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Patient is a 60 year old Hispanic male readmitted to ICU after being discharged AMA. Now in multiorgan failure r/t medical diagnoses of untreated hepatitis c, liver cancer, infection, and acute kidney injury. Patient is in hepato-encephalopathic coma after rapid deterioration during transport. Thirteen days prior he was admitted to the ED with c/o severe back and abdominal pain. He was admitted and diagnosed with liver disease and cancer r/t hepatitis c, infection, and dehydration. He tested positive for opiates and admitted to IV heroin use. During monitoring and stabilization he was advised that his disease processes were terminal but with treatment he could live another 6-12 months. His significant other, sister, brother in law, and nephew provided family support during this time. He denied visitation to his brothers and sister in law. After five days in critical care, he expressed he did not want to die in the hospital and he chose to leave against medical advice. Four days ago, he was delivered to the ED by EMS. He has been found down by a passer-by who called EMS. He was admitted to the ICU for treatment and stabilization.
Patient presents with HOB at 45 degree, head midline. He is responsive only to painful stimuli, pupils are equal, fixed, and dilated. General muscular tone is flaccid with episodic myoclonic movements. Patient is tachycardic, hypotensive, MAP >65, ICP >20, weak peripheral pulses, capillary refill greater than 3 seconds, poor skin turgor. Patient is on assist/control mechanical ventilation with PEEP of 8, 65% O2, RR off 26, tidal volume of 800 mL to induce mild respiratory alkalosis. Sclera appear yellow, skin is jaundiced, warm, diaphoretic, with generalized varices and brown pigmentation. Central line and peripheral IV sites exhibit oozing unresponsive to pressure. Gastrointestinal and genitourinary assessment show: Foley draining dark red urine at 23 mL/hr; perineum clean and intact; bowel sounds hypoactive in all quadrants; abdomen distended with presence of fluid wave; last bowel movement unknown; receiving low protein nutrition continuously via NG tube at 25mL/hour. Significant chronic psychosocial stressors. Laboratory assessment showed: leukocytosis; erythrocytosis; hypercalcemia; hypoglycemia; hypocholesterolemia; critical high ammonia; anemia; hyperalbuminemia; hypokalemia; hypernatremia, elevated aPTT and INR; elevated ALT/AST/alkphosphate. Diagnostics performed included: Chest/abdominal/pelvic X-ray; PET scan; liver scan; CT scans; ultrasound; MRI; EEG; cerebral perfusion study
Following diagnostics he was diagnosed with hepatic encephalopathy/coma and acute renal failure. Other diagnoses include: liver cancer; infection, multiple bilateral abscesses on arms r/t IV drug use; peritonitis; and current/long term heroin abuse. Treatment included paracentesis, biliary drainage, hemodynamic and respiratory support, antibiotic administration, wound care, pain management, and opiate withdrawal support.
Family was informed of treatment risks and benefits, plan of care, and possible prognoses. Investigation of patient wishes performed; patient did not have advanced directive, living will, physician’s orders for life sustaining treatment, or power of attorney. Significant other claimed they were married by clergyman during his recent admission but can not provide paperwork. Estranged siblings participate in care discussion and wish to continue aggressive medical management. His sister, brother in law, and “wife” wish to withdraw care. Would prefer to time withdrawal to avoid death on that Saturday as it is the day their daughter is getting married.
patient is experiencing powerlessness evidenced by dependence on others, nonparticipation in care r/t disease process. Neuman stressors include: Intrapersonal: disease processes; interpersonal: inability to interact with family/care team; extrapersonnal: Institutional Standards of care; absence of advanced directive; family members disagree on plan of care; not respectful of patient’s previously expressed wishes. Outcome identification: by end of shift, the family will make decisions regarding care and treatment when possible as evidenced by statements of decisions. Interventions include: initiate focused assessment, questioning, and education of family regarding disease process; allow time for questions; encourage family to write down questions and record summary of provided information; identify the strengths of the family and efforts to gain control of the unpredictable nature of end of life care. (Ackley & Ladwig, 2014) Upon evaluation this goal was partially met. Family was able to choose a plan of care that aligned with their interpretation of the patient’s wishes. Care was withdrawn to allow natural death with comfort measures only. Patient died in the hospital setting against his previously expressed wishes. Death of client does not allow for outcome revision.
Family is experiencing dysfunctional family processes evidenced by complicated grieving, failure to demonstrate respect for autonomy of members, and disrupted family rituals. Neuman stressors include: Intrapersonal: personal perceptions of disease processes, outcomes; interpersonal: differing belief systems; extrapersonnal: date of client’s niece’s wedding; institutional setting/location. By end of shift, family will identify three healthy coping behaviors they can employ to facilitate a shift toward improved family functioning. Interventions included: Provide brief education and individual counsel as a routine part of primary care; use verbal/nonverbal therapeutic communication encouraging family to verbalize concerns/fears, express emotions, and set goals; acknowledge range of emotions/feelings experienced during the health crisis of a loved one; use a family-centered approach when working with Latino clients; refer for family therapy or grief counseling (Ackley & Ladwig, 2014) This outcome was met. Family was able to identify four coping strategies including: designation of sister as next of kin to make treatment decisions and single point of contact with providers; seeking support from spiritual/religious leaders; organizing visit schedule; using reminiscence as part of grieving.
Collaborative team members included: shift nurse; charge nurse; wound care nurse; respiratory therapist; infectious disease MD; oncologist; nutritionist; Palliative Care Team (PCT); social worker, case manager; interns (interdisciplinary). PCT: advocated for patient; provided family education and support; identified next of kin/individual to make care decisions; drove evaluation of treatment and plans of care; initiated palliative plans of care; addressed psychosocial needs of family dynamic in collaboration with social worker; ensured adequate pain management.
The complex end of life client requires comprehensive support from care providers and family. The accurate and empathic assessment of client and family needs is critical and PCT’s can play an integral role in case management, patient advocacy, holistic care, and family support
Discussion Quiestions
- What would possible nursing diagnoses be for the patient during his recent admission with a focus on psychosocial needs?
- What conditions precluded this client from organ/tissue donation?
- What could have assisted this client in ensuring they received care that aligned with their end of life perceptions and wishes?
References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidenced-based guide to planning care (10th ed.). St. Louis, MS: Mosby Inc.
Del Giudice, P. (2004). Cutaneous complications of intravenous drug abuse. British Journal of dermatology, 150(1), 1-10. doi: 10.1111/j. 1365-2133.2004.05607.x
Hinkle, J. L. & Cheever, K. (2014). Clinical handbook for Brunner & Suddarth’s textbook of medical-surgical nursing (13th ed.). Philadelphia, PA: Wolters Kluwer | Lippincott Williams & Wilkins
WebMD. (2016). Heroin use, addiction, effects, withdrawal, and more. Retrieved from http://www.webmd.com/mental-health/addiction/heroin-use#2-7
