NRSG374 Palliative Approach AT2

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Australian Catholic University *

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Feb 20, 2024

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Tyler Morton is a 40-year-old man who spent is childhood and teenage years in Brisbane. Tyler, whilst growing up excelled in all sports and represented QLD in the state Cricket Team. Upon completing high school, Tyler graduated from the University of Queensland with a Bachelor of Business Management before joining the Royal Australian Airforce as a Pilot in 2004. Whilst training to become a Pilot, Tyler met is future wife Catherine in Newcastle and this is where the couple settled to commence their family. Tyler and Catherine have 3 Children. Catherine is a stay at home Mum to: · Andrea (8 Years) · Jessica (5 years) · Erin (2 Years) Being from Newcastle, Catherine’s Family is very close to Tyler and Catherine and spend a lot of time together. Tyler’s Family is in Brisbane and has only minimal contact with Tyler and his young Family. Unfortunately, Catherine and Tyler’s mother Joyce do not get along and this causes a lot of conflict in the marriage. 18 months ago Tyler experienced some weakness in his left hand. His grip strength was not a strong as his right hand and he found he would be dropping anything that he picked up. Tyler also noted he was getting short of breath without exertion. Considering his general fitness is quite good, this was highly abnormal. Tyler made an appointment with the GP on the Airforce base to discuss this concern. After multiple MRI’s and blood tests and lumbar punctures (over a 3-month period), Tyler was diagnosed with Amyotrophic lateral sclerosis (ALS). At the time of diagnosis, Tyler’s weakness in his left hand had progressed to his right hand and he had developed a foot drop in his left ankle. Upon diagnosis, Catherine was adamant that the children were not going to be told the reason that Dad is no longer working. Tyler’s diagnosis also caused more stress and tension with the relationship between Catherine and Joyce. Joyce wanted to visit and be there with her son, however Catherine was not supportive of Joyce and Tyler’s brothers visiting. 12 months ago Around 6 months after initial symptoms and 3 months after diagnosis, Tyler’s condition had deteriorated. Tyler now required a walking frame to mobilise. His dyspnoea has increased, he was suffering from headaches and was generally fatigued. Tyler was being assessed by a respiratory specialist for the requirement of Non-invasive ventilation (NIV) especially at night. Tyler now suffers from dysphagia and was being assessed in consultation with the respiratory specialist and dietician for the need for a gastrostomy. 6 months ago Tyler’s condition has continued to deteriorate. Due to insufficient nutritional intake secondary to dysphagia, Tyler had a gastrostomy inserted. Since insertion, he has had numerous infections at the insertion site. Tyler also requires assistance of NIV mainly at night, however the demand has increased significantly over the last couple

of weeks. Tyler’s mobility is limited. He walks intermittently with the use of an aid and one person. His mobility is limited due to progressive foot drop and increased dyspnoea. With his condition worsening, Tyler initiated the difficult conversation with Catherine about his mortality. Catherine is still not accepting of Tyler’s condition nor is she wanting the Children to know the extent of Tyler’s condition. Tyler completed an Advanced Health Care Directive and he ensured both Catherine and his mother Joyce had a copy. Tyler is currently visited weekly by the Community Palliative Care Team and he has daily support from Community nurse to assist with his activities of daily living. Despite Tyler’s progressive physical deterioration and the ongoing tensions with Catherine’s inability to accept his condition, Tyler values the time he gets to spend with his 3 girls. Watching them play together and their interactions are invaluable to Tyler. Tyler has insisted that his mother and brothers are able to visit monthly. When his family visit, Catherine generally takes the girls and leaves Tyler at home. Although this an ideal situation, Tyler has come to accept the conflict between Catherine and Joyce. Tyler is also still in contact with his colleagues from the Airforce who visit him frequently. Consider some of the following as you select one of the clinical practice guidelines supplied in the assessments folder to assist you with working through the diagnosis, and journey to the palliative care setting:  Rapid diagnosis and disease progression leaves little time to consolidate and prepare for death - spiritual, social and cultural needs must be considered  Was an adequate pain scale used?  How can the family be provided with support and continuing bereavement follow-up ?  Consider the adequate and detailed use of the SAS tool.  What can nursing staff provide families and the deceased patient to aid them in their grief, loss and need to say goodbye?  Are the National palliative Care standards considered in the CPG?  Were the NMBA and NQHS standards considered in the CPG?  What is your responsibility as an RN to understand the disease trajectory of your patient's, plan their care and the care of their loved one's through the knowledge of nursing standards?  Was the Advanced Health Care Plan followed in the care that was provided? Consider these points and the many others that you may have also thought of as you reflected on the case study. The content in the critique matches the outline presented in the introductory paragraph. Organised paragraphs with an excellent progression of ideas. The content flows from one paragraph to the next on all occasions. The critique ends with a concise, and rational conclusion. Excellent knowledge of National Palliative Care Standards aligned with at least one of NSQHSS and NMBA standards are demonstrated using a palliative approach within the critique. An applicable clinical practice guideline is selected supporting an excellent critique of the case study. Excellent identification of limitations, omissions and/or inaccuracies of care supported by contemporary credible literature and the selected Clinical Practice Guideline.

Introduction Episodes of care that I am having concerns of according to CPG chosen (Can use 400 words for positives) 12 negatives are there… Pain management? ACD? Social care? Spiritual care? At least talk about 4 negatives. What’s missing, what would have been improved My opinion, other literature EBP Conclusion Example: Health professionals conduct assessments on patients because they are the first step of the nursing process (). As identified in case study (ACU), Tylor was suffering from dysphagia. Through completing a swallow assessment and swallow function test, palliative care team upheld NPCS 1.3, 1.4 and 1.5 (), NBA 4.1, NSQSQSH 5.7. These standards instruct nurses to conduct holistic assessments. Multiple occasions of episodes and care Family meeting not conducted Insufficient support given to understand patient condition to wife According to CPG this is important. This is supported by CPG this, NMBA and other thing This is an omission of care. This is also supported by … especially in palliative care setting EBP that links to a theme upholds to Palliative care approach Communication PCC Autonomy and Pain management Highlight – According to Palliative Care Standards did not align with this. Nursing interventions include but are not limited to (Brown et al., 2017): · Facilitating communication · Reducing risk of aspiration · Facilitating early identification of respiratory insufficiency · Decreasing pain secondary to muscle weakness · Decreasing risk of injury related to falls · Providing diversional activities such as reading and companionship The purpose of utilising the standards is to have them as evidence that supports or questions the care provided to Tyler and his family. As you are aware the CPG provides professionals with a guideline of the care that is required, therefore the standards would all support the CPG and the CPG support the standards, thus I would utilise these to critique the case study and care that was provided and review the quality of that care, whilst highlight any care needs that you beleive were neglected. When you identify a negative aspect of care - you will most likely be identifying what should have happened, according to literature, the CPG, NPCS and the NMBA/NSQHSS. Therefore, I anticipate you will identify the omission, justify why it was an omission, and what should have been done.

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In saying that - primarily, according to the rubric - Excellent identification of limitations, omissions and/or inaccuracies of care supported by contemporary credible literature and the selected Clinical Practice Guideline - so the predominant focus is on identification. Referencing You are correct - in the intext citations, you should write the FULL name + corresponding abbreviations FIRST, and write the abbreviation for the rest of the essay/work, and in the reference of the reference list, we should always write FULL name instead of abbreviations in the author's part. Regarding intext citation format - If you have multiple documents with the same author and date you label them - e.g. (Australian Catholic University (ACU), 2022a), ACU, 2022b, ACU, 2022c Then in your reference list, ensure that the correct one corresponds with a, b, c e.g. Australian Catholic University. (2022a). Name of document .... etc Australian Catholic University. (2022b). Name of document... etc  Demonstrate knowledge on the illness trajectory of Motor Neurone Disease (MND) in line with Palliative Care Principles  Provide links between the case study and your chosen CPG to identify highlights or limitations in care Care for Dying patient  Continuation of the PEG (percutaneous endoscopic gastrostomy) feeding was also a negative aspect of the care provided to the patient. It was observed early in the treatment journey of the patient that recurrent infections were common near the insertion point of the feeding tube. However, no action regarding this was taken until the very end of the treatment process. According to CPG, a proper assessment of the benefits and risks of a treatment option should be done before administering any intervention. If the risks are far more than the benefits, the intervention should be discontinued or replaced.  The lack of counseling provided to the patient was a negative aspect of the patient care in the given case study. From the data, it can be understood that the patient was suffering from stress and anxiety because of the conflict between the mother and the wife of the patient. It was mentioned that counseling was conducted for the wife of the patient. However, As the condition of the patient was worsening, proper mental care should have been provided to the patient. According to CPGs, a patient should be given constant physical and mental support by the medical staff.

Pain Management and Documentation? Motor Neurone Disease (MND) is a fatal neurological disorder that affects the upper and lower limb function, speech, breathing, eating, and general body movement ( Lerum et al., 2017) . A series of common threads throughout the course of the illness trajectory were identified, including its diagnosis, deterioration, progression, and death, as well as fears about its progression whereas management of MND focuses on symptom reduction, and a palliative approach to care (MND Australia, 2022). The condition is not generally painful since motor neurones do not transmit or modulate pain signals, MND Australia (2022) states. Nonetheless, discomfort and pain are comorbidities of muscle weakening, stiffness, and immobility in ALS. The role of the nurse is multifaceted, requiring them to assess patients, administer medications, provide patients with alternatives for symptom relief, and collaboratively work with the multidisciplinary team to ensure the highest quality of care and comfort for both patients and their caregivers. An RN's scope of practise includes the provision of preventative care, curative care, education, psychosocial support, therapeutic care, and palliative care based on the best available evidence. Pain management is frequently a challenging task for health professionals which is made even more acute when the patient in pain is nearing the end of their life (Givler et al., 2021). According to CPG 1 - Care of the Dying Patient Plan constitutes of Symptom Observation Chart (SOC) where pain being only one component that must be assessed and recorded timely every 4 hours (ACU, …), which is also upheld by National palliative Care Standard (NPCS) 1.3, 1.4 and NSHQS 1.27. However, pain assessments have not been conducted on Tyler according to the patient notes from the community care nurse. Various data collecting strategies must be utilised such as questionnaires, patient diaries at periods following medication administration to monitor its effectiveness (Gaskell et al., 2009). Healthcare professionals emphasised the significance of patients' involvement in pain assessment and management where utilising pain assessment tools make easier to identify issues (Taylor et al, 2017). Health professionals recommend a formal assessment technique in which they asked patients to verbally rate their pain on a scale from zero to ten which I believe could have been utilized in Tyler’s case rather than just administering e xtra analgesia upon patients request. Establishment of rapport with the patients and pay close attention to their complaints of pain (Brant,2017). NPCS 2.1, NHQS 2.6 and 2.7, states that assessments conducted, and care delivered stands person-centred, and it is important to involve patients themselves and discuss their cultural, spiritual, physical, psychological, and social requirements. Living in a society that is ethnically and culturally heterogeneous necessitates that healthcare providers respect, consider and have an understanding of cultural differences compensates with more effective strategies at managing pain ( Givler et al., 2021) . MS Contin Suspension Controlled Release 20mg BD, Paracetamol 1g QID and PRN Oramorph has been charted for Tyler according to the provided medication chart. Thursday 19 th

March, according to Patient Notes from Community Nurses over 24-hour Period, in addition to e xtra analgesia administered during 1300hour visit, Paracetamol 1g and Oramorph 5mg has been administered via PEG during the 1900hour visit. Oxycodone is frequently mixed with less potent analgesics, such as paracetamol for the management of moderate to severe pain in adults in order to reduce the amount of opioid necessary to achieve a certain level of response, hence lowering adverse events (Edwards 2002). However, repeated administration of oxycodone can lead to tolerance, dependency and potential of abuse ( Gaskell et al., 2009) . The reliance of health professionals on medication is a significant barrier to the implementation of routine Pain Assessment techniques, as they neglect the benefits of initiatives by patients. It has been acknowledged that non-pharmacological pain management measures should be incorporated into pain management recommendations as part of a comprehensive strategy (Taylor et al, 2017). Introduction According to NPCS 1.1, and 9 The initial and ongoing assessments are carried out by qualified interdisciplinary personnel. NHSQS 5.5 The health service organisation has processes to: a. Support multidisciplinary collaboration and teamwork b. Define the roles and responsibilities of each clinician working in a team Pain management 4.4 There are protocols and procedures in place for the escalation of care where required, based on assessed needs. and 4.6 The effectiveness of care is measured according to established indicators and outcomes. NPCS 1.3, Clinical assessment tools are informed by the best available evidence and identify those approaching the end of life as well as those that are imminently dying. NPCS 1.4 The person’s needs are reassessed on a regular basis. NHSQS 1.27 The introduction, use, monitoring and evaluation of evidence-based clinical pathways support effective care, and promote an organisational culture in which evaluation of organisational and clinical performance, including clinical audit, is expected in every clinical service. According to NPCS 2.1 Care planning is informed by the assessment process and reflects a person- centred, holistic approach that incorporates cultural, spiritual, physical, psychological and social needs NHSQS 2.6, health service organisation has processes for clinicians to partner with patients and/or their substitute decision maker to plan, communicate, set goals and make decisions about their current and future care

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2.7 The health service organisation supports the workforce to form partnerships with patients and carers so that patients can be actively involved in their own care Documentation 1.25 Support the workforce to understand and perform their roles and responsibilities for safety and quality Infection prevention NHSQS 3.6 The risk of infection to patients, the workforce and visitors is minimised by the routine application of infection prevention and control strategies that include standard and transmission- based precautions. NHQS 5.15 Patients with end-of-life care needs are identified as soon as possible to maximise opportunities for appropriate decision making and care. Routine use of simple trigger tools and questions can prompt clinicians to use their clinical judgement to make a holistic assessment of whether a patient has end-of-life care needs. Depression, emotional discomfort, anxiety, doubt, and hopelessness are psychological symptoms that occur alongside physical pain. Poor reporting of treatments for acute pain has been recognized in the past, which lack data to apprise multidisciplinary team (Edwards 1999). Practitioners often describe a family’s reluctance to discuss palliative issues with patients as a barrier to appropriately managing pain in a dying patient. Further, health practitioners may misinterpret an unwillingness to discuss impending death as a refusal of appropriate pain management. Documentation; • inadequate data to guide clinical practise. Documentation in palliative care should enable nurses to use their knowledge and experience to synthesise observations and clinical information to gain a picture of the overall condition of the patient ( Jefferies et al, 2012 ). However, in practice, nurses face several challenges to carrying out effective documentation. Frequently cited issues include time constraints, inadequate organisational support, understaffing and a lack of clear guidelines for reporting care ( Blair and Smith, 2012 ; Ofi and Sowumni, 2012 ). Additionally, it has been noted

that nurses can rely too heavily on oral communication and clinical handovers, which lead to incomplete written records which do not include sufficient holistic or contextual factors ( Jefferies et al, 2011 ; Wang et al, 2011 ; Jefferies et al, 2012 ; Voyer et al, 2014 ). https://www.magonlinelibrary.com/doi/full/10.12968/ijpn.2017.23.12.577 Clinical Significance The education of health professionals can increase the appropriate use of pain medicine and palliative care. Health professionals can help patients and families dispel fears about opioid medications by explaining the proper use of opioid pain medicine. Givler, A., Bhatt, H., & Maani-Fogelman, P. A. (2021). The importance of cultural competence in pain and palliative care. In StatPearls [Internet] . StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493154/ Thursday 19 th March, according to vital sign observations, patient’s temperature remains above the range for standard adult body temperature which is 36. – 37. . RN appears not to pay attention on this. However, Pain score?  What is a SAS Tool?  What is the Problems Severity Score/ (PSS)  What is a Modified karnofsky Score? Building strong networks means that patients can be looked after at home if members of the ‘inner’ circle of care are trained in caring skills, such as manual handling and medication administration. Resilient support networks can fulfil and enhance a variety of functions ordinarily performed by professional services. Spiritual, psychological and social care are not the exclusive domain of professionals. Meaning and value in care is equally obtained in the context of supportive communities, and the same principle applies to physical care. Once strong social networks are in place, it is possible to consider changing the roles and functions of Every healthcare professional is responsible for attending to the needs of people with life-limiting conditions. Generalist palliative care, therefore, takes place in different settings, at hospitals, in primary care, and in the community. Generalist palliative care, like specialist palliative care, focuses largely on harm reduction as prescribed by the public health approach to end-of-life care (35). This is primarily achieved through early identification, advance care planning and prevention of admission to hospital within the framework of a multifaceted approach with good attention to symptom control. The social elements of the model reduce harm that comes from the difficulties of caring from the point of diagnosis right through to bereavement. KellehearA,O’ConnorD.Health-promotingpalliative care: A practice example. Crit Public Health 2008;18:111-5.

Abel, J., Kellehear, A., & Karapliagou, A. (2018). Palliative care-the new essentials. http://hdl.handle.net/10454/15625 Gaskell, H., Derry, S., Moore, R. A., & McQuay, H. J. (2009). Single dose oral oxycodone and oxycodone plus paracetamol (acetaminophen) for acute postoperative pain in adults. Cochrane Database of Systematic Reviews , (3). doi: 10.1002/14651858.CD002763.pub2. PMID: 19588335; PMCID: PMC4170904.  NSQHS - Medication Safety  Project teams should be multidisciplinary and include clinicians responsible for various medication management activities. Partnering with patients and carers in these processes can result in improved services and a higher level of satisfaction. 1  Ongoing monitoring and evaluation of the safety, quality and performance of medication management systems are also necessary to track changes over time, ensure that systems continue to operate effectively 2 and identify areas for improvement. Data from evaluation of medication management should be communicated back to clinicians. They can focus clinicians on areas that need improvement, and motivate them to change practice and take part in improvement activities. 2-4 Feedback processes also contribute to a culture of transparency and accountability. Intent Safety and quality systems support clinicians in the safe and effective use of medicines and reduce medicine-related risk. Action 4.01 a. Implementing policies and procedures for medication management b. Managing risks associated with medication management c. Identifying training requirements for medication management Action 4.02 a. Monitoring the effectiveness and performance of medication management b. Implementing strategies to improve medication management outcomes and associated processes c. Reporting on outcomes for medication management Some opioid-induced side effects, such as drowsiness and delirium, are dose-dependent and can be minimized and sometimes eliminated by reducing the amount of administered medication 11 ; thus dose reduction entails decreasing the amount of administered opioid to minimize adverse effects while preserving the benefits of a given analgesic medication. 4 Rogers, E., Mehta, S., Shengelia, R., & Reid, M. C. (2013). Four strategies for managing opioid- induced side effects in older adults. Clinical geriatrics , 21 (4). Educating the spouse

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This study's findings on the spouse's coping strategies, which involve suppressing or ignoring emotional reactions in favour of attending to urgent and practical concerns, are consistent with those of previous research[19,29]. Similar to previous research[20], the spouses in this study attempted to hide their emotions and present themselves as resilient. It's possible that a spouse of someone with MND never accept their partner's diagnosis completely. They go through a variety of psychological reactions, eventually settling into a new normal after some time has passed. This process is fraught with difficulties. Their typical coping mechanisms and the network of people who help them adjust are shown here. Strategies to cope with Stress, spouses utilise a variety of coping mechanisms, including denial, emotional outbursts, avoidance, laughter, and religious coping, during the illness trajectory. The loss of a spouse is greater than the loss of just one person but her self-confidence, safety, status, and her habits. (Warrier et al., 2020)

Communication and lack of education on patient condition Airway management maintaining airway patency and preventing the occurrence of reversible complications

References ACU Practice guideline. (2018). Care of the Dying Patient. https://leo.acu.edu.au/pluginfile.php/4991074/mod_resource/content/1/Care %20of%20the%20Dying%20Patient%20CPG.pdf ACU Practice guideline. (2021). End of Life Care. https://leo.acu.edu.au/pluginfile.php/4991076/mod_resource/content/1/End%20of%20Life %20Care%20CPG.pdf ACU. (2021). Tyler Morton Advance Health Directive. https://leo.acu.edu.au/pluginfile.php/4990157/mod_resource/content/3/Tyler%20Morton %20AHCD.pdf ACU. (2021). Tyler Morton Case Study. https://leo.acu.edu.au/mod/book/view.php?id=4317892 Australian Commission on safety and Quality in Health Care. (2020). National Safety and Quality Health Service (NSQHS). Retrieved from: https://www.safetyandquality.gov.au/standards/nsqhs-standards Brant, J. M. (2017). Holistic total pain management in palliative care: Cultural and global considerations. Palliative Med Hosp Care Open J , 1 , S32-8. Brown, D., Edwards, H., Thomas, B., & Aitken, R. L. (2017). Lewis’s Medical-surgical Nursing Ebook: Assessment and Management of Clinical Problems. Elsevier. Borbasi, S., Jackson, D., & East, L. (2019). Navigating the maze of research : enhancing nursing and midwifery practice (Fifth edition.). Elsevier Australia. Levett-Jones, T. (2018). Learning to Think Like a Nurse (2nd Ed). Pearson. 2018

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Nursing Midwifery Board of Australia. (2016). Registered Nurse Standards For Practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/ Professional-standards/registered-nurse-standards-for-practice.aspx Palliative Care Australia. (2018). National Palliative Care Standards (5th Ed.). Retrieved from https://palliativecare.org.au/standards Taylor, S., Allsop, M. J., Bekker, H. L., Bennett, M. I., & Bewick, B. M. (2017). Identifying professionals’ needs in integrating electronic pain monitoring in community palliative care services: an interview study. Palliative medicine , 31 (7), 661-670. Warrier, M. G., Sadasivan, A., Polavarapu, K., Kumar, V. P., Mahajan, N. P., Reddy, C. P. C., ... & Thomas, P. T. (2020). Lived experience of spouses of persons with motor neuron disease: preliminary findings through interpretative phenomenological analysis. Indian Journal of Palliative Care , 26 (1), 60. Lerum, S. V., Solbrække, K. N., & Frich, J. C. (2017). Healthcare professionals’ accounts of challenges in managing motor neurone disease in primary healthcare: a qualitative study. Health & social care in the community , 25 (4), 1355-1363. https://doi.org/10.1111/hsc.12432 https://www.mndaustralia.org.au/mnd-connect/for-health-professionals-service-providers/end-of-life

NRSG374 Palliative Approach AT2

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