Order Description

Discussion: Discussing End-of-Life Care

There is a human tendency to postpone uncomfortable or unpleasant tasks.

—Nancy Kummer, geriatric patient

This human tendency to avoid the unpleasant makes end-of-life care and hospice decisions difficult

for many patients to discuss with their families. Kummer is a former social worker who used to

counsel patients with terminal illnesses, yet she avoided discussing her own end-of-life wishes

with her children. While many Americans, like Kummer, agree that these discussions need to take

place, few have actually had these conversations with their families (Lazar, 2012). Although

initiating conversations about end-of-life care and hospice might be difficult for patients, as an

advanced practice nurse, facilitating these conversations is an integral part of your geriatric

nursing practice. For this Discussion, consider how you would facilitate care conversations with

the patients and families in the following case studies:

Case Study 1

Mrs. Sloan, a 69-year-old widow, is about to enter the hospital for an elective cholecystectomy;

she is being medically cleared by her primary care provider. During the discussion, she requests to

be placed on a no code status during her hospitalization. Mrs. Sloan claims that besides her

gallbladder problem, her general health status is good. She wishes to have the surgery to avoid any

further attacks, which have been very painful. She states, however, that if during surgery or her

postoperative period, she undergoes a cardiac arrest, she would prefer not to be resuscitated. She

has read about the chances of successful resuscitation, and has determined that the risk of brain

damage is too high. For this reason, she is requesting a no code status.

Case Study 2

Ms. Stearns is an 83-year-old nursing home resident with hypertension, coronary artery disease,

arthritis, renal insufficiency, hearing impairment, and a previous history of stroke. She also has

a foot deformity from childhood polio. She is disoriented at times. She has lived in the nursing

home for 10 years and rarely leaves the chair beside her bed. She has recently developed urinary

incontinence, but has refused a bladder catheterization to determine postvoid residual urine or

possible bladder infection. She does not have a diagnosis of dementia; however, current testing

reveals that she performs poorly on a standardized mental status examination. She can, however,

identify all the staff in the nursing home, and she can describe each patient who has been in the

bed next to hers over the past 10 years. When asked to explain why she does not want bladder

catheterization, she gives several reasons. She states that the incontinence does not bother her,

and that she has always been a very private person. She particularly dislikes and objects to any

examination of her pelvic organs; in fact, she has never had a pelvic examination nor has she ever

had sexual intercourse. She realizes that she has a number of medical problems and that any one of

them could worsen at any time. She states she is not willing to undergo any treatment for any of

her current problems should they become worse.

Case Study 3

Mr. Marley, age 91, is admitted to the intensive care unit following a stroke. The stroke

progressed from mild hemiparesis and difficulty speaking to complete unresponsiveness and an

inability to swallow. His daughter feels certain, based on prior explicit conversations with her

father, that he would not want to have any treatment that would prolong his life and leave him in a

severely disabled state. Mr. Marley’s oldest son disagrees with his sister’s assessment of their

father. The son claims that their father still has a strong desire to live, and that he has been

very active in his church until this stroke. Because Mr. Marley cannot swallow, he cannot be fed.

The family is asked about insertion of a feeding tube. It is explained to the family that without

food and fluids, their father will die fairly quickly. There are no existing advance directives or

a designated health care decision maker noted for Mr. Marley.

To prepare:
•Review Chapter 14 of the Holroyd-Leduc and Reddy text.
•Reflect on the role of the advanced practice nurse in facilitating the discussion of end-of-life

care with patients and their families.
•Think about how you, as an advanced practice nurse, would approach a family who wants “everything”

done for a patient with only a limited time to live.
•Consider when it is appropriate to involve hospice and how to approach patients and/or families

who refuse hospice services.
•Select one of the three provided case studies related to the end-of-life care of the frail

elderly. Reflect on potential patient outcomes and how you would facilitate the discussion of care

with this patient’s family.

By Day 3

Post an explanation of the role of the advanced practice nurse in facilitating the discussion of

end-of-life care with patients and their families. Explain how you would approach a family who

wants “everything” done for a patient with only a limited time to live. Then, explain when it is

appropriate to involve hospice and how to approach patients and/or families who refuse hospice

services. Finally, explain potential outcomes of the patient in the case study you selected and how

you would facilitate the discussion of end-of-life care with this patient’s family.