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end of life scenario/ teams and leadership/ long term confition
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End of Life ScenarioQuestion 1
The key issues with Barbara is right sided abdominal pain which she was admitted with, persistent nausea and
vomiting which she has been prescribed Cyclizine 50mg three times daily as required. Constipation which she
has been prescribed Lactulose 10ml twice a day. Barbara now has reduced mobility and is spending longer
periods of time in bed and is increasingly drowsy and weak. Barbara now needs assistance with most activities
of living. Barbara’s oral intake has diminished which has caused low urine output which was 10/ml in the past
hour. Barbara also has disease progression of metastatic ovarian cancer which has progressed to her liver,
lumbar spine, and lungs which may be causing the jaundiced.
The individualised plan for Barbara would be:
- to complete a holistic assessment, including a comprehensive pain assessment. The holistic assessment
would include asking Barbara about her physical, social, psychological, and spiritual needs and
developing in a plan which reports her wishes and decisions. (Anon., 2012)
- A comprehensive pain assessment would include a nurse using a pain scale which works with Barbara,
such as a visual analog scale, numeric rating scale etc. Family members can also input to help evaluate
Barbara’s reaction to medications and nonpharmacologic interventions. Barbara should be actively
included in a pain management treatment plan. Ensure to review Barbara’s understanding of the pain-
intensity scale and explain the steps that will be taken to minimize the pain stimuli. Determine the type
of pain, Barbara’s response to previous medications and whether they caused a difference in Barbara’s
ability to function – activities of daily living. Asking Barbara what makes the pain better/worse, open-
ended questions such as “what does your pain feel like?”, asking where the pain is and then using the
pain-intensity scale to rate the pain. Ask Barbara if the pain is constant, intermittent, continuous, a
combination and if it increases at a specific time of day or after completing a certain activity. Continue
to reassess Barbara’s pain status, assessing for adverse effects of medications such as respiratory
depression. Compare Barbara’s ability to function and perform ADL’s before and after pain
interventions, observe nonverbal behaviours such as facial expressions, body movements, restlessness,
behavioural changes and speaking out.
- Find out what Barbara’s understanding is of what is happening
, - Ask if she has any worries or concerns
- Identify any Advance Care Plan
- Refer to Specialist Palliative Care team for advice on symptom control and end of life care
- Review medication – considering an oral route.
It is important to know what Barbara knows and what she wants to know about her situation/condition. The
Leadership Alliance for the Care of Dying People identified 5 priorities for care, these are:
1. If the likelihood of the person dying within the next few days or hours, it will be communicated openly,
and decisions will be made in accordance with the person’s needs and wishes.
2. Sensitive communication will happen between carers, the dying individual, and their close family.
3. The individual, and those identified as significant to them, are involved in decisions regarding
treatment and care.
4. The needs of families and those identified as significant should be met as far as possible.
5. An individual plan of care should be agreed with the patient and delivered with compassion. (Anon.,
2012)
Question 2
The wider issues that may impact Barbara’s care would be monitoring Barbara’s input and output, ensuring
mouth care is carried out regularly. As Barbara is only responding to verbal cues, a nurse could use the
Nonverbal Pain Scale (NVPS). (Nonverbal Pain Scale (NVPS) for Nonverbal Patients, no date)
Barbara should be referred for End of Life care which will be discussed with Barbara prior to ensure you are
aware of her wishes such as if she wants to go home, to a hospice, care home or stay in hospital. Discussing
with Barbara about creating a lasting power of attorney to make her decisions when she can no longer do this
herself. Coordinate working with primary and community health care services and individual patient care. Find
out if there is already care in place and if Barbara has already made an Advance Directive and already has
portrayed her wishes previously. Find if there are any hospices already involved in Barbara’s care. Enquire with
family about living arrangements and Barbara’s wishes, refer for a capacity test to find if Barbara still has
capacity due to her 5/15 score GCS. There can also be time constraints depending on the deterioration of
Barbara’s condition and preparing carers if Barbara wants to go home and space is hospices and care homes.
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