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:

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. 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:

• 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.

By Day 3

Post 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 “everything” 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 patient’s family.

Week Four Paper will address and answer the following three sets of questions:

•                                             FOR QUESTION ONE:

Read the  article, “Protecting Yourself from Malpractice Claims” found at

https://americannursetoday.com/protecting-yourself-from-malpractice-claims/ (Links to an external site.)Links to an external site.

Read the article, “Nurses, Negligence, and Malpractice” found at:

http://www.nursingcenter.com/journalarticle?article_id=423284 (Links to an external site.)Links to an external site.

Read the article, “7 Legal Tips for Safe Nursing Practice”    (you will need to copy and paste the link below into your browser)

7 legal tips.pdf  (INCLUDED AS ATTACHMENT)

1. In connection with the readings relating to negligence/malpractice answer the following:

a. What was the most important information you gained from these articles?
b. What are the elements that must be present for there to be a valid claim of negligence?

Comment on this scenario: A comatose patient is admitted with a UTI. The RN documents turning the patient every 2 hours, but actually did not. The UTI resolves and the patient is discharged without any other changes in prehospital condition.

c. Was the RN negligent? Why or why not? 
d. Was the RN’s behavior ethical, why or why not? 
e. Would any of your answers change, and if so how,  if the patient had developed a bedsore during the hospitalization?

                                                        FOR QUESTION TWO:

Read the summary of Supreme Court case that reviewed Oregon Death with Dignity Act found at:

http://en.wikipedia.org/wiki/Gonzales_v._Oregon (Links to an external site.)Links to an external site.

Read the story of Brittany Maynard found at:

http://www.washingtonpost.com/news/morning-mix/wp/2014/11/02/brittany-maynard-as-promised-ends-her-life-at-29/ (Links to an external site.)Links to an external site.

 Read the case of Gonzalez v. Oregon, found at:

http://scholar.google.com/scholar_case?case=17055043890936848595&hl=en&as_sdt=2&as_vis=1&oi=scholarr (Links to an external site.)Links to an external site.

Read “ Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls” found at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070710/ (Links to an external site.)Links to an external site.

Review State-by-State Guide to Physician-Assisted Suicide found at:

http://euthanasia.procon.org/view.resource.php?resourceID=000132 (Links to an external site.)Links to an external site.

1. In connection with the topics of Euthanasia and Assisted Suicide, address the following:

a.       What is the difference between Euthanasia and Assisted Suicide?
b.      Explore your thoughts and feelings on the legality of assisted suicide and euthanasia. Should Florida follow Oregon?
c.       What guidance on this topic is found in the ANA Code of Ethics (Hint: Interpretive Statement to Provision One)?
d.      What is ANA’s position on Euthanasia and Assisted Suicide as expressed in its Position Statement on the topic?

                                                          FOR QUESTION THREE:

Read the article, “How We Die” found at: and answer question three. 

http://tuftsjournal.tufts.edu/2010/03_2/features/03/ (Links to an external site.)Links to an external site.

1. What actions could have been taken to prevent this situation from occurring? Describe how refusing treatment differs from euthanasia or assisted suicide.