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.

 

Diagnosis and Management of Hematologic and Metabolic Disorders

 

 

Case Study 2:

 

 Jimmy is a 3-year-old “picky” eater according to his mother. He refuses to eat anything but waffles for breakfast and macaroni and cheese or chicken nuggets for lunch and dinner. He will eat apples and bananas but refuses all vegetables except corn. After a normal physical examination, you obtained blood testing that revealed the hemoglobin is 11.4 mg/dl and his hematocrit is 30% (both obtained by venipuncture). The CBC revealed microcytic hypochromic RBCs.

 

To prepare:

 

•Review “Endocrine and Metabolic Disorders” and “Hematologic Disorders” in the Burns et al. text.

 

•Review and select one of the three provided case studies. Analyze the patient information.

 

•Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.

 

•Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.

 

•Consider strategies for educating patients and families on the treatment and management of the hematologic or metabolic disorder.

 

 

 

POST   1 TO 2 PAGES DISCUSSION PAPER ON :  1.An explanation of the differential diagnosis for the patient in the case study you selected.

 

2. Explain which is the most likely diagnosis for the patient and why.

 

3. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis.

 

4. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments.

 

5. Finally, explain strategies for educating patients and families on the treatment and management of the hematologic or metabolic disorder.

 

 

 

 

 

References

 

•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.

 

◦Chapter 25, “Endocrine and Metabolic Disorders” (pp. 529–556)

 

◦Chapter 26, “Hematologic Disorders” (pp. 557–584)

 

•Hyperbilirubinemia: current guidelines and emerging therapies by Schwartz,H.P., Haberman, B.E., & Ruddy, R.M. in  Pediatric Emergency Care, 27(9), 884-889.

 

 

 

Select one of the below-listed topics to use for your final project. Submit topic choice and a minimum of three references related to your topic to your instructor for approval. References should be five years or less since publication and be listed in the current APA Style. No Blog sites, WIKI, or another school of nursing references, please.

1. Nurse managers must work with staff to foster respect of different lifestyles. As a future manager, how can you provide culture-centered leadership to influence your team members and care for a culturally diverse patient population? Please incorporate concepts of cultural humility, sensitivity, or competence and one cultural theory into your response.  
2. Use Kouzes and Posner model to show how the nurse manager on a 30-bed rehabilitation unit would decide the best approach to finding out the cause of increasing urinary tract infections (UTIs) on her unit over the past 6 months. 
3. Quadruple Aim of Healthcare
   1. What are the guidelines for the quadruple aim?
   2. What is the importance of achieving the quadruple aim?
   3. What outcomes may be seen from promoting the leader-follower relationship?
4. The Chief Nursing Officer (CNO) of an acute care hospital is interested in becoming a Magnet-designated hospital. The CNO would like to create a strategic plan for nursing excellence. If you were the CNO, what would the mission statement for nursing say? What would the vision statement for nursing say? What would be the core values of the nursing department? Create an Incivility Statement/Policy. 
5. You are assigned some risk management activities in the nursing facility where you work. In investigating incident reports filed by staff, you discover that this is the third incident this week in which a patient has fallen while attempting to get out of bed and sit in a chair. How would you begin to address this issue? Decide how you would start a more complete investigation of this issue. For example, is it a facility-wide issue or one that is confined to one unit? Does it affect all shifts or only one? What safety issues are you going to discuss with your staff, and how are you going to discuss these issues? Do these falls involve the same staff member? 
6. Analyze differences among research, evidence-based practice, practice-based evidence, comparative effectiveness research, outcomes research, and quality improvement. How do these practices affect nursing and patient outcomes? 
7. Review the educational program TeamSTEPPS. Identify two strategies you can incorporate into your practice. Present your rationale for selecting those and create an action plan to incorporate those strategies into your practice. 

This week’s first assignment is Part 3 – Literature Review and Critical Appraisal.

complete the following items and submit a Word doc to the assignment link. 

1. Provide a title that conveys or describes the assignment.
2. Introduction (carry over from Part 2)
3. Overview of the Problem/Problem Statement (carry over from Part 2)
4. Background and Significance (carry over from Part 2)
5. Literature Review – Provide the key terms used to guide the search for the evidence and provide at least five (5) summaries of research studies to support the evidence.
6. Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and any gaps in knowledge from the research evidence.
7. Conclusion
8. References – Cite a minimum of five scholarly references in APA 6th ed format.

Expectations

• Format: Completed with references in APA 7th ed. format

 Assessment Description

Journaling provides a valuable tool for recording, reflecting on, and reviewing your learning. This approach provides an opportunity for you to “connect the dots” and observe the relationships between and among activities, interactions, and outcomes.

Unlike a personal journal of thoughts and feelings, this leadership journal is a record of your activities, assessments, and learning related to this academic experience.

Journal entries should include a record of the number of hours spent with your nurse leader each week.

Write a journal entry of 750-1,500 words on the subject of power, including the following:

1. Practicum Activities Reflection: Provide observations and thoughts on the activities in your practicum setting during Topics 1 and 2.
2. Application of Leadership: Identify your given “power” at your workplace or in your professional life. What is your greatest contribution in the lives of others?
3. Practicum Project Preparation: What are your ideas for you practicum project? How does this project refine and build skills related to your career goals?
4. Leadership Video Reflection: Reflect on at least two things you learned from the “Servant Leadership – Issue of Power” video.

Use the “Leadership Journal Template” to complete this assignment.

APA format is not required, but solid academic writing is expected. Please use the provided Leadership Journal template.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

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