Case Studies 2.3 & 1.1
Jessica Gragert
Lakeview College of Nursing
N309 Nursing of the Gerontological Client
July 15, 2012

Case Study 2.3 
It is important to maintain autonomy for a patient during end-of-life care if the patient is still able to make informed decisions for themselves.  The history states that Alice did possess some problem solving skills that caused her delay seeking medical care for the lump in her breast. However this in itself does not constitute an inability for Alice to make her own decisions. In thoroughly assessing her decision making capacity, Alice’s primary care physician would ask her to answer questions to “determine the ability of the patient to understand about treatment and the proposed options for care, the ability of the patient to appreciate how that information applies to their own situation, the ability of the patient to reason with that information in a manner that is supported by the facts and the patient's own values, and the ability of the patient to communicate and express a choice clearly” ((Tunzi, 2001, p. 301).  
	For those determined not to have the proper capacity for decision making, there are two advanced directives which may still be available to them.  Patients can decide on a person that they wish to allow make medical decisions on their behalf called a “durable power of attorney” (Mauk, 2010, p. 593). A patient can also write up a “living will” which is a document that “directs preferences for end-of-life issues” that “often include what type of care to provide and whether resuscitation measures should be taken” (Mauk, 2010, p. 593).  While it may not be possible to follow these decisions if the patient is determined unable to knowledgably make them, the living will can provide “direction to the decision maker” that is acting on their behalf (Mauk, 2010, p. 593).
	The primary care assistants (PCAs) were able to make Alice’s experience as positive as possible by keeping her physically comfortable. Other ways that they could have further enhanced her dignity at this time would be to allow the patient to reminisce over their life experiences, allowing her to spend as much time as possible with her family, and to ensure that she is able to obtain any spiritual guidance or assistance she may want before her passing (Mauk, 2010).  
	There are other arrangements and decisions that health care providers could have assisted Alice and her family in making in her final hours. Ensuring that Alice had obtained any desired advanced directives would ensure that her death would occur without intrusive attempts at resuscitation. Asking her who she wished to be present during her death, as welll as finding out if there are any religious or spiritual traditions that she would like to follow before, during, or after her passing, would allow for those arrangements to be made if possible. Also, asking if Alice has preferences for things such as music or candles to create an ambience that she feels comfortable with during her passing. And ensuring that desired funeral or burial arrangements are discussed and set up prior would ease the stress of her death as much as possible for her family (http://www.completingalife.msu.edu). 
	A hospice team is typically comprised of “nurses, physicians(s), home healthcare aides, spiritual care provider, social worker, and volunteers” (http://www.completingalife.msu.edu).  Together these professionals ensure that the dignity of the patient is upheld in their final hours.  They work to provide pain management, assistance, and reassurance to the patient and family members as well as keeping the patient physically comfortable. 
	While Alice was able to visit with her children before she passed, other means of communication that could have been taken are letters, emails, or video messages that she could send her family members or that they could make and send to her.
	Some questions that an individual should consider when hoping to plan for their last hours are: whether they wish to die at home, if this is not possible are arrangements made to avoid CPR, who do you wish to see before passing, who do you wish to be with you as you pass and have you discussed this with them, are they prepared for witnessing your passing, are there special rituals you wish to have when you pass and are these arranged, are there special arrangements you wish to have at your funeral, and are you prepared for what you may experience physically during your death (http://www.completingalife.msu.edu).  
	There are special considerations that a nurse should keep in mind while caring for a dying patient with dementia.  It is important to recognize when a patient is nearing death in order to avoid subjecting them to prolonged treatment that may cause discomfort during their end of life.  Pain management may be more difficult to maintain with dementia patients, and it is important to be aware of physical cues that may indicate is present and needs to be addressed.  Also, it is important to recognize that while the patient may not be fully capacitated; allowing the patient to communicate with providers and family members can improve quality in the patient’s last hours and allow them to pass with as much dignity as possible (Ryan, Ingleton, Gardiner, Nolan, & Gott, 2009).  	According to the website, some of the assessment tools that could be used by clinicians to assess the functional status of Harry and Alice are: the Edmonton Symptom Assessment Scale, the Palliative Performance Scale, and the Karnofsky Performance Scale (Gatto & Zwicker, 2006). 

Case Study 1.1
	The federal law enacted in 1991 ensuring that clients are informed to make health care decisions including how to complete an advanced directive (AD) is the Patient Self Determination Act (http://www.wsha.org/EOL-FedState.cfm).  With most patients stating a desire to get more information on Ads yet only twenty percent of Americans actually having one, it is important to consider what may contribute to such a low rate. A major factor is likely a lack of education on the matter.  Many patients may not know how to bring up the matter with their healthcare providers, and any questions they have on the issue will go unanswered unless the provider specifically brings it up.  Also, many patients may not understand the steps necessary in obtaining an AD and may not know how to go about setting up a legally binding AD. Two types of ADs are living wills and a durable power of attorney.  A living will “provides specific instructions to health care providers about particular kinds of health care treatment an individual would or would not want to prolong life” (Getty & Ramsey, 2008, para. 3).  A durable healthcare power of attorney allows one to designate a person “to make health care decisions for them should they lose the ability to make decisions or communicate their wishes” (Getty & Ramsey, 2008, para. 3).  In addition to the ADs that the patient has enacted regarding resuscitation, Melanie can also inform him of his right to draw up a Medical Directive that may allow him to specify his wishes regarding life-prolonging care from mechanical ventilation and feeding tubes.
	Mr. Barker’s question regarding any problems he may face if he were to be hospitalized while out of him home state is a valid one.  Most states do accept directives obtained in other states or have laws pertaining to reciprocity between states. However, if he were “if a person has residences in 2 states, it is advisable to complete documents for each state in which the person resides” (Westphal & Wavra, 2005, p. 7).  His question regarding the permanence of an AD is important as well.  Melanie should explain to him that while both documents can be effective indefinitely, they can also be immediately changed or even revoked and “the change or revocation may be made in any way that the person is able to communicate” (Westphal & Wavra, 2005, p. 6).  
	According to Aging with Dignity (2010), the “Five Wishes” allow patients to consider and record their feelings on different end-of-life issues. They cover matters of patient choice such as: who they want to make decisions for them if they are unable, what kinds of treatment they do or do not want, how comfortable does the patient wish to be, how do they want to be treated by providers, and what information they want passed on to their loved ones (http://www.agingwithdignity.org/five-wishes.php). Based on the information provided, Ms. Ruiz can designate the person of her choice to act as her healthcare agent, including her boyfriend.  Melanie’s witnessing of conflicts in other families as they face end-of-life issues is irrelevant, and she has a moral obligation to respect the wishes of Ms. Ruiz in keeping document a secret from her family.  She can however advise Ms. Ruiz to reconsider this stance and point her to the other resources on the website that could provide advice and support to Ms. Ruiz in order for her to better communicate with her family.  Ultimately though, the decision to share this information is up to Ms. Ruiz.
	The suggestions that I found most helpful on the Industry Collaboration Effort website were basically reminders to speak to patients in ways they can understand.  Speaking simply and avoiding technical language seems easy enough, but many professionals become so accustomed with the language of healthcare that they tend to forget that most patients are not.  It can be disorienting to find yourself in the unfamiliar setting of a hospital or healthcare environment, and those around you are speaking above your head and using terminology you don’t understand it only compounds the stress.  Taking the time to explain things to patients in a way that they can understand can put them at ease and allow them to better trust you and the care you are providing (Industry Collaboration Effort ICE, n.d.)

References
Gatto, M., & Zwicker, D. (2006). Palliative Care. Retrieved from http://consultgerirn.org/topics/palliative_care/want_to_know_more#item_2
Getty, E., & Ramsey, G. (2008). Geriatric nursing standard of practice: Advanced directives protocol. Retrieved from http://consultgerirn.org/topics/advance_directives/want_to_know_more/
Industry Collaboration Effort ICE. (n.d.). ICE C&L provider toolkit. Retrieved from http://www.iceforhealth.org/library/documents/ICE_C&L_Provider_Toolkit_7.10.pdf
Mauk, K. L. (2010). Gerontological nursing: competencies for care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Ryan, T., Ingleton, C., Gardiner, C., Nolan, M., & Gott, M. (2009). Supporting people who have dementia to die with dignity. Nursing Older People, 21(5), 18-23. 
Tunzi, M. (2001, July 15). Can the patient decide? Evaluating patient capacity in practice. American Family Physician, 64, 299-308. Retrieved from http://www.aafp.org/afp/2001/0715/p299.html
Westphal, C., & Wavra, T. (2005, September). Acute and critical care choicesguide to advance directives. American Association of Critical-Care Nurses. Retrieved from http://www.aacn.org/WD/Practice/Docs/Acute_and_Critical_Care_Choices_to_Advance_Directives.pdf