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PART 1: ONE PAGE

Week 4: Discussion on End-of-Life Decisions and Advanced Directives

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Participation Requirement: You are required to post a minimum of three (3) times in each discussion. These three (3) posts must be on a minimum of two (2) separate days. You must respond to the initial discussion question by 11:59 p.m. on Wednesday.  On additional days, respond to your peers’ posts as well as additional faculty posts. Responses to peers must be posted by 11:59 p.m. on Sunday each week a discussion is due.

Step 1: Read attached article entitled,  Advance Directives and Health Care Planning-Are all the pieces in place.pdf    Download Advance Directives and Health Care Planning-Are all the pieces in place.pdf 

Step 2: Read the following article:  Effect of Living wills on End of Life Care.pdf  Download Effect of Living wills on End of Life Care.pdf

Step 3: Watch the video, “Advanced Directives: Important Healthcare Tools for Supporting You and Your Family” https://www.youtube.com/watch?v=GOIrnjqP5_M (Links to an external site.) Minimize Video

Step 4: Watch the video, “How to Have an End of Life Discussion” https://www.youtube.com/watch?v=JtkgTzCSzqk (Links to an external site.) Minimize Video

An Advanced Directive is a document in which a client who is competent is able to express wishes regarding future acceptable health care. The document may include decisions including the desire for extraordinary lifesaving measures, such as resuscitation, intubation, and artificial hydration, and nutrition. The advanced directive may also be used to designate another person to make decisions when the client becomes physically or mentally unable to do so. The Patient-Determination Act requires all clients admitted to a health care facility be asked if they have advanced directives.

Planning guides for seriously ill clients includes:

1. Living will: Legal document that instructs health care providers and family members about what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to make decisions.

2. Durable power of attorney for health care: Legal document that designates another person to make health care decisions for the client when the client becomes unable to make decisions independently.

Nursing intervention in these types of situations is to ensure to communicate to the interdisciplinary health care team that the client has provided and advanced directive and that it has been placed in the client’s medical record. Clients who do not have advanced directives must be given written information outlining rights related to health care decisions.

Initial Discussion scenario:

Mr. Gomez is a 73-year-old man who is estranged from his wife. Since he prefers that she doesn’t make any medical decisions for him should the need arise, he has filled out an advance directive naming his daughter Elena as his health care proxy. He has suffered from diabetes for many years and is adamant that he does not want dialysis, even if it would sustain his life. He does, however, wish to have tube feeding for however long it will sustain him.

One evening while at home with his daughter, Mr. Suarez has a seizure. He is taken to the hospital immediately, but never regains consciousness and doctors do not expect him to do so. Elena contacts her mother Mr. Gomez’s estranged wife and she quickly joins her daughter at the hospital. They want to put him on dialysis (as his diabetes is worsening) and a feeding tube (as there is no other way for him to receive nutrients). His daughter informs the doctors of her father’s end-of-life wishes. The doctors warn her that without dialysis her father will pass away more quickly, even with the feeding tube. Mr. Gomez’s estranged wife informs Elena that she needs to follow the advice received from the doctors in order to save her father’s life. Elena says that although she is aware of the consequences, she wants them to carry out her father’s wishes.

The clients estranged wife immediately has her attorney file an order to stop Elena from following her father’s wishes that are in his advanced directive. She feels that even though they are estranged, she still should have the right to make decisions regarding Mr. Gomez’s care. This action delays Elena’s ability to honor her father’s wishes and the doctors feel that it is necessary to inform the hospital’s ethics committee about the ongoing issue.

Assignment: Discuss the following questions

1. What is the role of the doctors in deciding whether or not to respect Mr. Gomez’s advanced directive?

2. Does Mr. Gomez’s estranged wife have the authority to step in and ignore Mr. Gomez’s advanced directive. Explain your reasoning while providing evidence-based solutions in your conclusion.

3. Gomez’s estranged wife has filed temporary order to ignore the advanced directive. If you were Elena, how would you handle this dilemma? What rights does Elena have that allow her to honor her father’s wishes?

4. What is the role of the ethics committee and how can they best support the client and his family?

 

PART 1: ONE PAGE

Week 4: Discussion on Informed Consent

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Participation Requirement: You are required to post a minimum of three (3) times in each discussion. These three (3) posts must be on a minimum of two (2) separate days. You must respond to the initial discussion question by 11:59 p.m. on Wednesday.  On additional days, respond to your peers’ posts as well as additional faculty posts. Responses to peers must be posted by 11:59 p.m. on Sunday each week a discussion is due.

Step 1: Read the attached article entitled, “Informed Consent – The Joint Commission” 

Step 2: View the video entitled, “Nursing Fundamentals: Informed Consent, Advance Directives, Reporting and Nursing Documentation” https://www.youtube.com/watch?v=9u53jNI4qoU (Links to an external site.)

Informed consent is obtained after a client receives complete disclosure of all pertinent information provided by the provider regarding the surgery or procedure to be performed. The nurse may obtain informed consent only after the client verbalizes understanding of the potential benefits and risks associated with the surgery or procedure.

Elements of Informed Consent:

1. The individual giving consent must fully understand the procedure that will be performed, the risks involved, expected/desired outcomes, expected complications/side effects, and alternative treatments or therapies available.

2. Consent is given by a competent adult, legal guardian or designated power of attorney (DPOA), emancipated or married minor, parent of a minor, or a court order.

3. A trained medical interpreter must be provided when the person giving consent is unable to communicate due to a language barrier.

4. The nurse’s role is to witness the client’s signature and ensure the provider gave the necessary information and that the client understood and is competent to sign. If it has been identified that the client does not understand the procedure or is not competent to sign the informed consent, the nurse must STOP the process and the physician must be notified immediately.

A consultation occurs when a professional provides expert advice in a particular area and determines what treatment or services the client requires. The nursing intervention evolves around facilitating coordination with other health care providers throughout the continuum of care in order to protect the client from conflicting and potentially dangerous treatments.

A referral is a formal request for a special service by another care provider so that the client can access the care identified by the primary care provider or consultant. Some examples of referrals include physical therapy, wound care, and hospice. The nursing intervention continues to evolve around monitoring the client’s response and progress.

Directions: There are three scenarios that will be used in this discussion posting. You are all responsible for the initial discussion posting and then responding to one posting in the remaining scenarios. For example, my last name is Combs, therefore my initial discussion posting will occur from CASE #1. I will then be responsible for responding to one post from CASE #2 and one post from CASE #3.

CASE #1 (A to H); CASE #2 (I to Q); CASE #3 (R to Z)

CASE #1:

30-year-old male presents to the emergency department with RLQ pain and fever. Labs reveal an elevated white blood count. The surgical intern tells the patient that appendicitis is suspected and that the plan is to proceed with surgery to remove the appendix. He explains that the surgery is to be performed to prevent complications of appendicitis, including abscess formation, sepsis or even death. He goes on to explain the risks of surgery, including bleeding, infection and damage to adjacent organs. What additional information needs to be included in this consent? Provide an evidence-based reason for your answer.

1. Whether or not the intern would undergo the procedure in a similar circumstance.

2. Alternative to the surgery, including receiving antibiotics and monitoring the patient.

3. Name of the surgeon who will actually be performing the procedure.

4. A, B and C

5. B and C only

 

CASE #2: 33-year-old woman is in the operating room to undergo colectomy for ulcerative colitis. Patient was given appropriate information, and consented for the procedure. During the operation, a mass is identified involving the liver. Given the previous consent, it is acceptable for the surgeon to proceed further to either biopsy or excise the lesion. Provide an evidence-based reason for your answer.

1. True

2. False

 

CASE #3:

14-year-old girl presents to the emergency department, accompanied by her 10-month-old daughter and boyfriend. The boyfriend is the child's father. Patient complains of severe lower abdominal pain, although she is afebrile, with normal laboratory values and normal vital signs. No cause of the pain is able to be delineated, and the plan is to take the girl to the operating room to perform a diagnostic laparoscopy. In this case, from whom should informed consent be obtained? Provide an evidence-based reason for your answer.

1. Patient

2. Patient's parents

3. Patient's boyfriend