The case study

Answer

The case study

John McGregor (Mac) is admitted to a hospice for two weeks respite care. Mac is an 86-year-old gentleman with a history of Chronic Obstructive Pulmonary Disease and Alzheimer's.  You are doing rounds and come in to check if everything is alright and if there is anything that you can do. As you walk in, his wife of 66 years, Dorothy, is sitting beside his bed doing a crossword. She asks Mac "What's another word for vile?" to which Mac responds "You!". You glance at Dorothy. She is visibly shaken. Mac looks up at you and tells you to "fuck off and don't come back". You respond with "Okay, I’ll give you your space. Call out if you need anything" and walk towards the door. Dorothy meets you at the doorway and walks out with you. A few feet down the corridor Dorothy says "I am so sorry. Until my husband got sick with this Alzheimer's he would never speak like that and he would never, never use a profanity in front of a woman". She adds "I wish he could just die; this is not my husband." She pauses for a moment and adds “He’s ready to die. The next time he gets another chest infection he probably will.” You ask Dorothy if she would like to talk. She says “Yes please. I am having difficulty coping with all of this; I’m barely hanging on.”

Part 1: Assessment (1000 words)

• Discuss the legal and ethical issues and decision-making for Mac’s end-of-life care.
• Determine the means of creating a holistic care plan for Mac in collaboration with his wife Dorothy.
• What self-care strategies do you recommend for Dorothy?

Legal and Ethical Issues and Decision-Making

End-of-life care decision making is important as it has increased the chances of prolonging life. Therefore, deciding whether to hang on with the support of medical technologies and live longer or forego the treatment option and let the natural process of death continue requires proper guidance both for the patient and caregivers (Karnik & Kanekar, 2016). Due to these possibilities, end-of-life care is faced with various ethical dilemmas depending on the patient’s condition. Mac has diminished mental and physical capacity as side effects of  Chronic Obstructive Pulmonary Disease and Alzheimer's. This which means that the caregivers must act to ensure his overall well being is promoted. Overall well being includes weighing the benefits and burdens of actions proposed and taking into account the patient’s preferences and current and past wishes. The values and beliefs such as values of family members, patients, and staff should be identified and considered (Sade, 2018).

Decision-making legislation for individuals with diminished capacity should focus on acting in the best interest of the patient (Kollas & Kollas, 2017). This should be informed by their preferences and values if they are known n. For instance, in Mac’s case, the healthcare professional should take advantage of the fluctuations in cognitive impairments and obtain his consent on the preferred decisions during lucid periods. They should then assess the overall clinical benefit the treatment decision would provide and consider the option with the lowest restriction for the patient, including the option to avoid treatment (Fleischman, 2016). The patient should be encouraged and supported to be involved in the care and treatment decision making as long as he is able and wants. The healthcare provider should also seek information on previously expressed treatment preference for the patient such as the previous beliefs, wishes, and advance decisions or treatments. The views of people close to the patient should also be considered especially those with an ongoing personal relationship such as his wife (Dunn, Alici, & Roberts, 2015). Since Mac is unable to participate in the decision making the consenting process, ad advocate should be involved to support complex decisions (Schmidhuber et al., 2017). Healthcare decisions for a person without capacity should be made by the lead clinician in consultation with other healthcare professionals, family members, and carers in order to ensure the treatment values and preferences of the patient are well incorporated.

Means of Creating a Holistic Care Plan

According to Jasemi et al. (2015), nursing care plans are fundamental to achieve quality patient care as they define of the role of nurses and other caregivers in the patient’s treatment and offer care consistency. One of the main reasons people are put in hospices is Alzheimer's aggression. The condition which is fairly common involves making strange noises, biting, screaming, scratching, throwing things, pushing, kicking, grabbing, hitting, and cursing (Lee et al., 2017). From the case study, it is clear that Mac has vetted cursing and screaming upon his wife and nursing caregiver respectively. The implication is that the 86 years old had developed Alzheimer's related hostile behavior. Therefore, a suitable care plan should aim at dealing with Alzheimer's aggressive behavior (Sourdet & Maria E. Soto, 2015).

One of the means of developing an appropriate care plan is using a person-centered approach (Molony et al., 2018). This begins with an assessment of the patient to understand what triggered the behavior. One of the major triggers is recognition where the patient forgets what or who something or someone is. For instance, Mac may not recall Dorothy his wife or confuses her with someone else. Similarly, he may not be aware of the role of the nursing caregiver allocated to him at the hospice. Anti-anxiety medications, side-effects of other conditions such as the Chronic Obstructive Pulmonary Disease and inability to communicate also trigger agitation hence a reason for aggressive behavior.

Once the underlying cause is identified, management and treatment are designed to deal with the behavior (Sourdet & Maria E. Soto, 2015). Although there are medications that help ease aggressive behavior in dementia patients, they may have adverse side effects on Mac due to his age. In adverse cases, the medication may speed his death. Therefore, if medication is to be used, then Dorothy, his wife, should be informed of their potential risks and caution should be applied while administering (Lee et al., 2017). Non-medical interventions can also be used such as validation of their feelings, use of gentle and reassuring touches, and tones, following a regular routine, ignoring angry behavior, music, constant evaluation and use of humor (Sourdet & Maria E. Soto, 2015).

Self-Care Strategies

Caring for Mac can be emotionally and physically draining for Dorothy. Therefore, she should be encouraged to engage in strategies that can equip her with information and Support (Snyder et al., 2014). For instance, she can get a support group where she can vent and seek opinions from people that understand her situation. Support can be obtained from people known to her or through organizations such as the Family Caregiver Alliance or Alzheimer’s Association. She can also take a break and engage in other activities like having dinner with family or friends or visiting a park. This way, she can replenish her energy and be more rational with Mac. Behavioral management and good communication skills are also essential for family caregiver (Sullivan & Miller, 2015). Dorothy can practice communicating in short, clear sentences using a tone that does not upset. Alternatively, she can employ non-verbal communication that reduces anxiety and evokes calmness of spirit on the patient. Relaxation and taking care of her health are also fundamental. Another strategy is to change guilt into regret and practice self-forgiveness. Regret, in this case, means that as much as she cannot help the situation Mac is in, she is not wrong to feel that it is hard and often she has to make tough decisions. Besides, she should not label herself harshly when she feels exhausted, overwhelmed, frustrated, guilty, or angry (Snyder et al., 2014).

Part 2: Plan and implementation (1000 words)

Use Gibbs reflective cycle as a framework to reflect on an experience you have had with death or dying and how this has shaped your nursing care.

Gibbs Reflective Cycle on Personal Experience

Human life has an inevitable end at death. However, the situation is rarely addressed in society. Basically, individuals should strive to perceive death as a natural process which forms part of daily living. For healthcare workers, death and its phenomenon are interpreted on the basis of personal understanding. Besides, the fear of death and attitudes towards its occurrence shapes the quality of end-of-life care the patient receives. The Gibbs cycle, therefore, gives room for personal reflection to inform future thanatology and palliative care a healthcare worker will provide to dying patients (Jacobs, 2016). The cycle comprises of a series of various critical reasoning steps namely description, feelings, evaluation, analysis, conclusion and the action plan (Price, 2017).

Description: This is a statement of occurrence on which the reflection is based (Jacobs, 2016). This reflection is based on the experience I had when I lost a brain cancer patient following surgery.

Feelings: According to Koshy, Limb, Gundogan, Whitehurst, & Jafree (2017), when a situation happens, it evokes either positive or negative emotions. Losing a patient is not exceptional and as a caregiver, it is prudent to analyze the emotions I go through both intellectually and from a humanity perspective. Intellectually, I felt that undergoing brain surgery, especially after diagnosis with stage 4 glioblastoma was a game of chances and previously diagnosed but managed Type II Diabetes. I thought that the condition was not redeemable and the 20% chance of survival was not really on the surgeon’s expertise but highly on luck (Selingerová, Doleželová, Horová, Katina, & Zelinka, 2016). Emotionally, I was shocked, angry, and disillusioned as I watched the patient deteriorate to her last breath. I had seen many patients die in the cancer ward but the manner in which this particular one was different. She had hope and a fighting spirit which made me feel that she deserved another chance to face life.

Evaluation: According to Jacobs (2016), every experience has both good and bad sides. Therefore, it is important to evaluate what was carried out badly and what was executed properly. Although the patient expressed her hope on the success of the surgery and her will to live longer, she had lived life to the fullest and did not have any fear of death. Before the surgery, the patient has started episodes of vomiting whenever she ate anything. This means that she could not get sufficient nutritional nourishment. With two occurrences of end-of-life prolonged sleep and lack of consciousness, her last two weeks were peaceful. She did not suffer any physical or psychological pain owing to the fact that she had suffered dementia and lived at the moment. Besides, a family member was always at her bedside the entire period which translated to happy moments whenever she regained consciousness. However, owing to the stage of cancer she was diagnosed with, I still feel alternative treatment plans should have been explored such as chemotherapy and radiography with consent from family members. Nobody was ready for her death including the patient herself who had shown the symptoms for only a month.

Analysis: This aims at deriving sense out of the occurrence or rather trying to understand the pre-disposing factors that led to the experienced end result (Koshy, Limb, Gundogan, Whitehurst, & Jafree, 2017). Any brain cancer patient is a vulnerable case and restoring them to their original state is not guaranteed. Besides, undertaking surgery for glioblastoma patients is always a risk considering how the particular cancer type spreads drastically. Besides, surgery for diabetic patients is often an issue due to the prolonged wound healing process it presents. However, no intervention was done and the patient was left to die naturally from the condition, she would not have lived past 12 months (Selingerová, Doleželová, Horová, Katina, & Zelinka, 2016). Besides, she would encounter severe headaches and partial of full-blown seizures which would deteriorate her quality of life. This implies that she would have died painfully and totally dependent on caregivers for even basic needs and for a long period. Consequently, she would suffer and expose her caregivers to anguish, regrets, guilt, and other feelings of hopelessness. Thus, I doubt that the immune suppression presented by diabetes and the consequent cancer spread would have allowed her to live very long. On reflection, her death was not as unexpected and unprepared as it felt because both caregivers and family were aware it was the last available option taken purely on grounds of hope.

Conclusion: According to Jacobs (2016), the conclusion part of Gibb’s cycle is aimed at exploring alternative interventions that could have been explored to change the outcome. As her caregiver, I did everything towards achieving a positive outcome. I ensured she was well fed and hydrated, her diabetes medication were administered on time, and she was offered appropriate post-operative care. Besides, a multidisciplinary treatment action was applied to her case with professionals working together to achieve success. Finally, the family was well aware of the possible outcomes, whether negative or positive, and had time to spend the last two weeks with their loved one. Therefore, I am not sure anything else could have been done to affect the outcome. Consequently, I was not appealed with the manner at which I was upset and that is what prompted me to reflect on the case.

Action Plan: Jacobs (2016) points out that the action plan is aimed at describing future action and reactions when a similar scenario presents itself. Cancer cases are continually growing as more people suffer the condition. Therefore, I am sure the situation will arise again. Besides, I have witnessed many times where patients die when I do not think they should for various reasons. Therefore, I started talking with a grief counselor who had caused me to understand that grief is natural and watching a patient die is not easy. I have since learned to be kind to myself and when such situations present myself to give myself time to go through the grief process.