Critical analysis of the given case study based on End-of-Life Care CPG
Critical analysis of the given case study based on End-of-Life Care CPG
Introduction
The End-of-life Care Clinical Practice Guideline (CPG) is a guideline intended for healthcare professionals such as nursing and medical staff, involved in the early palliative care and support for patients suffering from a life-limiting health condition (ACU Practice guideline, 2021). The given case study identifies a patient named Tyler Morton diagnosed with a Motor Neuron Disease named Amyotrophic lateral sclerosis (ALS). ALS is one of the progressive neurological disease which affects the nerve cells of spinal cord and brain (ACU, 2021). The purpose of this essay is to critique the care provided to Tyler and Tylers family in the case study against the End-of-life Care CPG, utilising contemporary evidence-based literature and standards of care such as the National Safety and Quality Health Service (NSQHS), the Nursing Midwifery Board of Australia (NMBA) and the National Palliative Care Standards (NPCS). The essay will begin with a discussion and critique on 4 to 5 episodes of care as highlighted in the case study against the identified CPG and standards of palliative care. This will be followed by a rational and concise conclusion.
Critique and discussion
First episode of care: Thursday 19th March
As per the observation, Tyler has a red and inflamed peg site. Along with that the patient was also appearing to be extremely short of breath with decreased mobility and increased dependence on 1 or 2 people (ACU, 2021). This episode suggests the inability of professionals to make a timely and accurate diagnosis of the approaching terminal phase or final days of life in Tyler as according to ACU Practice guideline (2021), increasing drowsiness, inability to self-care are the clinical indicators of dying and infection is a reversible cause of deterioration. As per NMBA standard 3.1, the RN should consider as well as respond in an efficient and timely way to the health and well-being of the patient in relation to their capability of practice (Nursing Midwifery Board of Australia, 2016). In the case study, the identified symptoms and infection should have been considered immediately and the patient should have been recognised to be reaching the final days of life which should have further prompted optimisation of care in case of Tyler.
The ACU Practice guideline (2021), also states that palliative care is not just relevant to the ending weeks of life but needs to be given in a phased transition. Healthcare professionals must be capable of identifying the clinical indicators of dying in a patient along with the potential reversible causes of the deterioration. Further, the appropriateness of addressing these concerns should be assessed for individual patients. Supporting the argument, Taylor et al. (2017) states that clinicians need to be able to identify whether a patient is dying or not to ensure appropriate medical intervention, effective control of the symptoms, informed decision-making, consideration of any potential reversible issues and timely communication to the patients family. Moreover, if the professionals in Tylers case would have successfully recognised the indicators of deterioration, patients end-of-life care could have been optimised and managed effectively and eventually reduced patients discomfort during the terminal phase.
Second episode of care: Friday 20th March
As per the given case, Tyler was suggested hospital admission for treatment and discussion with both Tyler and Tylers wife Catherine were held and decision was taken to not opt for hospital admission as per Tylers wish and provide intravenous antibiotics at home (ACU, 2021). This depicts a positive episode of care considering the medical officer and nurses discussed the need for hospitalisation with both Tyler and Catherine before reaching any decision. The episode is also in accordance with the ACU Practice guideline (2021) which suggests that early, proactive and sensitive communication with the patients and their families supports shared decision-making and improves their satisfaction towards palliative healthcare. Not just that, shared decision-making also prevents conflicts and difference of opinion.
The care given to Tyler also complies with both NSQHS standard 2.06 and NPCS standard 5.2. As per NSQHS standard 2.06, the clinicians should partner with the patients and the substitute decision-makers in order to communicate and make the decisions about future care (Australian Commission on safety and Quality in Health Care, 2020). According to NPCS standard 5.2, health service should include effective communication to facilitate integrated care and support regarding end-of-life care plan (Palliative Care Australia, 2018). The involvement of medical officer, RN, Tyler and Catherine in decision-making shows that the professionals prioritise communication and it was essential for them that Tyler accepts the suggestion of hospital admission autonomously. Even Roodbeen et al. (2020) states that shared decision-making and communication are essential in facilitating a patient-centered care. It not only promotes understanding of patients needs but also improves their quality of life.
Third episode of care: Thursday 25th March
Tyler made requests regarding removal of Continuous positive airway pressure (CPAP) machine and contacting patients mother and brothers. However, instead of contacting Tylers extended family, the RN spoke to Catherine regarding the same. Also, despite Tylers request, CPAP was still used the next day (ACU, 2021). The episode of care is against the ACU Practice guideline (2021) that states the importance of respecting patients decision about ceasing a particular treatment while the patient is fully informed and competent of making a request. Moreover, the episode of care also does not comply with the NMBA standard 2.3, 2.4 and 2.5. The standards depict that RN should recognise patients to be the experts of their life, offer supports and direct the patients to resources which can improve their healthcare and advocate for the patients in a way which respects their autonomy. It can be analysed from the given case that Tyler was capable enough to make decisions regarding healthcare, but the RN did not respect the autonomy of Tyler and continued with the procedure of CPAP.
Also, it was imperative to contact Tylers mother and brother, but the RN spent time talking to Catherine and eventually Tylers extended family was not contacted as Catherine did not want to share the time with them. This disregards ACU Practice guideline (2021) as it suggests that wishes of an adult patient with the capacity of decision-making is paramount and should prevail over the wishes of patients family. The given care also goes against the Advanced Health Care Directive (AHCD) filled by Tyler which mentions that Tyler would want all the family to be present at the end (ACU, 2021). Although, the nurse did contact Tylers mother, but it was almost 3 days late. The need to respect patients autonomy is also discussed by Houska & Louka (2019) as the evidence suggests that supporting patients needs is a critical principle of care during end of life and it should not just be decreased to decision-making. It also ensures that patients dignity is maintained along with patients confidence and trust in clinicians. If Tylers extended family were contacted on time, Tyler would have spent his last days with them and if the CPAP machine was discontinued, it might have reduced his discomfort during the end.
Fourth episode of care: Friday 26th March Sunday 28th March
Proceeding regular visit to Tyler by the palliative care team including the social workers and nurses, support and counselling was provided to Catherine regularly for three days (ACU, 2021). This describes a positive episode of care as the patients family is offered effective resources and support to be able to cope with the grief. Although the ACU Practice guideline (2021) does not exactly mention the need for counselling or support for patients family during the patients end-of-life stage, but it does recognise the importance of arranging early meetings with the family to ensure consistent communication and allowing time for the family to accept and come to terms with the information. The care given is also in accordance with the NPCS standards 6.6 and 6.7 as the standards suggest that healthcare service should develop referral pathways and strategies in partnership with other service providers to assist patients family in feeling prepared for the loss of their loved one and counselling or specialist mental healthcare service should be offered for them (Palliative Care Australia, 2018).
Supporting the standards, Jung & Yeom (2021) also demonstrates that death counseling can significantly help the patient family and caregivers in preparing them for patients death and palliative care providers have a key role in ensuring maximum support to the patients family by arranging counseling for them. Similarly, Cuevas et al. (2021) also supports the idea of conducting a dignity therapy or psychotherapy for patients and their families during the end of life to relieve the existential and psychological distress and burden of the family members. Therefore, considering the case study, the clinical staff along with social workers visited Catherine and offered counseling and support. The involvement of social workers also shows effective partnership and integrated service for Catherine to be more prepared for Tylers death in near future. However, one of the negative aspects of this episode of care was that there is no mention of counseling or dignity therapy for Tyler. Evidence-based literature suggests that dignity therapy supports terminally ill patients in maintaining a sense of dignity and peace. It also improves the acceptance of adverse circumstances in patients and enables them to concentrate their strength on remaining calm and balanced (Iani et al., 2020). Hence, along with Catherine, counseling should also have been provided to Tyler.
Fifth episode of care: Monday 29th March
It is evident from the case study that Tyler died with Catherine by his side in their family home but Tylers children, mother and brothers were not present there (ACU, 2021). This is not just against the AHCD filled by Tyler but also against the CPG. The AHCD shows that Tyler did not want to die in the family home and wanted to be moved and cared at a hospice during the end stage and also wanted to be visited by a priest or minister during the end of life (ACU, 2021). Although a hospice bed was arranged for Tyler but it was too late considering Tylers condition but with respect to Tylers wishes, no priest or minister was contacted to visit Tyler in the end. As per the ACU Practice guideline (2021), patients values, preference and beliefs must guide the future course of healthcare. However, despite Tylers completed AHCD, no particular consideration was given to it during the end-of-life care for Tyler. Even the NPCS standard 2.8 has not been followed in this context as the standard states that the preferences and expectations of a patient and carers regarding the place of care and type of care must be documented and taken into consideration (Palliative Care Australia, 2018).
Welsch & Gottschling (2021) supports the argument by stating that respecting patients wishes during last phase of life is importance and it relieves the patients and their family of any unnecessary burden. Additionally, Glass et al. (2021) suggests that not receiving the preferred care in the form of location of death or any other request is one of the major challenges in palliative care that leads to dissatisfaction in patients and their families. Agarwal & Epstein (2018) also states that nurses can effectively facilitate the advance care planning in order to support the patients and their families during end-of-life care. Therefore, the RN and other clinicians should have fulfilled Tylers wishes and let Tyler die in peace and with dignity.
Conclusion
To conclude, the essay outlines five episodes of care where some of the aspects of care given to Tyler were positively associated with the End-of-life CPG and other standards whereas some of the care given did not comply with them. For instance, Tyler was respected for the decision to not be hospitalised and Catherine was counselled but Tylers AHCD and wishes were not followed effectively by the nurses and other clinicians in the case study.
References
ACU Practice guideline. (2021).End of Life Care.https://leo.acu.edu.au/pluginfile.php/4991076/mod_resource/content/1/End%20of%20Life%20Care%20CPG.pdf
ACU. (2021). Tyler Morton Advance Health Directive.https://leo.acu.edu.au/pluginfile.php/4990157/mod_resource/content/3/Tyler%20Morton%20AHCD.pdf
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