00:01
Hi, I'm Jackie.
00:03
Let's do a case study.
00:05
The title for today's
case study is:
Facilitating quality
end-of-life care.
00:10
Let's meet George
and his family.
00:13
The nurse assumes care
of this 89 year old male
on palliative care
for esophageal cancer
who is awaiting a percutaneous
endoscopic gastronomy
or PEG tube replacement.
00:25
To gain an understanding
of what's been going on,
let's take a look
at the nurses notes.
00:29
The nurse wrote,
care was assumed,
client lying on the bed
supine with eyes closed
wife and daughter
at the bedside.
00:37
The wife is observed moistening
the clients mouth with a sponge.
00:41
And the daughter is noted
to be staring at the floor
with their arms crossed.
00:46
The clients wife then
begins to cry and wail.
00:49
And the daughter states the last
nurse wouldn't let anyone back.
00:53
And family is everything to us.
00:56
Sounds like this is a really
difficult time for everybody.
01:00
So let's try a question
based on everything
that's happened so far.
01:04
So we've summarized it here.
01:06
And then we're going to
highlight some of the findings
that will make it easier to
break this question down.
01:12
Now let's look at each
of the highlighted areas
and decide whether
it requires immediate
follow up by the nurse.
01:20
Not that it requires
follow up in general,
but immediate.
01:24
We'll go one by one
to make it easier.
01:27
Noted to be lying supine.
01:29
So George is lying
on the bed face up.
01:32
Well, there's not really any
contraindication to that,
so we won't click that one.
01:38
With his eyes closed.
01:40
Well, without any other
symptoms or problems,
the fact that George's
eyes are closed
are also not a concern.
01:45
So we won't highlight that.
01:48
The wife is observed moistening
the client's mouth
with a sponge.
01:52
Well, this is a very caring
and thoughtful thing to do,
certainly doesn't indicate
a problem or concern.
01:57
So we won't highlight
that one either.
02:00
But let's look at
the last paragraph,
the daughter was noted to
be staring at the floor
with her arms crossed.
02:07
Well, this is definitely
a non-verbal way
to communicate dissatisfaction.
02:11
This definitely requires
an immediate follow up.
02:15
So we will click this one.
02:17
The clients wife then
began to cry and wail.
02:21
Something is unfortunately
definitely going on here
that is problematic
and concerning.
02:26
So the nurse needs to follow
the myths as soon as possible.
02:29
So we'll click this one.
02:31
And the final statement,
the last nurse wouldn't
let anyone back.
02:36
Family is everything to us.
02:38
Again, indicating
some dissatisfaction
and the nurse needs to
follow up immediately
and figure out
how they can help.
02:46
So we will also highlight that.
02:48
So this is the correct response.
02:52
As nurses, we definitely work
on an interdisciplinary team
with social workers at
respiratory therapists,
occupational therapists
and the like.
03:00
When the nurse comes
back the next day,
they happen to read
the case managers notes
to determine what's been going
on in the last few hours.
03:07
And this is what the note says,
met with the client and family.
03:11
The client and family share
that they are Cherokee,
have traditional Native American
values, and they currently
live on a reservation.
03:18
They are requesting to
have a smudging ceremony
to be performed by
a native healer.
03:24
Now that we know the
background about George
and we have some information
from the case manager,
we're ready for a question.
03:31
So based on the information
gathered by the nurse
and the case manager,
click to specify if the
clients family is at risk
or not at risk for these
potential problems.
03:40
We'll take each potential
problem, line by line,
remember, at risk
are not at risk.
03:47
Here's the first
potential problem.
03:49
Impair communication
between the client
and the healthcare
professionals.
03:53
While there's definitely an
indication that there's been some
nonverbal dissatisfaction,
some issues of communication.
04:00
So with this place the
client at risk for a problem?
Absolutely it would.
04:05
So we'll click this
as at risk for.
04:08
Decreased quality of
life at the end-of-life.
04:11
Well, if the family is not
getting their needs met,
and George is not
getting his needs met,
and not just medical,
but psychosocial and cultural,
then it's definitely going
to create an issue with
providing a quality and
the life experience.
04:24
So that's at risk for.
04:27
Resistance to palliative
care interventions.
04:30
Well, there's been nothing
in this story so far
that has indicated that
George or his family
are resistant to
any intervention,
just asking to have
their needs met.
04:38
So this is definitely
not at risk for.
04:42
Spiritual distress.
04:43
There's absolutely an association
between spiritual distress
and really poor
quality outcomes.
04:49
We're not able to
meet client's needs,
that's not quality care.
04:53
So this definitely at risk for.
04:56
Confusion regarding the plan of
care due to resource abundance.
05:00
Why didn't hear anything
in this story so far
that indicates that there's any
confusion on part of the family?
Asking for their
needs to be met,
which is not the same
thing as confusion.
05:09
So this is not at risk.
05:12
Take a look at these answers.
05:15
Now let's try another question.
05:16
Complete the following sentence
by choosing from
the list of options.
05:21
Here's the sentence.
05:22
While the client
is in the hospital,
the nurse identifies _____
as the priority concern primarily
influenced by the blank.
05:31
Ready?
Let's look at option one.
05:34
We're looking for what
is the priority concern,
the most important thing.
05:40
Now likely we're going to find
lots of important
things in this list.
05:43
More than one,
maybe all of them,
but one of them is going to rise
to the top as the most
important priority concern.
05:51
Here we go.
05:53
Achieving a desirable quality
of life at the end-of-life.
05:56
Is that a priority concern?
Sounds like it to me,
this is the first answer.
06:01
Let's see what else we have.
06:03
Symptom relief.
06:05
Well, that's a concern.
06:08
But he doesn't seem like he's
having any problems at this moment.
06:11
So maybe that's not
the priority concern.
06:14
I don't think it sounds
better than achieving
a quality and the
life experience.
06:19
So we won't click that one.
06:22
The next one.
06:23
The inability to
express spirituality.
06:26
Well, there's been lots of
expressions of spirituality,
we learned about the smudging
ceremony and the dissatisfaction.
06:31
So there's not evidence
that this is happening.
06:34
So we'll definitely
not choose this one.
06:36
And the final option, the
ability to build rapport
with the client and the family,
while the family is expressing
what their needs and desires are,
which is sort of
indicative of the fact
that we have open
communication and trust.
06:49
So that's not going
to be the answer.
06:51
So it was the first option,
achieving a desirable quality
of life at the end-of-life
is the priority
concern for the nurse.
07:00
Now, as we look for option two.
07:02
We're looking for what's
influencing that outcome?
Hmm.
07:07
Is it behavior the family
identified beliefs,
request for a smudging ceremony,
or the client's
current diagnosis?
Hmm.
07:16
Behavior of the family.
07:18
Well, certainly,
there are indicators
that the behavior is telling us
that we are not
meeting the values,
this is a problem,
it's not a concern.
07:27
So this wouldn't be
the correct answer.
07:30
Identified beliefs.
07:31
Well, the family's indicated their
beliefs are important to them.
07:35
And this is definitely an
important consideration
for achieving quality
end-of-life experience.
07:40
This sounds like a
pretty good answer.
07:43
But again, it's
only the second one.
07:44
So let's see what else we have.
07:46
Request for a smudging ceremony.
07:49
Well, there's no evidence
at the family's concerned
about the smudging ceremony,
they've just requested
that there be one.
07:56
So this isn't a problem.
07:57
So we won't select this one.
08:00
And the final option,
client's current diagnosis.
08:04
Unfortunately,
George is terminal.
08:06
But that doesn't mean we can't
have a quality experience.
08:09
So we're not going
to click that one.
08:12
So in fact, identified
beliefs is the best answer.
08:16
So here's the sentence in total.
08:18
While the client is in the
hospital, the nurse identifies
achieving a desirable quality
end-of-life experience
as the priority concern,
primarily influenced by
the identified beliefs.
08:29
And these are the beliefs
of George and his family.
08:32
Now, I have another
question for you,
which three solutions
overcome the barriers
and promote quality of
life for this client?
So what can we do
to make sure that George
has a good experience?
Well, option one,
provide exemption to
visitor guidelines.
08:49
Well, this is advocating
for George and his family.
08:52
Sometimes we have
to change the rules
to make sure that our
clients get what they need.
08:57
This is something that
would reduce a barrier.
09:00
So we'll select this one.
09:02
Coordinate accommodations with
the interdisciplinary team.
09:05
Remember, we work on a team,
we want to make sure that
all members of the team
know what's going on so that
they can advocate and support
the family as well.
09:14
So we're going to
check this one too.
09:17
The next option:
Suggest performing
rituals at night
when no one will notice.
09:23
This sounds like
we're sneaking around
and doing something
we shouldn't be doing.
09:26
It's not open and honest.
09:29
It sounds like we're
doing something shameful.
09:32
This isn't overcoming a barrier
and it's not promoting
quality of life,
it’s sneaking around,
so we won't check that one.
09:38
This is inappropriate.
09:40
The next one.
09:41
Explained thoroughly
the reasoning
regarding current
hospital guidelines.
09:46
Well, when we talk about,
we do things because
that's policy,
we do things because
those are guidelines.
09:52
It doesn't sound
very accommodating
and it doesn't make
people feel welcome.
09:55
So we're not going
to click this one
because it is also
inappropriate.
10:00
And the last option, examine
one's own values and beliefs.
10:04
Now, to be perfectly honest,
this is something we
all need to be doing
every day in every situation,
whether we're with a
George or with anyone.
10:12
Our own values and beliefs
and implicit biases
definitely affect our ability
to provide quality care.
10:18
So this is absolutely
going to be checked.
10:20
So here are your
three correct answers.
10:24
Now we're ready for
the next question.
10:26
So building on some
of the answers,
we had in the last
questions about
things we could do to help
clients feel supported,
which statement by the nurse
during the end of shift report
reflects an
intervention to promote
quality of care at the
end-of-life for George.
10:43
So these are all statements.
10:44
So which one is consistent
with following through
on some of those things
we mentioned in the
previous question.
10:50
Here's the first one.
10:52
I have been having
the family rotate
in and out of the room
so that only two
are at the bedside.
10:57
But everyone still
gets to see the client.
11:00
Does it sound like we made
any exemptions to the rules
or did anything special?
Nope, doesn't sound
like that to me either.
11:06
So that's not the best option.
11:09
The next statement,
I contacted the supervisor
about the smudging ceremony
to see if it can be arranged
to take place outside.
11:17
Hmm.
11:18
That sounds like we're
really working through
what the client asked for
her and what they needed.
11:23
That sounds like a good answer.
11:25
But let's see what our
other statements are.
11:28
I called the healthcare provider
to see if we can
expedite the discharge
so that being in the hospital
doesn't interrupt
is end-of-life care?
Well, if we read between
the lines on this one,
this one's, "Hurry up,
so that we don't have to deal
with the things you want to do.
11:41
And we'll just send you home
so you can have it
the way you want."
Well, they didn't
ask to go home,
they asked to have the smudging
ceremony performed at the hospital.
11:49
So this isn't doing
anything for the client.
11:52
So this isn't the best answer.
11:54
And finally,
it's crowded in there
with five family members.
11:58
But don't worry, I
already let them know
they won't all get chairs.
12:02
Well, that's not
hospitality at all.
12:04
And it doesn't sound
like we've done anything
to really promote a
quality experience.
12:09
So that's not the
best answer either.
12:11
So the second option,
I contacted the supervisor
about the smudging ceremony,
absolutely the right answer.
12:18
It's now Thursday.
12:19
Let's see what happened.
12:21
The hospital supervisor
contacted the nurse's station
to inform them that the
smudging ceremony was approved
to take place outside.
12:28
Attending the ceremony
with the nurse,
the hospital Supervisor
and the Supervising
health care provider.
12:35
The ceremony was performed
without any issues at all.
12:38
And the client
was actually moved
to a larger room to
allow for more visitors.
12:44
George's wife is
holding his hand
and there's music playing
and the family is sitting
on the client's bed,
looking through a photo album.
12:52
When the nurse asks if
George is having any pain,
or the family has
any further requests,
George just says thanks so much
for everything you've
done for my family.
13:02
That's how it should be.
13:04
So we're going to do
another highlight question.
13:07
So we've summarized
what's happened here,
and I'm going to highlight
all of the actions
that might be important.
13:12
And we're going to consider
whether these
statements indicate
that there's been
an improvement.
13:18
So not just what happened,
but are things better.
13:21
That's what we're looking for.
13:23
So here are the options.
13:25
Let's look at the statements.
13:27
The first statement,
the client was moved
to a larger room
to allow for more visitors.
13:32
Well, that happened.
13:33
And that's great.
13:35
But it doesn't necessarily mean
that there's an improvement
to anything yet.
13:38
So we won't check that one.
13:41
The spouse, George's wife says,
Thank you so much. Bless you.
13:46
That sounds like a
positive interaction.
13:48
They're saying thank you for
something had that has happened
that they appreciate.
13:52
This is positive.
13:54
So an improvement?
Absolutely.
13:57
We'll check this one.
13:59
The next statement.
14:00
Playing music and the family
is sitting on the client's bed,
looking through the photo album.
14:05
This again, sounds like
everyone's comfortable,
and it's a positive interaction.
14:09
So it sounds like we're
achieving quality outcomes here.
14:12
So we'll click this.
14:15
Client denies pain.
14:17
Well, that's great that
George denies any pain.
14:21
But it didn't sound
like he was having pain.
14:22
So this doesn't really
indicate an improvement.
14:25
It's just a good thing.
14:26
But we won't check that because
it doesn't answer the question.
14:30
But the final statement says,
thanks so much for everything
you've done for my family.
14:35
This is what George has said.
14:37
This definitely demonstrates
that we have met the
needs that George had
and supported his values
and supported his family.
14:47
All done.
14:48
Great job!