolonged period of being stable, Marjorie eventually slowly deteriorated. End-of-Life care was
initiated approximately five days before her peaceful death in the hospice.
During the preceding months Marjorie came to trust the hospice staff, and her family resigned to the fact
that Marjorie would eventually die. They visited when they could and when she eventually died they were
happy to leave our staff and volunteers to comfort and console Marjorie. We had made it our mission to
find ways of making Marjorie smile – and we did!
CareSearch is funded by the Australian Government Department of Health.Case Study on Death and Dying Assignment Papers.
What are your immediate thoughts?
Discuss it among the team: use it for in-service education, to reflect on how your service practices, or just
to consider palliative care in a different context or setting.
1. Please discuss the role of family meetings early during admission. How might this benefit a patient,
family and care team?
2. What strategies for supporting staff and volunteers do you use for patients who are sometimes
challenging?
3. Discuss the roles of the multidisciplinary team for supporting people and families like Marjorie?
4. How might PCOC tools assist in assessing the care required by patients like Marjorie?
5. How might sudden cessation of medications (for example as a result of dysphagia) affect Marjorie’s
symptoms?
6. What are the different arrangements that can be made in relation to decision making for patients
who no longer have the capacity? Eg, Enduring Power of Attorney, General Power of Attorney.Case Study on Death and Dying Assignment Papers.
Case Study: Meet Tim
It is important for you to consider that in the last year of life, whilst acknowledging symptoms may be disease specific, overall, the problems and challenges that patients and carers experience will be similar and can be broadly described in the four domains:Case Study on Death and Dying Assignment Papers.
• physical, pain and symptom control
• psychological, how is this patient/family coping
• social, what is the support network/what is the environment
• spiritual, finding meaning- which can include finding if there cultural and religious considerations.
Using this core framework as the basis for every assessment every time is recommended.
To learn more about the complexity of end of life care, we would like to take you through a series of conversations around one individual’s experience of end of life care, some of these are good examples and others are poor examples.Case Study on Death and Dying Assignment Papers.
Recent medical literature reports increased utilization of the intensive care unit (ICU) at the end of life, even for patients who are considered terminally ill, and the overall ICU adult mortality rate ranges from 10% to 29%. Therefore, ICU nurses require a level of comfort in caring for patients and families at this vulnerable time. At times, ongoing aggressive life-prolonging interventions for a terminally ill patient can create ethical conflicts and moral distress for nurses. This leads to the question: Can this level of treatment be compatible with a “good death?”
Medical recommendations are made based on the patient’s goals of care, appropriate treatment options, and associated benefits and burdens. How then should nurses respond when a patient or family does not agree with these medical recommendations? Through a case study, this article explores the moral and ethical conflicts that often occur in the ICU setting at end of life and aid to empower the ICU nurse to care for patients in a way that honors the patient’s wishes and maintains a healthy nurse-patient relationship.Case Study on Death and Dying Assignment Papers.
Article Content
The intensive care unit (ICU) is a site of care that can create great uncertainty for patients with a poor or terminal prognosis and their families. The usual culture of an ICU is one of restoring homeostasis with rapid responses and aggressive measures to help patients recover. But when a patient presents with what will likely be a terminal situation regardless of medical intervention, many providers want to support the patient and family into accepting a peaceful end-of-life experience and foregoing life-prolonging treatments. This can lead to ethical conflicts when clinicians and patients/families do not agree on the appropriate course of care. A case study will be used to explore the nebulous and personal definition of a “good death” and how clinicians can be confident knowing they provided the very best patient care at the end of life within an ethical framework.Case Study on Death and Dying Assignment Papers.
L.S., a 38-year-old man with stage IV colorectal cancer was admitted to the ICU with dehydration and acute renal failure following a fourth cycle of salvage chemotherapy. He had previously been treated with surgical resection at the time of diagnosis 3 years prior, radiation therapy, and multiple courses of chemotherapy. Over the past 36 hours, however, he had become acutely ill with anorexia, nausea and vomiting, and altered mental status with a creatinine of 3.8 mg/mL. He requires vasopressor support, intravenous antibiotics, and bilevel positive airway pressure support. His oncologist reports in his admission note that L.S. had not tolerated the salvage therapy well, his performance status had been worsening (Eastern Cooperative Oncology Group performance status 3), and he had lost 25 lb over the past 3 months. L.S. is obtunded now and without obvious distress or discomfort. He has a wife, 3 young children under 12 years, who were all in attendance with their community pastor at the time of admission and made it clear they wanted “everything done to save him.”
Twenty-four hours after admission to the ICU, L.S. continues to decline. He attempts to wake up and communicate with his family, but he is very lethargic and agitated. He is hemodynamically unstable and requiring blood transfusions. During multidisciplinary rounds, the primary ICU nurse requests a palliative care consult to help support the family and “make them understand L.S. is dying.” A family meeting is held with all family and their pastor to review the current status, a poor prognosis for survival, and recommendations to shift to comfort-directed care. It has been determined that none of L.S.’s conditions are reversible, and his decline is due to the progression of his terminal cancer. His wife wants to keep L.S. a full code blue and reports L.S. told her to always “do everything you can to keep me alive for my kids.” She shares that L.S. has been told by his oncologist that he is terminally ill, and the oncologist has recommended hospice to him several times, but L.S. has refused. He has told his family he wants to “go down kicking,” and she feels it is his way of showing his family he did all he could to live for them. She feels obligated to honor his wishes.Case Study on Death and Dying Assignment Papers.
After 5 days in the ICU, L.S. continues to decline overall. He is now less responsive, requiring increasing vasopressor support, and has been intubated. He is having frequent cardiac arrhythmias. The staff is growing resentful of the wife for not agreeing to shift his goals of treatment to comfort despite the medical team’s advice. In fact, most of the staff request to not be assigned to him because they feel they are inflicting harm to him. During the night shift of day 5, L.S. goes into cardiac arrest, prompting a code blue to be called. Four rounds of advanced cardiac life support are provided, and he does not respond. The chaplain and charge nurse are with the wife and children to keep them updated and supported. The attending physician comes to tell her he wishes to cease attempts at resuscitation because L.S. is not responding to the treatment, and the wife agrees. L.S. goes into asystole almost immediately after the cardiopulmonary resuscitation (CPR) attempts are stopped.Case Study on Death and Dying Assignment Papers.
After L.S. is pronounced, the family is appropriately grieving, but the wife states to the nurse she feels comfortable that she followed his wishes and “gave him every chance to live.” The next morning at shift change, the nurses discuss the events of his arrest and case. Many staff are angry that “she put him through that.” There is a great deal of sadness and frustration expressed by all of the staff surrounding the case.Case Study on Death and Dying Assignment Papers.
Because of the dissention among staff, the nurse manager schedules a debriefing the following morning for the staff. A facilitator from the hospital’s Employee Assistance Program and the unit chaplain lead the discussion to allow the staff to verbalize their feelings and emotions. By the conclusion of the session, everyone felt they at least understood the choices of the patient and family even if they did not personally agree with them. All agreed that they wanted more education and support surrounding difficult cases and ways to help themselves cope with providing care at the end of life.Case Study on Death and Dying Assignment Papers.
According to the nursing and medical literature, most patients with advanced illness state they would want to die at home in the presence of family and with a focus on their comfort; however, only 25% of those patients will die at home, 25% in a nursing home, and the remainder will die in an acute care setting.1,2 More specifically, more than one-third of patients with advanced cancer in the United States spend their final days in the ICU receiving life-prolonging measures including ventilator support, artificial nutrition, and CPR.3 Less than 50% of these patients with cancer will receive hospice services, and most that do receive services for only a matter of days.1,4 There are many factors influencing these statistics including the patient’s age, social situation, religious beliefs, and if he/she has had conversations about his/her end-of-life preferences and wishes.Case Study on Death and Dying Assignment Papers.
It is reported that up to one-fifth of patients with metastatic cancer receive chemotherapy in the last 14 days of life.1,5,6 With rising health care costs, this trend is receiving more attention, and efforts are being made to decrease this rate when there is no documented benefit for the patient. Oncologists are often criticized for continuing this aggressive treatment when the patient is nearing the end of his/her life, but many times this is a patient choice and desire to “fight to the end.”5
When the patients and/or the medical specialists want to continue all efforts to prolong life, even in a terminal situation, many conflicts can arise within and for the ICU team. End-of-life care and the continuation (or discontinuation) of aggressive measures have been cited as 2 of the most prevalent conflicts in the ICU that lead to staff burnout and poor quality of care. Intensive care unit nurses specifically are faced with a challenge of maintaining treatment delivery and providing honest communication and emotional support to the family.7 This can lead to an internal struggle for the nurse who may be feeling he/she is hurting versus helping the patient. This type of conflict can lead to feelings of powerlessness and will ultimately lead to less than optimal health care delivery.8,9 The term “moral distress” has been used to describe this human response, and it has been shown to lead to staff burnout, high staff turnover, and compromised patient care.10 Conflicts and distrust between nurse and physician can also arise if there is a feeling that the patient and family have not been fully and accurately informed of the terminal prognosis and perhaps have been given false hope.Case Study on Death and Dying Assignment Papers. When this occurs, nurses may feel the patient and family are not making informed choices about their goals of treatment when they choose to seek end-of-life care in an ICU versus choosing a more peaceful setting for their care.5
ETHICAL PRINCIPLES
Difficult cases, such as the one presented here, occur daily throughout all health care settings. As we explore each of the ethical principles, autonomy, beneficence, nonmaleficence, and justice, it is important to note that neither principle is more important than the other.11 For example, a patient’s right to self-determination (autonomy) does not carry more influence than the medical team’s responsibility to “do no harm” (nonmaleficence).11 While we rely on these principles to help sort out ethical conflicts, there is no guarantee that they can provide clear answers.Case Study on Death and Dying Assignment Papers. That is largely because of the fact that each case and subsequent dilemmas stem from the patient’s unique culture, values, beliefs, and personal preferences; therefore, there is no uniform solution to apply to all cases. Ethical principles must always be applied within the patient’s personal context, not that of the physician or nurse caring for the patient. Practitioners must be sure to not interject their opinion on how the case should be managed; instead, they must adhere to standards of health care appropriate for the situation. An approach cited in the literature, known as the “4 Box Model,” may serve as a useful guide to clinicians when ethical conflicts arise. This model encourages the utilization of the elements of medical considerations (diagnosis, prognosis), patient preferences, quality of life, and contextual features (conflicts of interest, legal issues, etc) when examining a complex medical case to help organize priorities and facts of a case. The emphasis remains intact that no one element holds more weight than another.11
AUTONOMY
Clearly, in this case, the medical team placed significant weight on this patient’s previously stated wishes and seemingly more weight than to that of the remaining ethical principles. Because the literature is clear that the likelihood of benefit of CPR in L.S.’s case was low with increased risk of harm, one could certainly argue that to offer this treatment would be nonbeneficial if not medically futile.12 However, states have specific laws related to CPR and definitions of medical futility. These may even differ among health care institutions within the same state. The nurse must be cognizant of the laws pertinent to the where he/she practices and acknowledge how these laws impact a medical provider’s practice.Case Study on Death and Dying Assignment Papers.
While the ethical principle of autonomy seeks to support a patient’s right to self-determination through informed consent or refusal, it does not demand that the physician provide treatments that are deemed more harmful or not medically appropriate.13 Why, then, don’t physicians make this decision unilaterally more often? Perhaps, it is fear of litigation from the surviving family. Even if the doctor would win such a lawsuit, he/she will still be subjected to the legal expense of judicial review.Case Study on Death and Dying Assignment Papers. There is also potentially the fear of a fractured relationship with the patient and the family. Physicians would certainly prefer to come to a consensus opinion on such important decisions. It could also be that the physician recognizes how deeply personal these decisions are and chooses to support patient wishes even if he/she does not agree. When consensus cannot be reached, some hospital-based teams have the option of ethics committee consultation to evaluate the case, determine the medical standard of care, and either support physician decisions or make alternative recommendations. In the case of L.S., an ethics committee was not available, and the decisions had to be made between the health care team and the patient/family.Case Study on Death and Dying Assignment Papers.
BENEFICENCE
This ethical principle demands that the medical team “always act in the best interest of the patient.”13 The nurses in this case no longer felt further life-prolonging aggressive medical interventions were in the best interest of L.S. because of his terminal illness. They also felt it would create suffering for him at the end of his life.Case Study on Death and Dying Assignment Papers.
When members of the medical team feel such conflict, it is important to note that life-prolonging medical treatments such as CPR, defibrillation, intubation with mechanical ventilation, and prolonged artificial nutrition are “ethically neutral.”11 That means, independently, they are neither good nor bad.Case Study on Death and Dying Assignment Papers. It is only in the context of a particular patient scenario that we can define these treatments as either “beneficial” or “harmful.”11 While the nursing team felt treatments were nonbeneficial, the patient and family clearly and consistently expressed their perceived value even after receiving full information from the medical team. This may be a good time for the nurse to ask himself/herself, “Whose life, and subsequent death, is this?” If the patient and family are fully informed and, based on their values and preferences, this is what they want this moment to look like, why is the nurse still so conflicted?Case Study on Death and Dying Assignment Papers.
NONMALEFICENCE
Nonmaleficence is based on the Hippocratic oath of “do no harm.”11 It was clear that the nurses felt they were harming L.S. by continuing to pursue life-prolonging treatment, not only by potential physical injury but also by not facilitating a more peaceful, dignified death.Case Study on Death and Dying Assignment Papers. As for the concern for physical injury, that is a valid concern. There are physical injuries that can occur from CPR including rib fractures, internal trauma, or neurologic injury from hypotension or hypoxia. If despite this knowledge the patient or family still wants certain treatment and it is still being offered, then there is no ethical dilemma with respect to the plan of care. However, it is hard to be the bedside nurse who actually has to perform the chest compressions when the patient codes.Case Study on Death and Dying Assignment Papers.
In the same way that doctors are not obligated to perform medical treatments that they find unethical and can transfer the patient to another provider, so too the nurse should not be forced to perform care that he/she deems unethical. Once this conflict is identified, the nurse needs to communicate this to his/her supervisor so the patient can be assigned to another nurse.Case Study on Death and Dying Assignment Papers.
The other issue is the nurse’s desire to facilitate a peaceful, dignified death for the patient. There is no universally accepted definition of a “good death,” and there is no algorithm to follow in order to help a patient achieve it. Many articles have explored this topic and report that there are consistent themes to describe a good death, including (1) pain and symptom management, (2) clear decision making, (3) preparation for death, (4) completion, (5) contributing to others, and (6) affirmation of the whole person, but what becomes clear is that each patient’s perception of a “good death” is deeply personal and is influenced by cultural and spiritual beliefs as well as past experiences with loss.14 Essentially, patients do not define their end-of-life preferences in the same way, nor do physicians, nurses, or families.15
If this is what is driving the conflict for the nurse, the nurse again needs to take a step back and reflect.Case Study on Death and Dying Assignment Papers. If we accept that the definition of a “good death” is deeply personal, then it is not for the nurse to oppose those choices simply because the patient is not dying the way the nurse thinks that they should.15
JUSTICE
The ethical principle of justice refers to the need to protect vulnerable populations and observe fair allocation of precious medical resources. With the rising cost of health care and hospital financial consequences of health care reform, it is imperative that the primary responsibility of this principle is to the patient, not the hospital’s financial well-being.16 That being said, this is a real issue with significant ramifications for our society. One could argue in L.S.’s case that there was perhaps injustice in the prolonged use of an ICU bed and the increased cost of aggressive care that would not change the outcome.Case Study on Death and Dying Assignment Papers.
Unfortunately, this conflict is harder to resolve. Currently, the focus is more on the patient and family goals, and if that goal is to pursue life-prolonging measures, then that level of care is provided regardless of cost. These types of decisions should never be made at the bedside but at a state or national level.Case Study on Death and Dying Assignment Papers. This will likely be a topic of much debate nationally as we move forward in the new era of health care reform.11
CAREGIVER AND FAMILY DYNAMICS
It is well documented in the literature that disorders such as anxiety, posttraumatic stress disorder, and depression are issues for families or caregivers who experience a death in the ICU setting.17,18 What is also recognized is that family involved in any high-risk illness in the ICU or in end-of-life decision making begins experiencing distressing feelings or this anxiety in the midst of the care event.Case Study on Death and Dying Assignment Papers. In the case of L.S., it was clear that his wife was struggling between her own anticipatory grief and the need to protect herself and her children and her need to honor her husband’s stated wishes. She acknowledged to the team that because of her helpless feelings related to his disease and prognosis, she felt this was the last element of control that she maintained. It is not uncommon for nurses and team members to mistakenly see this as “selfish” and not as a coping strategy for the family. It seemed to the team that she perhaps did not understand the terminal nature of his illness and the recommended path of a comfort-directed plan of care, which then led to feelings of frustration and hostility toward her by the staff. Many people look at this as denial, but in fact it is a common way of coping or protecting one’s self from the burden that is upon them.Case Study on Death and Dying Assignment Papers.
Identifying and then resolving conflict among staff and family can be challenging. There are several different conflict resolution strategies reported in the literature including dominating, obliging, avoiding, compromising, and integrating. The nursing literature reports that nurses predominantly use avoidance as their strategy. In the case presented here, this avoidance was toward the patient’s family and could potentially lead to the family feeling isolated at an extremely vulnerable time. Avoidance can also be seen as a protective mechanism for the staff to decrease the internal struggles they are going through related to a patient care plan.19
To decrease stress and conflict among both parties, the literature supports utilizing open and frequent communication, family meetings, and shared decision making and involving palliative care or other support services as mechanisms to prevent or reduce the incidence of posttraumatic stress disorder or long-term depression.17 These methods of involving family from the outset of the critical illness can help them see the decline as a process or trajectory and prepare them for possibilities of recovery or an ultimate decline and death.Case Study on Death and Dying Assignment Papers. This can help decrease or eliminate the surprise factor of the patient not responding to treatment, and support mechanisms can be put in place earlier to assist the family.17,18
STRATEGIES FOR THE ICU TEAM
Undoubtedly, there will be patients in the ICU who will continue to wish for life-prolonging measures despite the health care team’s education and recommendation to consider a more comfort-directed approach. Although this could be difficult to accept as a nurse, it could be used as an opportunity to get to know patients better and to explore what is driving that decision. Dr Timothy Quill explains that patients who say they want “everything” may or may not actually want those treatments that the physicians feel may be more harmful than beneficial.20 Quill recommends asking patients or families questions such as “what are your biggest fears?” He states that for many patients there is a fear that if they start to set limits to their treatment, the medical team will become “less vigilant” when changes in their health develop.20 They may have spiritual, psychological, or social stressors that are impairing their ability to cope with goals-of-care discussions. Other questions that may be helpful as nurses explore their patients’ goals are to ask them to define treatment success and what are they willing to go through in order to achieve it. Be aware that they may not trust the health care system.Case Study on Death and Dying Assignment Papers. If they are part of the population with known health care disparities or limited access to care, this is often the case. Nurses need to develop a trusting relationship with patients in order facilitate goals-of-care discussions. Reiterate to the patients that the medical team will never stop caring for them even when they cannot cure them and that there is always more that can be done to alleviate suffering. Because goals of care can and often do change over time as the disease progresses, nurses must maintain a therapeutic relationship with the patients and families in order to support them through those transitions.17,18,20
As shown in this case, L.S. and his wife chose a course of treatment at the end of his life that most nurses and health care providers would disagree with. However, this treatment plan was offered to him, and he made an informed decision based on his goals for showing his children he had attempted everything possible to live longer. This case also demonstrates a loss of a therapeutic relationship between nurse and family.Case Study on Death and Dying Assignment Papers.
SELF-CARE FOR THE NURSE
Nurses must explore their own fears of death and respect that these perceptions influence their ability to care for dying patients. Is death perceived as failure? Is it the enemy? Or is it a natural part of the human physiologic experience?10 Nurses can work through those feelings in order to be able to engage with terminally ill patients in a more meaningful way.18 Nurses must also recognize their need for more education on this topic and seek out local resources to obtain it. That may be through formal continuing education programs or simply by reaching out to a local hospice and palliative care organization for support and training. Finally, nurses need to be sure to engage in self-care strategies including spiritual practices, exercise, and quality time with family and friends. These strategies will help process the often heart-wrenching experiences witnessed at work on a daily basis. Nurses who are able to cope with their work in this healthy manner are better able to function both professionally and personally.18 As in L.S.’s case, nursing leadership acknowledged a need for staff support following this distressing event, and a debriefing was held to allow further exploration of feelings. There are multiple ways to hold staff debriefings, and each facility or unit may have specific methods of providing support that makes them feel supported.Case Study on Death and Dying Assignment Papers. This enables staff to find their own closure for difficult cases and a chance to process the events in a way that is most meaningful to each unit or staff. Having a facilitator lead the session allowed for an unbiased perspective to assist the staff in processing their viewpoints.19,20
HOW PALLIATIVE CARE CAN HELP
Multiple studies demonstrate the benefits of incorporating palliative care principles in the ICU.21 It is well documented that patients dying in the ICU suffer from multiple sources of physical and psychological distress, and their family members are at increased risk for prolonged grief.18 In response to this, palliative care programs are becoming more prevalent across the country in various health care settings; however, these specialized clinicians will never be able to meet all of the needs of the chronically or critically ill patients. It is the role of all clinicians caring for patients to engage in primary palliative care.Case Study on Death and Dying Assignment Papers. Primary palliative care is the basic skills and competencies required of all physicians and health care providers when taking care of their patients. This includes discussion and education about goals of care and management of distressing symptoms.22 Secondary palliative care is provided by clinicians with special training, and they provide formal consultation. This is appropriate for those cases when conflict within family is high and patient symptoms are not controlled with typical measures.22 As in L.S.’s case, secondary palliative care was engaged; however, the wishes of the patient and family were not altered. It should never be assumed that this consultation will automatically resolve any conflicting ethical issues, although this can be a great source of support to the health care team and to the patient and family to ensure that all involved are fully informed of the issues.Case Study on Death and Dying Assignment Papers.
SUMMARY
“Meet patients where they are and take them where they want to go.” This is a well-known saying among hospice providers, and it supports the concept that the end-of-life journey is unique to each individual patient. Furthermore, a “good death” is not a myth. It can be achieved, and it frequently needs to be fostered by a well-trained and caring medical team.23 Always screen for evidence of suffering (physical, emotional, social, and spiritual) and include all members on the team (social worker, chaplain) in the plan of care in an effort to relieve suffering.24,25 Offer education and support the patient’s and family’s decision once they have received the necessary information. In doing this, nurses are more likely to maintain a healthy nurse-patient relationship even in the most difficult of situations, and patients and their families can be supported through one of the most frightening times of their lives.Case Study on Death and Dying Assignment Papers.
The purpose of this assignment is to write a report on an episode of care received by a patient with palliative care needs, in which I have been involved in. It will also demonstrate my ability to meet the learning outcomes of the module, such as the critical evaluation of the policy landscape within which continuing, palliative or cancer services are delivered and the analysis of the integrated nature of service delivery, relevant in patients with palliative care needs and how it has enhanced the delivery of care. Integrated care is defined as “the act of making a whole out of parts; the co-ordination of different activities to ensure harmonious functioning” (Marriam Co, C & G.1998).Case Study on Death and Dying Assignment Papers.
In order to comply with the guidelines on confidentiality and consent as stated in the Nursing and Midwifery Code of professional Conduct (2008) and the guidelines of the University, I obtained permission from the ward sister, to use a patient’s information in my report. I also asked the patient directly for his permission, explaining the purpose of the report and in order to protect his anonymity, I would change his name, not mention the placement by name and not divulge any identifiable information about him. I have also explained he can withdraw consent at any time. Consent has been documented in the patient’s notes, from this point onwards I will refer to my chosen patient as “Phil” and the area as my placement.Case Study on Death and Dying Assignment Papers.
The report will be structured in sections. Section 1, will introduce the focus and structure of the assignment. Section 2, will give a brief description of “Phil”, his problems, diagnosis, care needs and who will be involved in his care.
Section 3, will discuss three key government policies, relevant in the care of people in the palliative stage of their illness.Case Study on Death and Dying Assignment Papers.
Palliative care is defined by the World Health Organisation (2002) as
An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (www.helpthehospices.org)
My chosen policies are The Department of Health End of Life Care Strategy (2008) The National Institute for Clinical Excellence (N.I.C.E) Supportive and palliative care services for adults with cancer and The Liverpool Care Pathway. I will be comparing and contrasting the patients experience to policy recommendations and how they have been implemented at a local level. Policies are described by Blank & burau (2007) as an action taken by the government, in order to improve, prevent or prioritise to achieve an end goal.Case Study on Death and Dying Assignment Papers.
Section 4, will contain an overview of salient points regarding the policies implementation, highlighting where areas could be improved and make any recommendations for future practice.
Section 2
Overview of my patient and the episode of care
“Phil” is a sixty five year old male, divorced, lives alone within the city and has one son. He was diagnosed with leukaemia twelve years ago in 1997. Alexander, Fawcette & Runcman (2006) describe Leukaemia as “a malignant disorder where abnormal and excessive of proliferation immature and ineffectiveness of blood cells”. There are two types, acute and chronic Leukaemia “Phil” has chronic Leukaemia, Alexander, Fawcette & Runcman (2006) further state, Leukaemia is rare within the UK and the incidence varies geographically, causation is not fully understood but exposure to radiation, chemicals, viruses and cytotoxin medication may increase incidence. People diagnosed with this type of Leukaemia can live for many years after receiving treatment.Case Study on Death and Dying Assignment Papers.
Phil’s Leukaemia was indolent for several years, until 2002 when he received a course of chemotherapy (cyclophosphamide), in 2006 was given more chemotherapy (fludarabine). Then in 2008 he was treated more aggressively with a higher dose of combination chemotherapy (cyclophosphamide & fludarabine). Phil retired at this time and had continued to deteriorate until being admitted to the hospital in April 09 with a fever where he was treated with intravenous antibiotics, his health declined further until he was admitted onto my placement for symptom control, however Phil moved very rapidly into the terminal stage. Terminal stage is defined as the end phase of life, at this stage someone’s life will normally be in the last days, where someone can be in the palliative phase for months or years (Kay 2003).Case Study on Death and Dying Assignment Papers.
After the admission and assessment care plans can be formulated whereby Phil’s individual care needs can be met, Phil’s problems are pain, constipation and a general unsettled feeling about how is son is coping with his illness. Involved in his care will be the specialised palliative care doctors, nurses, the spiritual care coordinator and a bereavement counsellor who will support, Phil’s only son, who at this time, has taken time out of University in order to be close to his father, at the end of his life.Case Study on Death and Dying Assignment Papers.
SECTION 3.
Policies and how they have been applied in the episode of care.
3.1a Summery of The Department of Health End of Life Care Strategy (2008)
The Department of Health End of Life Care Strategy (2008) was developed to improve standards of care across the United Kingdom (UK) for all adults at the end stage of life. It aims to provide frameworks that will guide our health care system putting great emphasis on the needs and wishes of the patient and their families. The key aims are, engaging groups in local communities to become more aware of end of life care. It aims to ensure that patients approaching the end stage of life have their symptoms managed to maintain optimal quality of life. It calls for the careful assessment of needs for people that are approaching the end stage of life, and recommends the use of the single assessment process (SAP). It aims to ensure that services accessed are coordinated to provide seamless care. It aims to ensure that people approaching end of life are considered holistically, the holistic approach covers the physical, psychological, social and spiritual needs.Case Study on Death and Dying Assignment Papers.
The policy’s main aim is for all health care providers to adopt and develop the use of the Liverpool care pathway or an equivalent. There is also great emphasis on involving and supporting carers and families, the policy calls for the need to provide information to the carers and family members about the person’s condition and also to support them on a practical and emotional level this is to include bereavement care. The Department of Health End of Life Care Strategy (2008)Case Study on Death and Dying Assignment Papers.
3.1b How the policies have been applied in practice to my patient
Phil was admitted using an adaptation of the single assessment process, (SAP), section 3.36 of the policy supports the use of this process. The SAP took place with the doctor, nurse and me, the student nurse present. It is not expressed in the single assessment process Guidance for Local Implementation (2002) that the doctor and nurse do this assessment together, but my placement feel it’s a more effective system when both parties are present and can feed back to other members of the team, this also avoids the patient having to repeat their details again.Case Study on Death and Dying Assignment Papers.
This sharing of information is carried out by the nurse, who admitted the patient, information is passed on during end of shift handover, where it is attended by nursing staff and health care assistants. The nursing staff also discusses his needs with other relevant people who will be involved in Phil’s care such as the spiritual care coordinator and bereavement councillor and family support team. Multidisciplinary working is covered in the policies key aims, this is carried out during weekly multidisciplinary meetings. Where all parties are in attendance that are to be involved in patient care, during meeting decisions are made regarding who needs to be involved and best ways of providing care.Case Study on Death and Dying Assignment Papers.
Integrated care provides patient with the best standard of care, however in order for it to work to the best effect again communication and team working has to be a priority, this is supported by Barrett, Sellman & Thomas (2005) who state “the quality of care received is dependent upon how effectively different professionals work as a team”, all these professionals write in the same patient notes to share information. The Nursing and Midwifery Council (2008) state good record keeping is one of the most important aspects of communication and enhances patient care.Case Study on Death and Dying Assignment Papers.
Further aims are to ensure pain and suffering is alleviated through skilful symptom control, this was carried out with the use of a combination of analgesic to alleviate his pain and also medication for constipation. Kay (2005) states that constipation is one of the most common side effects of analgesics and patients should be commenced on laxatives from the outset.Case Study on Death and Dying Assignment Papers.
Again in accordance to the policy key recommendations, patient and family involvement and support is vital and has been implemented, by way of, Phil and his son have been informed about his condition and their concerns addressed at all times by staff. Phil’s son is also receiving counselling and will continue to be offered bereavement counselling after his father’s death as mentioned in the key recommendations. Luton (1995) states if patients and their families have an understanding that the symptoms can be controlled, dignity is maintained and feel supported by staff, are better prepared to cope with the difficult and emotional time ahead.Case Study on Death and Dying Assignment Papers.
A further recommendation was to raise the profile of end of life care. Whilst on placement a group of six form students from a local school who are currently studying health and social care, asked to spend some time at my placement, to raise their awareness of end of life care which is part of their course learning.Case Study on Death and Dying Assignment Papers.
In accordance to the policy, as well as Phil’s health needs the assessment also encompasses his social and spiritual needs. Phil has been attending the day centre facility adjacent to my placement, for around six months, this has been a time where he has been able to have some social interaction away from home and has continued to be offered to attend.Case Study on Death and Dying Assignment Papers.
The spiritual coordinator has also spent time with Phil addressing any wishes he may have or talking about his feelings regarding his illness, he only expressed that his son received support which he has and he die at my placement. Although he declined, Phil was also given the chance to access support services that would facilitate him to leave lasting mementos for his son for example, a memory box or letters.Case Study on Death and Dying Assignment Papers.
My placement also supports the use of the Liverpool Care Pathway as recommended in the policy and it was applied to Phil when it was apparent he had reached the end of life stage. The End of Life Care Strategy (2008) have been very well implemented and my placement and has considered the persons needs as well as supporting the family needs.Case Study on Death and Dying Assignment Papers.
3.2a Summery of The National Institute for Clinical Excellence (N.I.C.E) Supportive and palliative care services for adults with cancer(2004)
The National Institute for Clinical Excellence (N.I.C.E) Supportive and palliative care services for adults with cancer (2004) advises those who are responsible for the delivery of cancer care about how to ensure their patients, families and carers are well supported the policy has made twenty key recommendations. This includes for example, key personnel who are involved in the in the delivery of care required in people with palliative care needs, will oversee that the policies guidance is being implemented. Patients and their families are involved in decisions about their care and encouraged to make their voices heard.Case Study on Death and Dying Assignment Papers.
The policy recommends that a holistic approach should be adopted in people affected by cancer have full support physically, emotionally, spiritually and socially. The guidance recommends that patients have access to support groups and have help and advice regarding money or access to help with personal needs. The guidance recommends that systems are available 24 hours a day and equipment is provided without delay to support patients to stay at home. (The National Institute for Clinical Excellence Supportive and palliative care services for adults with cancer (2004).Case Study on Death and Dying Assignment Papers.
3.2b How the policies have been applied in practice
The guidance recommends that key personnel will oversee that the policies guidance is being implemented. In my placement this is overseen by the head of nursing staff, together with the introduction of clinical governance to my placement, clinical governance is a frame work that monitors care that is provided, ensures care is of the highest standard and is evidence based(www.dh.gov.uk). A holistic approach was adopted during his care as mentioned earlier and Phil and his son were involved in all decisions made regarding his care on arrival, yet when he became semi- conscious, although it was explained to him what care he would receive, he was no longer capable of responding and all decisions were then made by nursing staff and doctors.Case Study on Death and Dying Assignment Papers.
Although some of the guidance may have applied to Phil if he had of went home as intended on admission. His health declined so rapidly I can no longer comment on whether some of the policies recommendations were well implemented or not, yet arrangements were in process for Phil to have a home visit with the occupational therapist who would assess his needs at home and any adaptations that would be needed.Case Study on Death and Dying Assignment Papers.
Support from day hospice to help with personal care and he was to continue to visit the day centre. Day hospice is another of the large array of service providers needed when providing care for patients with palliative care needs. The team have very good relationships between outside service providers and seem to have communicated well during Phil’s illness.Case Study on Death and Dying Assignment Papers.
3.3a Summery of the Liverpool Care Pathway
The Liverpool Care Pathway (LPC) was developed by the Royal Liverpool University Trust and the Marie Curie Centre in Liverpool in 1997. Its aim is to bring the model of care used in hospices to all health care setting. It is an integrated pathway that guilds the health care workers in providing “best practice”. Its key aims are to improve the knowledge of the process of dying and to improve the quality care, delivered to patients in the last day and hours of life.Case Study on Death and Dying Assignment Papers.
The focus of the LCP is upon initial assessment, ongoing assessment and care after death. This incorporates the spiritual beliefs of the patient, what the patient and their family understand about the illness and what arrangements have been made after death. Someone is commenced onto the pathway when it is agreed by the multidisciplinary team that the person is dying and have two or more indicators that the team will recognise. These indications are, the patient has become bed bound, the patient is semi-conscious, the patient is only able to take sips of water and the patient is not able to swallow tablets.Case Study on Death and Dying Assignment Papers.
The LCP also gives guidance on areas such as symptom control, prescribing medication that may be needed, stopping other treatments that are no longer required, providing comfort for example mouth care. This documentation is to be filled out every four hours. The policy focus is that the patient’s symptoms are controlled and four core drugs are administered (www.mariecurie.org.uk). Kay (2003) states, that all patients will receive Morphine for pain, Midazolam to control agitation, Cyclizine for nausea/vomiting and Hyoscine that controls secretions or an equivalent drug to the same affect at the end stage of life.Case Study on Death and Dying Assignment Papers.
3.3b How the policy has been implemented to my patient in practice
Phil was admitted for symptom control of pain, on admission he was fully mobile, he was eating small amounts and coherent. However his health deteriorated rapidly, within days he needed support of two people when getting in and out of bed, over the next five days he was not eating, he could no longer talk and could not swallow his medication, as stated in the policy these are the indications that he has entered the terminal stage.Case Study on Death and Dying Assignment Papers. It was agreed by one of the doctors and a staff nurse that he was now in the terminal stage and the LCP should be applied. One of the doctors and a staff nurse went together, yet the doctor took the lead when explaining to Phil and his son what changes were occurring. The staff nurse stayed after the doctor left to support both Phil and his son.Case Study on Death and Dying Assignment Papers.
My placement has a leaflet explaining the symptoms of the end stages of life which was given to Phil’s son. Providing information is one of the policies main aims and as mentioned previously knowledge can better prepare patients and their families for the end stages of life.Case Study on Death and Dying Assignment Papers. Phil was reassessed at this point and the LCP was now the only paperwork that was to be filled out. The LCP is a very structured plan that can be altered in some ways to give a more individual approach, yet I did not see it being changed in any way regarding Phil’s care or any other patients whilst on placement.Case Study on Death and Dying Assignment Papers.
The LCP does provide an efficient checklist, however after the initial assessment I felt the care became just a ticking box exercise and as Phil was now semi- conscious the only time nursing staff went into his room was to provide comfort and on occasions the time had lapsed after the four hour recommended time stated in the policy, this view is supported by Kelly (2003) who states:Case Study on Death and Dying Assignment Papers.
that care of the dying may be standardised to such a degree that reality is reduced to a flow diagram and palliative care is simply a series of boxes to be ticked be professional care givers.Case Study on Death and Dying Assignment Papers.
However Taylor (2005) states that if the LCP implementation is carried out by health care professional that are fully trained in palliative care and the use of the LCP the documentation can be used to its full potential.Case Study on Death and Dying Assignment Papers.
Phil was also prescribed the recommended medications and died peacefully with his son by his side. After death care is also a goal of the policy and shortly after he had died a member of staff explained to Phil’s son that nursing staff would wash and dress his father also asking if he had expressed any wishes and to contact his chosen funeral director, after which Phil’s son was given as much time as he wanted to spend with his father. Before leaving my placement Phil’s son was given the phone number of the bereavement counsellor. After Phil’s son has left the funeral director is contacted again by one of the nursing staff to collect the body.Case Study on Death and Dying Assignment Papers.
Conclusion
This report has covered policies that are used in people with palliative care needs, the overriding message from all the policies is, support of patients their carers and families, the need to approach care from a holistic aspect, covering the person’s physical, psychological, social and spiritual needs. For patients to be involved in decision making and be informed about their treatments and the care they will receive. All the policies call for a high standard of care delivery for people with palliative care needs and end of life care. The policies aim to ensure that patients approaching the end stage of life have their symptoms managed to maintain optimal quality of life until death.Case Study on Death and Dying Assignment Papers.
This placement has taken place in a palliative care unit and whilst writing this piece I am very aware that my placement area offers a very high standard of care that applies most of the principles of each policy. The Department of Health End of Life Care Strategy (2008) states that the principles of the policy should be offer to all dying patients. However, during my time spent on the ward there was only ever one patient admitted for end of life care that did not have cancer, to which staff commented on why she was here. So it seems that cancer patients are part of a privileged group when reaching the end of life.Case Study on Death and Dying Assignment Papers.
For future practice I would recommend that the LCP has a section that requires nurses to check on patients more regular, not to provide any care but reassure patients and their families their needs are being met and staff are always on hand. I would like to see all patients with palliative care needs be offered the same quality of care as cancer patients receive at a hospice. Yet I am aware that providing this standard of care to all people would over stretch the already limited available resources. Yet my own philosophy of care is not driven by money but providing the best care for my patients regardless of illness.Case Study on Death and Dying Assignment Papers.
