Clinical Gerontology - Critical Reflection of Frans - Case Study Example

Nursing: a critical reflection of Fran’s case study Student’s Name: Instructor’s Name: Course Code and Name: University: Nursing: a critical reflection of Fran’s case study Introduction As a clinician, I am in a better position to know certain aspects of caring for chronically ill patients. This is especially common if the patient’s mental state is bound to deteriorate. Fran’s case presents a situation where the patient’s needs certain decisions made about her care because she is terminal. Kim and Mick are aware of the struggles and the processes that Fran has gone through since she became ill. As such, they are aware of the wishes their mother had expressed in her advance care plan (ACP) and, they accepted this decision readily. However, Karen is estranged from her mother; therefore, she is unaware of the processes that Fran, Kim, Mick and the clinician went through to arrive at the decisions of the ACP (Curtis et al, 2004, 201). According to the VA/DoD clinical practice guideline (2009, 1), the choices that clinicians make to exclude or to perform certain services of procedures on a patient need to be derived from a schematic perspective. This means that consideration of the methods should be from a holistic point of view. The holistic approach will include certain aspects of the patient’s care including the efficacy of the practices, population benefit and satisfaction of the patient. Criteria that relates to the aspects above should be reviewed before an appropriate decision is made. Fran’s wishes as to the type of care that she expected if her condition got worse were for her comfort and satisfaction. Other people who may be affected by the decision included her children. They represent the population benefit. Kim and Mick were comfortable with following the decision that would make their mother happy; thus, they would benefit from their mother’s happiness. However, Karen is unhappy with the turn of events because of her absentia from her mother’s life. As such, she thinks that the use active treatment will make her mother happy. Body Managing patients who are showing symptoms of continuous deterioration should primarily emphasize on avoiding further mental and physical harm to the patient as well as enhancing recovery. This type of goal enhances the quality of life of the patient and, increases their chances of recovery. When Fran was taken to St. Jude’s residential home for care. Her condition was so bad that she looked as if she had less than twelve months to live. However, she received excellent care in the residential home and, she ended up living for three and a half more years. The care she received focused on promotion of recovery and, her life expectancy at the time was increased significantly. In addition, the supervision she received at the residential institution as well as the presence of people around her contributed to a healthy social environment that improves quality of death for patients with terminal illnesses (Curtis 2008, p. 799). Fran does not do well when she is alone. Before, when Fran was taken to the ward for admission, her condition had gotten worse because her children, Kim and Mick, had been away for a week and, they came back and found their mother lying on the floor alone. The presence of people around her helped her with the process of recovery and improved her quality of life. Adopting the ACP Fran had discussed earlier is a good goal because it acknowledges Fran’s preferences. This is an example of a person-centered approach to care that includes the recognition of the needs, preferences and wishes of the patient. Fran was aware that a time would come when she would be unable to make decisions regarding her health because of her deteriorating mental health. Consequently, the ACP development was her way of maintaining some control over her life even when her mind would not permit her to do so (Dean 2008, p. 48). Patients with chronic conditions need some allowance to live as independently as possible. Independence does not mean that they should be left alone. Rather, it refers to the personal choices that they enjoy as well as the nature of their daily environment. Providing care to chronically ill patients also requires flexible access to medical care, timely treatment and interventions and, care that is closer to home (Weiss & Lee 2010, p. 1). Fran received most of this care during her time of illness. However, the treatments she received were not timely. The healthcare facility would wait for her to report conditions instead of checking her for any anomalies. When Fran was admitted to the hospital, her condition was worse because her hygiene had not been attended to for some time. In addition, she had been experiencing symptoms of CHF for a while without reporting them. Fran should not be left without supervision and, not just family supervision but that of a trained healthcare provider. Even when Fran was taken to St. Jude’s for admission, her condition had become worse. With regular visits from a healthcare professional, this fast deterioration could have been avoided (Goodridge 2006, p. 390). It is not enough that she lives close to her children, her family should be also be trained on how to notice when her condition is worsening to allow early intervention. Karen’s issues with her mother’s current path of treatment are expected but they are complicated. Fran did not discuss issues to do with ensuring financial and medical power of attorney with her children. Only Kim and Mick are aware of the ACP. This is a challenge since her lack of communication will make it harder to convince the whole family to implement her wishes. Care guidelines recommend that the patients as well as their families are respected and taken seriously. The family and the patients as well as other relevant individuals who have provided significant support to the patient throughout their illness often determine plans for care. The family does not only constitute blood relatives (Celli & MacNeen 2004, p. 932). The nature of the relationship is more relevant and, the amount of information that the support group has about the patient’s condition. On one hand, Karen is family and, her input should be allowed. On the other hand, she has been estranged from her mother for over a decade and, is unaware of the medical progress and procedures that her mother has gone through over the years. Knowledge of these things could have helped her to understand her mother’s ACP decisions. Care begins as soon as the patient is diagnosed with a chronic condition. Chronic diseases affect the patient as well as their family because the family watches their patient through their suffering at the time they die. Consequently, care should be provided to the patient’s family as well. Her family should be involved in the treatments process and, be aware of what is going on with their mother’s health. Lack of this leads to ethical challenges that bring up issues in decision-making. These complications are often more severe in the last days of the patient when debates arise between offering end of life care and reviving active treatment through invasive procedures. Comprehensive care involves offering the patient a multifaceted assessment that covers emotional, psychological, spiritual, social and physical relief from suffering (Man 2006, p. 10). It is the care provider’s duty to help patients and their families understand the changes taking place because of the disease and, the implications that the changes have on future care plans. Kim and Mick were aware that their mother would go through some cognitive impairment, thus, they understood their mother’s reason for the ACP and, they were ready to comply with the decision their mother made. Convincing Karen will be harder because she has not been around, thus, did not receive family care that would have prepared her to deal with the current turn of events. Karen would have a better idea of the differences between palliative care and restorative-curative care (Janssen et al 2010, p.1). Knowing these differences will also help her make the right choice for her mother in terms of care that she requires at the time. There is a need to decide on whether to pursue restorative care measures or to ensure that Fran\s quality of life and quality of dying are improved (Janssen et al 2010, p.1). Certain measures and treatments that can be taken improve a patient’s life and prolong it significantly. However, these measures can also be unnecessary steps that take up valuable time that may have been of use in making improvements to the patient’s quality of life. The invasive procedures that Karen is advocating for and active treatment are so that Fran can be fixed. However, Fran has been in residential care for three and a half years and, if there was something that could be done to improve her condition or ‘fix her,’ it would have been done. This shows that pursuing Karen’s suggestions would be unnecessary. As a clinician, it is important to take the perspective of all the people involved in Fran’s life and, take into consideration how the different decisions will affect them all while keeping in mind that that the patient should receive the best care available. Issues that are relevant to Fran include the fact that her condition is deteriorating and she may die soon. Other than that, her PAS scores have indicated that she has mild cognitive impairment. Though she is currently unable to make decisions about how her care should proceed, she had drafted an ACP years before and, had spoken to Kim and Mick about the plan. Whether or not the plan is implemented is up to her three children. They have the task of establishing a balance between Fran’s best medical care and quality of life and death. The main issue is to ensure that the patient is not burdened unnecessarily and that his quality of life is improved (Yohannes 2007, p. 5). In order to help with Fran’s emotional state, the discussions between Karen and her siblings should be facilitated calmly so that their mother is not agitated. Karen needs assistance to accept her mother’s situation so that she can refrain from putting pressure on the medical personnel and her siblings to accept active treatment. The fact that Fran is in a residential facility means that she is getting adequate end-life-care that will improve the quality of her life (Weiss & Lee 2010, p. 1). Fran’s prognosis is guarded since there have been previous predictions that she may not last long. For instance, when she first went to St. Jude’s, it was not expected that she would last for more than twelve months. However, following the care that she received, he condition improved (Weiss & Lee 2010, 1). She always seems to get better when given adequate and quality care. This presents and ethical dilemma that most clinicians have to deal with when providing care for patients with advanced COPD and other terminal illnesses. COPD manifests in serious and almost dire ways including pneumonia attacks and cognition issues. Giving Fran certain types of care may exclude her from some of important and conscious times that she would get to spend with her family and friends. The invasive treatments Karen is advocating for may not work as needed since her condition is too advanced. Intubation and mechanical ventilation are examples of these treatments. Putting their mother on this support will lower the quality of life she has in her last days. In addition, it will be harder to wean her from the use of these machines (Dewan et al 2000, p. 662). Her family has to weigh between beneficial measures and burdening ones from their mother’s perspective. Especially Karen since Kim and Mick has stated that they will comply with what their mother would want. Communication is an important element in the decision-making process of end of life care (Truog et al 2008, p. 953). Karen needs to talk to her mother and family so that she understands what is going on. Fran seems to thrive in an environment with communication options as well as society. Prolonged periods of being alone have always resulted in her condition worsening. Though Kim and Mick visit her often, they each have their families meaning that there are times when she is alone for prolonged periods. However, an environment, like the residential institution, provides her with an opportunity to thrive (Truog et al 2008, p. 953). Fran’s best chance of living a quality life as well as ensuring her quality of death is maintained is to implement her ACP and help Karen to understand the situation because all family members are important to a patient’s well being. The family’s cohesiveness should be restored for Fran’s sake. Another important element of end of life care is resolving conflict (VA/DoD, 2009, p. 1). The conflict could be within the family or between the family and medical practitioners. The commonality between these conflicts is that they are often about the care the patient should receive. However, sometimes communication may fail if the family is pushing for the use of certain procedures or interventions that the clinicians do not view as necessary or advisable. Simply telling them that the intervention should not be pursued will not work. The conflicting parties need to state their points and positions clearly including giving reason for pursuing the intervention or not pursuing it (Truog et al 2008, p. 953). If everyone gives a reason as to why they are pursuing a certain goal of care, the discussions will be more effective as they will help each party to see the other’s point of view. For instance, Karen’s goal is to fix her mother. Since Fran is terminal, this is not possible. My role as a clinician is to give the family all the information about Fran’s prognosis including what they can achieve by pursuing their intervention as well as implementing Fran’s ACP. The major challenges that I face in this situation are helping Karen to accept the situation and, to understand her mother’s point of view from the ACP. As highlighted above, enhancing communication is the key to helping Karen sort through the problems. Conclusion Caring for chronic and terminal patients is an area that requires comprehensive expertise as it affects both the lives of the patient and their family. This demands that he clinician have high levels of competence and knowledge on medical matters and, social issues such as dealing with families and enhancing communication between them. The main issues in Fran’s situation are that she presently not mentally competent. In addition, she is terminal meaning that decisions about end of life care need to be made. Other than that, her daughter Karen is having a hard time accepting this and is advocating for invasive procedures and active treatment. Additionally, all the decisions that are made should be towards ensuring that Fran’s quality of life is improved. Communication is the main goal that will help in dealing with these issues. The communication will help Karen understand the situation and resolve the conflict of treatment. Communication will help achieve goals of helping Karen understand, enhancing the family’s cohesiveness and to help maintain family normalcy around Fran to give her a healthy social environment (VA/DoD, 2009, p. 2). List of References Curtis, J.R, Engelberg, R.A, Nielsen, E.L, Au D.H, Patrick, D.L 2004, Patient-physician Communication About End-of-life Care for Patients with Severe COPD. European Respiratory Journal, vol. 24, no. 2, pp. 200-205. Curtis, J.R 2008, Palliative and End-of-life Care for Patients with Severe COPD, European Respiratory Journal, vol. 32, pp. 796-803. Dean, M.M 2008, End life Care for COPD Patients, Primary Care Respiratory Journal, vol. 17, no. 1, pp. 46-50, viewed 28 Aug 2011. http://www.thepcrj.org/journ/vol17/17_1_46_50.pdf. Goodridge, D 2006, People with Chronic Obstructive Pulmonary Disease at the End of Life: a Review of the Literature, International Journal of Palliaivet Nursing, vol. 12, no. 8, pp. 390-396. Janssen et al 2010, En d-of-life care in a COPD patient awaiting lungtransplantation: a case report, BMC Palliative Care, vol. 9, no. 6, viewed 28 Aug 2011, http://www.biomedcentral.com/content/pdf/1472-684X-9-6.pdf. Man, L.W 2006, Palliative Care in Advanced COPD Patients (Part 1), HKSPM Newsletter, no. 1, p. 10, viewed 28 Aug 2011. http://www.fmshk.org/database/articles/palliativecareinadvancedcopdpatients4.pdf. 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