Question

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.

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.

Answer 1

Role of the advanced practice nurse in facilitation of end of life care

1.make time -these conversations should not be rushed.

2.make space -choose a private, quite place where everyone can be seated.

3.find out what the patient knows,

4.listen carefully to the patient 's response,

5.discover the patient 's goals

Clinical decision making for providing end- of- life care is first based on the physiologic realities of the patient's condition,which also help to frame the options for decision making. Firstly the patient must know what is possible and what can no longer be accomplished. Health care providers must acknowledge, and then provide, this information in clear terms to the patient and family. Secondly, the information should be shared when the health care team recognizes that the condition is terminal or the death is near. Next, once physiologic parameters have been used to frame options, then patient preferences can be elicited based on clinical realities. Decision making should focus on patient preferences.Finally, use of advance directives -which come into play when the patient is unable to, or chooses not to, speak for her -or himself;this also include identification of a surrogate, someone who will represent the patient 's preferences in decision making.

The approach to a family who wants 'everything' done

One of the greatest challenges of end-of-life care is not offering care that cannot benefit the patient .Nurses must have the knowledge and communication skills to explain patients ,and more often to families, why certain measures,for example, organ transplantation,chemotherapy,CPR or an IV cannot help this patient and therefore should not be provided.

Appropriate time to introduce hospice care

Hospice care is appropriate any time after a doctor has estimated that a patient has six months or less left to live and both doctor and patient have decided to move from active curative treatment to a regimen more focused on quality of life.

Potential outcomes for this patient -elective laparoscopic or open cholecystectomy can be safely performed in healthy elderly patients, as demonstrated by low complication rates.

In case of ending up with terminal condition during or after the surgery, this should be discussed with patients family by methods stated above.