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Case Study on Palliative Care

Case Study on Palliative Care

Assessment 1: Case study – part 1
Wayne is a 78-year-old man who lives with his wife, Margaret (76). Wayne was diagnosed with heart failure several years ago, is a smoker with mild COPD and has some cognitive impairment secondary to vascular dementia. Over the last twelve months Wayne has become increasingly immobile due to his worsening heart failure and COPD. He is no longer able to sleep in his bed as he must be sitting up in a chair so he can breathe comfortably. He has presented to ED twice in the last twelve months for distress and shortness of breath and was admitted both times for observation. Wayne’s GP is concerned that his condition is deteriorating, and his confusion is increasing, placing more strain on Margaret, his principle carer. Margaret has been having problems with managing her own health conditions as Wayne has become increasingly more dependent at home.
Wayne and Margaret have two children –David and Jenny, both of whom are married and have children of their own. They are a very close, supportive family and all live nearby each other.
Wayne’s children talk to their Mum about what has been happening and the strain that it has been putting on her. Margaret wants to keep looking after Wayne but admits that she is suffering at the same time. She tells her children that she is terrified of losing Wayne and she has started to notice that he is becoming more confused and getting angry with Margaret more often. She also tells them that Wayne is getting frustrated as he is almost always out of breath nowadays and does not want to ask for help. The children are finding the whole situation confronting and want to help their parents, but they don’t know how. David calls you and asks how you can assist Margaret and Wayne.
1. Outline how you might develop the goals of care for Wayne and what your priorities for providing care to Wayne and his family?
2. Describe practical ways that Margaret could be supported?
3. What resources can you provide to Wayne and his family to support them.
The following resources may be useful in answering the above questions.
palliAGED – Recognising Change
ELDAC – Assessing Palliative Care Needs
ELDAC – Work Together

Assessment 1: Case Study on Palliative Care

Example of Case Study on Palliative Care on Wayne and Margaret 

Case Synopsis

Wayne and Margaret are an aged couple aged 78 and 76 years old, respectively. Wayne is a smoker diagnosed with heart failure, mild COPD, and has cognitive impairment secondary to vascular dementia. He has become increasingly immobile owing to his deteriorating heart failure and COPD. He cannot sleep on his bed; instead, he sleeps on the chair in a reclined position to breathe comfortably. The GP is concerned about his deteriorating health condition and increasing confusion that has placed more strain on his principal carer. Margaret has been experiencing problems managing her own health conditions, and her husband has become increasingly dependent. She is frustrated as he is always angry, out of breath and does not want to ask for help. Despite being a tightly knit family, their children are worried about the parent’s deteriorating health and strain. Accordingly, this paper presents a discussion on the goals and resources of palliative care for Wayne and his family.

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Palliative Care

Wayne and Margaret are in their 70s, and they need palliative care since aging has brought forth chronic illnesses and frailty. Palliative care can be defined as treatment, healthcare, and support for persons living with a life-limiting illness that cannot be cured and could cause death in the foreseeable future (MacLeod & Van, 2019. Palliative care will offer prevention and reprieve of pain and suffering through early identification, assessment, pain treatment, physical, spiritual, and psychosocial support. The palliative care will be provided by various health and care professionals, general practitioners, community care nurses, and tertiary referral palliative care services (Mitchell, 2011; Roth et al., 2011). The family, friends, and neighbors provide vital support too. Nurses spend most of the time with the patient and family than other health professionals. Thus, they can reduce the distress and burden of those facing death and provide the support that matches their physical, psychological, spiritual, and social needs (Engberink et al., 2020). Overall, the combination of palliative care and active treatment can improve control of symptoms, family satisfaction, and the patient’s quality of life.

Question 1: Priorities for Wayne’s Palliative Care

From a nursing perspective, palliative care will be a vital part of an interdisciplinary team approach in creating comprehensive care plan over the disease trajectory. The establishment of shared treatment and care goals will improve the Wayne and Margaret’s quality of care by facilitating suitable and desired outcomes. In this case, palliative care will support Wayne and Margaret’s family to handle a challenging situation. The palliative care priorities are to help the couple achieve a good quality of life by ensuring that they get the care needed to live well as it involves managing physical symptoms like depression, nausea, breathlessness, fatigue, and anxiety. It also entails the provision of psychological, emotional, and spiritual support and social care (Centre for Palliative Care, 2011). The palliative care integrates spiritual and psychological elements of care and a robust support system to help the couple live as actively as possible and their family to cope during their parent’s illness and bereavement. Another priority of palliative care is assisting the family in coming together and discussing sensitive issues, support for the fulfillment of cultural obligations, counseling, and referrals to respite services. Most importantly, the palliative care will help them live comfortably and thoroughly as possible with Wayne’s progressive disease, while at the same time easing the suffering of the patient and his family.

Recognizing Changes

Wayne is an elderly patient with deteriorating heart failure and COPD. In the last twelve months, he has had two episodes of sickness and deterioration and spent some time in the local hospital dealing with his health crisis. First, the nurse should undertake specific CHF and COPD assessment considerations and review the management strategies, including non-pharmacologic and pharmacological interventions, quality care indicators, care transition of quality improvement, and end-of-life issues (Azad & Lemay, 2014). The case reveals that Wayne’s confusion and anger are increasing, which could be attributed to dementia, prevalent among senior citizens. The nurse should get Wayne’s detailed history detailing signs linked to dementia, health chronology, other conditions, and medications. Additionally, neurological tests and chronic and functional assessments should be conducted to rule out Alzheimer’s disease.

Over time, the decline might continue, making it difficult to recognize the changes as they occur. Thus, planning for further changes is needed. The typical change indicators are lower interest in acting, talking, eating, loss of weight, physical activity, immobility, incontinence, and difficulty swallowing (Palliative care aged care evidence, 2018). SPICT4ALL will help health and care specialists identify whether Wayne and Margaret could benefit from palliative and supportive care to think ahead and plan care in the future (Pike et al., 2017). Thus, the SPICT-4ALL tool will help recognize and talk about signs that Wayne’s overall health could be declining. This will help Wayne and his carer obtains better-synchronized support and care at residential aged care.

The ELDAC Model

The ELDAC Model offers guidance to help the staff and health specialists fulfill the needs of elderly persons approaching the end of their lives. In Wayne’s case, the ELDAC Model will help determine whether he is approaching the end of his life, planning and delivering care, assessing how his care needs could change over time, useful resources in providing care, and education needs (ELDAC, 2017). In Wayne’s case, the core priorities are advanced care planning, assessment of palliative care needs, provision of palliative care, working together, and response to deterioration.

Advance Care Planning

The role of nurses in advanced care planning is to support the promotion of care, consistent with Wayne’s goals, preferences, values, and beliefs to prepare the patient and his family to plan for health care in the future (Palliative Care Network, 2019). The advance care planning will help ensure Wayne’s family and doctors identify his personal and health preferences.

Assessment of Palliative Care Needs

The palliative care will assume a person-centred approach to ensure all needs are fulfilled, considering Wayne’s life experiences like age, culture, ethnic group, religion, and other personal experiences. The palliative nurse should conduct a periodic re-assessment, and key transition points in his trajectory like substantial functional decline, medical decline, sudden acute event, discussions around goals of care are necessary mostly around futile treatment, and hospitalization (CareSearch, 2020). In 2016, the National Clinical Programme for Palliative Care devised the Needs Assessment Guidance for Palliative Care as a framework, which considers needs in four main domains: physical, social and occupational, psychosocial, and spiritual wellbeing. The  nurse should use vast clinical tools used to assess the palliative care needs include the symptom assessment scale, abbey pain scale, pain numeric rating scale, dyspnoea visual analogue scale Kessler psychological distress scale, mini-nutritional assessment short-form, short confusion assessment method, and needs assessment tool for carers tools.

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Provision of Palliative Care

Palliative care will be integrated into Wayne’s overall care and the care received by his family. The core principles include ensuring that both physical and psychological needs have been evaluated and recognized. Also, the patient, his carer, and family are involved in planning and decision-making for end-of-life care and the receipt of equal and well-timed accessibility to suitable end of life care. Wayne’s end of life care needs due to cognitive impairment should be fully understood and fulfilled in residential aged care as a holistic and integrated approach delivered by suitably trained and experienced staff. His carers and family ought to be treated with respect and supported in the event of bereavement. Following the assessment of Wayne’s palliative care needs, his history of symptoms and preceding treatments and their effects should be reviewed.

The effect of the problems on Wayne’s and daily functions should be determined along with his treatment options (National Clinical Programme Palliative Care, 2016). The proposed symptomatic treatments are memantine and cholinesterase inhibitors to improve Wayne’s cognitive function (Konstantina & Sokratis, 2020). Also, antidepressants and anxiolytic drugs can aid in minimization of frustration, disturbing and agitated behavior. The subsequent actions are agreeing and implementing a care plan with Wayne, his family, and the multidisciplinary care team. In the event, severe problems are have been anticipated and identified, the nurse should refer him to specialist palliative care services (Walshe et al., 2018). Consequently, the care plan is updated to replicate his palliative care needs.

Question 2: Margaret’s (Carer’s) Support

Margaret has expressed her concerns and strain due to the husband’s deteriorating health condition. Caring for somebody with a serious illness at home is life-changing in different ways, as it can be both rewarding and overwhelming. Thus, the main priority is making time for oneself due to the intensity of the situation could be extremely hard to handle (Breitbart & Alici, 2014). Margaret is experiencing difficulty sleeping, and she is feeling anxious. The practical ways that Margaret can be supported is encouraging her friends to visit often to allow her to rest, offer moral support, and enhance her social connections (PalliAGED, 2020). In addition, she could be provided services such as respite care to provide temporary relief by allowing her to take a break from the caregiving demands of the sick spouse. Margaret could join a local support group for carers and attend regular training programs for the carer.

Margaret should focus on self-care to maintain balance in her life by recharging and reconnecting. A physical self-care plan can be written to include activities that will help her relax, stay physically fit, and maintain her health (PalliAGED, 2020). The plan will also include regular sleep routine healthy diet, lunch breaks, and walking exercise after work regularly. It will consist of psychological self-care activities that can help Margaret feel clear-headed, cope with the stress, and engage with personal challenges. The activities include a reflective journal, regular meetings with Wayne’s palliative care teams, and spending time with family (Ingleton & Larkin, 2015). The plan will incorporate emotional self-care to allow Margaret to express her emotions safely by developing supportive friendships and sharing how she is coping with life demands (Therapeutic Guidelines Limited, 2016). Lastly, the self-care plan will include a spiritual self-care to establish a great sense of perspective in everyday life. The activities include religion, reflective practices, meditation, connecting with nature, and yoga.

Question 3: Family Resources

Various resources can be provided to Wayne and his close family to support them in coping with their situation. For instance, the Salvation Army Aged Care provides a wide range of personalised services that can support Wayne and Margaret live independently at home and continue being a part of the community. The fourth quality standard ensures that consumers get safe and effective services and support for daily living to meet their preferences, needs, and goals while optimizing their health, independence, wellbeing, and quality of life (Aged Care Quality and Safety Commission, 2019). Information can be provided to enhance his family’s preparedness for likely changes. Wayne is seriously ill; thus, changes can happen in all facets of his life, such as pain, fatigue, loss of appetite, mobility, and independence. Also, the family could be advised to talk to a psychologist about emotional adjustments to understand their feelings and manage emotional problems (CareSearch, 2020). Majority of the palliative care services are free. However, there are some costs related to hospital care, equipment, and medication. Financial resources could be provided to allow the family to pay medications and essential equipment. Finally, a case conference could be held to discuss the benefits of palliative care, and Wayne’s care needs with family members. The palliative care team will guide the family in trying and taking on new care activities to enhance the couple’s quality of life.

References

Azad, N., & Lemay, G. (2014). Management of chronic heart failure in the older population. Journal of geriatric cardiology: JGC, 11, (4), 329–337. https://doi.org/10.11909/j.issn.1671-5411.2014.04.008

Australian Institute of Health and Welfare (2020, June 25). Palliative care services in Australia. AIHW media release. https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/summary

Australian Government Department of Health. (2019, 17 July). Health topics: Palliative care. Commonwealth of Australia, Department of Health. https://www.health.gov.au/health-topics/palliative-care/about-palliative-care/what-is-palliative-care

Breitbart, W., & Alici, Y. (2014). Psychosocial palliative care. University Press.

CareSearch (June 2020). Palliative Care Support for Patients, Carers, and Families. Australian Government Department of Health. https://www.caresearch.com.au/caresearch/Portals/0/Documents/ABOUT-CARESEARCH/Project-Resources/Materials-to-order/CareSearch-Understanding-Palliative-Care-Booklet.pdf

CareSearch (2020). palliAGED Practice Tips for Nurses in Aged Care. Australian Government Department of Health. https://www.palliaged.com.au/Portals/5/Documents/Practice-Tip_Sheets/Practice-Tips-for-Nurses-in-Aged-Care-SET.pdf

Centre for Palliative Care, University of Melbourne., & St Vincent’s Hospital. (2011). No greater gift: Carers reflect on their palliative experience. Centre for Palliative Care.

Commonwealth of Australia (2019, 26 July). A National Framework for Advance Care Directives. Australian Government Department of Health and Ageing. https://www.health.gov.au/health-topics/palliative-care/planning-your-palliative-care/advance-care-planning

ELDAC (2017, November). End of life directions for aged care project. Australian Government Department of Health. https://www.eldac.com.au/tabid/5020/Default.aspx

Engberink, A. O., Mailly, M., Marco, V., Bourrie, D., Benezech, J. P., Chevallier, J., Vanderhoeven, S., Crosnier, R., Bourrel, G., & Lognos, B. (2020). A phenomenological study of nurses experience about their palliative approach and their use of mobile palliative care teams in medical and surgical care units in France. BMC palliative care, 19(1), 34. https://doi.org/10.1186/s12904-020-0536-0

Ingleton, C., & Larkin, P. (2015). Palliative care nursing at a glance. Wiley-Blackwell.

Konstantina G.Y., & Sokratis G. P. (January 01, 2020). Current and Future Treatments in Alzheimer Disease: An Update. Journal of Central Nervous System Disease. 12 https://doi.org/10.1177/1179573520907397

Mitchell, G. K. (2011). Palliative care in Australia. The Ochsner Journal, 11(4), 334–337. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241066/

MacLeod, R., & Van, D. B. L. (2019). Textbook of palliative care. Springer.

National Clinical Programme for Palliative Care (2016). HSE clinical strategy, the palliative care needs assessment guidance. www.hse.ie/palliativecareprogramme.

PalliAGED (2018, September 21). Palliative care aged care evidence: Recognising Changes. Australian Government Department of Health. https://www.palliaged.com.au/tabid/4355/Default.aspx

PalliAGED Practice Resources (2020, April 2029). Palliative care aged care evidence: Caring for Carers. Australian Government Department of Health. https://www.palliaged.com.au/tabid/5878/Default.aspx

Palliative Care Network (2019). Advance care planning: A patient’s guide. Perth, Western Australia: Government of Western Australia, Department of Health, WA Cancer and Palliative Care Network. https://www.health.gov.au/health-topics/palliative-care/planning-your-palliative-care/advance-care-planning

Palliative Care Australia (2018). The National Palliative Care Standards, PCA.

Pike, L., Price, L., Boyd, K. (2017). P-56 Spict-4all – a tool to help everyone identify people who may need palliative and supportive care. BMJ Supportive & Palliative Care, 7, A30. https://spcare.bmj.com/content/bmjspcare/7/Suppl_2/A30.1.full.pdf

Roth, A. R., In Roth, A. R., In Selwyn, P. A., & In Eti, S. (2019). Palliative care: Elsevier.

Therapeutic Guidelines Limited. (2016). Therapeutic guidelines: Palliative care, version 4. Therapeutic Guidelines Limited.

Ulep, M. G., Saraon, S. K., & McLea, S. (January 01, 2018). Alzheimer Disease. Journal for Nurse Practitioners, 14, (3), 129-135, https://doi.org/10.1016/j.nurpra.2017.10.014

Walshe, C., Preston, N., & Johnston, B. (2018). Palliative care nursing. Open University Press.

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