Palliative Nursing Care Case Study

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Introduction: “Palliative care is the specialised care of people who are no longer responsive to curative treatment and who are dying. The aim of palliative care is to provide symptom management by addressing pain and other physical symptoms, and by providing psychosocial and spiritual care” (Koutoukidis, Stainton, & Hughson, 2017, p. 1115).
Question 1: Case study

Penny is a 97-year-old lady who resides at a local Residential Aged Care Facility (RACF). Penny was diagnosed 10 years ago with Alzheimer’s Disease.  Two years ago a lump was observed on her left breast.  This was diagnosed as breast cancer.  Due to her age and health status, no active treatment was commenced.  The lump has just recently developed into a fungating wound which requires management.

Prior to her admission to the facility Penny was cared for at home by her granddaughter, Margaret, until she was no longer able to cope.  More recently due to her wandering and intrusive behaviours Penny has been cared for in a Dementia specific unit.  Penny is widowed and has four children.  Two live locally and two live interstate.  The two that live locally visit regularly however they are elderly as well and less able to contribute to her care.

Margaret visits frequently, is Penny’s next of kin and holds Enduring Power of Attorney for Penny’s health decisions.  Margaret has noticed a visible decline in Penny over the last 2 months and now she is refusing to take food and only minimal fluids.  She is becoming weaker and no longer is at risk of wandering, has become increasingly confused, lost weight and spends her days nursed in bed or in a comfort chair.

At family conference Penny’s doctor has advised her family that she is now requiring palliative care and active medical interventions would be ceased and interventions will be more focused on keeping her comfortable and pain free. The doctor states he will instruct that she be commenced on an End of Life Pathway.

  1. Margaret has come to see you and has asked you to explain ‘palliative care’. (100 words)
Palliative care is care that helps people live their life as fully and comfortably as possible when living with a life limiting or terminal illness. Palliative care is based on individual needs and the services offered will differ with every person (Palliative Care Australia, 2017). A primary goal of palliative care is to relieve physical and emotional suffering that affects the patient and their family. With symptom relief as a focus, paying close attention to those who are suffering is an essential practice for the palliative care team. In short, relieving the suffering of an individual despite age, stage, or setting is high on the agenda. Team members focus on the patient’s comfort and physical needs, as well as their emotional, social, and spiritual needs. This health care approach is patient centred, as patients and their families are able to fully participate in determining the goals of their care during serious or critical illnesses, as well as during the end of life (American Psychological Association).
  1. Margaret goes on to ask you what is likely to happen to Penny. Your answer should specifically address changes to Penny’s nutrition and hydration status and requirements to relieve pain and discomfort (100 words)
  • Appetite and thirst – If Penny is able to eat and drink then food and beverages of choice will be provided any time she feels like eating (Koutoukidis et al, 2017, p. 1125). As Penny nears end of life, her appetite and thirst may decrease and she may have little desire to eat or drink. This is a natural process and is not painful for the person. Sips of water, or using a swab to moisten her mouth may help (Palliative Care Australia, 2017).
  • Pain management – medication is the core treatment for pain in terminal illness. Some other measures that can be used for pain or discomfort include using hot packs, careful positioning and repositioning or support for a painful body part, and therapies such as relaxation mediation, music therapy, and aromatherapy acupuncture and acupressure (Palliative Care Australia, 2017).
  1. The doctor mentioned ‘end of life’ pathway. What is this and how will it help Penny to have a ‘good death’? (100 words)
An end of life pathway is a document that guides the steps needed to provide high quality care to the patient in the last week or days of their life. A patient will be started on an end of life pathway when there are signs or the patient shows symptoms or physical changes that suggest they may be dying. The final decision to start a patient on an end of life pathway is made by the doctor and care team after talking with the patient, their family and/or substitute decision maker. An end of life pathway works by providing the best possible care for the patient at the end of their life. It helps to keep the patient comfortable up until they die, and it allows the resident to be cared for, and their family to be supported, in familiar surroundings by staff they know (Care Search, 2017).
  1. Using the symptoms listed on the Qld Health Residential Aged Care End of Life Pathway (EOL) identify, the management and clinical nursing skills required to relieve these for Penny. Include in your answer the management of her skin integrity and wound care of her malignant breast lesion.
Good management of symptoms at end of life is one of the main concerns of patients and their families. The physical comfort of dying patients requires thorough assessment, excellent nursing care and careful prescribing (Care Search, 2017).

Signs and symptoms that indicate Penny will commence the EOL pathway include her visible decline, her refusal of food and her increasing weakness. Part of Penny’s care management for her symptoms can include commencing a subcutaneous infusion for her pain, assessing Penny’s need for a special mattress and commencing a comfort care chart. It would also be ideal to address any spiritual, religious, or cultural needs Penny may have as well as having regular communication with Penny’s family. Penny’s comfort care chart should be addressed every two hours and all results and findings documented on the chart (Queensland Government, 2017).

Managing fungating wounds can be difficult for nurses. These types of wounds can spread rapidly and are often associated with breast or head and next cancers. They can have an enormous impact on the physical and psychological wellbeing of a patient. Some of the problems associated with a fungating wound include offensive exudate, pain and discomfort, infection, and bleeding. Effective wound assessment and the use of correct dressing as well as symptom management and monitoring of pressure care are essential (Care Search, 2017).

Question 2 – Case Study

John aged 19 has stage IV Metastatic Melanoma. He has been receiving chemotherapy over the duration of his illness. Chemotherapy can cause side effects such as nausea, vomiting depression, tiredness and thinning or loss of hair.

His family cared for him at home until two weeks ago. He has now moved to a hospice for respite care.

John is a member of the local surfing community and therefore he receives many visitors.

  1. Briefly explain the Pathophysiology of Metastatic Melanoma. How will his illness impact on the physical aspects of his activities of daily living? (200 words)
Melanoma is a form of cancer that develops in the skin’s pigment cells. Metastatic melanoma is also known as stage IV melanoma. When it has reached this stage, it means that the melanoma cells of any kind such as cutaneous, mucosal or ocular, have spread through the lymph nodes to distant sites in the body and/or to the body’s organs. The liver, lungs, bones and brain are most often affected by these metastases (growths). As with other cancers, metastases occur when the melanoma is not caught in the early stages. Often, symptoms only become present once it is has already spread. Once melanoma has spread, determining the original type is nearly impossible which makes planning the right treatment very difficult hence why early detection is crucial (MRF, 2017). The physical impact of cancer and cancer treatments can affect a person’s life and emotions in different ways. During treatment, John may experience symptoms such as fatigue, pain and nausea. Fatigue is the most common side effect of chemotherapy. It is often described as paralyzing and can come on suddenly. Ways John could manage it can include planning things at the time of day when he feels less tired, spending time outside in the fresh air each day, doing exercises, and pacing himself (Cancer Council Victoria, 2017).
  1. With whom would you discuss the psychological impacts of John’s disease? Discuss strategies that the Enrolled Nurse (EN) could use is assist John cope psychologically with his current condition. (150 words)
People with any form of cancer can experience a variety of emotions during their journey. These can include:

  • Anger
  • Sadness
  • Fear
  • Feeling out of control
  • Feeling helpless

Negative feelings come and go and usually improve over time as the person gets used to their diagnosis and treatment, and learns to cope with the stress. Social and emotional issues can be quite difficult for patients to understand and talk about which in turn can lead to problems like depression and anxiety (Cancer Institute NSW, 2017).

To assist John in coping psychologically with his condition the EN could use strategies such as therapeutic communication. Therapeutic communication is an important nursing intervention used to assist patients in palliative care. Empathy and active listening is also essential. John should be allowed time to express his feelings and thoughts. Making time to listen and interact in a sensitive way enhances the relationship between the nurse and patient (Brown, et al., 2015, p. 91). If there is serious concern for the psychological impact John’s disease is having on him then it can be discussed with the RN or Medical Officer, John himself, John’s family or carer, and allied health professional such as counsellors and psychologists (Queensland Government, 2017).

  1. Describe the social factors that should be considered when providing John with nursing assistance. (100 words)
People who are aware that their lives have been shortened by life limiting diagnoses face huge alterations and challenges to many aspects of their lives. Family and community based support can make a difference to the quality of people’s lives. Whether the patient with cancer has support or feels supported are major factors in how they manage socially, spiritually, physically and emotionally (Care Search, 2017). John is part of the surfing community and usually has lots of visitors. There will be several times that he feels as if he is missing out. To maintain some of John’s social life it would be ideal for the nurse to consider the timing of his pain relief with his visitations and the timing of care procedures so as not to interfere with him socialising with his friends and family.
John has now been readmitted to your palliative care ward due to the severe side effects from the chemotherapy. He pain is worsening and he is struggling to eat and take oral fluids.  The care team have decided to introduce subcutaneous pain relief by using a syringe driver to deliver his morphine.  John is reluctant to start something new and feels he will lose his mobility if he is connected to a machine.  Describe how you would explain what a syringe driver is and how it can help manage Johns pain.  (200 words)
The administration of medication using a subcutaneous infusion device is common practice in palliative care. A syringe driver is a portable battery operated pump that allows for medication such as morphine, to be administered in smaller amounts via an IV cannula or subcutaneous butterfly. It is usually delivered in minute doses (Koutoukidis, Stainton, & Hughson, 2017, p. 580). The syringe driver works by delivering the medication slowly through the cannula into the space just under the skin. The medication is easily absorbed into the body to help control symptoms such as pain, nausea or vomiting. A syringe driver helps if the patient is having trouble swallowing medication, has been vomiting, or other medications are not working to control symptoms. Patient’s with a syringe driver are still able to walk around with it as well as wear normal clothes meaning John could would not lose his mobility. He also has the option of buying a belt bag to conceal and carry the device discreetly but he needs to be aware that the syringe driver should not be put in or near water as it may get damaged (NSW Health, 2017). It is essential to ensure that John and his family have received a full explanation of how the syringe driver works, its purpose for use, and a 24-hour support number (Queensland Health, 2017).
  1. John’s medication includes morphine.
  • Describe the actions of this drug. 
  • List two common side effects and include management strategies for each of these side effects.
Morphine is a narcotic used to treat moderate to severe pain. It binds to natural endorphin stimulant receptors in the brain which depresses pain perception and can cause profound euphoria (Koutoukidis, Stainton, & Hughson, 2017, p. 961).

Side effects to morphine are typically short lived and mild. Two common side effects of morphine are:

  • Drowsiness – this is a common side effect of several drugs and may occur for only a short time after starting treatment or increasing the dose. It is advised to not drive a car, operate machinery, or do anything else that could be dangerous if you are drowsy or feeling uncoordinated such as drinking alcohol (NPS, 2017).
  • Nausea or vomiting – As morphine may cause nausea and vomiting, your doctor is likely to prescribe medicine for you to take or receive before the morphine, to stop you feeling sick. Morphine may also cause constipation, so your doctor is likely to prescribe laxatives to prevent this happening (NPS, 2017).
  1. Identify five (5) nursing actions that could help John alleviate his discomfort other than medication.
Options to help John alleviate his discomfort other than medication can include complementary therapies such as:

  • Massage – this can reduce various palliative care symptoms such as pain, nausea, anxiety, anger, depression, stress and fatigue
  • Aromatherapy – this can help to reduce anxiety and depression. It is often used in conjunction with massage and can contribute short term to patient’s quality of life
  • Music therapy – this has been adopted as one of the complementary therapies frequently offered to patients in palliative care. Studies suggest improvements in symptoms related to pain, mood, and other psychosocial variables
  • Meditation and relaxation techniques – although this one shows no benefit to physical symptoms, it does show benefits to anxiety, comfort and emotional response
  • Acupuncture – this is used widely for pain and nausea as well as other symptoms (Care Search, 2017).
Question 3

Research an ethnic group, either your own or one different to your own and answer the following questions.

  1. Identify the family and relationship structures that may impact on the nature of palliative care. (150 words)
Accepting the end of life is part of Hindu philosophy. Hindus believe that the time of death is determined by one’s destiny and they accept death and illness as a part of life. As a result, treatment is not required to be provided to a Hindu patient if it merely prolongs the final stages of a terminal illness as this is thought of interfering with karma. Under these circumstances, it is permitted to disconnect life supporting systems. However, suicide and euthanasia are forbidden in Hinduism (Queensland Health, 2017). Interventions such as intubation or artificial feeding in the face of a terminal illness would go against traditional Hindu thinking but caregivers should be aware that palliative and comfort care are in line with Hindu thoughts on karma and reincarnation. Healthcare decisions in Hindu families will likely be made by the most senior member of the patient’s family or the eldest son (Medscape, 2017).
  1. Describe the culturally significant beliefs of this culture, about death and dying that need to be considered throughout the palliative care period. (100 words)
  • The patient’s eldest son is expected to be present before during and after death, even if the son is a small child.
  • Other family members may wish to be present and to participate in the care of the patient
  • Family members may request that patients not be told about a terminal diagnosis directly
  • A Hindu patient may wish for a Pandit (priest) to be present to perform certain rituals including:
    • tying a sacred thread around the neck or wrist
    • placing a few drops of water from the River Ganges into the patient’s mouth
    • placing a sacred tulsi leaf (holy basil) in the patient’s mouth
  • Patients may wish to read or recite religious chants and prayers. However, some patients may prefer to listen on a personal media player or small radio

When a Hindu patient dies

  • A deceased Hindu’s body is usually washed by close family members with the eldest son taking a leading role
  • The family may wish to light a small lamp or burn incense near the body
  • If possible, all jewellery, sacred threads and religious objects should be left in place
  • Health care providers should advise family members if it is necessary to remove these items
  • The deceased patient’s family may have a preference for the position of the body after death (Queensland Health, 2017).
Question 4

Not all patients adhere to cultural protocols and traditions, as the EN, how will you discover whether these protocols and traditions are relevant to your client? How would you raise these matters with the client or family? (200 words)

Understanding the process for assessing cultural patterns and factors that influence individual and group differences is critical in preventing overgeneralisation and stereotyping. There are a number of important considerations that need to be kept in mind in relation to “culture” and “cultural identity”, including:

  • People may be influenced by and identify with more than one culture or cultural group
  • Everyone has a cultural identity; however, it is not always recognised or defined by the person themselves. Sometimes, culture is seen simply as “just the way we do things”.
  • It is the choice of the individual as to which culture they identify with regardless of their cultural background.

When caring for a patient from a culture different from your own, the nurse needs to be aware of and respect their cultural preferences and beliefs; otherwise, they may consider you insensitive and indifferent, possibly even incompetent. Also be aware of assuming that all members of any one culture act and behave in the same way; in other words, don’t stereotype people. The best way to avoid stereotyping is to view each patient as an individual and to find out their cultural preferences. Using a culture assessment tool or questionnaire can help you discover these and document them for other members of the health care team (Nursing 2017, 2017).

Question 5

A patient you have been caring for and developed a close relationship with has just died. On hearing this news, you experience a sense of loss.  Reflect on your feelings and discuss what personal strategies, values and attitudes you could use to help you cope with this situation. Include in your answer, social and community support systems

Many nurses who care for dying patients do so because they are passionate about providing quality palliative care. Caring for dying patients however, is intense and emotionally draining. A bond or connection often develops between the patient and the nurse but it is essential that nurses are aware of how grief affects them personally. Nurses are not immune to feelings of loss and it is quite common for nurses to feel helpless and powerless when dealing with death. Palliative care agencies can provide care for their team members via professionally assisted groups, informal discussion sessions and flexible time schedules (Brown, et al., 2015, p. 94).

I would personally find it helpful to talk with family, co-workers or friends during this time as they are my biggest support system. I would also take time to myself to reflect on my feelings and appreciate the fact that I was able to know the person. I would also find comfort knowing I did all I could for the patient at the end of their life.

Question 6

Michelle is at end stage of her terminal illness. In the lead up to her final weeks Michelle has talked extensively with her husband, daughter and medical staff about what is to happen with her in her final hours before dying. As part of her planning she has discussed and signed an Advanced Care Directive (ACD) with her doctor and legal representative.  In this she has indicated that she wants no interventions to extend her life.  Her husband is her next of kin and appointed attorney.  She has agreed to pain and symptom relief if required.

  1. Explain what an Advanced Care Directive is.  Who can use the form? When should it be used? Who has authority over its use?
Lewis’s medical-surgical nursing states that Advanced Care Directives (ACD) are written statements of a person’s wishes regarding medical care in certain future circumstances (Brown, et al., 2015, p. 88). An ACD allows a person to make clear legal arrangements for their future health, end of life, preferred living arrangements and other personal matters. It also allows a patient to appoint one or more substitute decision makers to make those decisions on their behalf if in the future they are unable to do so themselves. An ACD can be used by anyone 18 years and over. They must know what an ACD is, know what it will be used for and know when it will be used (SA Government, 2017). An ACD comes into effect when a patient’s cognitive health deteriorates and they become unable to make their own decisions (Queensland Government, 2017). If an ACD is valid then decisions must be made in accordance with it. Health care professionals and persons responsible have no authority to override a valid ACD (NSW Government, 2017).
You have been told at handover that Michelle’s death is imminent and likely to occur in the next few hours.  She has become restless and her daughter feels she may be in pain.  Her doctor has order a small subcutaneous dose of morphine which has just been given. 

When you enter her room to check on her, you see that her husband and daughter are present and she is surrounded by extended family.  Her ex-husband and his two young children, and three of Michelle’s friends are huddled in the corner of the room crying.  Her ex-husband is demanding that something be done.

  1. As the EN caring for Michelle, what would you do in this situation? Include in your answer two strategies you could use to improve this situation? (150 words)
Due to Michelle still being in pain the EN could work to collect data on her pain. This can be done using a pain assessment as well as interventions such as repositioning Michelle, applying a heat pack or even using complimentary therapies such as music. The EN works in a multidisciplinary team and in regards to the current environment and Michelle’s pain, the EN could speak with the RN and any other appropriate team members to relay information and assessment findings, and discuss what is best for Michelle. Due to the EN not knowing who the enduring power of attorney for Michelle is, it would be best to discuss Michelle’s status with her next of kin who would more than likely be her current husband but must still be checked. The EN could set up a private area out of Michelle’s room for the family and friends to gather and express their emotions. It would be ideal for them to be made aware that although Michelle is not conscious, she can still hear and hearing the anxiety and emotions coming from her family and friends could be making her anxious herself as well as restless and uncomfortable.
Question 7

Members of an elderly client’s family want to know if their mother has indicated how she intends to dispose of her estate. What is the EN’s role in relation to this request? (100 words)

The EN needs to refer to the standards for practice for enrolled nurses in this situation. The standards that the EN should consider are:

  • Standard 1: “functions in accordance with the law, policies and procedures affecting EN practice” – this includes (1.1) demonstrating knowledge and understanding of commonwealth, state and/or territory legislation and common law pertinent to nursing practice, and (1.10) liaising and negotiating with the RN and other appropriate personnel to ensure that needs and rights of people in receipt of care are addressed and upheld.
  • Standard 2: “Practises nursing in a way that ensures the rights, confidentiality, dignity and respect of people are upheld” – this is an important standard in this particular situation, namely (2.7) ensures privacy, dignity and confidentiality when providing care.
  • Standard 7: “Communicates and uses documentation to inform and report care” – this includes providing accurate and appropriate information to enable informed decision making by others and using a variety of communication methods to engage appropriately with others (Nursing and Midwifery Board of Australia, 2017).

Using these standards, the EN should inform the family that she can not divulge this sort of information due to confidentiality policies regardless of if the EN knows the details of the patient’s estate or not. The EN should let the RN know of the family’s question and the RN may be able to point the family in the right direction in relation to getting their question answered.

Question 8

Jane is 14 years old and is suffering a terminal illness. She is aware that her condition is deteriorating but still she feels her parents are not telling her the truth about her prognosis. You are assisting her in the shower one day when she says “I’m dying aren’t I?

  1. What is your response to her question? (50 words)
Children often have questions about their illness, care and dying. It is important that responses to these questions are open, honest and age appropriate. Effective and age appropriate communication with children can help them in accepting their condition. It is essential to take into account a child’s age, individual developmental stages and any neurological impairments when communicating with them. Sometimes it is best to consider family members who need to be involved in the conversation such as the parents. Some tips to remember when communicating with a child include:

  • Tailor communication to meet the child’s developmental stage
  • Assess prior knowledge and what needs to be discussed
  • Acknowledge emotions
  • Be honest and maintain trust
  • Be clear with responses to questions
  • Be prepared to listen to and revisit conversations (PCC4U, 2017).

In regards to Jane, I would ask her questions regarding what she knows of her illness and listen to what she says. I would show Jane empathy and let her know that I will get the RN to come and speak with her about her illness.

  1. Research and briefly discuss the legal age of consent in Queensland. (50 words)
Queensland Law Handbook states that a parent or guardian of a child generally has authority to consent to or refuse medical treatment on behalf of their child. However, a child under 18 can make their own medical decisions where they have sufficient understanding and intelligence to fully understand the treatment. In terms of operations, hospital authorities generally require a parent’s or guardian’s consent to perform any operation where the patient is under 18 years except in cases of emergency (Queensland Law Handbook, 2017).
Question 9

Nurses are governed by the Code of Ethics for Nurses in Australia.

  1. Identify the purpose of this code and explain how this code can be used to assist the nurse in decision making with regard to palliative care patients.  Consider the values expected of the nurse in your answer.
The Code of Ethics for Nurses in Australia has been developed for the nursing profession. It is relevant to all nurses at all levels and areas of practice including nursing students and people requiring or receiving nursing care. The Code outlines the nursing profession’s commitment to respect, promote, protect and uphold the fundamental rights of people who are both the recipients and providers of nursing and health care. It guides nurses towards ethical decision making and practice which is necessary in the palliative care setting (Nursing and Midwifery Board of Australia, 2017).
Considering the code identify which value statement fits appropriately in the following situations.

  1. Your patient identifies as a different culture to you and has listed specific requirements for care of his body after his death. (30 words)
Nurses value the diversity of people (value statement 3). This involves acknowledging and responding to each person as a unique individual, and to their culture. It requires nurses to develop cultural knowledge and awareness, and greater responsiveness to the language spoken which enable the nurse to better understand and respond effectively to the cultural and communication needs of people in their care (Nursing and Midwifery Board of Australia, 2017).
  1. Your client is in pain and is refusing regular pain relief as he says he does not want to become ‘addicted’. (30 words)
Nurses value informed decision making (value statement 5) – “Nurses value the legal and moral right of people, including children, to participate whenever possible in decision-making concerning their nursing and health care and treatment, and assist them to determine their care on the basis of informed decision making” (Nursing and Midwifery Board of Australia, 2017).
The nurse could consider educating the patient on pain relief and the benefits of receiving it.
Question 10

Provide a definition of each type of pain.

  1. Nociceptive pain
Nociceptive pain is the most common type of pain and is caused by damage to body tissue. It is normally felt as a sharp, aching, or throbbing pain and is typically responsive to anti-inflammatory agents and opiates. Examples of nociceptive pain include cuts and broken bones (Medtronic, 2017).
  1. Neuropathic
Neuropathic pain happens when nerves have been damaged. It is often described as a burning or heavy sensation, or numbness along the path of the affected nerve. Causes of this type of pain can be a result of nutritional imbalance, alcoholism, toxins, infections of the nervous system or auto-immunity. Examples of neuropathic pain include carpal tunnel syndrome and shingles (Medtronic, 2017).
Question 11: Case study

James has been admitted to your ward for pain control. He has a diagnosis of bowel cancer and treatment has required him to undergo extensive surgery and radiotherapy. He has a couple of good friends who visit him regularly. He lives alone and is no longer able to self-care. James does not engage in conversation and spends most of his time sleeping. He has become dis-interested with life. The Oncologist has explained to him that he is in the end stages of his disease and that all will be done to keep him comfortable and free from pain.

On admission you are the EN assigned to care for him, in collaboration/consultation with the RN address the following;

  1.  Using the following three headings identify one nursing diagnosis for each of the following care domains. Ensure your answer considers aspects related to James’ pain and social history. (100 words)
  • Physical
  • Psychological
  • Social
  • Physical: James has been diagnosed with bowel cancer and is at the end stage. Due to this he will need pain relief. James also spends most of his time sleeping. This puts him at risk for impaired skin integrity
  • Psychological: James is no longer able to self-care and has become dis-interested with life. This puts James at risk for depression and at risk of ineffective role performance (feels unneeded)
  • Social: James has good friends who visit him regularly but no longer engages in conversation. James is at risk for social isolation
  1.  Using the nursing diagnosis, you have formulated, develop two (2) care interventions for each domain. (150 words)
Physical: Check James’ skin integrity at all care procedures. Second hourly pressure area care whilst he is laying for long periods of time. Position client properly using pressure reducing or pressure relieving devices. Keep James’ skin clean. Keep bed linen dry and wrinkle free. The nurse should also complete a waterlow assessment as well as a pain assessment.  All findings should be recorded and reported.

Psychological: Build therapeutic relationship with James (ask questions, ensure privacy and confidentiality, take time to listen, allow James to respond, show interest, maintain eye level, use positive body language, give reassurance, seek consent). Encourage James to verbalize feelings, perceptions, and fears of his current situation. Help James set up a network of people he can talk to during emotional times

Social: Encourage contact with friends and family. Move James periodically to a more stimulating environment when conditions allow.

  1.  Giving consideration to his current emotional & social status, describe how you might provide an appropriate care environment for James and evaluate the effectiveness of his care (100 words)
Physical illness can have profound social and emotional consequences. Communication skills are not only fundamental to good clinical care but they also facilitate detection of psychological and social problems. James needs to be provided with patient centred care which includes providing care that is respectful of and responsive to his individual needs. Incorporating activities such as board games or cards may improve James’ current status. It can help alleviate depression and anxiety as well as improve social interaction. Introducing music is another therapy that could help James. Music can stimulate emotional and motor responses (BMA Science and Education, 2017).
Question 12

Your client is an indigenous Elder and has received many visitors during his stay in hospital. His death is imminent.  As the EN with whom will you discuss final arrangements? What protocols will need to be considered and why? (100 words)

It is important that the nurse identify the appropriate person to talk to and be aware that the next of kin might not always be the appropriate person to communicate with in regards to the patient’s medical status. Hospital staff need to be aware of the immediate family structure so the correct family (or non-family) member can be notified. Often it is best to ask the senior member of the family this question in private. The nurse should also ask the family and if there are any cultural protocols that need to be made known to staff. When it is known to a family or community that there is an expected death of an Aboriginal or Torres Strait Islander person, large gatherings at the hospital may take place to support and show respect for the family member who is close to death. If an Elder of a community has passed, or their health is deteriorating, many members of the community will gather and there will be ceremonies that reflect the respect and honour that the community had for the Elder (NSW Government, 2017).
Question 13

Your patient is a Muslim lady from Syria and has strong religious beliefs. She is at the end stage of her life. Her two brothers have recently arrived from her native country to be with her and to offer support to the family.

  1. Discuss the Interpreter services that may be required for this family
If the patient and family is assessed to have inadequate English, health care providers must provide a professional interpreter. Queensland Health provides a state-wide interpreter service that can provide onsite, telephone and video remote interpreters in several languages (Queensland Health, 2017).
  1. Using your cultural research skills identify;
  • who you would be discussing the final arrangements with and
  • What protocols would need to be observed for this client pre and post death.

Include in your answer the observances the EN would need to consider regarding your patient’s nutrition and hydration status and then the impact of loss and grief on this family. (50 – 100 words)

Final arrangements would be discussed with the patient’s family. Islam recognises that death is an inevitable part of life. Furthermore, Islam does not require treatment to be provided if it just prolongs the final stages of a terminal illness. If death appears imminent, a Muslim patient’s family may wish to perform certain customary religious rites. If the patient is in a state of consciousness, she may wish to recite the Shahadah which is a declaration of faith and pass away while reciting these words. If the patient’s family is not present, health care providers should contact the Islamic Council of Queensland who can arrange for an appropriate person to attend. In Islam, public grief is allowed for only three days. This period allows for non-family members to visit and offer their condolences. After that period, the family is left to grieve privately (Queensland Government, 2017). Nutritional support is considered basic care and not medical treatment, and there is an obligation to provide nutrition and hydration for the dying patient unless it shortens life, causes more harm than benefit, or is contrary to an advance directive that is consistent with Islamic law (Alsolamy, 2017).
Question 14

All hospitals and nursing homes have policy and procedure relating to palliative care.  Research Queensland Health’s document Clinical Guidance for the Dying Patient and answer the following questions.

  1. Apart from family members, who must be notified when your client dies? (30 words)
When a person dies, a declaration of life extinct procedure is carried out. This is done when all vital signs have ceased. This procedure can be carried out by registered nurses, registered midwives or qualified paramedics in circumstances where there is no medical officer available on site or in a reasonable timeframe. Certification of death must be done by a medical practitioner only which then allows and authorises the funeral director to collect the body (Brown, et al., 2015, p. 84). If the death of the patient is a reportable death then a coroner would also need to be called upon (NSW Government, 2017).
  1. Identify two (2) pieces of information that can be provided to the person’s family or next of kin in order the help them move forward, both practically and emotionally. (50 words)
Grief is a normal and natural response to loss. It allows people to gradually adjust to their loss and find a way to go on with life without their loved one. Providing a person’s family or next of kin with information that will help them access services such as a counsellor or social worker may be helpful. Some people also find comfort in joining a support group. Some organisations that provide information or telephone counselling are:

  • Australian Centre for Grief and Bereavement
  • Lifeline (24/7)
  • Kids Helpline
  • Mensline
  • Parentline
  • Beyond Blue (Palliative Care Australia, 2017).
Question 15

Using organisational policy and procedure explain the processes that may occur as a part of after death care. If you don’t have access to a workplace policy and procedure, do an online search.  Your answer should address:

(a) Who determines the person is deceased?

(b) What happens to the body immediately after death?

(c) What happens to the client’s belongings and to whom should they be given?

(d) Identify an appropriate counselling resource you could refer a grieving family to?

(e) Request for autopsy

  1. words)
  1. Determining a person is deceased can be done by a medical officer, RN or registered midwife. A certification of death can only be done by a medical practitioner (Brown, et al., 2015, p. 84).
  2. Practice guidelines recommend that after death care be delivered in a respectful manner to preserve the dignity of the deceased and honour family preferences (Medscape, 2017). After death occurs, the pupils of the patient will be fixed, dilated and unresponsive to light. The skin will turn pale, waxen, and cool to the touch. Death initially causes the muscles to relax. The jaw falls open, and the sphincters release urine and stool. Often, the eyes will remain open (Modern Medicine, 2017).
  3. All jewellery apart from the wedding ring should be removed in the presence of another staff member (unless the family have asked you not to do so) and then documented. Any personal items are usually then packed up and returned to the next-of-kin (Queensland Government, 2017).
  4. There are many appropriate counselling resources available to the family and friends of patients who have passed. Most health care setting will have pamphlets and brochures which will guide them in the right direction. Some examples of counselling resources include
    • 24 hour helplines such as 13 HEALTH and Lifeline
    • Local support such as a hospital social worker or your local GP
    • Centacare (Queensland Government, 2017).
  5. The purpose of an autopsy is to better understand the factors that may have contributed to a person’s death. Generally, autopsies are only performed if the deceased died from an unknown or unnatural cause such as an accident and is typically requested by a doctor (NSW Government, 2017). The family of the deceased can request an autopsy if they have good reasons for the request (NSW Law, 2017).
Question 16

Research and briefly explain the process of Organ and Tissue Donation. (50 words)

Organ and tissue donation is a life-saving and life-transforming medical process which consists of removing organs and tissues from a person that has died and transplanting them into someone who in most cases are very ill or dying from organ failure. Organs that can be transplanted include the heart, lungs, liver, kidneys, intestine and pancreas. Tissues that can be transplanted include heart valves and other heart tissue, bone tissue, tendons, ligaments, skin and parts of the eye such as the cornea and sclera. The way in which a person dies influences how the donation process can take place and which organs and tissues can be donated (Australian Government, 2017).
Conclusion
Palliative care is a speciality area of nursing. The palliative care team aims to meet physical, psychological and spiritual needs that arise for individuals at the end of their life and to support the individual’s family. Nurses are an important part of the multidisciplinary team supporting a good death for individuals in the home and inpatient settings (Koutoukidis, Stainton, & Hughson, 2017, p. 1127).

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