Outcomes of Quality Healthcare Discussion

Experience

Working in long term care there often comes a point that as a nurse we must discuss palliative care options with the residents and the families. There are times when the families make all of the decisions as the patient does not have the cognitive abilities to do so. Other times the resident is cognitively intact, yet their body is giving up. These conversations are difficult every time, but always necessary. Currently, only a small portion of residents in LTC receive hospice care despite the numerous benefits they can provide (Xiong, B., Freeman, S., Banner, D., Spirgiene, L., 2020).

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One resident is suffering from end-stage liver failure, the only treatment option left is a liver transplant, which she is not a candidate for. This resident has been in and out of the hospital due to high lactic acid levels and feeling ill.She returned to us from the hospital with this prognosis that she will not recover without a new liver, and that they were not going to consider her for this surgery.This information was given to the staff, but not to the resident who is cognitively intact.It then became my responsibility to speak with this resident about her prognosis and her options.I was very honest with her and at the end of this conversation, she decided that hospice care would be her best option.Now, this resident spends her days with loved ones (before COVID-19), attending activities, and most of all she is happy and pain-free.

Incorporating her values and preferences brought us to the decision to bring in hospice care.She is not traveling back and forth to the hospital, she is not in pain, she is not restricted with fluids or diet, and she is happy.The resident understands her treatment plan and she is happy with it, knowing what to expect with her prognosis.

Patient Preferences

When patient preferences and values are incorporated into a treatment plan the patient is more likely to be compliant with the plan.Increased compliance often means quicker healing in patients who can be cured.In patients who cannot be cured in compliance with their plan of care leads to increased happiness of them and their family and a better relationship between them and the healthcare team.This patient enjoys drinking a great deal of coffee, which she was not supposed to do before her decision to be a hospice patient.She was in a great deal of pain each day, and with hospice involved stronger pain medications can be considered. Pain is a common diagnosis among patients in end-stage diseases (Xiong, B., Freeman, S., Banner, D., Spirgiene, L., 2020).This resident is also diabetic and was on a strict diet, upon entering hospice care she is now able to eat what she wants, which also improves her happiness and the relationship between her and the staff members.

Due to the fact that her treatment plan is no longer focused on keeping her as healthy as possible, and is now focused on keeping her as happy as possible the treatment plan is effective.The resident is happy, her family is supportive, and she has a healthy relationship with her healthcare team.

Decision Aid

One decision aid used for patients with a terminal illness is titled Looking Ahead: Choices for Medical Care when you’re seriously ill.This decision aid is often used with patients who are in inpatient facilities.This aid focuses on decisions dealing with artificial nutrition, hydration, mechanical ventilation, and CPR.This DA was found to be acceptable and empowering.Many participants stated they wished this had come into their treatment plan sooner as they had already made some of these decisions.The patients felt they had more control and played a more active role in their treatment plan through the use of this aid (Matlock, D. D., Keech, T. A. E., McKenzie, M. B., Bronsert, M. R., Nowels, C. T., & Kutner, J. S., 2014).

When used at the right time this DA could assist patients with terminal illnesses to develop a treatment plan along with their healthcare team to address all possible outcomes throughout their illness.When a patient knows what to expect and what options are available to them they are better able to make educated decisions.If this patient had had the option to make a plan such as this in advance it could have saved her from some anxiety, fear, and uncertainty she experienced through the stages of her illness (Matlock, D. D., Keech, T. A. E., McKenzie, M. B., Bronsert, M. R., Nowels, C. T., & Kutner, J. S., 2014).

Personal Practice

We currently use an advanced directive questionnaire that asks a few generic questions related to their wishes.Being in long term care a more developed and detailed decision aid would be useful.A patient decision aid is a tool that can inform the patient and family of the different options, providing clarification and communication allowing their personal values to be utilized (Malloy-Weir, L. J., & Kirk, A., n.d.).We could educate the residents on their specific diagnoses and prognoses and personalize the aides to these facts and to the residents themselves. In patients with dementia if this tool is utilized in the early stages of their disease their wishes can be honored through every stage of their treatment and disease process (Malloy-Weir, L. J., & Kirk, A., n.d.).It could take a great deal of time to complete these for all eighty residents but could be very useful and helpful in the long run.

References

Malloy-Weir, L. J., & Kirk, A. (n.d.). Development and pilot testing of a decision aid for the initiation of antipsychotic medications in persons with dementia in long-term care using a systematic approach: a study protocol. BMJ OPEN, 7(10). https://doi-org.ezp.waldenulibrary.org/10.1136/bmj…

Matlock, D. D., Keech, T. A. E., McKenzie, M. B., Bronsert, M. R., Nowels, C. T., & Kutner, J. S. (2014). Feasibility and acceptability of a decision aid designed for people facing advanced or terminal illness: a pilot randomized trial. Health Expectations, 17(1), 49–59. https://doi-org.ezp.waldenulibrary.org/10.1111/j.1…

Xiong, B., Freeman, S., Banner, D., & Spirgiene, L. (2020). Hospice Utilization Among Residents in Long-Term Care Facilities. Journal of Palliative Care, 825859720907415. https://doi-org.ezp.waldenulibrary.org/10.1177/082…