Case Studies
Please Note: All case studies are intended to be generic so that substitutions can be made, according to your own clinical roles. Feel free to adjust the case studies so they are relevant to your participant’s clinical needs.
Module 8
Case Study #1
Mr. Ahmed: A Case for an Advance Directive
You are an Advanced Practice Registered Nurse (APRN) on a Palliative Care team at a local hospital. You have been seeing Mr. Ahmed for the past four months, since his hospitalizations have increased due to severe symptoms from cardiomyopathy. The palliative care team has been vigilant about treating his symptoms, such as angina, pedal edema, and dyspnea.
Mr. Ahmed, a Muslim, is 42-years-old, and has a wife and 7 children (ranging from 4 years to 18 years of age). His heart continues to deteriorate, and you notice a huge decline in his physical status since he was last admitted, three weeks ago. Mr. Ahmed is going in and out of consciousness and has refused to sign an advance directive. Despite the fact that his condition is worsening by the hour, you and the other members of the Palliative Care team have repeatedly talked with both Mr. and Mrs. Ahmed about signing an Advance Directive. Over the past four months, since you and the palliative care team have been seeing Mr. Ahmed, he and his wife have refused to discuss home hospice. Mrs. Ahmed states that she knows her husband is dying and requests that his bed be turned, so that it faces Mecca.
Discussion Questions:
1. How would you and the Palliative Care team proceed in obtaining an Advance Directive? Is one necessary at this time?
2. What unique role does the APN have in this situation?
3. How would you meet this patient’s potential spiritual needs?
4. How would you manage dyspnea, fluid overload, anxiety, hypertension, etc., in the realm of palliative care?
5. Identify possible needs of the wife, children, other family members.
Module 8
Case Study #2
Billy: Conflict with a Son
Billy is an 81-year-old male with congestive heart failure, chronic renal failure, and diabetes. Billy has been on peritoneal dialysis for the past 6 years and has had two episodes of septicemia. He and his wife, Lorraine, agreed that they wanted palliative care services six months ago. An advance directive was signed at that time.
Billy and Lorraine have four adult children. Their youngest daughter died two years ago of metastatic colon cancer. Two of the adult children live in the same city as Billy and Lorraine and one son, Ed, lives in another state about 300 miles away. Ed has not seen his father in three years, and when he was contacted by his sister a month ago and told that his father was quickly deteriorating, he decided to come home for a visit. When he walked into the house, he was shocked, confused, and angry that his father was so ill. He demanded to talk with the hospice nurse—he wanted to know why his father had lost so much weight, why he was not eating, why his breathing was so “heavy,” and why his doctors are not treating him more aggressively. “My sister had hospice, and you all let her die. I will not let you kill my father, too.” The hospice nurse arrives at the home to speak with Ed. Ed demands that his father be admitted to the hospital where “he can get constant care and nutrition through his veins.”
Discussion Questions: Part 1:
1. How would you respond to Ed’s demands?
2. How could you assist Ed in respecting his father’s wishes?
3. How could you use the other family members to assist with Ed’s anger and confusion?
4. Would you consider placing Billy back into the hospital, per Ed’s demands? Why or why not?
Case Continued:
As the hospice nurse, you have been asked by the family to speak with Ed and to explain that his father had an advance directive. Lorraine is also present and she explains to Ed how his father’s health has deteriorated and that his wishes are “to let nature take its course”—without extra food or water. Lorraine goes on to explain to him that since his father requested palliative care services, in many ways his quality of life had improved. In addition, Lorraine informs Ed that his father’s implantable cardioverter defibrillator (ICD) will be turned off today, per Billy’s request.
Discussion Questions: Part 2:
5. Since Billy has requested to have the ICD turned off, what does this tell you about his decision “to let nature take its course?”
6. How might this hospice nurse, who sees many patients like Billy every day, take care of herself so that she can care for others?
Module 8
Case Study #3
Jennifer: Ending of One Life, Beginning of Another
Jennifer is a 26-year-old woman who gave birth three days ago to a healthy 9 pounds 2 ounce baby girl. The vaginal delivery was uneventful. Two hours after the birth, Jennifer began to complain of an “excruciating headache.” Within one hour of receiving acetaminophen for her headache, Jennifer became unconscious and suffered from a respiratory arrest. She was coded, placed on a ventilator, and sent to the ICU. A CT scan revealed that she had suffered from a massive cerebral hemorrhage. After it was determined that the damage to the brain was irreversible and that Jennifer would be unable to breathe on her own, her husband, Brett, made the decision that his wife should be removed from life support. “Our neighbor had Lou Gehrig’s disease and Jennifer would go visit with him and his wife. She always said she would never want to live like that,” stated Brett. However, Brett was not quite ready to have the ventilator removed. The Palliative Care team was called to visit with Brett, and also Jennifer’s parents. It was decided that Jennifer would be moved from the ICU down to one of the two new palliative care suites, and have the ventilator removed there.
Upon arriving to the palliative care suite, Brett and Jennifer’s parents were introduced to Nancy, the nurse that would be taking care of Jennifer and her family. Nancy was sensitive in talking with the family and had a great desire to find out what they wanted. The family agreed that the ventilator would be removed at noon the next day, to give family and friends an opportunity to say good-bye. Throughout the rest of the day, evening, and the next morning, over 75 people came to say good-bye to Jennifer.
Brett’s mother requested to stay with the new baby in the newborn nursery. Brett was so torn between spending time with his new baby girl and his wife. Nancy agreed that it was a good plan to have Brett’s mother care for the baby, while Brett concentrated on making decisions regarding Jennifer. Per Brett’s request, his mother brought the baby to the palliative care suite two times.
Jennifer’s pastor came by to spend time with Brett. He supported Brett in this very difficult decision. The hospital chaplain was also present. Nancy suggested some memory-making rituals such as taking a clipping of Jennifer’s hair, so her baby girl would have for later on. Footprints and handprints were made of Jennifer, per her parent’s request. A hand mold of the baby’s hand in her mother’s hand was made. Both Jennifer and the baby’s hospital name bands would be removed and placed in a memory box. Jennifer’s mother requested to bathe her. Brett brought in Jennifer’s favorite college sweatshirt to put on her. CD’s of some of Jennifer’s favorite music were brought in and played.
The next day, as per the request of the family, the palliative care team reviewed with Jennifer’s family how they would extubate her. They talked about possible symptoms and how they would treat those. Brett, Jennifer’s parents, two brothers, and 12 other close friends were all together with Jennifer in the palliative care suite. The nurse from the newborn nursery brought the baby and laid her on Jennifer’s abdomen, per the family’s request. They were all reminiscing and telling Jennifer how much they loved her and how much she had meant to all of them. The palliative care nurse, physician, and chaplain were all present in the room and encouraged the family to take as much time as they needed. At 2 pm, the family reluctantly requested that the ventilator be removed.
When Jennifer was extubated, she turned cyanotic and began gasping for air. The team administered supplemental oxygen and morphine. Jennifer continued to gasp for air, and the morphine was doubled. This was repeated one last time until Jennifer was no longer dyspneic. Unfortunately, Jennifer remained cyanotic. Jennifer died 15 minutes, after she had been extubated. The palliative care team stayed with the family during the entire process.
The palliative care nurse made arrangements for Jennifer’s body to be picked-up by the funeral home directly from the palliative care suite. The family had requested that she not be taken to the hospital morgue. The team remained with the family, until the funeral home came. Once Jennifer’s body was removed by the funeral home, Brett left the palliative care suite to visit his new daughter in the newborn nursery. “One life so precious is gone, and yet, God has blessed me with another new life.”
Discussion Questions:
1. Would you consider this a “good death?” Why or why not?
2. How did the nurse and other members of the interdisciplinary team assess and manage this family?
3. How could you use evidence-based research to establish practice standards for withdrawing ventilator support?
4. What kind of bereavement services would you want to offer this family?
5. Are there additional memory-making rituals that could have been used?
______
ELNEC-Core Curriculum Module 8: Final Hours Page M8-65
© COH & AACN, 2007 Case Studies
Revised: June 2016