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End of Life Care

Introduction

Mr. Rue (hypothetical patient) is a 75-year-old legally married to Mrs Rue. He has stage D heart failure. Heart failure is a medical condition where the heart cannot pump blood as required. I am the nurse discussing Mr Rue’s options of care with his wife Mrs Rue, children and siblings on the medical floor. I chose the medical floor because I need to observe privacy, quietness and comfort.

Mr Rue has not responded to medication within the last three months of hospitalisation. Prognosis indicates Mr Rue has a life expectancy of six months or less therefore qualifying the need for transition to hospice care. Mr Rue is at high risk of sudden cardiac arrest often characterised with painful symptoms. His capacity for decision-making is still intact. I have decided to take Mr Rue to hospice for comfort care to help relieve suffering and improve his quality of life as he dies.

I recognise that HF occurs from recurrent damage to the myocardium leading to worsening of symptoms. I further recognise that advanced (Stage D) HF is characterised by a burden of symptoms, suffering and death (Kida, Doi & Suzuki, 2020). Standard oral therapies do not offer adequate symptom relief for advanced HF patients. Mr Rue has increasing physical and spiritual suffering making him face growing risk for death. The available options for Mr Rue are continuation of medical therapy as directed in the NCCN Guidelines for palliative care, device interventions and cardiac transplant.

Actions Addressed

I understand the need for clear and open communication about Mr Rue’s condition and decisions to be made. Prior to this discussion, I held a frank conversation with Mr Rue regarding the possible range of prognosis. I did this because the moral guidelines require us to observe patient’s autonomy and self-determination (Kida, Doi & Suzuki, 2020). The information that I will collect after this conversation will help me assess the medical, psychosocial and spiritual goals of the Mr Rue and family. In our previous conversation, Mr Rue said he wants to be at peace with God, have you (family) around and be mentally aware when he dies.

The treatment options that I can possibly consider for Mr Rue include continuation of medical therapy as directed in the NCCN guidelines, device interventions and cardiac transplant. Hospice care aims to deliver medical, physical, emotional, social and spiritual support using an interdisciplinary approach from a broad spectrum of caregivers before end of life (Kida, Doi & Suzuki, 2020). The aim is to reduce suffering of the dying patient. Therefore, I will not consider device interventions and cardiac transplant for Mr Rue because he is not responding to these types of interventions. Mr Rue’s main concern is pain, dyspnoea, oedema, fatigue and depression. I will consider therapies to manage the above symptoms based on how they manifest on Mr Rue.

Obligations

I acknowledge the conflict in demands concerning Mr Rue’s options of care. Mr Rue has agreed to be taken to hospice care but you, the family, want us, the healthcare workers, to continue treatment to prolong his life. I encounter these situations of conflicting demands regularly. I will have reached a mutually agreeable solution by the end of this discussion. According to the NCCN guidelines, I are obliged to provide comprehensive and compassionate care (Dans et al., 2017). These include evaluating the patient’s condition and sharing the information with you.

We all agree that Mr Rue has a capacity to make decisions regarding his course of life. The resources available for resolving the ensuing conflict are the Code of Ethics for Nurses and Nursing’s Social Policy Statement (American Nurses Association, 2016). I have given each of you a copy for reference. The principle of autonomy and self-determination specify that we let Mr Rue have what he desires. That would be the last favour we could accord to him (Karnik & Kanekar, 2016). It is in his best interest that we do what benefits him the most.

Options

Mr Rue exhibits symptoms such as dyspnoea, pain, nausea, fatigue, constipation, oedema, depression and sleep disorders (Maciver & Ross, 2018). I would like to inform you that the options I have for Mr Rue’s condition are limited to managing his symptoms. For dyspnoea, I have an option of therapeutic diuresis and vasodilation to reduce pulmonary congestion (Kida, Doi & Suzuki, 2020). However, Mr Rue’s Stage D HF with hypertension and renal dysfunction may limit the effectiveness of dieresis.  I will not consider this option. I will instead administer low dose opiates. Opiates will control pain symptoms. I will also administer selective serotonin reuptake inhibitors to manage depressive symptoms.  

As previously explained our focus as healthcare workers is to control symptoms and optimise Mr Rue’s quality of life rather than extending life as you have expressed. I recognise that I need to consider both Mr Rue’s, Mrs Rue’s, the children and siblings’ concerns to achieve the required quality end of life. Our decisions have considered your and Mr Rue’s values. I have been honest with you by giving you consistent information regarding Mr Rue’s condition. I have considered Mr Rue’s wishes when making this decision to take him to hospice.  Our decision is in response to his emotional needs while ensuring that I provide comprehensive treatment that focus on him and his health condition. This is a difficult decision to make, and it may appear that I am helpless in regaining Mr Rue’s health. However, advanced HF is best managed through hospice, especially when Mr Rue is not responsive to medication, as I have seen over the last three months.

Barriers and Facilitators

The unique course of HF and difficulty in providing prognosis is a barrier to timely referral to hospice.  I predominantly use prognosis data to decide if a patient is due for transition to hospice (Cross et al., 2019). I also face policy barriers such as six-month survival requirement and low fixed daily payment rate. Other factors such as lack of integration of palliative care with cardiology, inadequate research in palliative care in HF and patients overestimating survival hamper transition to hospice. Nursing factors such as inconsistent communication, unclear communication between concerned healthcare personnel, difficulties in specifying timelines for end of life care and feelings of unpreparedness in discussing the end of life issues with patient and family are other factors (Ziehm et al., 2016). Inadequate knowledge about the disease and its progression hamper the patients and relatives preparedness to ask questions thus presenting as barriers. They, therefore, direct the nurses to do everything possible to prolong the life of the patient.

Facilitators of good end of life care include streamlined communication channels in the healthcare team that facilitates the consistent flow of honest information to patients and family members (Pivodic et al., 2018). Highly skilled and knowledgeable healthcare team facilitates quality end of life care through providing the most appropriate care that considers the patient’s wishes, values and beliefs while adhering to the NCCN guidelines of end of life care (Dans et al., 2017). A qualified team provides a comprehensive treatment that is responsive to the patients and relatives emotional needs.