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Daphne has hypertension, Type 2 diabetes and recently has been diagnosed with vascular dementia. Her diabetes and hypertension are well managed by her General Practitioner (GP), however he has concerns…
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Case Study- multidisciplinary team; As OCCUPATIONAL THERAPIST Daphne McCartney is a widow who has two adult sons, Timothy and Jonathon. Daphne has hypertension, Type 2 diabetes and recently has been diagnosed with vascular dementia. Her diabetes and hypertension are well managed by her General Practitioner (GP), however he has concerns that because of her increasing physical frailty she should be admitted to residential care. He also has concerns about her living arrangements with her younger son Jonathon although her older son Timothy is her Enduring Guardian and Power of Attorney. Timothy has informed the GP that he believes Daphne is vulnerable to bullying and pressure from Jonathan, particularly in relation to money and this is adding to her frailty. The GP refers Daphne to a geriatrician for a comprehensive geriatric assessment.
Before the assessment is undertaken, Daphne falls heavily in the shower and fractures her hip. Timothy contacts Jonathon, who calls an ambulance and after assessing Daphne the paramedics transfer her to hospital. Following surgery Daphne spends a month mobilising in the rehabilitation ward before being transferred to the sub-acute Transitional Care Unit. Here she is assessed for continuing transient ischaemic attacks (TIAs) and for further signs of cognitive impairment and memory loss. At the multidisciplinary team case conference it is decided that, due to Daphne’s increasing frailty and cognitive decline, her discharge planning will include an ACAT Assessment for high level care in a Residential Aged Care Facility (RACF). As Daphne’s Enduring Guardian and Power of Attorney, Timothy is contacted to participate in a family case conference with the multidisciplinary team, consisting of a geriatrician, resident medical officer (RMO), physiotherapist, occupational therapist, dietician, social worker, and a transitional unit registered nurse responsible for discharge planning.
Q1: In your allocated role as part of the HOSPITAL multidisciplinary team in the case conference, what are the issues you need to consider in order for Daphne to be admitted to residential care? - 150 words
As an occupational therapist, my role is to assess the home environment to make recommendations for residential care. The ability that Daphne has to look after herself needs to be taken into account, as someone who is unable to carry out daily life without significant help may require admission into residential care. As part of the hospital-based team, I would also consider what type of residential care that Daphne might need – some residential care homes offer more independence than others. Although there is continuing memory loss and cognitive impairment, one of the most worrying aspects of Daphne’s health is the TIAs which could lead to more serious health-related problems in the future and would need to be monitored as part of residential care. Any residential care home for Daphne would need to be able to provide care and monitoring for this. Additionally, her hypertension and Type II diabetes would need to be fully assessed for severity to advise the residential home staff of her requirements.
Q2 In your allocated role as an ACAT assessor, on what issues will you focus in relation to Daphne’s dementia and assessment for high-level care? - 150 words
As an ACAT assessor, I think the main issues to focus on with respect to Daphne’s dementia are the actual cognitive ability that she does possess (awareness of surroundings, ability to form judgments etc.) and how this is affecting her ability to interact with other people and her surroundings. Additionally, I think the rate of decline observed by the GP and her sons over the past few years would also be useful because this could help gauge the future for Daphne. The assessment for high-level care will focus on the ability of Daphne to carry out everyday tasks by herself (washing, cleaning, using the toilet etc.) and this can be used as a guide for future occupational therapy as well as provide information for those working in the residential care home with her. It might also be useful to perform standardized mental ability tests to better understand how Daphne interacts with her environment and how much she understands.
Answer questions 3 and 3a based on YOUR allocated role as the GP or Registered Nurse (Residential Care):At the case conference, Daphne’s older son Timothy expresses concern about his level of understanding of Daphne’s plan for care, her wishes for the future, and her capacity to make decisions. It is explained to him that as part of the discharge planning process, a letter will be sent to their GP who will discuss the options for advanced care planning with Timothy.
Q3 In your allocated role as GP what are the main issues to consider when discussing advanced care planning with Timothy?
Q3a In your allocated role as Registered Nurse (Residential Care) what are your responsibilities in relation to advanced care planning. 150 words
As a GP, it is important that Timothy understands the situation his mother will be in and why this is required. It is important that he understands about the discharge process and how this will affect him, his mother and his brother. It is also important that he understands his mother’s capacity to choose her own treatment and residential care options and how to involve her in the decision as much as possible.
As a Registered Nurse, the main responsibilities are for me to make sure that advanced care meets Daphne’s needs. Additionally, it is necessary to make sure that the correct treatments are delivered to her as and when needed, and that the residential care home that is chosen has the ability to provide this for her. I also think that I would involve her living family members in the decisions that are made, as well as attempting to get information about her own requirements/wishes as far as possible.
Always write the answer from the point of view of an Occupational therapist and to be written on first person.
BELOW IS A DISCUSSION FROM ANOTHER PERSON.READ THE DISCUSSION TO ANSWER THE QUESTION BELOW RELATED TO THE CASE SCENARIO.
Registered nurses are often involved in the process of advanced care planning. As the nurse, I would need to be familiar with the medico-legal legislation surrounding advanced care planning in my state, so that I can best talk with the patient and give them advice. Nurses are the primary patient advocate, and are therefore very important in the process. They often have better rapport with the patients and families than doctors, and are therefore more appropriately placed to discuss the process with the patient. In this case I could talk with Timothy and explain the ACP in detail, answering any questions he has and hopefully alleviating his concerns.
Australian Nursing and Midwifery Foundation. (2013). Advanced care planning: The nurses role. Available: http://www.anmfsa-cpd.org.au/tutorials/tutorial-aged-care-advance-care-planning-the-nurses-role. Last accessed 7th Oct 2013.
Caresearch. (2011). Advance Care Planning (Nurses Hub). Available: http://www.caresearch.com.au/caresearch/tabid/1476/Default.aspx. Last accessed 7th October, 2013
Week 13 question:
"Discussion of issues raised by the case with reference to at least one other group members contributions made in [week 12] of this discussion". WRITE 150 WORDS.
This person raises some good points about understanding the medico-legal requirements of the state when it comes to long-term care. For example, there may be issues involved with consent when it comes to someone like Daphne who has some impairment in memory and cognition but apparently still seems to have some awareness of her surroundings. Additionally, it is important to understand how the diabetes and hypertension will play a role in long-term care, despite the fact that the dementia is the primary reason for her requiring residential care. I also think that some of the family dynamics involved in the case are interesting and should be considered, such as Timothy’s desire to fully understand the ACP and the fact that the younger sibling may be taking advantage of her mental disabilities. It’s important to involve the family in making decisions but ultimately it is up to Daphne and the medical team to provide the best service for her care. Read More
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