Case Study 1 Mrs. Osmani is an alert and oriented 88-year-old White woman who was recently diagnosed with heart failure with an ejection fraction of 20%. It has been 10 years since the death of her beloved husband, and all her children are deceased. Most of her friends are also deceased or living in nursing homes. In addition, her best friend Carol has Alzheimer’s disease. Mrs. Osmani lives in her own home and is cared for by a live-in assistant, Marina. Mrs. Osmani has been under the care of Dr. Frimet for the past four years. Marina takes Mrs. Osmani to see Dr. Frimet, who explains to Mrs. Osmani that her heart failure is not curable, and her life expectancy is limited. With a compassionate tone and in language the patient understands, the physician explains that she probably has less than six months to live. With Marina by her side, Mrs. Osmani listens as Dr. Frimet tells her about hospice care and she agrees to an introductory meeting with the interdisciplinary team, which is quickly arranged. The next day, Mrs. Osmani and Marina meet with the hospice nurse, Sandra, and the social worker, Tim. They spend the next two hours discussing the philosophy of hospice care and services that can be provided through the HMB. Sandra explains the guidelines for determination of appropriateness for hospice services. After Sandra conducts a patient assessment, she explains how hospice can provide care in Mrs. Osmani’s home. Marina states that she is fearful that hospice wants to take her job away. Tim makes it clear that Marina will still be Mrs. Osmani’s primary caregiver, and the hospice team will support Marina as she cares for her. Mrs. Osmani appears anxious about the home visits and asks what Sandra will do during visits. Sandra attempts to alleviate any fears and explains that during each visit she will perform a physical assessment, discuss any problems, and update the plan of care according to Mrs. Osmani’s wishes. In very simple language, Sandra explains that the assessment at each visit will focus on any physical symptoms that Mrs. Osmani may report. Sandra discusses the questioning and listening that she will perform regarding expected symptoms such as pain, changes in appetite, and bowel and bladder function. Sandra offers a detailed explanation of the physical assessment she will perform for common respiratory issues as well as alterations in skin integrity, urinary elimination, and cardiac/circulatory function. She explains everything in nonmedical language and frequently asks Mrs. Osmani and Marina if they understand or have any questions or concerns. Sandra also discusses her role in managing Mrs. Osmani’s medications and consulting with Dr. Frimet. She describes a symptom management comfort pack that will be kept in the home and includes medications for pain or other distressing symptoms that Mrs. Osmani may develop. Sandra explains that she will visit weekly to oversee Mrs. Osmani’s care, but Marina will remain her primary caregiver. If Mrs. Osmani or Marina believe they need further help, hospice can provide an aide several times a week to assist with Mrs. Osmani’s care. Tim, the social worker, then recommends certain safety measures to prevent falls, including adequate lighting, adequate phone access, and removal of area rugs. Supplemental oxygen is also discussed because it is commonly prescribed for patients with heart failure. Tim explains to Mrs. Osmani that he will be responsible for ordering home medical equipment, such as a hospital bed and a wheelchair, should they be needed. During this conversation, Mrs. Osmani asks for a walker. Tim tells Mrs. Osmani and Marina that if either of them has any problems coping, he, along with the bereavement and spiritual counselors, can help with emotional support. When Tim asks about advance directives, Mrs. Osmani gives him a copy of her living will and states that her neighbor and close friend, Ida, is her healthcare surrogate and understands her end- of-life wishes. Mrs. Osmani mentions that a few weeks before,
A patient’s spiritual perspective across the dying trajectory stems from their belief system; faith; values; life’s purpose; and perception of the meaning of their existence in relation to others, including family members and close friends, nurses, physicians, social workers, and pastoral counselors (Fitch & Bartlett, 2019). Spiritual distress is just as critical as body and mind distress (Fitch & Bartlett, 2019). A spiritual approach to coping with dying can enhance the patient’s life and can be instrumental for those who have a life-threatening disease and for their family members (Fitch & Bartlett, 2019) What this model can teach clinicians who work with those who are coping with life-threatening illness is that spirituality is woven throughout a person’s beliefs about their illness, even if the term spirituality or religion is never mentioned. Clinicians can begin to assess the spirituality of patient by asking “Does spirituality play a role in your life?” Once addressed, clinicians can focus on the wholeness of the patient, which includes the patient’s body, mind, and spiritual essence. Additional spiritual questions to explore with patients are (Anderson & Sacred Dying Foundation, 2017): ● What items of special meaning do you want in your room? ● What can you tell your spiritual companion about the people you want—or don’t want—around you? ● How do you want God to be present with you as you go through your death? ● Dying often takes days or weeks. How do you like to be comforted and reassured? ● Do you want or expect to have visions of loved ones as you prepare to die? If so, who might you see? ● What spiritual insights have you recently had? ● What are the spiritual understandings you feel you have lived your life by? ● What are your beliefs about the afterlife? ● What do you think will happen to yourself/your soul in the afterlife? ● Do you have special prayers/readings you want said? Although chaplains, community-based clergy, and pastoral counselors recognize and explore spiritual distress, all professional care providers can inquire into this significant part of the patient’s being (CCH, 2020). Bowman (2016) notes that spirituality is now routinely included in palliative care and that spiritual care is not synonymous with religious practice. This difference may cause tension for those providing end-of-life care because, all too frequently, patients near the end of life may reveal things when ready to clinicians with whom they experience comfort; clinicians need to be ready to address any spiritual and grief concerns when voiced (Bowman, 2016). Accordingly, a palliative care team may help patients and families move toward acceptance and peace if they are challenged by the illness and are looking for spiritual support (Ernedoff & Cox, 2017; Moestrup & Hvidt, 2016). Theoretical models of the dying process help clinicians see that there is not only one way to provide support at the end of life (ANA & HPNA, 2021). Each patient faces terminal illness and dying in their own unique way. Clinicians can use these models as a guide while providing care at any point in the dying trajectory. Clinicians must realize that they need to individualize their approach to end-of-life care with patients based on the patient’s awareness level, what is sacred to them, and what struggles they may be facing (NHPCO, 2021). Clinicians can note how the principles of the theories are reflected in their practice and focus on how they can adapt or modify the concepts of the coping-with-dying theories to meet the needs of those they help. Moreover, they can promote a discussion with those they help about the principles noted in the theories (ANA & HPNA 2021).
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Book Code: PYFL4024
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