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Question: An explanation of the role of the advanced practice nurse in facilitat

Question: An explanation of the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families. Explain how you would approach a family who wants “everything” done for a patient with only a limited time to live. Then, explain when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services. Finally, explain potential outcomes of the patient in the case study you selected and how you would facilitate the discussion of end-of-life care with this patient’s family. We are in a unique position to guide patients and their families through an increasingly complex health care system toward the goal of a “good death” one that is comfortable and self-determined. Answers: An explanation of the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families   With the aging of the US population, the number of seriously ill patients with complex conditions is expected to rise and the overwhelming majority of deaths occur among the older adult population. Older adults typically die slowly of chronic diseases, with multiple coexisting problems, progressive dependency on others and heavy care needs that are met mostly by family members. The dilemma of end-of-life care becomes a crucial issue for the advance practical nurses. As a nurse practitioner, we have a crucial role in facilitating end-of-life care discussion with patients and families. It is not that easy to explain to them about hospice or comfort measures. A lot of patients and families have misconception about end-of-life care. They are thinking about the literal word of killing or giving up someone’s life. We are here to assist elderly patients with their advanced chronic illness and their families as they experience the final phase of life. We are here to serve the patients and family members caring for patients to promote excellent communication with family, encourage appropriate advance care planning and decision making, support home care, demonstrate empathy for family emotions and relationships, and attend to family grief and bereavement (Rabow, 2004). We should have the ability to listen which is the most valuable skill that can be used and allow them the opportunity to tell “their story.” End-of-life issues are very sensitive. That is when we are all most vulnerable, cared and thinking of what we did or did not do in our lifetime. NPs who can be empathetic and “be” with the patient at this very important time will have one of the most rewarding experiences of their career (Knox, 2010). The value of the advanced practice palliative nursing role extends beyond specialized and expanded knowledge, critical thinking, and evidence-based practice to enhanced communication skills that facilitate direct patient care through informed decision-making, patient and family education, and psychosocial-spiritual care. Nurses have the communication skills necessary to engender trust and draw patients and their families into a partnership of care. Their commitment to quality and safety motivates them to continuously improve the care they provide and make valuable contributions to the interdisciplinary team (Yeager, 2014). The interdisciplinary team helps ensure that the right care at the right time and in the right place is going to happen for the person. The NP often calls on the case manager, social worker and chaplains to assist with identifying and meeting the critical needs in a timely manner. As a nurse practitioner in palliative care, we need to be skilled in communication, diagnosis, treatment and pharmacology, and they need to counsel and support patients and families emotionally. Providing pain and symptom management and addressing patient suffering are important parts of the role (Knox, 2010).     Explain how you would approach a family who wants “everything” done for a patient with only a limited time to live The amorphous relationship between practitioners and the families of patients at the end of life presents both challenges and opportunities for which nurse practitioner’s may be unprepared. Families play important roles in the practical and emotional aspects of patient care and in decision making at the end of life. At the same time, family members may carry significant burdens as a result of their work. The discussion of death and dying is one that most people and also most healthcare professionals find very difficult to talk about. As a nurse practitioner, I would be more empathetic and be a good listener on their feelings about the situation. I will let them tell their stories, verbalized their feelings and thoughts and find the reason why they want everything done for the patient. Being a good listener and empathetic to their feelings will help them be more comfortable in discussing the prognosis of the patient. I will respect their opinions but at the same time I will explain to them thoroughly the minimal benefits that the patient could get if will do everything for him. I will be more realistic to them and show them the outcome if patient will go for an aggressive treatments. I will make a reasonable effort to clarify their doubts, questions, and communicate with them the risk and its potential benefits. Considering the patient’s advanced age and poor prognosis, I will have them a clear understanding of the patient’s prognosis and the pros and cons of doing everything for the patient like CPR. Although all patients who require CPR have severe acute illness by virtue of needing CPR, there may be differences in the type or severity of the acute illness leading to CPR that could influence outcomes. I will emphasize to them the minimal benefits that the patient gets from such procedures and at the same time I will explain to them the advantages and benefits that the patient gets from palliative care and the quality of life that he would have on his last days of his life. The final months of the patient is the most precious one and we want the patient to spend the rest of his life in a comfortable and peaceful way of living (Ehlenbach, et al, 2009).     Explain when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services If a patient has life-limiting illness like HIV, Stage 4 cancer with metastasis to multiple sites, or CVA with persistent vegetative state should consider hospice as a care option. Hospice is also recommended to patient or family that chooses comfort care, if a patient has a loss of functional or physical decline, has multiple comorbidities, dependence in most activities of daily living, and increase in ER visits and hospitalizations. Hospice is the comprehensive care system for patients with limited remaining life expectancy and can be provided at home or in institutional settings (Flaherty & Resnick, 2014). As a nurse practitioner, we have to assess the knowledge of the patient or family about hospice care because some of them think that it is one way of giving up the patient’s life. It is our sole responsibility to explain well to patient and family about the purpose and benefits of hospice care. We have to acknowledge and address their stress, doubts, and concerns about hospice care. We should explain to them that we are not giving up the patient, instead, we are there to support him and make him feel comfortable until his last breath. They should realize that hospice is a specialized palliative care limited to patients who have poor prognosis with 6 months or less to live. We should discuss to them about the comfort measures, alleviation of pain and the utmost quality care that he will get from hospice care. Since some families think that patient will be neglected, they should realize that hospice patients are cared for by an interdisciplinary team like physicians, nurses, social workers, chaplains, aides, therapists, dietitian, and volunteers. We should tell them that hospices provides medications, supplies, equipments, and other services related to the terminal illness. They should realize that if the patient condition improves, he can be discharged from hospice and may return to aggressive treatments or routine daily life. We should tell them that hospice staff will visit them regularly and have an access to a hospice physician. By providing a detailed explanation of the significance of hospice care, patients and family will not only be relieved from pain and stress but will also have the utmost quality care and quality of life that patient deserves (Flaherty & Resnick, 2014).   Explain potential outcomes of the patient in the case study you selected and how you would facilitate the discussion of end-of-life care with this patient’s family. Case Study 3: is the one that I selected…. Mr. Marley, age 91, is admitted to the intensive care unit following a stroke. The stroke progressed from mild hemiparesis and difficulty speaking to complete unresponsiveness and an inability to swallow. His daughter feels certain, based on prior explicit conversations with her father, that he would not want to have any treatment that would prolong his life and leave him in a severely disabled state. Mr. Marley’s oldest son disagrees with his sister’s assessment of their father. The son claims that their father still has a strong desire to live, and that he has been very active in his church until this stroke. Because Mr. Marley cannot swallow, he cannot be fed. The family is asked about insertion of a feeding tube. It is explained to the family that without food and fluids, their father will die fairly quickly. There are no existing advance directives or a designated health care decision maker noted for Mr. Marley. Answer: Facing end-of-life is not that easy for anyone. We should establish a good nurse practitioner-family relationship and initiate paths for them to express their own doubts, anxiety’s, and emotions. Every single person in the family has its own reaction about end-of-life, so we have to consider each and every one of them when discussing end-of-life. In case study #3, Mr. Marley was already 91 years old and became unresponsive due to progressive stroke. Mr. Marley had a severe stroke that could worsened his neurologic status and leave him in a severely debilitated state. Prior to his debility, Mr. Marley claimed that he did not want any procedure to be done if he is gonna leave him in vegetative state. Though the patient has no actual advance directives or written living will, the surrogate decision maker or next of kin should consider the patient’s wish when making decision for him. In the absence of discussions about or documentation of preferences for care, surrogates are inaccurate in their predictions of what type of care a loved one would want (Holroyd-Leduc & Reddy, 2012). Emotional support is vital when discussing about end-of-life care, and as a nurse practitioner we are the influential component in providing support to patient and families at this challenging times. The daughter or son should consider and respect Mr. Marley’s wish that he would not want to prolong his life if he will just be in severely disabled state. As his nurse practitioner, I will discuss to them the pros and cons of a procedure and present to them the reality or the potential outcomes once Mr. Marley had the peg placement. He would have the feeding, he would have the nutrition, but his neurological status and debilitated state will stay the same and might get worse in the near future. Because of his unresponsiveness and functional neurological debility, he is prone to acquire more complications like pressure ulcers, pneumonia, or brain death which is a life-threatening complication of stroke. Unnecessary procedures that will only gain a minimal benefit for the patient will just prolong his agony and suffering (Flaherty & Resnick, 2013). All older adults should be offered the opportunity to document advance care plans because trajectory of illness is often unpredictable, and many lose the capacity to make decisions at the end of life (Holroyd-Leduc & Reddy, 2012).     References: Ehlenbach, W. J., Barnato, A. E., Curtis, J. R., Kreuter, W., Koepsell, T., Deyo, R., & Stapleton, R. (2009). Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. The New England Journal of Medicine, 361(1), 22–31. Note: Retrieved from the Walden Library databases.   Flaherty, E., & Resnick, B. (Eds.). (2014). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (4th ed.). New York, NY: American Geriatrics Society. Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide.Hoboken, NJ: Blackwell Publishing. Knox, P. (2010). Palliative Care Nurse Practitioners. Retrieved from Rabow, M. W., Hauser, J. M., & Adams, J. (2004). Supporting family caregivers at the end of life: “they don’t know what they don’t know”. Jama, 291(4), 483-491. Yeager, K. (2014). The Role of Advanced Practice Nursing in Palliative Care. Retrieved from


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