Penny is a 97-year-old lady who resides at a local Residential Aged Care Facility (RACF). Penny was diagnosed 10 years ago with Alzheimer’s Disease.  Two years ago a lump was observed on her left breast.  This was diagnosed as breast cancer.  Due to her age and health status, no active treatment was commenced.  The lump has just recently developed into a fungating wound which requires management.

Prior to her admission to the facility Penny was cared for at home by her granddaughter, Margaret, until she was no longer able to cope.  More recently due to her wandering and intrusive behaviours Penny has been cared for in a Dementia specific unit.  Penny is widowed and has four children.  Two live locally and two live interstate.  The two that live locally visit regularly however they are elderly as well and less able to contribute to her care.

Margaret visits frequently, is Penny’s next of kin and holds Enduring Power of Attorney for Penny’s health decisions.  Margaret has noticed a visible decline in Penny over the last 2 months and now she is refusing to take food and only minimal fluids.  She is becoming weaker and no longer is at risk of wandering, has become increasingly confused, lost weight and spends her days nursed in bed or in a comfort chair.

At family conference Penny’s doctor has advised her family that she is now requiring palliative care and active medical interventions would be ceased and interventions will be more focused on keeping her comfortable and pain free. The doctor states he will instruct that she be commenced on an End of Life Pathway.

1. Margaret has come to see you and has asked you to explain ‘palliative care’. (100 words)

2. Margaret goes on to ask you what is likely to happen to Penny. Your answer should specifically address changes to Penny’s nutrition and hydration status and requirements to relieve pain and discomfort (100 words)

• Appetite and thirst – If Penny is able to eat and drink then food and beverages of choice will be provided any time she feels like eating (Koutoukidis et al, 2017, p. 1125). As Penny nears end of life, her appetite and thirst may decrease and she may have little desire to eat or drink. This is a natural process and is not painful for the person. Sips of water, or using a swab to moisten her mouth may help (Palliative Care Australia, 2017).
• Pain management – medication is the core treatment for pain in terminal illness. Some other measures that can be used for pain or discomfort include using hot packs, careful positioning and repositioning or support for a painful body part, and therapies such as relaxation mediation, music therapy, and aromatherapy acupuncture and acupressure (Palliative Care Australia, 2017).

3. The doctor mentioned ‘end of life’ pathway. What is this and how will it help Penny to have a ‘good death’? (100 words)

4. Using the symptoms listed on the Qld Health Residential Aged Care End of Life Pathway (EOL) identify, the management and clinical nursing skills required to relieve these for Penny. Include in your answer the management of her skin integrity and wound care of her malignant breast lesion.

Signs and symptoms that indicate Penny will commence the EOL pathway include her visible decline, her refusal of food and her increasing weakness. Part of Penny’s care management for her symptoms can include commencing a subcutaneous infusion for her pain, assessing Penny’s need for a special mattress and commencing a comfort care chart. It would also be ideal to address any spiritual, religious, or cultural needs Penny may have as well as having regular communication with Penny’s family. Penny’s comfort care chart should be addressed every two hours and all results and findings documented on the chart (Queensland Government, 2017).

Managing fungating wounds can be difficult for nurses. These types of wounds can spread rapidly and are often associated with breast or head and next cancers. They can have an enormous impact on the physical and psychological wellbeing of a patient. Some of the problems associated with a fungating wound include offensive exudate, pain and discomfort, infection, and bleeding. Effective wound assessment and the use of correct dressing as well as symptom management and monitoring of pressure care are essential (Care Search, 2017).

John aged 19 has stage IV Metastatic Melanoma. He has been receiving chemotherapy over the duration of his illness. Chemotherapy can cause side effects such as nausea, vomiting depression, tiredness and thinning or loss of hair.

His family cared for him at home until two weeks ago. He has now moved to a hospice for respite care.

John is a member of the local surfing community and therefore he receives many visitors.

1. Briefly explain the Pathophysiology of Metastatic Melanoma. How will his illness impact on the physical aspects of his activities of daily living? (200 words)

2. With whom would you discuss the psychological impacts of John’s disease? Discuss strategies that the Enrolled Nurse (EN) could use is assist John cope psychologically with his current condition. (150 words)

• Anger
• Sadness
• Fear
• Feeling out of control
• Feeling helpless

Negative feelings come and go and usually improve over time as the person gets used to their diagnosis and treatment, and learns to cope with the stress. Social and emotional issues can be quite difficult for patients to understand and talk about which in turn can lead to problems like depression and anxiety (Cancer Institute NSW, 2017).

To assist John in coping psychologically with his condition the EN could use strategies such as therapeutic communication. Therapeutic communication is an important nursing intervention used to assist patients in palliative care. Empathy and active listening is also essential. John should be allowed time to express his feelings and thoughts. Making time to listen and interact in a sensitive way enhances the relationship between the nurse and patient (Brown, et al., 2015, p. 91). If there is serious concern for the psychological impact John’s disease is having on him then it can be discussed with the RN or Medical Officer, John himself, John’s family or carer, and allied health professional such as counsellors and psychologists (Queensland Government, 2017).

3. Describe the social factors that should be considered when providing John with nursing assistance. (100 words)

4. John’s medication includes morphine.

• Describe the actions of this drug. 
• List two common side effects and include management strategies for each of these side effects.

Side effects to morphine are typically short lived and mild. Two common side effects of morphine are:

• Drowsiness – this is a common side effect of several drugs and may occur for only a short time after starting treatment or increasing the dose. It is advised to not drive a car, operate machinery, or do anything else that could be dangerous if you are drowsy or feeling uncoordinated such as drinking alcohol (NPS, 2017).
• Nausea or vomiting – As morphine may cause nausea and vomiting, your doctor is likely to prescribe medicine for you to take or receive before the morphine, to stop you feeling sick. Morphine may also cause constipation, so your doctor is likely to prescribe laxatives to prevent this happening (NPS, 2017).

5. Identify five (5) nursing actions that could help John alleviate his discomfort other than medication.

• Massage – this can reduce various palliative care symptoms such as pain, nausea, anxiety, anger, depression, stress and fatigue
• Aromatherapy – this can help to reduce anxiety and depression. It is often used in conjunction with massage and can contribute short term to patient’s quality of life
• Music therapy – this has been adopted as one of the complementary therapies frequently offered to patients in palliative care. Studies suggest improvements in symptoms related to pain, mood, and other psychosocial variables
• Meditation and relaxation techniques – although this one shows no benefit to physical symptoms, it does show benefits to anxiety, comfort and emotional response
• Acupuncture – this is used widely for pain and nausea as well as other symptoms (Care Search, 2017).

Research an ethnic group, either your own or one different to your own and answer the following questions.

1. Identify the family and relationship structures that may impact on the nature of palliative care. (150 words)

2. Describe the culturally significant beliefs of this culture, about death and dying that need to be considered throughout the palliative care period. (100 words)

• The patient’s eldest son is expected to be present before during and after death, even if the son is a small child.
• Other family members may wish to be present and to participate in the care of the patient
• Family members may request that patients not be told about a terminal diagnosis directly
• A Hindu patient may wish for a Pandit (priest) to be present to perform certain rituals including:
  • tying a sacred thread around the neck or wrist
  • placing a few drops of water from the River Ganges into the patient’s mouth
  • placing a sacred tulsi leaf (holy basil) in the patient’s mouth
• Patients may wish to read or recite religious chants and prayers. However, some patients may prefer to listen on a personal media player or small radio

When a Hindu patient dies

• A deceased Hindu’s body is usually washed by close family members with the eldest son taking a leading role
• The family may wish to light a small lamp or burn incense near the body
• If possible, all jewellery, sacred threads and religious objects should be left in place
• Health care providers should advise family members if it is necessary to remove these items
• The deceased patient’s family may have a preference for the position of the body after death (Queensland Health, 2017).

Not all patients adhere to cultural protocols and traditions, as the EN, how will you discover whether these protocols and traditions are relevant to your client? How would you raise these matters with the client or family? (200 words)

• People may be influenced by and identify with more than one culture or cultural group
• Everyone has a cultural identity; however, it is not always recognised or defined by the person themselves. Sometimes, culture is seen simply as “just the way we do things”.
• It is the choice of the individual as to which culture they identify with regardless of their cultural background.

When caring for a patient from a culture different from your own, the nurse needs to be aware of and respect their cultural preferences and beliefs; otherwise, they may consider you insensitive and indifferent, possibly even incompetent. Also be aware of assuming that all members of any one culture act and behave in the same way; in other words, don’t stereotype people. The best way to avoid stereotyping is to view each patient as an individual and to find out their cultural preferences. Using a culture assessment tool or questionnaire can help you discover these and document them for other members of the health care team (Nursing 2017, 2017).

A patient you have been caring for and developed a close relationship with has just died. On hearing this news, you experience a sense of loss.  Reflect on your feelings and discuss what personal strategies, values and attitudes you could use to help you cope with this situation. Include in your answer, social and community support systems

I would personally find it helpful to talk with family, co-workers or friends during this time as they are my biggest support system. I would also take time to myself to reflect on my feelings and appreciate the fact that I was able to know the person. I would also find comfort knowing I did all I could for the patient at the end of their life.

Michelle is at end stage of her terminal illness. In the lead up to her final weeks Michelle has talked extensively with her husband, daughter and medical staff about what is to happen with her in her final hours before dying. As part of her planning she has discussed and signed an Advanced Care Directive (ACD) with her doctor and legal representative.  In this she has indicated that she wants no interventions to extend her life.  Her husband is her next of kin and appointed attorney.  She has agreed to pain and symptom relief if required.

1. Explain what an Advanced Care Directive is.  Who can use the form? When should it be used? Who has authority over its use?

When you enter her room to check on her, you see that her husband and daughter are present and she is surrounded by extended family.  Her ex-husband and his two young children, and three of Michelle’s friends are huddled in the corner of the room crying.  Her ex-husband is demanding that something be done.

2. As the EN caring for Michelle, what would you do in this situation? Include in your answer two strategies you could use to improve this situation? (150 words)

Members of an elderly client’s family want to know if their mother has indicated how she intends to dispose of her estate. What is the EN’s role in relation to this request? (100 words)

• Standard 1: “functions in accordance with the law, policies and procedures affecting EN practice” – this includes (1.1) demonstrating knowledge and understanding of commonwealth, state and/or territory legislation and common law pertinent to nursing practice, and (1.10) liaising and negotiating with the RN and other appropriate personnel to ensure that needs and rights of people in receipt of care are addressed and upheld.
• Standard 2: “Practises nursing in a way that ensures the rights, confidentiality, dignity and respect of people are upheld” – this is an important standard in this particular situation, namely (2.7) ensures privacy, dignity and confidentiality when providing care.
• Standard 7: “Communicates and uses documentation to inform and report care” – this includes providing accurate and appropriate information to enable informed decision making by others and using a variety of communication methods to engage appropriately with others (Nursing and Midwifery Board of Australia, 2017).

Using these standards, the EN should inform the family that she can not divulge this sort of information due to confidentiality policies regardless of if the EN knows the details of the patient’s estate or not. The EN should let the RN know of the family’s question and the RN may be able to point the family in the right direction in relation to getting their question answered.

Jane is 14 years old and is suffering a terminal illness. She is aware that her condition is deteriorating but still she feels her parents are not telling her the truth about her prognosis. You are assisting her in the shower one day when she says “I’m dying aren’t I?

1. What is your response to her question? (50 words)

• Tailor communication to meet the child’s developmental stage
• Assess prior knowledge and what needs to be discussed
• Acknowledge emotions
• Be honest and maintain trust
• Be clear with responses to questions
• Be prepared to listen to and revisit conversations (PCC4U, 2017).

In regards to Jane, I would ask her questions regarding what she knows of her illness and listen to what she says. I would show Jane empathy and let her know that I will get the RN to come and speak with her about her illness.

2. Research and briefly discuss the legal age of consent in Queensland. (50 words)

Nurses are governed by the Code of Ethics for Nurses in Australia.

1. Identify the purpose of this code and explain how this code can be used to assist the nurse in decision making with regard to palliative care patients.  Consider the values expected of the nurse in your answer.

2. Your patient identifies as a different culture to you and has listed specific requirements for care of his body after his death. (30 words)

3. Your client is in pain and is refusing regular pain relief as he says he does not want to become ‘addicted’. (30 words)

Provide a definition of each type of pain.

1. Nociceptive pain

2. Neuropathic

James has been admitted to your ward for pain control. He has a diagnosis of bowel cancer and treatment has required him to undergo extensive surgery and radiotherapy. He has a couple of good friends who visit him regularly. He lives alone and is no longer able to self-care. James does not engage in conversation and spends most of his time sleeping. He has become dis-interested with life. The Oncologist has explained to him that he is in the end stages of his disease and that all will be done to keep him comfortable and free from pain.

On admission you are the EN assigned to care for him, in collaboration/consultation with the RN address the following;

1.  Using the following three headings identify one nursing diagnosis for each of the following care domains. Ensure your answer considers aspects related to James’ pain and social history. (100 words)

• Physical
• Psychological
• Social

• Physical: James has been diagnosed with bowel cancer and is at the end stage. Due to this he will need pain relief. James also spends most of his time sleeping. This puts him at risk for impaired skin integrity
• Psychological: James is no longer able to self-care and has become dis-interested with life. This puts James at risk for depression and at risk of ineffective role performance (feels unneeded)
• Social: James has good friends who visit him regularly but no longer engages in conversation. James is at risk for social isolation

2.  Using the nursing diagnosis, you have formulated, develop two (2) care interventions for each domain. (150 words)

Psychological: Build therapeutic relationship with James (ask questions, ensure privacy and confidentiality, take time to listen, allow James to respond, show interest, maintain eye level, use positive body language, give reassurance, seek consent). Encourage James to verbalize feelings, perceptions, and fears of his current situation. Help James set up a network of people he can talk to during emotional times

Social: Encourage contact with friends and family. Move James periodically to a more stimulating environment when conditions allow.

3.  Giving consideration to his current emotional & social status, describe how you might provide an appropriate care environment for James and evaluate the effectiveness of his care (100 words)

Your client is an indigenous Elder and has received many visitors during his stay in hospital. His death is imminent.  As the EN with whom will you discuss final arrangements? What protocols will need to be considered and why? (100 words)

Your patient is a Muslim lady from Syria and has strong religious beliefs. She is at the end stage of her life. Her two brothers have recently arrived from her native country to be with her and to offer support to the family.

1. Discuss the Interpreter services that may be required for this family

2. Using your cultural research skills identify;

• who you would be discussing the final arrangements with and
• What protocols would need to be observed for this client pre and post death.

Include in your answer the observances the EN would need to consider regarding your patient’s nutrition and hydration status and then the impact of loss and grief on this family. (50 – 100 words)

All hospitals and nursing homes have policy and procedure relating to palliative care.  Research Queensland Health’s document Clinical Guidance for the Dying Patient and answer the following questions.

1. Apart from family members, who must be notified when your client dies? (30 words)

2. Identify two (2) pieces of information that can be provided to the person’s family or next of kin in order the help them move forward, both practically and emotionally. (50 words)

• Australian Centre for Grief and Bereavement
• Lifeline (24/7)
• Kids Helpline
• Mensline
• Parentline
• Beyond Blue (Palliative Care Australia, 2017).

Using organisational policy and procedure explain the processes that may occur as a part of after death care. If you don’t have access to a workplace policy and procedure, do an online search.  Your answer should address:

(a) Who determines the person is deceased?

(b) What happens to the body immediately after death?

(c) What happens to the client’s belongings and to whom should they be given?

(d) Identify an appropriate counselling resource you could refer a grieving family to?

(e) Request for autopsy

150. words)

1. Determining a person is deceased can be done by a medical officer, RN or registered midwife. A certification of death can only be done by a medical practitioner (Brown, et al., 2015, p. 84).
2. Practice guidelines recommend that after death care be delivered in a respectful manner to preserve the dignity of the deceased and honour family preferences (Medscape, 2017). After death occurs, the pupils of the patient will be fixed, dilated and unresponsive to light. The skin will turn pale, waxen, and cool to the touch. Death initially causes the muscles to relax. The jaw falls open, and the sphincters release urine and stool. Often, the eyes will remain open (Modern Medicine, 2017).
3. All jewellery apart from the wedding ring should be removed in the presence of another staff member (unless the family have asked you not to do so) and then documented. Any personal items are usually then packed up and returned to the next-of-kin (Queensland Government, 2017).
4. There are many appropriate counselling resources available to the family and friends of patients who have passed. Most health care setting will have pamphlets and brochures which will guide them in the right direction. Some examples of counselling resources include
   • 24 hour helplines such as 13 HEALTH and Lifeline
   • Local support such as a hospital social worker or your local GP
   • Centacare (Queensland Government, 2017).
5. The purpose of an autopsy is to better understand the factors that may have contributed to a person’s death. Generally, autopsies are only performed if the deceased died from an unknown or unnatural cause such as an accident and is typically requested by a doctor (NSW Government, 2017). The family of the deceased can request an autopsy if they have good reasons for the request (NSW Law, 2017).

Research and briefly explain the process of Organ and Tissue Donation. (50 words)

References

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