Advanced Practice Nurse Role In Facilitating End-Of-Life Care

Cruz-Oliver et al. (2017) defines end of life care as the type of care offered to patients in their final hours or days of life, as well as to patients who are suffering from advanced terminal illnesses or diseases, and whose conditions have progressed to the level of being incurable. Nurses play a significant role in ensuring that this type of health care is available and delivered effectively by performing a variety of small tasks that ensure the patient is cared for holistically.

The most important role of an advanced practice nurse in facilitating Mrs. D’Angelo’s end-of-life care is to identify her needs (Abelsson & Willman, 2020). These needs range from basic dietary requirements to advanced emotional, spiritual, psychological, and even economic requirements. The involved nurse should strive to identify these needs and reason out possible ways to meet them, and if possible, involve Mrs. D’Angelo’s family. These needs can be identified by asking Mrs. D’Angelo about her thoughts on the subject, conducting a physical examination, analyzing her medication profile and allergies, observing her coping abilities, assessing support needs, and screening for implementation needs (Morioka et al., n.d.). By identifying the needs, the nurse in charge is able to plan how to meet those needs in the best interests of the patient.

Making decisions is an important part of the end-of-life process (Abelsson & Willman, 2020). The nurse(s) in charge play an important role in assisting Mrs. D’Angelo in making decisions such as whether to continue or discontinue the current chemotherapy regimen, whether to make plans to receive care somewhere other than at home, whether to discuss her wishes for care and treatment planning with her family, and whether to appoint someone to be her substitute decision maker. This helps in clarifying unsure concerns, avoiding distress or upset, eliminating concerns about negative outcome, helping Mrs. D’Angelo on being sure on what to do next and avoid cases her being preoccupied with the decision made.

Advance practice nurses also play important role in promoting meaningful interactions between Mrs. D’Angelo and her significant others (Abelsson & Willman, 2020). By encouraging Mrs. D’Angelo to make informed decisions, she will find it easier to decide what to discuss with a specific family member or significant other. Time is an important consideration. In the event that she develops advanced pancreatic cancer, which significantly reduces her life expectancy, she can discuss and plan with her family on how to manage the available family resources. By ensuring that the correct information is shared with Mrs. D’Angelo’s family, the family members can interact without fear of losing their loved one at any time, especially if the pancreatic cancer is not in an advanced stage and a cure can be achieved through surgery. This reduces the likelihood of emotional instability interfering with Mrs. D’Angelo’s expected interaction with her significant others.

Advanced practice nurse plays a role in controlling Mrs. D’Angelo’s symptoms and, in the event that she does not recuperate from the adverse reaction to chemotherapy or the cancer, facilitates a peaceful death (Abelsson & Willman, 2020). Nurses first do the assessment of Mrs. D’Angelo before coming up with a nursing diagnosis. They then come up with a plan on how to alleviate the patient’s symptoms before implementing the plan. Implementation includes psychological care, eliminating any form of fear, be it of pain, of feeling meaningless or fear of loneliness and abandonment. I the event that Mrs. D’Angelo’s cancer turns out to be non-curable, the nurses help in ensuring that she is able to make proper arrangements for whoever or whatever is going to be left behind, enjoy her final moments and, live a satisfactory final moments. This help in facilitating peaceful death.

Advance Directives

Advance directives, according to Dalmau-Bueno et al. (2021) are legal documents that outline formal preferences on actions that caretakers or doctors should take if the individual’s health deteriorates to an extent that they are no longer able to make appropriate decisions about self. The goal and objectives of advance directives is to ensure patient autonomy during end-of-life care, thereby enabling the caregivers to prioritize the patient’s medical care preferences, which must be within reasonable clinical options. Advance directives come in a various types and include a living will, durable power of attorney, advanced healthcare directive, preferred intensity of care(PIC) form and, do not resuscitate (DNR) order (Dalmau-Bueno et al., 2021).

A living will is a legal document that outlines an individual’s needs and wishes when they are unable to make competent decisions on their own. The living will, unlike the other forms, does not allow the patient to name someone to make decisions for him or her. In addition, unlike the other forms, two witnesses who are not related to the patient are required for validation. A durable power of attorney, on the other hand, is a legal device that allows one person, known as the “principle”, to delegate authority to another person, known as the “attorney-in-fact”, to act on his or her behalf (Dalmau-Bueno et al., 2021).

As a result, the decision is based on what the “attorney-in-fact” believes is appropriate for the “principle”. Unlike the appointed “attorney-in-fact”, the appointed “attorney-in-fact” is limited by their own knowledge of legal matters and finances, leaving room for error. The durable power of attorney is used for financial matters, whereas the advanced healthcare directive is used for medical matters.

The advanced healthcare directive specifies who you want to make healthcare decisions for you and only becomes active if the patient is unable to make decisions or is unconscious. In the event of a medical emergency, the PIC form is typically used to specify what should and should not be done. The DNR order is a form that requests that cardiopulmonary resuscitation not be performed if the patient’s heart stops beating or if he or she stops breathing (Dalmau-Bueno et al., 2021).

Mrs. D’Angelo will need an advanced directive if she wants to legally protect herself from unwanted medical procedures, such as when she does not want to be resuscitated in the event of cardiac failure (do not resuscitate order). In addition, if her cancer is advanced and she is unlikely to recover, the directives may specify the type of care she prefers, such as whether she wants to continue with chemotherapy or discontinue it. Advanced directives will also be useful if she wishes to receive a specific type of treatment regardless of how ill she is. Mrs. D’Angelo will also be able to relieve her family of the need to sit down and make difficult decisions about her care.

How To Approach The Topic Of Advanced Directive With A Patient.

The first step is to disclose all information about pancreatic cancer to Mrs. D’Angelo in a way that she understands, including the stage and the options for treatment available (Gieniusz et al., 2018). In the event that the cancer is at an advanced stage, explain to her the terminality of the condition. Also, explain to her the side effects of the available treatment modes. After the above disclosure of information, always give the patient hope, but not false hope. Explain to her the probable outcomes in case of ongoing treatment. Listen actively, assist her with medical decision making and also ensure effective communication with all individuals involved in her care and her family members. If she resents grieving, allow her to finish grieving until she gets to the acceptance phase.

Once she does accept her condition (s) and the possible outcomes, explain to her the prospect of advanced directives and allow her to make her own decision with your help on what she wants about her health and her financial capability. You can allow her to consult with a legal team if she has one. Help her select a directive that is in accordance with her religion, financial ability and, culture or ethnicity. Once she has decided on an advance directive, she can fill out the form in the presence of witnesses if necessary and present it to her advocate or legal team.

Ethical Principles and Legal Challenges related to End-of-life and Palliative Care.

Ethical Principles

Beneficence: This is the balance between what is good and what is harmful to the patient (Brodtkorb et al., 2017). The nurse and the involved healthcare officer should make decisions and take actions that will improve Mrs. D’Angelo’s life rather than worsen it. If, for example, the use of chemotherapy causes more harm than benefit in the form of adverse reactions, it can be discontinued and the Whipple procedure performed without initiating chemotherapy.

Autonomy: It is defined as the right of self-governance (Sprung et al., 2019). In this situation, it is allowing Mrs. D’Angelo to decide for herself the type of treatment she is to receive and also have a final say in her financial and family matters. This can be done through advanced directives.

Legal Challenges

Limitation to patient autonomy: Mrs. D’Angelo cannot demand a treatment that is not in their best interests. Further, the intervening doctors and the doctors need not to strive to preserve life.

Withholding and withdrawing treatment: If Mrs. D’Angelo and the doctor agree that there is no benefit of continuing chemotherapy they can stop it (Sprung et al., 2019). The doctor and Mrs. D’Angelo should agree to withdraw or discontinue the chemotherapy prior to the Whipple procedure.

Effective Communication Strategy for End-of-life Care

Mrs. D’Angelo is entitled to bad news if her condition worsens and she is diagnosed with a terminal illness. However, there may be some good news in between the bad news, and what is most important is how the advance practice nurse communicates the same news to Mrs. D’Angelo. This necessitates a communication strategy that includes skills for communicating with the seriously ill as well as responding to serious questions with sensitivity.

Upon diagnosing an individual with a serious or life-threatening illness and noticing that the individual is nearing the end of their life, effective communication is critical. As Anderson et al. (2019) notes, good and timely communication can help alleviate stress and distress, in addition to enabling the patient and the caregiver to discuss and plan for advanced care. The best known approach is the 9-Step Approach (Anderson et al., 2019).

To begin, the meeting must be convened. This entails gathering the members of the medical professional and Mrs. D’Angelo’s family in a private and quiet location and having all members introduce themselves to establish a good rapport. Second, it entails reaching an agreement on the meeting’s purpose. Update everyone on Mrs. D’Angelo’s health from your perspective, breaking the news about her health. After that, discuss the decision with the appropriate members. Help anyone who may require emotional or psychological support.

Third, find out what the patient or family knows and assess their level of understanding, language they understand better, potential misconceptions or misinformation, and the last time they were updated. Fourth, find out what information they need to make a decision and show them how much you appreciate them in the process. This includes the diagnosis, likely course of action, and prognosis.

Fifth, share the necessary information with them and try to get them to agree on their common desires in a peaceful manner. Try to evaluate them to discover their goals, hopes, expectations and, fear with the hope of understanding their “history”. Try to address their needs as per their financial capability and for the best interest of the patient. Create a plan for them that include when to break the bad news to them, decision-making and anticipated decisions, and the necessary support to assist them and Mrs. D’Angelo in coping and reducing potential fears. Finally, schedule a follow-up with them, inviting them to share any unresolved concerns and, in doing so, normalize their experience (Anderson et al., 2019)

References

Abelsson, A., & Willman, A. (2020). Caring for patients in the end-of-life from the perspective of undergraduate nursing students. Nursing Forum, 55(3), 433–438. https://doi.org/10.1111/nuf.12448
Anderson, R. J., Bloch, S., Armstrong, M., Stone, P. C., & Low, J. T. (2019). Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence. Palliative Medicine, 33(8), 926–941. https://doi.org/10.1177/0269216319852007
Brodtkorb, K., Skisland, A. V.-S., Slettebø, Å., & Skaar, R. (2017). Preserving dignity in end-of-life nursing home care: Some ethical challenges. Nordic Journal of Nursing Research, 37(2), 78–84. https://doi.org/10.1177/2057158516674836
Cruz-Oliver, D. M., Little, M. O., Woo, J., & Morley, J. E. (2017). End-of-life care in low- and middle-income countries. Bulletin of the World Health Organization, 95(11), 731. https://doi.org/10.2471/BLT.16.185199
Dalmau-Bueno, A., Saura-Lazaro, A., Busquets, J. M., Bullich-Marín, I., & García-Altés, A. (2021). Advance directives and real-world end-of-life clinical practice: a case-control study. BMJ Supportive & Palliative Care. https://doi.org/10.1136/bmjspcare-2020-002851
Gieniusz, M., Nunes, R., Saha, V., Renson, A., Schubert, F. D., & Carey, J. (2018). Earlier goals of care discussions in hospitalized terminally ill patients and the quality of end-of-life care: A retrospective study. The American Journal of Hospice & Palliative Care, 35(1), 21–27. https://doi.org/10.1177/1049909116682470
Sprung, C. L., Ricou, B., Hartog, C. S., Maia, P., Mentzelopoulos, S. D., Weiss, M., Levin, P. D., Galarza, L., de la Guardia, V., Schefold, J. C., Baras, M., Joynt, G. M., Bülow, H.-H., Nakos, G., Cerny, V., Marsch, S., Girbes, A. R., Ingels, C., Miskolci, O., … Avidan, A. (2019). Changes in end-of-life practices in European intensive care units from 1999 to 2016. JAMA: The Journal of the American Medical Association, 322(17), 1692–1704. https://doi.org/10.1001/jama.2019.14608