Life Care Plan for Client
Linda Foster
American Sentinel University
Case Management Capstone
N555C
LIFE CARE PLAN FOR CLIENT N555C 8
Life Care Plan for Client N555C
NAME: R.H.
SOCIAL SECURITY NUMBER: 999-99-9999
DATE OF BIRTH: 06/03/1952
DATE OF ONSET: 6/28/13
DATE OF EVALUATION: 7/27/2013
DATE OF COMPLETED REPORT: 8/9/2013
Narrative Section:
The client is a 61 year old white male with recent diagnosis of alcoholic hepatitis and cirrhosis. He is married and has one adult daughter that lives nearby. He has been employed full time as a machinist at JD Machines for the last 20 years. He was recently admitted in Acute Renal Failure, likely due to hepatorenal syndrome with rapid progressing edema and development of ascites; Hyponatremia, related to hypervolemic state from liver disease including Hepatic encephalopathy and alcohol dependence. “Hepatorenal syndrome (HRS) is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure,” (http://en.wikipedia.org/wiki/Hepatorenal_syndrome).
Alcohol abuse is the most common cause of serious liver disease in Western civilizations (Lee, 2013). In the United States alcoholic liver disease affects more than 2 million people which can be calculated to 1% of the population. It is difficult to report the true prevalence of alcoholic hepatitis, because in its milder forms because patients may be asymptomatic and never seek medical attention. “The overall 30-day mortality rate in patients hospitalized with alcoholic hepatitis is approximately 15%; however, in patients with severe liver disease, the rate approaches or exceeds 50%. In those lacking encephalopathy, jaundice, or coagulopathy, the 30-day mortality rate is less than 5%. There is a 1-year mortality rate after hospitalization for alcoholic hepatitis is approximately 40” (Mukherjee, 2012, p. 1).
Medical Intake/History Review
Beginning July 27, 2013, the initial reviewing of the ongoing medical record and discussion with Clinical Case Manager at MRMC to develop a Life Care Plan for the above stated client. The reviews of physician progress notes from the Primary Care Physicians (Hospitalists), as well as consults from Surgery, Gastroenterologist, Nephrologist, Intensivist and Pulmonologist, as well as, laboratory results, and radiology reports were made available. Also the reports from Physical and Speech therapists on progress of his physical abilities were reviewed.
Medical Records Provider
J. D., Clinical Case Manager
Maury Regional Medical Center
1224 Trotwood Avenue
Columbia, Tennessee, 38401
Chief Complaint and Subjective History
Initially the client was admitted 6/28/13 from the Emergency department with progressive lower extremity edema due to possible hepatorenal syndrome. Increased complaint of abdominal pain revealed from CT, free air within the hepatic vein region and colon. He was sent to surgery and discovered ischemic colon which was removed with a total colectomy and ileostomy placed. Returned to Intensive care unit with acute liver failure and placed on ventilator. He had a tracheostomy placed 7/17/13 and peg tube. His plan included stabilization of liver and kidney function and weaning from the ventilator at a Long Term Acute Care (LTAC) facility as determined by family and accepted by his insurance provider. There has been difficulty in wound healing complicated by refractory ascites and leaking from the wound site. The treatment of secretory large volume diarrhea from colostomy was controlled with a Sandostatin, (Octretide) drip. On 7/28/13 he was moved out of the ICU to a step-down bed as he has been weaned to room air on trach collar and off vasopressors and steroids. His wife is present and active in his care. She does not wish for him to be transferred to a nursing home but is willing to have him in a rehabilitation facility as needed. The initial LTAC was not approved by insurance provider but they did approve another Rehabilitation facility in the same area. Physical Therapy and speech therapy have been working with client and plans for transfer can be made if he can build up to tolerate 3 hours of physical therapy per day before transfer. His kidney function has not improved and his serum creatinine and blood urea nitrogen (BUN) are staying elevated. Prognosis is stated to be poor with acute liver failure but family asked for second opinion regarding the benefit of hemodialysis as treatment option.
Client, when asked was not wanting to have hemodialysis initially and then stated would consent if it could just be once per week. Further discussion with client and family documented that this would not promote the best outcome if the treatment plan of three treatments a week was not effective treatment for his renal failure. Further investigation would be needed in facilities that would be able to manage hemodialysis within the facility or outsource to Dialysis center outpatient facility. Transportation per ambulance would need to be addressed with insurer and obtain approval as well as their ability for airway management for client with trach.
On August 4th the family asked to speak with Hospice as option and chose Compassus to discuss the process. The group was contacted and plan for meeting was arranged with client, wife and daughter on the evening of August 5th. The process was explained and at that time there was no consensus arrived at by family to make decision.
Effects of Injury on Daily Living
The severe metabolic encephalopathy is causing confusion and inability to carry out interaction with family and many functions of daily living. He has a gastronomy tube that was placed after colon resection and has not been successful in implementing a feeding regimen for appropriate calorie intake due to poor absorption. This has also impeded healing of surgical wounds. His limited stamina to ambulate and maintain oxygenation related to tracheotomy, post prolonged ventilator support, and oxygen support has put on hold any physical therapy.
Current Physical Complaints
Currently, the client has ventilator failure, severe toxic metabolic encephalopathy, sepsis, and post bowel resection for bowel obstruction. His lung fields have coarse rhonchi throughout with diminished breath sounds in both lower lobes. His heart rate was described as somewhat irregular with no murmurs, rubs or gallops. His colostomy bag is intact on his abdomen. His extremities are cold and feet are pale to touch with neurologic exam revealed him to be totally unresponsive at time of examination.is hearHis heartH
Past Medical History
The client’s past medical history was positive for Cataract removal, hypertension, gastro esophageal reflux, left hip replacement in December of 2010. Earlier in 2010 he fell from barn loft and had several rib fractures. He reported smoking two packs a day for the last 30 years and drinks two 6-packs of beer a day. He has denied any issue with alcohol and has not been in any rehabilitation program for abuse of alcohol. He had more recently been diagnosed with cirrhosis of liver and renal disease.
Current Medical and Rehabilitation Situation
The lack of improvement in condition and ability to make needs known, the referral request to LTAC facility was cancelled as approval for transfer had not been granted approval thus far. The family of client has requested to be transferred to Hospice Care. Client was moved to in-patient room on Oncology room for the Hospice Compassus to initiate care protocols.
Financial Summary
Client had been employed as machinist until recent illness and admitted to the hospital and has since then his wife has made application for Permanent Disability which has been registered with the State of Tennessee. He has Commercial Insurance (BC Select).
Conclusion
After in-depth conversations with primary care providers, physician consultants and social workers over several days have brought the family to request Hospice care, there is a focus “on caring, not curing” (Mullahy, 2010, p. 671). It had been after earlier evaluations for palliative care his family decided to accept care August 9, 2013. His wife stated she had come to the decision that he would not want to live in this condition and that even if everything else of his physical condition improved, living with the colostomy would be unacceptable to him. The physician to certify the transfer to palliative care also agreed that General Inpatient Care (GIP) care would be the best option for his current condition and can be re-evaluated as his condition changes.
The client expired with his family staying with him August 11, 2012.
References
Kidney disease statistics for the united states. (2012). Retrieved August 15, 2013, from http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/#18
Lee, W. (2013). Acute liver failure in the united states. Retrieved from http://www.medscape.com/viewarticle/463472
Mukherjee, S. (2012, August 20). Alcholic hepatitis. Medscape Reference, (). Retrieved from http://emedicine.medscape.com/article/170539-overview#aw2aab6b2b4aa
Mullahy, C. M. (2010). The case manager’s handbook (4th ed.). Sudbury, MA: Jones and Bartlett Publishers.
Appendices:
General Inpatient Care
Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9 §40.1.5 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf
Levels of care are defined as: Level 1- Routine home care (refer to §40.2.1); Level 2 - Continuous home care (refer to §40.2.1); Level 3 - Inpatient respite care (refer to §40.1.5 and §40.2.2); and Level 4 - General inpatient care (refer to §40.1.5).
General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting.
GIP is not intended to be custodial or residential. Once a beneficiary’s symptoms are stabilized, or pain is managed, he/she must return to a routine level of care. The beneficiary may remain in a facility due to safety, but Medicare will not pay for GIP unless the beneficiary is in need of this level of care, and it is clearly documented in the medical records.
Updated: 07.25.12
Hospice Compassus
OUR PHILOSOPHY
Hospice Compassus recognizes death as a natural part of the life cycle and promotes pain relief and symptom management as appropriate clinical goals.
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Hospice Compassus affirms life and provides hospice interventions that will seek neither to hasten death nor to postpone it.
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Hospice Compassus understands that psychosocial and spiritual pain is often as significant as physical pain, and that addressing all three requires the skills of an interdisciplinary team.
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Hospice Compassus believes that patients and loved ones are an integral part of our Plan of Care.
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http://hospicecompassus.com/pg-healthcare-professionals.html
Future Routine Medical Care
To be eligible for hospice care, the patient’s doctor and the hospice medical director must certify that the patient has a life expectancy of six months or less, if the disease progression were to run its normal course. Hospice services are designed to meet the needs of patients and their families and friends.
Aggressive Treatment Plan
The aggressive treatment option for client with severe toxic metabolic encephalopathy would need for hemodialysis to improve toxic waste removal from his current state if tolerated. The use of hemodialysis to treat patients with End Stage Renal Disease (ESRD) remains one of the most resource-intensive therapeutic interventions. The advantages presented are lower mortality rate, better control of blood pressure, less diet restriction, and better solute clearance. The disadvantages are they can restrict independence as access to source can be limited. As it requires high water quality and electricity, requires reliable technology like dialysis machines. The procedure is complicated and requires that care givers have more knowledge and time needed to set up and clean dialysis machines, as well as the expense of machines and the associated staff. Comorbidities can influence the efficacy of this intervention. The current expense per patient per year for Hemodialysis treatments for ESRD is $80,000 to $90,000 Medicare costs ("NIDDK," 2012).
Drug Needs with Hospice
Medication / Purpose / Dose / Per unit Cost / Recommended ByChlorpromazine / Hiccups / 10-25mg TID prn / $1.70 / Med Director of Hospice
Zofran / Nausea & vomiting / 4mg every 4hrs prn / $26.71 / Med Director of Hospice
Benadryl / pruritus / 25-50mg every 6hr prn / .25 / Med Director of Hospice
Morphine sulfate / pain / 50mg/500ml saline Adj. gtts/hr / $3.80 / Med Director of Hospice
Morphine sulfate / Break thru pain / 6mg Every 4hr prn / .64 / Med Director of Hospice
Haldol / Confusion/ agitation / 0.5-2mg every 4hrs prn / $1.13 / Med Director of Hospice
Ativan / anxiety / 0.5mg TID prn IVP / .64 / Med Director of Hospice
Supplies
Description / Base Cost / Replacement schedule / Source/ Reference / Annual CostColostomy pouch / $ 34.82 / monthly / Hollister web site / $417.84
Flextend skin barrier / $30.29 / monthly / Hollister web site / $363.48
Adapt paste / $11.18 / monthly / Hollister web site / $134.16
Adapt lubricating skin barrier / $20.16 / monthly / Hollister web site / $241.92
Total $1157.40
Diagnostic Testing / Educational Assessment - NA
Projected Evaluations - NA
Projected Therapeutic Modalities - NA
Aids for Independent Function - NA
Orthotics/ Prosthetics - NA
Wheelchair Needs and Accessories - NA
Orthopedic Equipment - NA
Home Care/ Institutional Care – See GIP care account in preceding Conclusion part of paper
Transportation - NA
Home Furnishings and Accessories - NA
Architectural Renovations/ Housing Options - NA
Leisure Time and/or Recreational Equipment - NA
Potential Complications - Client does not find relief from pain; or family changes agreement with the Hospice program.