NURS1137-Palliative Care-Case Study Of Melissa

Introduction

Advanced care planning can be referred to as the formal decision making that is for helping the patients establish decisions about the future care that comes in to effect when they lose the capacity (Lovell & Yates, 2014).

The assignment is based on the Melissa, a 37 years old women, who had been suffering from stage 4 Bowel cancer and requires advanced care planning. The assignment aims to focus on the benefits of the advanced care planning process Melissa, the possible preparation needed before the initiation of the advanced care planning process including the choice of the members for the discussion process, the multidisciplinary teams , the mental or the physical status of the patient to be able to participate in the decision making process.  This assignment will also discuss about the type of information that should be included in the advance care planning and when and how the advance care will be reviewed.

Possible benefits of the advance care planning for Melissa

Advanced care planning is important for people who are too old and frail or are suffering from terminal disease such as cancer, where apart from the treatment the wishes of the patient are documented or the ill person in encouraged to choose a substitute decision maker to know the health care preferences of the ill person (Lovell & Yates, 2014). In an ACP the patients, families and the health professionals discuss and establish the future goals of care according to the preferences of the patient (Lum,  Sudore & Bekelman, 2015).  It is evident form the case study that Melissa had been suffering from stage 4 Bowel cancer. A stage 4 cancer means that the disease have spread from th  colon to the distant organs. Melissa might already be going through several physical and emotional burden. The burden of cancer, medications and the chemotherapy is very painful and causes several side effects that decreases the quality of life. Furthermore the sense of having very few days of life can bring about depression in the patient (Houben et al., 2014).

The advanced care planning includes getting information about the different types of life sustaining treatments that are normally available, deciding on the type of treatments that is anticipated, sharing the personal values with the loved ones (Bischoff et al., 2013). It is evident that Melissa has two children, hence Melissa might wish to consult a lawyer to discuss about the will, or whether her children should be given in charge of her ex-husband since, and there had been a shared caring towards the children. Furthermore, Melissa might also want her husband to be contacted, since they had been separated for long 10 years and she might want to discuss about how their children should be taken care off. Melissa might also need some time to wrap up her work as she had been working as a full time administration assistant in a publishing company and had been managing the important sector of the company. Furthermore, cancer is a chronic complication that brings along several comorbidities that needs to be addressed by the help of a multidisciplinary care team. Inadequate ACP might affect people’s life and their experiences with the health care.  At the end of life, most of the people prefer for treatment that are less effective and focusses on the quality of life. According to Brinkman-Stoppelenburg, Rietjens & van der Heide, (2014), the family members of the patient who have received an intensified treatment at the end of life experience more guilt, depression and the reduced quality of life. Initiation of conversation about the decision of care is necessary in front of the whole family, hence at first Melissa should be provided support to become mentally strong to take part in the decision making process. Such conversations should not be done when the patient is too emotionally weak or is going through heavy pain. 

Time for the planning

Before an advanced care planning the clinicians might decide whether Melissa is eligible for the advance care planning initiatives. Advanced care planning for a patient is initiated when the patient is well enough to participate any kind of discussions, hence it is necessary that Melissa is in an awakened state and have that functional capability to take part in the discussion process. There are some studies that have discussed about some particular triggers for initiating conversation, such as the recurrence of cancer. Since sudden changes might occur in the course of the diseases, the opportunity to take part in the advanced care planning could be omitted if the subject is not broached early (Billings & Bernacki, 2014). There are literary evidences that claims that advance care planning might not be done to early as the course of the disease might change or such planning might bring about additional distress of him which might deteriorate her physical and mental health before the expected time (Greer et al., 2013).  

Preparation prior to the discussion

The responsibility of engaging the patients in the advance care planning do not lie solely on the physician. The multidisciplinary team are expected to work together in a coordinated fashion for engaging the patent and the families. They should work in a coordinated fashion for engaging the families and the patients (Chiarchiaro,  Buddadhumaruk, Arnold & White 2015).  Before the initiation of the advance care planning it is necessary to assess the readiness of the patient to discuss the advanced care planning. For this it is necessary to engage in frank and the friendly conversation with the patient (Mullick, Martin, & Sallnow, 2013). Planning should be incorporated over multiple visits. The existing clinic program can be modified for supporting the advanced care planning such that at the time of the planning all the applicable state laws and the scope of the practice requirements are met and there should be a minimum of the direct supervision in addition to the other rules (Zimmerman et al., 2015). 

The clinicians might advise to consult the Medicare Administrative Contractors regarding the requirement of the documentation. One of the important aspect that should be taken care of in the advance care planning is the communication skill of the health care professionals. A number of authors have potentially recognized the challenging, sensitive and the complex nature of the conversation regarding the advanced care planning (Bernacki & Block, 2014). One of the component of such high skilled communication is not knowing when not to proceed with the discussions and how to titrate the information in front of the patient depending upon the level of distress caused to the patient.  While preparing to offer the discussions it is necessary to consider certain things- Melissa might require some time to think and reflect hence the initial advance caring planning process might extent to more than the stipulated time (Mack et al., 2013). It is to be noted that the outcomes of the discussion are shared equally among the relevant members of the Multidisciplinary team (Mullick, Martin, & Sallnow, 2013). It is necessary to start the conversation with general open ended questions that should be guided by the patient cues and the responses for knowing whether further has to be explored. At the time of the conversation it is necessary choose the language in which Melissa is comfortable with. Enough information should be provided to the patient in order without overloading them. Any ambiguous statements should be clarified. The conversation can be ended by summarizing what has been discussed properly (Mack., 2012).

Members to be included in the advanced care planning

In case of Melissa, both her parents should be encouraged in the discussion. Melissa’s ex-husband can also be called upon for the discussion. Joshua can also be engaged in the discussion as he is 15 years old and might serve as the mediator when Melissa would not be able to take part in the decision making process any more. Furthermore there can be legal documents for replacing the power of attorney, which allows the patient to nominate someone to whom they want to transfer the decision making power.  According to Chiarchiaro et al. (2013), discussions should not take place in wider family or social networks as that might give rise to conflicts and hence any kinds of advanced care decisions should be made in front of the chosen individuals. Other than this the members of the multidisciplinary team can be included. 

Information shared in the advanced care discussions

In an advanced care planning discussion the patient is normally given a vivid description about the prognosis of the illness and the future course that the disease might take place, including the financial burden, the effect of the medicines, and the loss in the functionality. The patient will be educated about the importance of surrogate decision maker and will address the different barriers (Sudore, & Fried, 2010). Then it is required to articulate the values of the patient over time and establish the leeway in the surrogate decision making. According to According to Victorian Government., (2018), the best practice standards for the advanced care planning are that, the decisions are person centered, respect for the autonomy, health decisions can be broad, decisions can be related to any time in the future. Section 38 of the Guardianship and Administration Act 1986, enables some other person to take decision on behalf of the person who cannot make decision by himself , but the patient’s wishes will be given the first priority. According to Victorian Government., (2018), it is necessary ask the patient whether he wanted the plan made for him to be implemented. If the person chooses, a legislative forms might be used for appointing an enduring power of attorney or fill up a refusal of treatment form. All the planning discussions needs to be documented for future purposes.

Review of the planning

It is necessary to review the discussion if necessary such as if the patient would like to refuse any kind of treatments. Although there are no specific timings for reviewing the decisions. Personal experiences and several factors are there relevant should be of prompt review. New therapeutic options might get available with the progressing condition, the value and the goals of the patient might change (Mack., 2013). In this case Melissa might not want Joshua to become the decision maker as he is still not matured and might want her parents to take the decision. 

Conclusion

The primary objective of the advanced care planning is to prepare the patients and the surrogates you work with the health care professionals for making the best possible medical decisions. The health care professionals help the patient and the surrogates in the outpatient set him for communicating their beliefs and the values. In this case it is necessary that Melissa’s parents, her elder son Joshua and her ex-husband to take part in the advanced care planning. A good friend can also be included in the plan. Preparing the patient before the discussion of the advanced planning is an important step in the process. Choosing the appropriate surrogate decision maker is also one of the important step in the advanced care planning process of Melissa. However it is recommended to review the planning process if in case the attorney needs to be changed. 

References

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Billings, J. A., & Bernacki, R. (2014). Strategic targeting of advance care planning interventions: the Goldilocks phenomenon. JAMA internal medicine, 174(4), 620-624.

Bischoff, K. E., Sudore, R., Miao, Y., Boscardin, W. J., & Smith, A. K. (2013). Advance care planning and the quality of end?of?life care in older adults. Journal of the American Geriatrics Society, 61(2), 209-214.

Brinkman-Stoppelenburg, A., Rietjens, J. A., & van der Heide, A. (2014). The effects of advance care planning on end-of-life care: a systematic review. Palliative medicine, 28(8), 1000-1025.

Chiarchiaro, J., Buddadhumaruk, P., Arnold, R. M., & White, D. B. (2015). Prior advance care planning is associated with less decisional conflict among surrogates for critically ill patients. Annals of the American Thoracic Society, 12(10), 1528-1533.

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Sudore, R. L., & Fried, T. R. (2010). Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making. Annals of Internal Medicine, 153(4), 256–261. https://doi.org/10.1059/0003-4819-153-4-201008170-00008

Victorian Government., 2014-2018.Advance care planning: have the conversation. Access date: 7.10.2018. Retrieved from:https://www2.health.vic.gov.au/-/media/health/files/collections/research-and-reports/a/advance-care-planning—strategy—pdf.pdf

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