1. Instructions for Completing Case Study Review all slides in detail. Complete all required reading, including links to external material. Review questions and answers included throughout the case study. Once finished, click on the ‘CE Form’ link located at the end of the study. Answer the 3 questions included on the form, provide payment information for processing your $10.00 CE fee and return the form to the NACNS office. A valid email address is required for CE certificate delivery. * Continuing Education is optional. If you are not interested inCEs, please disregard the $10.00 fee. CONFIDENTIAL - Do not forward or share

2. CNS Advanced Practice Curriculum: A Case for Geriatric Nursing Evidence-based PracticeEnd of Life Care Case Study # 2 Alyce Ashcraft, PhD, RN, CNS, CCRN, CNE Texas Tech University Health Sciences Center Anita Thigpen Perry School of Nursing Wanda J. Borges, PhD, ACNS-BC New Mexico State University School of Nursing

4. Required Reading Coleman, E. Parry, C. Chalmers, S. & Sung-joon, M. (2006). The care transitions intervention. Archives of Internal Medicine, 166: 1822-1828. Available online at: http://www.caretransitions.org/documents/RCT.pdf Gillick, M. (2003). Promising practice. Innovations in End-of-Life Care. Available online at: http://www2.edc.org/lastacts/promprac.asp Institute for Clinical Systems Improvement. (2009, Jan). Diagnosis and Management of Chronic Obstructive Pulmonary Disease, 7th Ed. Available online at: (http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html) Qaseem, A., Snow, V., Shhekelle, P., Casey, D., Cross, J., & Owens, D. Evidece-based interventions to improve the palliative care of pain, dyspnea and depression at the end of life: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148: 141-146. Available online at: http://www.annals.org/content/148/2/141.full

5. Required Readings (cont’d) Registered Nurses Association of Ontario (RNAO). (2005, Mar). Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). Toronto (ON): Registered Nurses Association of Ontario (RNAO). Available online at: http://www.guideline.gov/content.aspx?id=7008&search=copd#Section420Solvari, A., Kocheril, A., Yunis, N.& Crausman, R. (2006). Corpulmonale. Available online at: http://www.emedicine.com/med/topic449.htm Stapleton, R., Nielsen, E., Engelberg, R, Patrick, D & Curtis, J. (2005). Association of depression and life-sustaining treatment preferences in patients with COPD. Chest, 127(1): 328-334. Available online at: http://www.medscape.com/viewarticle/498650

6. CNS Spheres of Influence: Patient/Client Sphere Within this sphere of influence the CNS is a provider of direct patient/family care. The following activities may be included in this sphere: Advanced holistic assessment of patient/family needs Nursing and medical diagnosis Disease management including pharmacologic and non-pharmacologic interventions Holistic approach to patient management incorporating health promotion and risk reduction Facilitation of interdisciplinary patient management across the health care continuum

7. About the Patient As the CNS working in a 40 bed nursing home a part of your routine includes assessment of newly admitted residents. Upon being hired, you conducted a needs assessment and found a high rate of transfers to the emergency department for patients with Do Not Hospitalize orders. To assist in decreasing the rate, you are working with a palliative care team. Mrs. J. is a 76 year old woman who was admitted yesterday. She has been living at home alone after her husband died 7 months ago. She has 3 children, all living in other cities. Her youngest daughter is the closest, 220 miles away. Because of her shortness of breath she has been unable to maintain her nutritional needs at home alone, even with a local “Meals on Wheels” program. The decision was made to admit her to the nursing home.

8. Subjective data Problems 1. Mrs. J. is sitting on the edge of her bed leaning over her bedside table. She is dyspneic, respiratory rate is 50 per minute. O2 is at 4 liters per nasal cannula and Mrs. J. has an inhaler in her right hand. The CNA who is helping Mrs. J. with hygiene needs states, “Someone needs to do something, she can’t keep this up.” Mrs. J. states through gasps, “I’m okay, just winded.” 2. Medical diagnoses include COPD and corpulmonale. Patient has been hospitalized 3 times in the past year for COPD exacerbation and has been intubated each time. 3. Patient is extremely thin in appearance.

9. Question #1 What other subjective information specific to problem #1 do you need to know?

10. Answer to Question #1 Current medications, including those used by the patient to treat dyspnea http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html Presence of anxiety or pain Patient’s assessment of the current dyspneaepisode Dyspnea is a subjective experience and should be believed A quantitative measuring scale such as a visual analog scale or a numeric rating scale, i.e. 1-10 http://www.guideline.gov/content.aspx?id=7008&search=copd

11. Answer to Question #1 (cont'd) History chills/fever/cough

12. Answer to Question 1 (cont'd) Patient’s desires for treatment at this time http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html

13. More Subjective Data Patient states, “I get like this whenever I move around. I just used my inhaler – it will get better.” Denies pain but states she is always anxious when she can’t breathe. Denies chills, fever, or cough. Rating of dyspnea is 10 on a 1-1- 10 scale CNA states that the patient was not dyspneic until she sat up in bed to brush her teeth. Patient has a living will which states that she does not want life saving measures.

14. More Subjective Data Continues to agree with her Living Will and Do Not Hospitalize orders – expresses fear of being intubated again Expresses the desire to be kept as comfortable as possible because she is aware of her prognosis States Ativan helps but she gets anxious mostly when she is short of breath States she believes her children understand her wishes

15. More Subjective Data Current Medications: Hydralazine 50 mg PO tid Digoxin 0.125 mg PO qd Theo 24 – 400 mg PO qd Lasix 40 mg PO qd Potassium supplement AdvairDiskus – 250/50 mcg, 1 puff bid SpirivaHandihaler – 18 mcg inhaled qd Albuterol Inhaler, 2 puffs q 4-6 hrs PRN Lorazepam 0.5 mg PO tidprn

16. Question #2 Based on the subjective data, what does your initial differential diagnosis for problem #1 include? For each medical or nursing diagnosis, provide a rationale for its inclusion.

17. Answer to Question #2

18. Question #3 Based on the subjective data, what does your initial nursing diagnosis for problem #1 include? For each diagnosis, provide a rationale for its inclusion. List nursing diagnoses and provide brief rationale for inclusion (use as many slides as you need)

19. Answer to Question #3

20. Question #4 What other data do you or the nurses you lead need to collect at this point? Provide rationale for your answer.

21. Answer to Question #4 Physical exam – rule out differential diagnoses and assess need for hospital transfer Pulse oximetry – assess current oxygenation status Recent labs and spirometry tests – assess status of COPD/Corpulmonale Spiritual assessment (Timmins & Kelly, 2008) Patient’s prognosis – assess need for hospital transfer http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html

22. Answer to Question #4 (cont'd) Assessment of functional status enables adequate plans to be made for providing palliative care Use of the Palliative Performance Scale provides a method for determining care needs for the palliative care patienthttp://www.healthcare.uiowa.edu/igec/tools/function/palliativePerformance.pdf Assess for depression as this could affect the patient’s decision for life-sustaining treatmenthttp://www.medscape.com/viewarticle/498650 Use of the Geriatric Depression Scale which is a standardized tool is recommended http://www.stanford.edu/~yesavage/GDS.html

23. Additional Data Collection Physical Exam: VS: HR-110, BP-132/90, RR – 40, Temp – 98.6, Pulse Ox – 88% General: Thin, cachetic appearance, alert and oriented. HEENT: PERRLA Neuro: CN II – XII intact Respiratory: Dyspnea on exertion, tachypneic at rest, using accessory muscles to breath, lungs with course rales from mid lobes to bases bilaterally. Percussion – hyperresonance to all lobes. Rib cage easily seen through chest wall. Cardiovascular: Heart sounds S1, S2with S3 gallop and systolic murmur, regular, no JVD, Pulses 3+ to all extremities, no peripheral edema, hepatojugular reflux present. Abdomen: Soft, non-tender on palpation, bowel sounds in all quadrants Musculoskeletal: Weak movement of extremities, sensation present in all extremities, muscle wasting noted Skin: Emaciated appearance with poor skin turgor, Stage 1 pressure ulcer to coccyx

24. Additional Data Collection Chart Review: PMH of COPD x 10 years with diagnosis ofCorpulmonale 2 years ago. Most recent hospitalization was 2 months ago with ventilator management x 1 week – patient extubated herself Primary care provider documents poor prognosis Living Will/Do Not Hospitalize order BMI = 16 Immunizations up to date Nutritional assessment - PO Intake has decreased – documentation of patient’s refusal of food for last week

25. Additional Data Collection Diagnostictest results prior to nursing home admission: Theophylline level: 18 mcg/ml Digoxin level: 2.0 mg/ml Potassium: 4.0 mEq/L Bun/Creatinine: 18 mg/dl/1.2 mg/dl Albumin: 1.5 mg/dl Spirometry 2 months before admission: FEV1 <30% predicted

26. Additional Data Collection Patient’s prognosis is poor at this time based on the severity of her dyspnea and disease process Based on her current living will, advanced directive, transfer to hospital is not indicated http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html Geriatric Depression Scale Score – 8.0 – indicating no depression Palliative Performance Scale is 6 – indicates a need for total care, mouth care should be done as needed because intake is minimal

27. Question #5 What is your assessment of each of Mrs. J’s presenting problems? Provide rationale for your assessment.

28. Answer to Question #5 #1: Grade 5 dyspnea Per Medical Research Council (MRC) scale in COPD Guidelines, grade 5 is too breathless to leave the house or breathless when dressing or undressing (National Guideline Clearinghouse, COPD Guidelines). This is a common symptom at the end-of-life requiring palliative care (Hansen, et al., 2008).

29. Answer to Question #5 #2: Very severe COPD with Corpulmonale Spirometrytesting is the gold standard for evaluating status of COPD (Tierney, McPhee & Papadakis, 2005). FEV1 <30% expected is diagnostic of very severe COPD.

30. Answer to Question #5 (cont'd) Corpulmonale is a complication that can be seen in patients with COPD due to pulmonary hypertension that results in right ventricular failure (Sovari et al., 2006). More than 50% of cases of corpulmonale are caused by COPD. There is a 30% chance of 5 year survival in patients with COPD who are diagnosed with corpulmonale with a high 2 year mortality rate. http://emedicine.medscape.com/article/154062-overview

31. Question #6 What is your plan for this patient. Include all components and provide rationale for your choices.

32. Answer to Question #6 Palliative Care Plan Diagnostic: At this time, no diagnostic studies will be ordered. The patient has a Living Will with a Do Not Hospitalize order. She is at the end-of-life and requires palliative care. No further tests are needed at this time (Qaseem et al., 2008). http://www.annals.org/content/148/2/141.full Therapeutic: Review options for care plan with patient. Discuss nutritional needs, skin care, dyspnea management with morphine and oxygen with possible non-invasive ventilatory assistance (Sovari et al, 2006). http://www.emedicine.com/med/topic449.htm

33. Answer to Question #6 (cont'd) Palliative care plan Referral/consult: Consult with PCP about patient needs and desires, Palliative Care Plan, Hospice consult, Psychiatric/Mental Health CNS/NP. If agreed to by the patient, dietary consult for nutritional status, and spiritual care consult as needed PT/total assist for transfers Mouth care as needed due to decreased PO intake

34. Answer to Question #6 (cont'd) Palliative care plan Patient Education: Anxiety, pain, and dyspnea management. Plan family/team conference with family members as able – can use available technology for facilitating family involvement of those living in other areas Apply Culturally and Linguistically Appropriate Services standards http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 Follow-up: Follow up daily, more often as needed for dyspnea episodes to adjust care plan for optimal level of comfort. Dyspnea plan was developed for this patient with Morphine sulfate 2-4 mg q 15 minutes prn until dyspnea resolves with use of nebulizer during dyspneic episodes as needed (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2003).

35. CNS Impact Working in the patient sphere, the CNS brings expertise in pathophysiology, physical assessment and therapeutic interventions for managing chronic disease. Employed by the LTC facility, the CNS is uniquely positioned to respond to acute episodes as illustrated by this case. In addition, the CNS can provide needed assessment of palliative care issues and interface with the primary care provider to ensure the treatment plan is adjusted based on patient needs and desires. Education of the patient and their family in the process is another important direct care role.

36. CNS Spheres of Influence: Nurse Sphere Within the nurse sphere of influence, the CNS evaluates nursing practice to ensure optimal patient outcomes, as well as develops and implements strategies for changing nursing care to achieve optimal outcomes.

37. Nursing Staff Decision-making Mrs. J was transferred to the Emergency Department during the night due to increased dyspnea. Chart review reveals one dose of morphine had been given to the patient prior to transfer. The transfer represents the discomfort staff have caring for patient’s at end-of-life who are dyspneic and have concerns about the “double effect” of medications at end-of-life.

38. Question #7 What support does the nursing staff require?

39. Answer to Question #7 Nursing staff requires understanding of palliation at end-of-life as well as personal assessment of comfort with the treatment plan. (Field & Cassel, 2003, pg. 207). Impact of family members input on decision to transfer needs to be assessed. http://www.caretransitions.org/documents/RCT.pdf Incorporate case studies in teaching nursing staff about dyspnea plan.http://www.eperc.mcw.edu/FileLibrary/User/jrehm/EPERC/Cases/CaseStudiesDyspnea.pdf For this to be achieved, nursing staff must be included in care planning team meetings with the patient and the family. http://www2.edc.org/lastacts/promprac.asp

40. CNS Impact Within the nursing practice sphere, the CNS is able to identify educational needs of staff members related to palliative care, as well as role model the importance of the nurse’s role in palliative care. Providing evidence about the need for palliative care and the guidelines for palliative care treatments can assure the nursing staff of compliance with standards of care.

41. CNS Spheres of Influence: System Sphere Within the system sphere of influence the CNS evaluates system processes to ensure optimal patient care delivery and outcomes, as well as leads organizational change efforts that are based in theoretical foundations and evidence based practice. The goal is to facilitate lasting change that will improve patient care delivery and outcomes within a system of care.

42. Status of Palliative Care Plan In most instances failure to sustain a palliative care plan can be traced to system-level issues.

43. Question #8 What system level recommendations would help to maintain palliative care plans?

44. Answer to Question #8 CNS Recommendations: Consider working night shifts to identify barriers to palliative care that may be unique to that shift. Continue to work with the team that was developed to implement palliative care at the end-of-life to identify barriers Use a theoretically driven organizational change plan to achieve the goals http://www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf

45. Answer to Question #8 Guidelines for end of life care in patients with serious illnesshttp://www.annals.org/content/148/2/141.full Examples of successful programs in planning for palliative care within the nursing home environmenthttp://www2.edc.org/lastacts/promprac.asp

46. CNS Impact Within the organization/system sphere, the CNS can work closely with staff to identify a team for developing and implementing a plan to provide palliative care to all patients. This process can assure an appropriate level of evidence-based standardization, yet attend to the individual needs of patients. With expertise in needs assessment, as well as development and implementation of nursing interventions, the CNS is able to achieve optimal organizational outcomes for this patient population.

47. CNS Impact Overall The number of patients dying in long term care (LTC) setting has increased from 18% in 1986 to 23% in 2001 (Hanson et al., 2008). These patients experience a range of symptoms as end-of-life draws near – pain, dyspnea, poor intake, problems with cleanliness and delirium. As the population ages, more patients will be requiring palliative care at the end of life. Working within the three spheres of influence, the CNS is an essential member of the Palliative Care Team in the Long Term Care facility (NACNS, 2004).

48. Additional Resources Education in Palliative Care and End-of-Life Care – www.epec.net End-of-Life/Palliative Education Resource Center - http://www.eperc.mcw.edu/ Center to Advance Palliative Care – http://www.capc.org/palliative-care-across-the-continuum/long-term/ Hartford Center of Geriatric Nursing Excellence – www.nursing.upenn.edu/centers/hcgne/palliativecare.htm National Guideline Clearinghouse - http://www.guideline.gov/summary/summary.aspx?doc_id=5061&nbr=003545&string=COPD

49. References Buttaro, T., Trybulski, J., Bailery, P. & Sandberg-Cook, J. (2003). Primary Care a Collaborative Practice, 2nded, pp. 52, 391-394. Field, M. and Cassel, C. Editors. (2003). Approaching Death: Improving Care at the End of Life. Available online at: http://www.nap.edu/catalog/5801.html Gillick, M. (2003). Promising practice. Innovations in End-of-Life Care. Available online at: http://www2.edc.org/lastacts/promprac.asp Hanson, L., Eckert, J., Dobbs, D., Williams, C., Caprio, A., Sloane, P. et al. (2008). Symptom experience of dying long term care residents. Journal of the American Geriatric Society, 56: 91-98. Institute for Clinical Systems Improvement. (2009, Jan). Diagnosis and Management of Chronic Obstructive Pulmonary Disease, 7th Ed. Available online at: (http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html) National Association of Clinical Nurse Specialists (NACNS). (2004). “Statement on Clinical Nurse Specialist Practice and Education.” Glenview, IL: NACNS. Qaseem, A., Snow, V., Shhekelle, P., Casey, D., Cross, J., & Owens, D. Evidece-based interventions to improve the palliative care of pain, dyspnea and depression at the end of life: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148: 141-146. Available online at: http://www.annals.org/content/148/2/141.full

50. References (cont'd) Registered Nurses Association of Ontario (2002). Toolkit: Implementation of clinical practice guidelines. Toronto, Canada:Registered Nurses Association of Ontario. Available online at: http://www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf Solvari, A., Kocheril, A., Yunis, N.& Crausman, R. (2006). Corpulmonale. Available online at: http://www.emedicine.com/med/topic449.htm Stapleton, R., Nielsen, E., Engelberg, R, Patrick, D & Curtis, J. (2005). Association of depression and life-sustaining treatment preferences in patients with COPD. Chest, 127(1): 328-334. Available online at: http://www.medscape.com/viewarticle/498650 Tierney, L., McPhee, S. & Papadakis, M. (2005). Current Medical Diagnosis and Treatment, 44th Ed, p 235-236. McGraw Hill. Timmins, F. & Kelly, J. (2008). Spiritual assessment in intensive and cardiac care nursing. Nursing in Critical Care, 13(3): 124-131.

51. Thank You For Completing This Case Study To retrieve your CE certificate, please click ‘here’ to access our CE form. Please answer all questions and return the form to the NACNS office to earn your CE certificate. *Continuing Education is Optional CONFIDENTIAL - Do not forward or share