Palliative Care - Case Study Example

? A Case Study on Palliative Care A Case Study on Palliative Care This is a case study of a 78 year old male who was brought into the (ER) emergency room by the emergency medical services after being found down and altered. The report describes the clinical picture of the patient and explores relevant literature on the palliative care aspect of the patient. The report then discusses the case in light of current medical practice in the field of palliative care and applies the ACE model in the design and implementation of the palliative care plan of the patient. Introduction Palliative care for the elderly is a critical healthcare service whose objective is to improve the quality of life of the elderly. Although a lot has been done in terms of research initiatives, and education of healthcare providers, the quality of healthcare is yet to reach the desired standards (Jerant, Azari, Nesbitt, & Meyers, 2004). In many instances, design of care provision often overlooks the elderly who in fact have the greatest need for the care due to the complex nature of their needs (Cicely Saunders Foundation, 2011). Despite this, palliative care is progressively being incorporating the elderly in the design of care and has played a major role in alleviating pain and distressing symptoms thereby gaining wide acceptance as a recognized specialty of nursing (Becker, 2009). Palliative care and nursing are also closely intertwined and the knowledge and skills required are applicable across the nursing profession. It is therefore critical that nurses acquire critical skills and knowledge that would enable them to conduct research and apply current evidence based practice guidelines in palliative care delivery. This report will be based on a case study of a 78 year old man brought into the ER after being found down and altered by a friend. Case Report Description The patient was a 78 year old man who denies a history of allergies, and medications. He was brought in by the emergency medical services after he was found down and altered by a close friend. The friend noted that the patient had lost about 30 pounds since they last met (4 weeks). Patient has difficulty in remembering what he ate before the previous day. He denies having any form of pain, and reports that he has been coughing. On physical examination, the heart rate was in the 110’s and improved to 130 and then to 140’s systolic with fluid resuscitation. On further examination; the patient is noted to be cachetic, and malnourished. He was alert, oriented, awake and talking. The mucous membranes were very dry. He had tachycardia with inspiratory rales on the right upper lobe of the lung. The abdomen was non distended and non tender. His laboratory results revealed a white blood cell count 16.1 with a left shift, the sodium concentration was 128, the creatinine level was 2.0, and lactate at 5.1. His chest x ray was clear and the head CT scan of the head revealed moderate hypoattenuation of the white matter. The patient has evidence of having an acute kidney injury and hyponatremia. The patient displays evidence of failure to thrive. The initial diagnosis made included altered mental status, acute kidney injury, failure to thrive, malnourishment, starvation, weight loss, history of alcohol abuse, severe chronic obstructive pulmonary disease, dehydration, and hyponatemia, The condition of the patient was determined to be critical and he was admitted into the medical intensive care unit. While in the MICU, the patient complained of increasing cough, difficulty swallowing and abdominal pain. On auscultation of the lungs, there were scattered rhonchi across the lung fields both posterior and anterior. The patient grimaced on palpation of the abdomen and had a productive cough. The bowel sounds were hyperactive and the abdominal x-ray revealed a large amount of stool within the rectosigmoid colon. There were also several air filled loops in the mid to upper abdomen. The mucosal lining appeared thickened and distorted. The x-ray of the chest revealed multifocal air space disease in the right mid and lower lung. There was blunting of the right costophrenic angle. The patient took a bedside swallow and failed together with speech evaluation. A CT chest revealed mixed density layers dependently within the distal trachea and both main stem bronchus intermedius. The CT of the chest also revealed multifocal consolidative opacities in the dependent distribution. Literature Review It is critical that healthcare providers note that the elderly have more complex medical needs largely due to their age and the changes that come with ageing. Nurses in particular need to understand the effect of ageism on the care of the elderly. It is only with a deep understanding of ageism that nurses would be able to design care programs that are evidence based and tailored to suite the complex nature of the needs of the elderly. Ageism is the discrimination and stereotyping against individuals based on their age. As a result of ageism, healthcare providers have biased attitudes and hold certain myths towards the elderly (Clark, & Baldwin, 2004). Some of the common conditions associated with the elderly include chronic disease like osteoarthritis, dehydration, dementia, depression delirium etc. There are certain principles that guide the care of the elderly. Knowledge of these principles is vital in the delivery of palliative care to the elderly. These principles influence the actions of nurses and actually act as a guide to their actions. The principles hold that all the confusion displayed by an elderly person may not be dementia, a nurse is supposed to consider psychological, physiological and pharmacological aspects of disease before taking any form of action, the objective of offering care is often to gain function rather than cure and that the elderly have interdependent systems that are affected by chronic diseases and illnesses (Clark, & Baldwin, 2004). This calls for holistic care while treating and delivering palliative care. In order for ease of disease identification, a thorough knowledge of the changes that occur due to aging is essential. As people age they experience functional design. In a meta-analysis of 78 studies, older individuals displayed functional decline in 11 particular areas. These areas included cognitive impairment, depression, increased or decreased BMI, a limitation in the lower extremity function, a lower level of physical activity, smoking, poor self perceived health, impairment of vision, and disease burden. Emerging information advocates for the screening of the elderly for cognition. This allows for early detection of memory problems associated with ageing and timely intervention (Clark, & Baldwin, 2004). Our patient would benefit greatly from screening for cognition as he had already started to display symptoms of memory loss (inability to remember food that he ate). The patient had displayed signs of pain when palpated on the abdominal area. The pain was acute and represented a new problem. It is vital that a nurse utilizes the pain scales available to determine the amount of pain. After evaluating the pain it is then important that a plan for pain management and care is implemented according to current palliative are guidelines (Clark, & Baldwin, 2004). The plan for pain management may include pharmacological interventions like use of opioids which are good analgesics and are not addictive. The patient under discussion displayed a host of conditions and diseases based on the diagnosis that was made. This requires interdisciplinary effort and participation by different healthcare professionals in order to deliver the best service possible (Benedict, Robinson, & Holder, 2006). Research is a vital aspect of the palliative care plan and based on the complex nature of this particular case, and the multiple perspectives that need to be recognized, it may be critical that a research strategy that is appropriate for this particular case study be implemented. This will give rise to useful information that can be integrated into the palliative care plan of the team in order to optimize the quality of the care (Caress, Graham, Caress, & Todd, 2004). The complexity of care for adult patients who have been hospitalized is on the increase and a need for the formation of an inter-disciplinary team of healthcare providers. This will call for coordination of care in order to enhance and facilitate positive outcomes. In this particular case, the patient would benefit from examination by a gastroenterologist, a nephrologist, a cardiologist and a host of nurses who offer tender loving care and ensure that they patient is as comfortable as possible. Discussion Notably, at the time of discharge the patient was deemed unable to take care of himself. He could therefore not be released into the community and would instead be in the care of a facility for the elderly. The patient had a final diagnosis of partial obstruction of the bowel, aspiration pneumonia, severe malnutrition, severe dysphagia, serial hypokalemia, leucocytosis, dementia, fungal abdominal abscesses and chronic obstructive pulmonary disease. Dsyphagia is capable of resulting in dehydration, malnutrition, aspiration pneumonia, and death in the worst case scenario. The patient had been diagnosed with malnutrition, aspiration pneumonia, and dehydration. It is possible that these conditions are closely associated with dyspahagia. The patient had also failed the bedside swallow assessment. It is therefore evident that the patient had dyspahgia. In an effort to manage dysphagia in there is need to have the patients diet modified (Mertz, & Chamber, 2010). Dyspahgia occurs in patients who are suffering from acute neurologic damage which may arise from brain damage or stroke. It may also occur in individuals with diseases like Parkinson’s disease and amyotropic lateral sclerosis. Dysphagia is most common in the elderly and as the population of the elderly increases it becomes necessary that palliative care directed towards the elderly is emphasized. Our patient having displayed characteristics of dysphagia and been diagnosed with dysphaigia, the management of the case ought to be multidisciplinary. The management will consist of a series of interventions like the patient tilting his head downwards. This allows the bolus of food to flow away from the airway. The patient is to also double swallow. This clears any bolus that may have remained in the unprotected airway. Dietary medication is also a critical aspect of the management of dysphagia. The implementation of the modification is best achieved by the presence of the nurse, physician, dietician, speech language pathologist, occupational therapist (Mertz, & Chamber, 2010). Closely associated with disphagia is dementia. Current statistics reveal that 60-80% of all the residents under long term care had a dementia diagnosis. This places them at high risk of malnutrition and weight loss. Good palliative care for the case patient would involve good hydration and nutrition. This is a matter of concern to both the healthcare team and the family members. Dementia has been known to affect the nutrition and hydration of an individual (Curfman, 2005). In the early stages, the patient may forget to eat, become depressed and loose interest in food. The patient may be distracted and leave the table without eating. In the second stage, the patient may be unable to sit for long in order to eat. They wander more and in the process spend more energy and therefore their energy needs rise. In the last stage, the patient may not have oral motor skills necessary for chewing and swallowing. This sets stage for wasting away and malnourishment (Curfman, 2005). In order to manage the presented conditions well administering antibiotics to help resolve the pneumonia and other pharmacological interventions may be necessary in order to resolve the abscesses e.g. use of antifungal drugs would eliminate the fungal abdominal abscesses. The need to have a care plan that is multidisciplinary is of great importance. Adoption and use of the Acute Care of the elderly Model promotes and facilitates the interdisciplinary management of the elderly patients (Benedict, Robinson, & Holder, 2006). The main aim of this team of specialists is to alleviate pain, maintain function, and achieve medical stability. The team is composed of physicians, primary nurses, clinical care specialists, pharmacists, dieticians, and a discharge planner. The nurse takes the lead role in designing a plan of care and implementing it. It is possible for the team to work as a unit and deliver quality care that is based on evidence and in accordance with current guidelines of care (Benedict, Robinson, & Holder, 2006). Although the ACE model is particularly suited for patients who will be based in the community it can be tailored to fit the needs of our patient who will be based in a home of the elderly. Fundamental elements of the ACE model include having a prepared environment for the patient, having care that is patient centered, assessing the activities of the daily living of the patient, Intervention of geriatric syndromes e.g. mobility fall risks, nutrition, skin integrity, confusion, anxiety, depression, and continence, team rounds led by the primary nurse and goal oriented planning and implementation (Tringali, Murphy, & Osevala, 2008). The nurse may take a central role be the leader of the team. She/he takes a role in advising and educating other nurses within the team and offering critical advise to the team members with regard to offering the best palliative care to the patient (Mahler, 2010). It is possible to then plan a quality palliative care plan for out patient around these elements of the ACE model. The home can be prepared for the patient and he can receive care that is tailored to his needs (patient centered) with ease from there. The progress of the patient can be monitored by all the specialists of the team and recommendations made. Despite all the effort that may be put into providing quality of care, once the patient is in the home his dementia may worsen. And once in stage three, he will continue wasting away and loosing body condition. This is referred to as failure to thrive among the elderly. It is noted in nursing homes whereby the patient looses cognitive ability and physical function gradually and withdraws from human contact and food. Some of these individuals fade away and die (Braun, Wylke, & Cowling, 1988). At this point it is vital that the nurses take the central role and educate the family of the individual on dignified dying. Dignified dying is associated with themes like going in peace, dying on ones own terms and maintaining the integrity of the body (Volker, &Limerick, 2007). Summary Care of the elderly is an important aspect of nursing care. There is a need to integrate current guidelines of practice with research in order to provide quality patient centered palliative care. The number of the elderly is rapidly growing and the need for elderly care is equally rising. There is need for more in depth research to be conducted in the field of palliative care in order to be able to meet the increasing demand as well as offer better services and improve on the overall outcomes. Conclusion According to the diagnosis made, the patient will be enrolled into a nursing home of the elderly. The implementation of the ACE model would see him improve his current condition. With a good interdisciplinary team the outcomes of the case study could be good. In the worst case scenario advising the family member on dignified death may be of value. References Baker, R. (2009). Palliative care 1: Principles of palliative care nursing and end of life care. Nursing Times, 105(13) Benedict, L., Robinson, K., & Holder, C.(2006). Clinical nurse specialist practice within the acute care for elders interdisciplinary team model. Clinical Nurse Specialist, 20(5), 248- 252. Braun, V.J., & Cowling, R.W. (1988). Failure to thrive in older persons: A concept derived. The Gerontological society of America, 26(8), 809-812. Cecily Saunders Foundation (2011). Palliative care of the elderly. Retrieved from: http://www.cicelysaundersfoundation.org/research/palliative-care-for-the-elderly Clark, A.P., & Baldwin, K. (2004) Gest practices for care of older adults: Highlights and summary from the preconference, Clinical Nurse Specialist 18(6), 288-299. Curfman, S. (2005). Managing dysphagia in residenst with dementia: Skilled intervention for a common and troubling disorder. Retrieved from: http://findarticles.com/p/articles/mi_m3830/is_8_54/ai_n15338409/ Jerant, A.F., Azari, R.s., Nesbitt, T.S. & Meyers, F.J. (2004). The TLC model of palliative care in the elderly: Preliminary application in the assisted living setting. Annals of Familiy Medicine, 2(1), 54-60. Mahler, A.(2010)The clinical nurse specialist role in developing a geropalliative model of care. Clinical Nurse Specialist, 24(1), 19-24. Mertz, G.J., Chambers, E.(2010). Managing dysphagia through diet modifications. American Journal of Nursing, 110(11), 26-33. Tringuli, C.A., Murphy, T.H., Osevala, M.L. (2008). Clinical nurse specialist practice in a care coordination model. Clinical Nurse Specialist, 22(5), 231-239. Volker, D.L., & Limerick, M. (2007). What constitutes a dignified death? The voice of oncology advanced practice nurses. Clinical Nurse Specialist, 21(5), 241-147. Walshe, C.E., Caress, A.L., Graham, C.C., & Todd, C.J.(2004). Case studies: A research strategy appropriate for palliative care? Palliative Medicine, 18, 677-684. Read More