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PALL8436 Palliative Care In Aged Care Settings

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PALL8436 Palliative Care In Aged Care Settings Question: Let’s consider Wilf, a 78 year old man who lives with his wife, Mavis (76), in your local area. They are a very devoted couple and Mavis has been Will’s principle carer for many years but is beginning to struggle with caring for her husband. She has been having problems with hypertension recently and has been told to “slow down”. Wilf has become increasingly dependent on Mavis and has stopped doing a lot of the things that had previously given him great joy in life (except smoking!!). He was a keen gardener and loved playing lawn bowls with his mates but his health has declined to the point where it is very difficult to now do these things.  Wilf and Mavis have two children -David and Jenny, both of whom are married and have children, giving Wilf and Mavis a total of six grandchildren. They are a very close, supportive family and all live nearby each other. The following is Wilfs relevant medical history for you to consider:  • Mild COPD • Osteoarthritis • Hypertension • Chronic Heart Failure • Mild Cognitive Impairment secondary to vascular dementia  Wilfs children talk to their Mum about what has been happening and the strain that it has been putting on her. Mavis wants to keep looking after Wilf but admits that she is suffering at the same time. She tells her children that she is terrified of losing Wilf and she has started to notice that he is becoming more forgetful and getting angry with Mavis more often. She also tells them that he is getting really frustrated because he can’t do the things he wants and is getting out of breath really quickly nowadays but won’t give up the cigarettes. The children are finding all this information a bit confronting but really want to help their parents. Tasks: 1. What are the short and long term goals for Wilf from your perspective? Are there any specific goals relevant to your discipline / profession? 2. What do you need to consider to support Mavis? 3. What conversations need to be held with David and Jenny, and who is the person most appropriate to do this? 4. How can you manage the competing interests of maintaining Wilfs safety while respecting and facilitating his right to exercise his personal autonomy / decision making? 5.In your assessment consider using the clinical reasoning paper to answer these questions  Answer: Introduction Artificial nutrition and hydration is a treatment intervention whereby fluids and nutrients are delivered into the body by other means other than orally (Staff, 2018). This nutrition is divided into two categories; enteral and parenteral. In enteral method, fluids and nutrients are channeled via a tube into the gastrointestinal tract via the nose, throat or even the abdominal wall. In parental category, fluids and nutrients are driven into the body via a catheter intravenously in the lower part of the arm close to the wrist or the central vein that is close to the heart. The nutrition method is often used in patients with terminal illness (Orrevall, Tishelman, Permert & Lundström, 2013). Euthanasia is whereby the life of a seriously (terminally) ill person is put to an end in order to save the person from suffering (Bolt, Snijdewind, Willems, van der Heide & Onwuteaka-Philipsen, 2015). The issue brings mixed reactions to the society and raises several ethical concerns like, what is the ethical support of ending someone’s life, even if he/she is terminally ill? How can euthanasia be justified? Is there a moral difference between killing someone and letting someone die? (Have & Welie, 2014) This case study will look into euthanasia and ANH in a move to come up with a plan of care for Wilf, following the conflicting opinions of Wilf’s children, Jenny and David. The ultimate goal will be helping the family solve the conflict. Opinion For ANH ANH from my own point of view is useful to the patient and to the family too. When there is a way to preserve life, human beings should always go for that. Preserving life is important than considering living a quality life. Besides there have been cases in the past where patients under this nutrition method have recovered and been able to feed orally. A fairly healthy person who only has malfunctioned gastrointestinal channel cannot be denied the right to live on the basis of the disadvantages of ANH especially when that person seriously feels the effects of hunger (Druml et al., 2016). The same case applies to a person with a blocked bowel, a person with chronic temporary nausea and vomiting or has diarrhea but functioning properly even at the advanced age (Hartwell, Cotton & Rozycki, 2018). In most cases, the argument against the discontinuation of ANH is based on mistaken negative feeling that its administration is equitable to feeding babies (Howland & Gummere, 2014). Argument Against ANH To start with, ANH is not just a simple intervention that can be performed by anyone like oral feeding (MacFie & McNaught, 2015). ANH is a medical process with specialized devices strategically placed by trained personnel using technical procedures (Orrevall, 2015; Schwartz et al., 2014). Technical expertise is needed to handle this processes and that is certainly not very efficient in a home setting. This, therefore, means the patient is restricted in healthcare environments, and therefore his/her family can only interact with him in these kind of environments (Gent, Fradsham, Whyte & Mayland, 2014). For a terminally ill person who is nearing the end of life, ANH is just burdensome to the family in terms of finances and other investments such as their time (Formby, Cookson & Halliday, 2018). At the end of it all many patients still end up dying after having spent so much feeding intravenously. The procedures attached to ANH and its subsequent administration come with many complications, risks and discomfort (Toussaint, Van Gossum, Ballarin & Arvanitakis, 2015). In most cases, the goals of ANH are not to decrease a patient’s discomfort since they easily adapt to coping with hunger or thirst. One of the complications is the risk of infection (sepsis) that come with the use of central catheters and TPN. There is a risk of pneumothorax whereby the lungs may collapse when inserting a catheter. Another risk is blood clotting in the veins (thrombosis) to cause inflammations and when the clots move to the brain, death can occur instantly. ANH is also associated with irregular heartbeats and electrolyte disturbances like low sodium, potassium or low blood sugar (Le Roux, Levine & Kofke, 2013). All the mentioned risks and complications put the life of the patient at a vulnerable position of suffering death anytime. Nasogastric and gastrostomy tubes are the main causes of discomfort besides the risks they too impose on the person (Orrevall, et al., 2013). A nasogastric tube leads to chocking and extreme discomfort during placement and afterwards. Sometimes it has led to serious pneumonia when it is misplaced during placement. The tubes also cause erosion and scratches and sometimes perforations on the nasal pathways, gullet and stomach that lead to chronic bleeding. A correctly placed tube is still a predisposing factor for pneumonia. When the patient is confounded, he might pull the tube and that is tragic especially on psychic distress and increased anxiety. With a gastrostomy tube, anesthesia is a requirement upon placement. Abdominal injuries and infections come with the procedure leading to excessive bleeding, blockage and bowel perforations (Orrevall, et al., 2013). Diarrhea and aspiration pneumonia are common disorders associated with the tubes. ANH procedures that require insertions like IV tubing, are associated with pain (Rekman et al., 2017). A localized infection of the skin occurs with blood clotting in the veins. Swelling and discomfort are common with IV tubes. Sometimes there is a fluid overload that leads to swelling of the body, arms or legs. ANH IV tubes also contribute to electrolyte imbalances with low sodium or potassium (Rekman et al., 2017). Opinion Against Euthanasia In my own point of view, I detest euthanasia. Life is a Godly gift and from a spiritual and moral perspective, only God should take it. God has created human beings as intellectuals with the capacity to discover ways of cure and perform them. At times the patient may request for euthanasia not by his sound will, but on the basis of emotions, confusion or psychiatric illness without interpreting correctly the consequences of their consent. Sometimes, the doctor’s diagnosis could be wrong and there could be a probability of recovery and survival. What am trying to put across is that life is a precious gift, and doctors’ role is to preserve it and not to take it away. Giving chance to euthanasia is giving chance to anyone who is unwilling to endure pain to commit suicide. In other cases, people who are unwilling to incur health costs will go for euthanasia and it might become involuntary. A case to support my opinion is one of an American called Sidney Cohen. Sidney was suffering from cancer. When he asked for euthanasia because of the agonizing pain he was going through, he was denied. Sidney believed that he would die in a short period of time, but after 8 months he was still alive and even affirmed that death is inevitable and claimed that he was enjoying life though under hospital care. He was now a strong opposition of euthanasia (“Life’s Worth: The Case against Assisted Suicide”, 2018). Argument For Euthanasia Euthanasia ends suffering of the dying patient (Köhler et al., 2017). Patients of chronic and incurable diseases undergo a lot of pain, thus living a very low quality life. Having sleepless nights because of pain and that happening on a daily basis is a disgrace to human nature. According to proponents of euthanasia, it is like an insurance policy that will eliminate a death of agony and unremitting suffering. They go on to say that by legalizing it, the vulnerable will be protected from wrongful death and bring a peaceful death. Some of these people prefer to die than to suffer. Others might be suffering, but his brain is malfunctioned to the extent he cannot speak for himself. Euthanasia is humane in that it considers ending suffering of a human being without pain. By so doing the patient does not have to live a life of pain (Emanuel, Onwuteaka-Philipsen, Urwin & Cohen, 2016). The economical aspect of euthanasia is also a consideration (Köhler et al., 2017). People who are under life support or are under specialized healthcare services spend a lot of money because of the expensive technology. To ensure a better life for the remaining relatives, euthanasia is a consideration. Most of the time the ones under life support eventually die and the family is left with a huge medical bill which leads to poverty (Rady & Verheijde, 2012). Physician- assisted death should, however, be the last option when all the other medical interventions have failed and the patient is in the last phase of life. By so doing the patient dies with dignity. People with dead brain or those who are paralyzed and immobile are willing to die because they do not want to live in such a hopeless state (Warren & Manderson, 2013). They reach a point where they say that it is their decision to live or to die. When these people cannot add any economic value to the society, but continue to deprive it of its resource without hope of recovery, it is only reasonable to end their life in a respectable manner. Without the patient’s assistance, these people could terminate their life in a traumatic way just to put their suffering to an end (Köhler et al., 2017). In a study in 2013 in Netherlands, it was found that 2500 patients annually, seek doctors’ pledge to help them die when suffering is intolerable. There were also nine thousand open cases of patients who request for euthanasia. In Belgian, Hugo Claus who was suffering from Alzheimer’s disease committed suicide ending his own life by euthanasia. In conclusion, when the diagnosis is correct, the disease is hopeless or at a terminal phase and the suffering is unbearable, proponents of euthanasia allow for mercy killing to medical standards. Reflection On ANH After conducting a research on the other side of ANH, I have realized that indeed, its elimination is justified. For example, in the treatment of anorexia of cancer, the goals of treatment cannot even be met by ANH. The patient does not gain any significant strength, relief from hunger, nausea, and even extended life. ANH is thus a burden. The study also helped me understand that there are alternative ways of ANH, like keeping the patient’s mouth and mucus membranes moist by use of ice chips. Considering the technicality of ANH compared to normal feeding, there is surely a burden imposed on the patient as well as the family. This form of nutrition is not even possible in home settings without medical intervention. It is also evident that not many patients survive after the ANH. My original view of ensuring survival without necessarily being a quality life has less effect now. This has been backed by the fact that there are not as many cases to show a better life after ANH. We must agree that ANH is a medical treatment that comes with so many side effects and complications as much as it is beneficial to the patient. What I find with ANH is that it is only applicable in rare cases of injuries on the gastrointestinal channel as well as blocked bowel, without other serious diseases like cancer or dementia. The stress and complications that result from ANH is extreme to the patient who are struggling with illness. Sometimes when the process leads to infections and diseases like pneumonia, the patient is even at a higher risk of death. Reflection On Euthanasia A new perspective on euthanasia has been developed. My new insight is that there is no need of preserving a life that is not of quality and is on the verge of ending, and not just ending, but ending with pain and suffering. It is only humane to end the life as per hospital standards without causing pain on the patient to give a respectable death. By so doing, the patient is relived off the agonizing pain and the family protected from poverty from continued high cost from the costly technol ogy and the specialized healthcare. This does not go contrary to the sanctity of life, since the death is a death of dignity and it also puts to an end a life of agony. To further justify euthanasia, the patients are sometimes the ones who ask for it and it is only humane to do as per their will as failure to do so has led to alternative ways of ending it like dangerously committing suicide or continued extreme pain. When the patient is with a damaged brain, it becomes even worse because he is unable to make a sound decision. There is no one who wants to live a hopeless life full of pain with no hope of recovery. It is therefore reasonable to terminate the life to secure resources as well as the dignity of the ailing. Response To David And Jenny I will explain to Jenny that she needs to accept the fact that her dad can no longer live a quality life. 6 months without progress is a long time and artificial hydration and nutrition and hydration come with added complications that will eventually lead to the ending life of their father. I should explain to her that there are infections that come with the artificial feeding and that will make the situation worse. The injuries that come with catheter insertions as well IV tubing are a torture to the old man who is now towards end life. Considering the fact that Wilf is mostly confined to bed (immobilized), ever sleepy, and confounded, ANH will have no improvement on these. In fact, it can only make things worse by facilitating more immobilization. ANH cannot mobilize Wilf. Neither can it solve his sleepiness. In the same case, it cannot end his confusion. I should explain these complications to help Jenny accept to let go and preserve his father’s dignity. I should explain to him that there is a risk of pneumothorax whereby the lungs may collapse when inserting a catheter, blood clotting may result in the veins (thrombosis) causing swelling and when the clots move to the brain, death can occur instantly. I should further explain to her that ANH could result to irregular heartbeats and low blood sugar.  I should eventually explain to her to accept David’s alternative of euthanasia. Jenny should be made aware of the consequences of continued stay of Wilf in the hospital on their financial state. Wilf is an old man and can only stay indoors. Previously before coming to the residential care for the aged, he was still dependent on Mavis, his wife. He has led a hopeless life considering his previous gardening interests and gaming. That, could make Jenny face the situation from a different angle and accept to let go. Conclusion Wilf’s remaining best choice is euthanasia. Unlike ANH, euthanasia has no side effects. It solves Wilf’s condition there and then ending the misery of having his dementia and COPD. Euthanasia will solve Wilf’s hopelessness and low quality life. It will ensure that he gets a respectable death with limited suffering. Waiting for Wilf to suffer to his death is certainly not humane. Jenny should look at many negative effects that come with ANH and allow for euthanasia for her father. Considering her father cannot make sound decisions regarding what he thinks should be done, Jenny’s consent to euthanasia is an important factor to consider. References Bolt, E., Snijdewind, M., Willems, D., van der Heide, A., & Onwuteaka-Philipsen, B. (2015). Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living?. Journal Of Medical Ethics, 41(8), 592-598. doi: 10.1136/medethics-2014-102150 Druml, C., Ballmer, P., Druml, W., Oehmichen, F., Shenkin, A., & Singer, P., …Bischoff, S., (2016). ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clinical Nutrition, 35(3), 545-556. doi: 10.1016/j.clnu.2016.02.006 Emanuel, E., Onwuteaka-Philipsen, B., Urwin, J., & Cohen, J. (2016). Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe. JAMA, 316(1), 79. doi: 10.1001/jama.2016.8499 Formby, A., Cookson, R., & Halliday, S. (2018). Cost analysis of the legal declaratory relief requirement for withdrawing Clinically Assisted Nutrition and Hydration (CANH) from patients in the Permanent Vegetative State (PVS) in England and Wales. Retrieved 9th Aug. 2018 from Gent, M., Fradsham, S., Whyte, G., & Mayland, C. (2014). What influences attitudes towards clinically assisted hydration in the care of dying patients? A review of the literature. BMJ Supportive & Palliative Care, 5(3), 223-231. doi: 10.1136/bmjspcare-2013-000562 Hartwell, J., Cotton, A., & Rozycki, G. (2018). Optimizing Nutrition for the Surgical Patient: An Evidenced Based Update to Dispel Five Common Myths in Surgical Nutrition Care. The American Sergeon, 84(6), 831-835. Retrieved 9th Aug. 2018 from Have, H., & Welie, J. (2014). Palliative Sedation Versus Euthanasia: An Ethical Assessment. Journal Of Pain And Symptom Management, 47(1), 123-136. doi: 10.1016/j.jpainsymman.2013.03.008 Howland, J., & Gummere, P. (2014). Challenging Common Practice in Advanced Dementia Care. The National Catholic Bioethics Quarterly, 14(1), 53-63. doi: 10.5840/ncbq201414148 Köhler, A., Collymore, C., Finger-Baier, K., Geisler, R., Kaufmann, L., & Pounder, K., …Strähle, U., (2017). Report of Workshop on Euthanasia for Zebrafish—A Matter of Welfare and Science. Zebrafish, 14(6), 547-551. doi: 10.1089/zeb.2017.1508 Le Roux, P., Levine, J., & Kofke, W. (2013). Monitoring in neurocritical care. Philadelphia, PA: Elsevier/Saunders. Life’s Worth: The Case against Assisted Suicide. (2018). Retrieved 9th Aug. 2018 from MacFie, J., & McNaught, C. (2015). The ethics of artificial nutrition. Medicine, 43(2), 124-126. doi: 10.1016/j.mpmed.2014.11.012 Orrevall, Y. (2015). Nutritional support at the end of life. Nutrition, 31(4), 615-616. doi: 10.1016/j.nut.2014.12.004 Orrevall, Y., Tishelman, C., Permert, J., & Lundström, S. (2013). A National Observational Study of the Prevalence and Use of Enteral Tube Feeding, Parenteral Nutrition and Intravenous Glucose in Cancer Patients Enrolled in Specialized Palliative Care. Nutrients, 5(1), 267-282. doi: 10.3390/nu5010267 Rady, M., & Verheijde, J. (2012). Ethical Challenges With Deactivation of Durable Mechanical Circulatory Support at the End of Life. Journal Of Intensive Care Medicine, 29(1), 3-12. doi: 10.1177/0885066611432415 Rekman, J., Wherrett, C., Bennett, S., Gostimir, M., Saeed, S., & Lemon, K., …Martel, G., (2017). Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections. Surgery, 161(3), 650-657. doi: 10.1016/j.surg.2016.08.026 Schwartz, D., Barrocas, A., Wesley, J., Kliger, G., Pontes-Arruda, A., & Márquez, H., …DiTucci, A., (2014). Gastrostomy Tube Placement in Patients With Advanced Dementia or Near End of Life. Nutrition In Clinical Practice, 29(6), 829-840. doi: 10.1177/0884533614546890 Staff, f. (2018). Artificial Hydration and Nutrition – Retrieved 9th Aug. 2018 from Toussaint, E., Van Gossum, A., Ballarin, A., & Arvanitakis, M. (2015). Enteral access in adults. Clinical Nutrition, 34(3), 350-358. doi: 10.1016/j.clnu.2014.10.009 Warren, N., & Manderson, L. (2013). Reframing disability and quality of life (p. 94). Dordrecht: Springer.

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