DEIB Case Study: Facilitating Quality End-of-Life Care (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    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!

    About the Lecture

    The lecture DEIB Case Study: Facilitating Quality End-of-Life Care (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course NGN DEIB Case Studies.

    Author of lecture DEIB Case Study: Facilitating Quality End-of-Life Care (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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