Case study of 374 palliative approach The

Case study of 374 palliative approach The Patient: Tyler Morton… Case study of 374 palliative approach The Patient: Tyler Morton is a 40-year-old man who spent is childhood and teenage years in Brisbane. Tyler, whilst growing up excelled in all sports and represented QLD in the state Cricket Team. Upon completing high school, Tyler graduated from the University of Queensland with a Bachelor of Business Management before joining the Royal Australian Airforce as a Pilot in 2004. Whilst training to become a Pilot, Tyler met is future wife Catherine in Newcastle and this is where the couple settled to commence their family. Tyler and Catherine have 3 Children. Catherine is a stay at home Mum to: · Andrea (8 Years) · Jessica (5 years) · Erin (2 Years) Being from Newcastle, Catherine’s Family is very close to Tyler and Catherine and spend a lot of time together. Tyler’s Family is in Brisbane and has only minimal contact with Tyler and his young Family. Unfortunately, Catherine and Tyler’s mother Joyce do not get along and this causes a lot of conflict in the marriage. Friday 20th March The medical officer (MO) reviewed Tyler after concerns raised by Registered Nurse. Tyler had developed another peg site infection. It was discussed with Tyler the need for IV antibiotics. The MO suggested admission to hospital for treatment, however Tyler was not keen on this suggestion. After discussing hospital admission with both Tyler and Catherine together, it was decided that this was not an option. The Community Palliative Care Team would provide further care to Tyler with provision of IVAB’s in the home. It was arranged for Tyler to have a day visit to the local hospital for insertion of a PICC line due to expected long duration of antibiotics. Notes made by MO following review of Tyler: “Overall decline in patient’s condition on observation. Physically dependent for all activities of daily living.” “Patient appears to be orientated to person, place and time. Some confusion at times, most likely due to infection present.” “Patient’s wife appears to be supportive of patient and his decisions. It is my observations that the patient’s wife is expecting a full recovery from current infection. It is uncertain of her understanding of the patients condition.” Palliative Care Phase – Unstable Wednesday 24th March (Afternoon) Tyler’s peg site appears to be less inflamed and redness has subsided a little. Tyler remains warm to touch. RN administered PRN oramorph to assist with Tyler distress and discomfort. Tyler has developed a wheeze. Repositioned to the semi- recumbent position to assist with breathing. Tyler appeared slightly confused, although was orientated place, person, and time. Tyler’s mood appears low. He puts a brave face on when his daughters are around, however Catherine is noticing a significant difference in his demeanour. Thursday 25th March (Morning) Tyler is visited by the Palliative Care Registered Nurse. Catherine is out dropping the children at school. Tyler appears to be extremely short of breath and struggling to breathe. O2 2L via NP was insitu. The RN applied NIV to assist Tyler with his breathing. Thursday 25th March (Afternoon) When attending to Tyler’s personal cares, Tyler made some requests to the RN. He asked for the CPAP machine to be removed, more analgesia for his increased pain and discomfort, he requested for arrangements to be made for a bed in the hospice and requested for his mother and brothers to be contacted. The RN spoke with Catherine regarding contacting Tyler’s extended family. Time was spent with Catherine talking about Tyler’s condition at present. Tyler was orientated to person, place and time. Catherine did not want to share this time with Joyce and Tyler’s brothers and therefore she did not contact them Friday 26th March (Morning) – Sunday 28th March (Morning) Tyler was visited 3 times per day by the palliative care team. At different times nurses and social workers visited. Symptom management included: Break through intermittent pain relief Pressure area care Dyspnoea relief – intermittent use of CPAP combined with 02 therapy Mouth cares Peg feeds continued Support and counselling given to Catherine Sunday 28th March (Afternoon) When the palliative care nurse visited Tyler, she found him to be restless and agitated. Tyler stated he was in pain, and he just wanted it all to be over. Tyler asked again after his mother and brothers and the chance of being transferred to the hospice. After a thorough assessment, talking to Tyler and Catherine extensively, the nurse implemented the following: Subcutaneous butterfly (waiting for the order for continuous analgesia infusion) Called the hospice and arranged a bed for the following morning Peg feeds discontinued Called Joyce to inform her of Tyler’s condition A syringe driver containing morphine, haloperidol and ondansetron was commenced after an order was received from the MO. A hospice bed was arranged for transfer Monday afternoon. Joyce and Tyler’s brothers were making flight arrangements to be there asap. Modified Karnofsky Score – 30 RUG-ADL – 17 Tyler is now in the Terminal Palliative Care Phase Monday 29th March (Morning) Upon arrival of the palliative care nurse, Tyler appeared still and comfortable. His breathing was short, shallow and laboured with a respiration rate of 5. Catherine was sitting by Tyler’s bedside. Tyler’s girls were visiting neighbours. Joyce and Tyler’s brothers were due to arrive at 1pm. At 1025 hrs, Tyler’s respiration rate decreased further. Upon inspection, Tyler’s peripheral extremities were cyanosed. Tyler’s pupils were fixed and dilated, and he took is last breath with Catherine by his side in the family home. Quality of Life Considerations Consider some of the following as you select one of the clinical practice guidelines supplied in the assessments folder to assist you with working through the diagnosis, and journey to the palliative care setting: Rapid diagnosis and disease progression leaves little time to consolidate and prepare for death – spiritual, social and cultural needs must be considered Was an adequate pain scale used? How can the family be provided with support and continuing bereavement follow-up ? Consider the adequate and detailed use of the SAS tool. What can nursing staff provide families and the deceased patient to aid them in their grief, loss and need to say goodbye? Are the National palliative Care standards considered in the CPG? Were the NMBA and NQHS standards considered in the CPG? What is your responsibility as an RN to understand the disease trajectory of your patient’s, plan their care and the care of their loved one’s through the knowledge of nursing standards? Was the Advanced Health Care Plan followed in the care that was provided? Questions: Review and critique the care given to the patient against Care for dying patient which is selected CPG and provide evidence to support your critique through additional research that you will undertake Highlight the importance of the National Palliative Care Standards and at least one of the NSQHSS and/or the NMBA Standards and how they influence our practice. Please relate with case study. Demonstrate knowledge on the illness trajectory of Motor Neurone Disease (MND) in line with Palliative Care Principles. Please relate with case study. Provide links between the case study and your chosen CPG to identify highlights or limitations in care Note: Please relate or link all these questions with case study following CPG (Care for Dying people).

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