Question

End-of-Life Care and Decision Making

Kelsey is a nursing student in her first clinical rotation. One of her classes focuses on bedside manner. The purpose of the course is to give students time to speak with patients and understand their perspectives - their knowledge, hopes, and fears. Kelsey and a few of her classmates are assigned to a hospice, where each spends time talking in a non-medical capacity with a patient. In the previous semester, the students heard lectures on how to take histories from different types of patients (e.g., children, the elderly) and on special topics (e.g., cultural sensitivity and end-of-life care). Kelsey had had one lecture about talking with the elderly and one lecture about end-of-life issues and options before her first visit to the hospice.

On one trip, Kelsey was assigned to spend time with Mrs. Walsh, an amiable 70-year-old woman who had entered hospice care 2 days earlier. Mrs. Walsh’s chart said that she and her family members had elected to discontinue chemotherapy, which was making her feel terrible and not having any effect on her cancer, which had metastasized to her spine and lungs. Mrs. Walsh had a do-not-resuscitate (DNR) order in place. The visit was going well: Mrs. Walsh was talking happily about her husband, her children, and her grandchildren. Then Mrs. Walsh related her struggles with cancer and the decision to enter hospice care. Next Mrs. Walsh began to talk about facing mortality and said she was frightened about how she would die. She was not sure what the end would be like for her and questioned whether hospice was the right choice, though she was not really sure what would have been a better choice.

Throughout this time, Kelsey remained quiet. She wanted to empathize with Mrs. Walsh, to encourage her to continue thinking about these tough topics, and to ask questions that would help Mrs. Walsh flesh out her own ideas. She wanted to talk about the other options (not having a DNR order, receiving aggressive treatment, dying in an ICU on a ventilator) in ways that might remind Mrs. Walsh why she and her family had chosen hospice care in the first place. But Kelsey didn’t know whether she was allowed to enter into this type of conversation with a patient - she’d barely begun her nursing training, after all.

Adapted from: Tan, A. (2013). Medical students and dying patients. AMA Journal of Ethics, 15(12), 1027-1033.

Questions

If you were Kelsey’s clinical instructor, what advise might you share with Kelsey about Mrs. Walsh and being in a similar situation in the future?

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Answer 1

I would advise Kelsey that the hospice exists to provide support and care for persons in the last phases of incurable diseases and aims to provide symptom management, advance care planning, spiritual care, family support including bereavement. The patient and the family need to be the focus of care. Nursing interventions for such patients should be focused on comfort and improving the quality of life. Psychosocial care and physical care are interrelated for both the dying patient and the family members. Adequate pain relief is an important outcome for all patients but in particular for patients who are terminally ill. When the goal of treatment of the terminally ill is providing adequate painn control to alleviate suffering, the goal is based on the principle of Nonmaleficience, preventing or reducing harm to the patient.