Assessment 4: Case Presentation
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cf_Exemplar_MSN-FP6610_Assessment_4.pptxCASE PRESENTATION
Case Presentation
Learner’s Name
Capella University
Introduction to Care coordination
Case Presentation
September, 2019
Plan for Continuing Care for Rebecca Snyder
Objectives
Safe transition from primary care to end-of-life care at a hospice for Mrs. Snyder
Hospice must cater to her Orthodox Jewish religious requirements in addition to providing palliative care
Hospice must provide good-quality kosher food
Hospice must accommodate pet visits so she can see her two dogs
Hello, all. In today’s presentation, I will discuss the case of Mrs. Rebecca Snyder. The presentation will outline her medical history, her diagnosis, the treatment she has received to date, and the plan for continuing care proposed by the interprofessional care team. The goal is a safe transition for Mrs. Snyder from primary care to end-of-life hospice care. The hospice facility must cater to her specific Orthodox Jewish religious requirements in addition to providing palliative care. She is attached to her two pet dogs, so the hospice must accommodate pet visits.
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Patient Assessment (1)
Physical Assessment
57 years old
Stage 4 ovarian cancer
Secondary metastatic brain tumor
Emotional Assessment
Pain
Anxiety
Unwilling to be a burden
The interprofessional care team developed a holistic understanding of Mrs. Snyder’s case to develop a plan to continue care for her. The elements considered by the interprofessional team were a complete patient assessment, medical and diagnostic reports, outcomes from nursing interventions provided at the primary care center, and an outline of expected patient outcomes. Let us begin with the patient assessment, where the physical, emotional, religious, functional, age-related, economic, and environmental aspects of the patient’s case were assessed.
Rebecca Snyder is a 57-year-old woman who is clinically obese. She was diagnosed with ovarian cancer 7 months ago. She also has a secondary metastatic brain tumor. She was recently diagnosed with stage 4 ovarian cancer, giving her a prognosis of 6 months or less.
Mrs. Snyder is in a lot of pain and suffers from anxiety brought on by her chemotherapy and wants to discontinue treatment beyond palliative care. She isn’t perturbed by her new, shorter prognosis. She would like to spend her last days at home but is reluctant to let others help her with household chores. She insists on not being a burden to those around her.
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Patient Assessment (2)
Spiritual Assessment
Is of Orthodox Jewish faith
Follows a kosher diet
Attends religious services on Fridays and Saturdays
Functional Assessment
Can walk short distances
Suffers from fatigue
Suffers from shortness of breath
Mrs. Snyder is Orthodox Jewish. She requires kosher food and insists on attending religious services on Fridays and Saturdays. Her secondary care centre must accommodate these wishes.
Mrs. Snyder suffers from a decline in her functional status. She can walk short distances inside the house by holding onto furniture and requires minimal assistance with daily activities. She requires additional time to perform tasks because of fatigue and shortness of breath. She requires the assistance of one person to shop for groceries and for cleaning.
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Patient Assessment (3)
Age-Related Assessment
Diabetes mellitus and obesity
Hypercholesterolemia
Hypertension and anxiety
Bloating, nausea, and weight loss
Economic Assessment
No specific economic barriers to seeking care
Environmental Assessment
Lives in a multistory house
Bedroom and bathroom on the second level
One flight of stairs to the second level
Resides with husband and two teenage sons
Prepares meals, drives, and manages personal finances
Mrs. Snyder is a 57-year-old woman with a medical history of poorly controlled diabetes mellitus, hypertension, hypercholesterolemia, anxiety, and obesity. She feels bloated and is not hungry. She feels nauseous when she does eat. She has experienced some weight loss over the last 7 months. Mrs. Snyder has not mentioned any economic barriers to seeking care.
Mrs. Snyder lives in a multistory house with one flight of steps to the second level. The bedroom and bathroom are on the second level. She resides with her husband, debilitated elderly mother (who has since been moved to a home), and two teenage sons. Her household duties include meal preparation, driving, and managing personal finances.
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Medical Results and Diagnostic Reports
Medical History
Diabetes mellitus
Obesity
Hypercholesterolemia
Hypertension
Anxiety
Diagnosis
Metastatic ovarian cancer
Secondary metastatic brain tumor
Uncontrolled diabetes mellitus
Hypertension
Hypercholesterolemia
Gastrointestinal bleeding
Anxiety
Obesity
Mrs. Snyder suffers from poorly controlled diabetes mellitus, hypertension, hypercholesterolemia, anxiety, and obesity.
She was diagnosed with metastatic ovarian cancer with a secondary metastatic brain tumor. Her most recent blood sugar count was 401. She has reported gastrointestinal bleeding.
Her oncologist discussed the diagnosis with Mrs. Snyder and educated her about her secondary metastatic brain tumor. Her family was present in the room.
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Outline of Patient Outcomes
End-of-life care at a hospice
Palliative care and pain relief
Constant communication
Visits by her rabbi
Good-quality kosher food
Pet visits
Mrs. Snyder will spend her remaining months at a hospice. The hospice will provide palliative care with a focus on pain relief. The hospice staff will stay in constant communication with Mrs. Snyder and her family to understand her needs and make her as comfortable as possible. The hospice will accommodate visits by Mrs. Snyder’s rabbi as and when she requires them. The hospice will procure kosher food of good quality. The hospice will accommodate pet visits.
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Nursing Interventions (1)
Chemotherapy Intervention
Mrs. Snyder resisted chemotherapy because of the pain, nausea, and anxiety the therapy caused her.
The nausea was treated with an over-the-counter antiemetic. Side effects included itchy eyes and drowsiness. Mrs. Snyder discontinued the use of the antiemetic.
Outcome
The interprofessional care team discussed ways to mitigate the side effects of the chemotherapy with the oncologist and an oncology nurse.
The nurse discussed alternate medication for pain and nausea management with the interprofessional team.
The oncologist agreed to adjust the chemotherapy dosage.
Mrs. Snyder initially resisted chemotherapy, which was recommended by her oncologist. This resistance was primarily due to the pain and nausea it caused, which made her anxious. She was on an over-the-counter antiemetic but stopped taking it because it made her drowsy and made her eyes itch.
The interprofessional care team consulted with an oncology nurse about ways to mitigate the side effects of the chemotherapy. The nurse spoke with Mrs. Snyder about medication that could be used to manage her pain and nausea. The team also spoke with the oncologist. Apparently, Mrs. Snyder never told the oncologist about the extent to which she struggled with the side effects. The oncologist agreed to adjust the dosage of the chemotherapy. Mrs. Snyder was relieved. She didn't know that these options were available and decided she wanted to give another round of chemotherapy a try.
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Nursing Interventions (2)
End-of-Life Care Intervention
After the new prognosis, Mrs. Snyder wanted to spend her last days at home.
Devorah, her daughter, agreed to help out but is 6 months pregnant and has two young children.
Avi, her son, is a recovering alcoholic.
Janet, her sister, lives in Florida and suffers from a back problem.
Outcome
The interprofessional care team discussed potential red flags in Mrs. Snyder’s situation that are barriers to effective home hospice care.
Mrs. Snyder agreed to go to a hospice facility.
Given the new diagnosis and the new prognosis of 6 months, Mrs. Snyder stated that she wanted to spend her last days at home. Devorah, her daughter, supported the idea and agreed to assist her mother at home. However, Devorah is 6 months pregnant and has two young children. She also had a history of third-trimester complications during her previous pregnancies and required bed rest. Devorah suggested that Avi, her brother, help. However, Avi is a struggling alcoholic who only recently got out of rehab. Devorah also suggested that her aunt Janet, who lives in Florida, help, but Mrs. Snyder said that suffered from a back problem that could prevent her from flying.
The interprofessional care team convinced Mrs. Snyder and her daughter that a hospice facility would be better for her. The team pointed out the risks involved with Mrs. Snyder’s staying at home. Devorah may need bed rest, and her mother-in-law may be unable to look after the children. Avi could also start to drink again. To assuage her concerns about isolation, the team explained that her family could still be very involved in her care and discussed all the resources that are available at hospice facilities.
After thinking about it, Mrs. Snyder and her family decided that hospice care was the right decision. Devorah and Avi admitted that they were relieved by this decision because they both doubted their ability to care for their mother adequately.
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Overall Scope: Deliverables
Comparison of Potential Hospices
St. Francis House
Run by Father Miguel Rivera
Has a nondenominational chaplain on staff
Can accommodate visits from a rabbi
Could possibly accommodate a kosher diet, though it would be the first time
Pet-friendly
Fern Hill Center
Represented by Kathryn Marcus
Can work with Mrs. Snyder and family to accommodate religious needs
Prioritizes communication to make patients as comfortable as possible
Procures kosher food from a Jewish hospice facility
Pet-friendly
The interprofessional team compared two hospices that could accommodate Mrs. Snyder’s specific requirements.
Mrs. Snyder and her family were introduced to Father Miguel Rivera from the St. Francis House hospice facility. He confirmed that they have a nondenominational chaplain on staff and that Mrs. Snyder is free to have her rabbi visit the hospice. The facility is pet-friendly and can accommodate her kosher diet, even though they have never had to accommodate such a diet before.
Next, Mrs. Snyder was introduced to Kathryn Marcus from the Fern Hill Center hospice facility. Kathryn assured Mrs. Snyder that her facility would be able to work with her and her family to meet her religious needs. The facility prioritizes communication with patients to make them as physically and emotionally comfortable as possible because end-of-life care needs to be tailored to the individual. Kathryn stated that her hospice currently has a patient who observes a kosher diet and that they get kosher food from a nearby Jewish hospice facility. She also told Mrs. Snyder that she could have her pets visit if they’re well-behaved.
The interprofessional care team recommended Fern Hill Center because they prioritized communication with the patient and the family to make the patient as comfortable as possible. The staff at the facility have demonstrated that they can procure kosher food as they already have a patient with those requirements. The facility is also pet-friendly.
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Overall Scope: Constraints and Assumptions
Constraints
Mrs. Snyder prefers to go to a Jewish hospice facility
No immediate opening at the Jewish hospice facility
Assumptions
Red flags in potential caretakers
Devorah
6 months pregnant
Two children
Third-trimester complications in previous pregnancies
Avi
Recovering alcoholic
May relapse
Janet
Lives in Florida
Suffers from a back problem
Mrs. Snyder would prefer to go to a Jewish hospice facility that she knows of because it offers kosher food and Jewish religious services. However, it does not currently have an open space. She would rather go home than to a non-Jewish facility. After assurances that the team will do its best to find her an appropriate facility where she can get kosher food and feel comfortable, she relented reluctantly.
The interprofessional care team recommended against home hospice care because of red flags noticed in her family situation. Devorah, her daughter, is 6 months pregnant with two little children. There were complications in her third trimester during her previous pregnancies that required her to take bed rest. The assumption is that she might require bed rest for the third trimester of the current pregnancy as well, rendering her unable to help her mother with home hospice needs. Avi, her son, is a struggling alcoholic who has only recently come out of rehab. The assumption is that he might relapse, rendering him unable to help his mother with home hospice needs. Janet, her sister, currently lives in Florida. She suffers from a back problem that could prevent her from traveling by air. This could make it difficult for Janet to care for her sister.
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Interprofessional Care Team (1)
Develops clear understanding of patient’s wishes and values
Delivers respectful end-of-life care
Reduces stress for family members
An interprofessional care team develops a clear understanding of a patient’s wishes and values. This understanding is crucial “to delivering respectful end-of-life care and to reduce stress for family members who are faced with difficult decisions on behalf of their loved ones” (Ho, Jameson, & Pavlish, 2016). The team accomplishes this by working with people within and outside the health care profession, the patient, and the patient’s family to gain a holistic understanding of the patient’s case to deliver high-quality patient outcome.
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Interprofessional Care Team (2)
Members of the Interprofessional Team
Oncologist
Case manager
Social worker
Rehabilitation specialist
Diabetes educator
Family members
In Mrs. Snyder’s case, the interprofessional team included the oncologist, case manager, social worker, rehabilitation specialist, and diabetes educator to develop a holistic understanding of her case and the care she has received to date. The team also spoke with her daughter Devorah and her son Avi to understand the extent of support they can realistically afford her. The team also spoke with Mrs. Snyder to understand her state of mind as well as her religious requirements.
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Factors Affecting Patient Outcomes
Psychological factors: Stress, anxiety, and depression
Physiological factors: Hair loss, pain, fatigue, nausea, and vomiting
Social factors: Social isolation, role, and function loss
Spiritual and religious factors
The main factors affecting Mrs. Snyder’s quality of life during end-of-life care are psychological factors such as stress, anxiety, and depression; physiological factors such as hair loss, pain, fatigue, nausea, and vomiting; social factors such as social isolation, role, and function loss; and spiritual and religious factors. Psychological, physiological, and social factors affect the quality of life of cancer patients negatively, while religious and spiritual factors affect it positively in some cases (Üstündağ & Zencirci, 2015).
Mrs. Snyder underwent chemotherapy before her new diagnosis and prognosis. She has been through and is still suffering from the physical and psychological effects of the chemotherapy. She is a strong-willed woman and is used to caring for others in her family, having cared of her elderly debilitated mother and two teenage sons. She feels bad that her mother has since moved to a retirement home and is reluctant to let others help her with tasks such as cooking and cleaning. When discussing end-of-life care, she is insistent on following a kosher diet and attending religious services on Fridays and Saturdays, implying that religion is a source of comfort for her. She has a couple of pet dogs she is attached to.
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Resources for Continuing Care
Hospice staff for palliative care and medication for pain alleviation
Regular consults with the physician for diabetes mellitus, hypertension, hypercholesterolemia, and obesity
Counselling services for anxiety and depression
Hospice staff assistance with ambulation
Resources to fulfil religious requirements
Mrs. Snyder’s new prognosis of 6 months makes her eligible for hospice care. In addition to palliative care by the hospice staff and pain alleviation medication, she requires regular consults with a physician for her diabetes mellitus, hypertension, hypercholesterolemia, and obesity. She suffers from anxiety and depression and could benefit from counseling services at the hospice facility (Buera & Dalal, 2017). She can walk short distances but is prone to falling, so she may require assistance with ambulation.
Mrs. Snyder is Orthodox Jewish and observes the Sabbath from sundown on Friday to Saturday evening after dark, as dictated by the tenets of her religion. During the Sabbath, she may refrain from actions that could be “considered work, such as writing, carrying or moving certain objects, [and] using electrical devices and telephones” (Gabbay, McCarthy, & Fins, 2017). Effective communication with her and her family would be crucial to ensuring no barriers to the care she requires during the Sabbath. The hospice facility must also cater to her kosher diet requirements. The interim hospice facility must make provisions for visits by her rabbi until she can move to the Jewish hospice facility she prefers. Arrangements must also be made for pet visits.
Thank you
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References
Dalal, S. & Buera, E. (2017). End-of-life care matters: Palliative cancer care results in better care and lower costs. The Oncologist. (22)4, 361–368. https://doi.org/10.1634/theoncologist.2016-0277
Gabbay, E., McCarthy, M.W., & Fins, J.J. (2017). The care of the Ultra-Orthodox Jewish patient. Journal of Religion & Health. (56)2, 546–560. https://doi.org/10.1007/s10943-017-0356-6
Ho, A., Jameson, K., & Pavlish, C. (2016). An exploratory study of interprofessional collaboration in end-of-life decision-making beyond palliative care settings. Journal of Interprofessional Care. 30(6), 795–803. https://doi.org/10.1080/13561820.2016.1203765
Üstündağ, S., & Zencirci, A.D. (2015). Factors affecting the quality of life of cancer patients undergoing chemotherapy: A questionnaire study. Asia-Pacific Journal of Oncology Nursing. 2(1), 17–25. https://doi.org/10.4103/2347-5625.152402
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