2500 words ± 10%
Weighting: 50%
Having completed themes 3, 4, and 5 of the Learning guides, you will have an improved knowledge of how individuals cope with palliative care emergencies. You will also be able to identify the information required when making decisions for the time between diagnosis of the emergency and the treatment required.
The purpose of this assessment is to provide you with an opportunity to demonstrate your understanding of this content through the analysis of a patient.
For this assessment, you are required to develop a case analysis by choosing a patient who has experienced a palliative care emergency
You are expected to demonstrate how contemporary best practice guidelines contribute to optimal patient outcomes in the symptom management of advanced palliative care.
Outline the type of palliative care emergency/s, including the aetiology, risk factors, pathophysiology and signs and symptoms presented.
Discuss the most appropriate interventions for managing palliative care emergency with reference to contemporary evidence.
Provide the rationales for each intervention, indicating why they are appropriate for your chosen client and the particular care setting. Relate your rationales to the multi-faceted causes of your client\’s health problems.
Critically reflect upon your management of the client. Consider the strengths and weaknesses of your nursing care considering current research, and how you have validated, modified or changed your practice, as a result of completing this assessment item.
Examine the legal issues that may arise for the time between diagnosis of the emergency and the treatment required.
Evaluate the nursing practices pertaining to this emergency condition which are evident in your workplace and discuss the pertinent ethical considerations associated with those practices.
Critically appraise your role within the multidisciplinary team while communicating (truth telling) your patient’s condition with their family and providing support to them.
Support your case analysis with reference to current literature including best practice guidelines in order to demonstrate clinical reasoning and evidence-based practice.
NOTE: It is important to obtain patient consent and maintain patient confidentiality. In your written submission you must provide a script of approximately 575 words of what you said to the patient when asking for consent. You must also state that the patient gave consent.
Assessment criteria
2500 words ± 10%
Weighting: 50%
Having completed themes 3, 4, and 5 of the Learning guides, you will have an improved knowledge of how individuals cope with palliative care emergencies. You will also be able to identify the information required when making decisions for the time between diagnosis of the emergency and the treatment required.
The purpose of this assessment is to provide you with an opportunity to demonstrate your understanding of this content through the analysis of a patient.
For this assessment, you are required to develop a case analysis by choosing a patient who has experienced a palliative care emergency
You are expected to demonstrate how contemporary best practice guidelines contribute to optimal patient outcomes in the symptom management of advanced palliative care.
- Outline the type of palliative care emergency/s, including the aetiology, risk factors, pathophysiology and signs and symptoms presented.
- Discuss the most appropriate interventions for managing palliative care emergency with reference to contemporary evidence.
- Provide the rationales for each intervention, indicating why they are appropriate for your chosen client and the particular care setting. Relate your rationales to the multi-faceted causes of your client’s health problems.
- Critically reflect upon your management of the client. Consider the strengths and weaknesses of your nursing care considering current research, and how you have validated, modified or changed your practice, as a result of completing this assessment item.
- Examine the legal issues that may arise for the time between diagnosis of the emergency and the treatment required.
- Evaluate the nursing practices pertaining to this emergency condition which are evident in your workplace and discuss the pertinent ethical considerations associated with those practices.
- Critically appraise your role within the multidisciplinary team while communicating (truth telling) your patient’s condition with their family and providing support to them.
Support your case analysis with reference to current literature including best practice guidelines in order to demonstrate clinical reasoning and evidence-based practice.
NOTE: It is important to obtain patient consent and maintain patient confidentiality. In your written submission you must provide a script of approximately 50–75 words of what you said to the patient when asking for consent. You must also state that the patient gave consent.
Assessment criteria
Advanced Concepts in Palliative Care Nursing
Student’s Name
Institutional Affiliations
Advanced Concepts in Palliative Care Nursing
Advanced palliative care patients usually experience severe symptoms that negatively impact their quality of life. With an enhanced understanding of symptom management, palliative care nurses can positively contribute to the provision of comfort for patients who need advanced palliative care (Yates, 2017). According to Henson et al. (2020), the ability to cope with palliative care emergencies is one of the key skills that palliative care nurses require to effectively manage affected patients. The National Health System (NHS) Scotland defines palliative care emergencies as sudden life-threatening situations that commonly occur in patients with terminal illnesses. These changes, when left unmanaged, often affect a person’s quality of life and result in a deterioration in health. Examples of such emergencies include massive hemorrhage, spinal cord compressions, bone fractures, convulsions, and hypercalcemia (NHSScotland, 2020). The purpose of this assignment is to use a patient scenario to analyze evidence-based interventions to be utilized in palliative care emergencies. The assessment will evaluate contemporary best practice guidelines that will contribute to optimal patient outcomes in the symptom management of advanced palliative care for a prostate cancer patient experiencing hypercalcemia emergencies.
Type of Palliative Care Emergency
People with advanced prostate cancer usually have an increased likelihood of developing hypercalcemia. An abnormal rise in blood calcium levels leads to a condition known as hypercalcemia. The patient case that will be the focus of this assessment is a 78-year-old white male with an advanced form of prostate cancer. Mr. John was diagnosed with prostate cancer about 10 years ago. He has been under end-of-life care in a hospice facility for the past seven months because he cannot be cared for effectively at home considering his current health status. Mr. John has just been diagnosed with hypercalcemia after he suffered problematic symptoms. He now requires advanced palliative care to be able to achieve the necessary comfort.
For proper patient evaluation and treatment, it is imperative that the palliative care nurse understands the etiology, risk factors, pathophysiology, as well as signs and symptoms of hypercalcemia in patients with prostate cancer. The primary tumor cells and adenocarcinomas associated with prostate cancer are the primary etiologies of hypercalcemia in affected patients. The pathophysiology of the palliative care emergency is not clearly known and it is believed to entail changes in the production of hormones responsible for bone synthesis (Alhatemi et al., 2020). A study conducted by Alhatemi et al. (2020) found that hypercalcemia in prostate cancer patients is associated with the secretion of parathyroid hormone-related peptides (PTH-rP). These peptides trigger osteolysis or bone degeneration leading to a rise in blood calcium levels.
While there are uncertainties in the risk factors of hypercalcemia in cancer patients, some studies have found an association between the palliative care emergency and thyroid conditions. For instance, granulomatous disease and primary hyperparathyroidism increase a person’s risk of developing hypercalcemia in patients with prostate cancer (Goldner, 2017). Hypercalcemia causes a number of symptoms in patients with advanced prostate cancer. These symptoms include fatigue, muscle pain, nausea and vomiting, confusion, anorexia, and constipation. Common signs include general deterioration, reduced energy, and reduced tendon reflexes (NHSScotland, 2020). Healthcare professionals usually evaluate these symptoms to diagnose hypercalcemia in prostate cancer patients who develop suspecting symptoms.
The initial step in the management of Mr. John involved a detailed patient assessment to confirm the diagnosis. The palliative care nurse obtained patient consent before implementing assessment and treatment procedures. The following script was used to obtain patient consent and assure him of confidentiality; “The purpose of this therapeutic relationship is to assess your health status in order to determine the best practice guidelines that will contribute to effective symptom management and optimal palliative care outcomes. Data that you provide here will be used only for your care and will be kept confidential and private. I will not share your personal and health data with any other person not involved in your care.” The patient consented to the request authorizing the palliative care nurse to proceed with assessment and treatment.
The Most Appropriate Management Interventions
Palliative care nurses should base their decisions on contemporary best practice guidelines when managing a patient who has experienced a palliative care emergency. The most appropriate intervention for managing hypercalcemia in patients with advanced prostate cancer is the use of bisphosphonates administered intravenously. The National Health Service, the National Institute for Health and Care Excellence (NICE), the Scottish Palliative Care Guidelines, and evidence-based research recommend the use of bisphosphonates for the treatment of sudden hypercalcemia in patients with advanced prostate cancer (NHSScotland, 2020; NICE, 2019; National Health Service, 2017; Mallik et al., 2017). Bisphosphonates are a group of pharmacological substances that have confirmed effectiveness in preventing the breakdown of bones. The mechanism of action of these drugs entails the inhibition of osteoclasts responsible for bone resorption. Their inhibition prevents the formation of softened areas of bones commonly known as osteolytic bone lesions thereby preventing osteolysis. Various types of bisphosphonates have been confirmed to improve hypercalcemia symptoms in patients with prostate cancer. These include zoledronic acid, ibandronic acid, pamidronate sodium, and sodium clodronate (NICE, 2019). The type and dosage of bisphosphonate to use depend on the severity of the patient’s symptoms, baseline creatinine clearance, and estimated glomerular filtration rate (eGFR) (National Health Service, 2017). The patient should attain good quality of life when the drug administered is effective against symptoms of hypercalcemia.
Bisphosphonates would be applied to treat hypercalcemia experienced by Mr. John because their use is recommended by contemporary best practice guidelines and evidence-based research. Besides, these medications are readily available in the facility which would allow the palliative care nurse to quickly address the palliative care emergency that Mr. John is currently experiencing. According to NICE (2019), the primary rationale for using bisphosphonates to manage hypercalcemia in patients with advanced prostate cancer is that evidence-based research has confirmed that sudden osteolysis may be present in these patients leading to hypercalcemia as a palliative care emergency and poor quality of life. The Scottish Palliative Care Guidelines further indicate that the aim of using bisphosphonates to treat hypercalcemia in prostate cancer patients is to improve symptoms by correcting blood calcium levels back to normal concentrations. Normal values of blood calcium that would not cause problematic symptoms should range between 2.12 and 2.62mmol/l. During treatment, the palliative care nurse should be careful to select dosages that will not have negative effects on renal function. This explains why it is important to assess the severity of the patient’s symptoms, baseline creatinine clearance, and eGFR (National Health Service, 2017). Evidence from empirical studies can guide the nurse to make sound clinical decisions when using bisphosphonates to treat hypercalcemia in patients with advanced prostate cancer.
When managing Mr. John’s hypercalcemia symptoms, the palliative care nurse should evaluate the responsiveness of the administered drugs based on a number of outcome measures. These outcomes are linked with the multifaceted causes of hypercalcemia symptoms. According to NICE (2019), the effectiveness of bisphosphonates is usually evaluated using a number of outcome measures including health-related quality of life, pain levels as measured on the pain scale, changes in analgesia use, all-cause mortality, the rates of severe adverse events, rates of dropouts, and the presence of other palliative care emergencies such as spinal cord compression, atypical fractures, and osteonecrosis of the jaw. Mallik et al. (2017) conducted a study to examine the responsiveness of intravenous bisphosphonates on cancer patients with hypercalcemia and the prognosis thereafter. The goal of the study was to determine whether calcium levels would return to their normal values when bisphosphonates were administered to cancer patients experiencing hypercalcemia. The researchers employed a retrospective cohort study design to collect outcome data from 63 adult patients treated with bisphosphonates. Out of the 63 patients, 36 achieved normal blood calcium levels after receiving bisphosphonate treatment. Blood calcium levels were reduced significantly in patients who did not achieve normocalcaemia. Additionally, there was a symptomatic improvement and prolonged survival in the 63 patients (Mallik et al., 2017). Based on study findings, the researchers recommend the use of bisphosphonates in cancer patients experiencing hypercalcemia due to their effectiveness in reducing blood calcium levels, improving symptoms, and causing prolonged survival.
Strengths and Weaknesses of Nursing Care
As a reflection on the management of Mr. John by the palliative care nurse, there were some strengths and weaknesses of nursing care considering current research. The insights acquired from the experience have validated and improved the nurse’s approaches to advanced prostate cancer patients experiencing hypercalcemia. The main strength is that the palliative care nurse has obtained consent from Mr. John before beginning treatment. Additionally, the nurse has conducted a comprehensive assessment of the patient to confirm the presence of hypercalcemia symptoms.
Another strength is that the palliative care nurse has utilized evidence-based treatment intervention to treat Mr. John’s hypercalcemia. When selecting treatment intervention, the palliative care nurse has relied on the best practice approaches recommended by the National Health Service, the National Institute for Health and Care Excellence (NICE), the Scottish Palliative Care Guidelines, and evidence-based research (NHSScotland, 2020; NICE, 2019; National Health Service, 2017; Mallik et al., 2017). The nurse has taken appropriate caution to prevent renal function impairment by selecting the type and dosage of bisphosphonate after considering the severity of the patient’s symptoms, baseline creatinine clearance, and estimated glomerular filtration rate (eGFR) (National Health Service, 2017). These considerations resulted in the improvement of Mr. John’s symptoms by correcting blood calcium levels back to normal range. The only notable weakness of nursing care in Mr. John’s scenario is that since the hypercalcemia was sudden, the palliative care nurse was unable to inform the patient’s wife who was not around at the time of treatment and could not be reached on phone. Despite this weakness, the nursing experience helped the palliative care nurse to learn the key factors to consider when managing patients with advanced forms of prostate cancer experiencing palliative care emergencies, particularly hypercalcemia.
Legal Issues that May Arise Between Diagnosis and Treatment
Properly identifying and addressing legal issues that might arise when managing palliative care emergencies can help the nurse to enhance therapeutic relationships with the patient and his or her family. The healthcare facility has adopted practice policies that guide palliative care nurses when providing care to patients with advanced forms of terminal illnesses (Fernando & Nair, 2021). The legal issue that arose between the time of diagnosis of the emergency and treatment concerned whether the nurse should withhold treatment until the patient’s wife returned. The facility’s practice policy prohibits nurses from administering a new treatment intervention to a patient with advanced disease in the absence of a close relative or significant others. According to Fernando and Nair (2021), legislative and organizational policies can cause legal dilemmas for clinicians who are managing palliative care patients during emergencies. For example, legislation that prohibits the provision of life-sustaining therapy for dying patients may cause confusion for nurses who are working with patients who need such therapy to have an improved quality of life. The authors recommend the application of ethical principles when faced with legal dilemmas in emergency situations. In the current situation, the palliative care nurse applied the principle of beneficence and decided to administer bisphosphonates in order to maximize therapeutic benefits for Mr. John.
Nursing Practices Pertaining to this Emergency Condition
Nursing practices at the workplace support care provision to advanced prostate cancer patients experiencing hypercalcemia as a palliative care emergency. The practice setting has healthcare policies that clearly outline the standard operating procedures for administering bisphosphonates. The facility ensures that healthcare professionals ensure patient safety when administering bisphosphonates to patients. Zhang et al. (2021) confirmed that bisphosphonates are safe and effective when used in cancer patients with hypercalcemia. Additionally, De Roij et al. (2021) recommend that healthcare professionals should closely monitor renal function in patients who are receiving bisphosphonates. Nursing practices at the facility place these factors into consideration when managing hypercalcemia in patients with advanced prostate cancer.
Zoledronic acid is the type of bisphosphonate available at the facility for use with patients experiencing hypercalcemia. As outlined in the organizational policy, palliative care nurses usually administer 4 mg of Zoledronic acid to patients whose baseline creatinine clearance is greater than 60 mls/min. Patients whose baseline creatinine clearance is below 60 mls/min receive 3-3.5 mg of the drug. The medication is diluted in 100 ml of sodium chloride 9% over 15 minutes before intravenous administration. The dosage is given once in a period of 4 weeks because it is expected that a single dose of Zoledronic acid will enable the patient to attain normal levels of calcium in the blood for a period of 3 to 4 weeks. The hospital’s policy is aligned with the National Health Service, the National Institute for Health and Care Excellence (NICE), the Scottish Palliative Care Guidelines, and evidence-based research (NHSScotland, 2020; NICE, 2019; National Health Service, 2017; Mallik et al., 2017). Patient monitoring is key to ensuring that patients attain an improved quality of life. Nurses in the facility periodically monitor renal function and blood calcium levels in the treated patients.
The pertinent ethical considerations associated with these nursing practices are guided by the ethical principles of autonomy, beneficence, justice, and non-maleficence. Precisely, when administering bisphosphonates to patients experiencing hypercalcemia, palliative care nurses respect patient autonomy by obtaining informed consent. They also use safe dosage to maximize benefits for the patients as a demonstration of respect to the principle of beneficence. The nurses observe justice by not giving such medication to severely ill and dying patients. Moreover, they monitor patients after drug administration to eliminate any possible risk of harm in demonstration of respect to the principle of non-maleficence (Akdeniz et al., 2021). Their aim is to improve symptoms by correcting blood calcium levels back to normal concentrations.
Critical Appraisal of Personal Role Within the Multidisciplinary Team
Palliative care nurses work with multidisciplinary teams and patients’ family members to achieve nursing goals. NICE (2019) recommends multidisciplinary team involvement in the care and management of cancer patients experiencing hypercalcemia. The role of the palliative care nurse within the multidisciplinary team is to maintain truth when communicating the palliative care emergency to the patient and his family members (Shibata et al., 2021; Suikkala et al., 2021). Additionally, the palliative care nurse is charged with the responsibility of helping the patient’s family to accept their kin’s condition and encouraging them to offer support during end-of-life (Becqué et al., 2021). The goal of the palliative care nurse should be to ensure an improved quality of life for both the patient and his family.
Conclusion
As palliative care nurses treat patients with terminal illnesses, they should also understand the palliative care emergencies that commonly occur in these patients and the best practice intervention that should be implemented to address them. Hypercalcemia is one of the common palliative care emergencies in patients with advanced stages of cancer. Contemporary best practice guidelines recommend the use of bisphosphonates in the treatment of hypercalcemia in patients with advanced prostate cancer. Palliative care nurses should work with multidisciplinary teams, provide support for patients’ families, and make appropriate legal and ethical considerations when managing terminally-ill patients with hypercalcemia and other palliative care emergencies.
References
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