Clinical Judgment Case Study - End of Life Care

Instructor: Carolyn Lichtfuss

After raising and home schooling her children, CJ got her Certified Nursing Assistant (C.N.A.) certification and headed back to school, taking prerequisites while working at a Skilled Nursing Facility (S.N.F.) where she pursued her passion for working with the elderly. She was accepted into the Associates Degree in Nursing (A.D.N.) Program at Front Range Community College in Colorado, a program that was and is notoriously challenging and continues to have a high success rate for students, CJ included, passing the NCLEX on the first attempt. CJ was accepted to the R.N. to B.S.N. program at the University of Wyoming and was able to complete her degree online over three consecutive semesters. The next eight years were spent at a pediatric clinic providing direct patient care including immunizations and performing telephone triage as needed. At this point she wanted to make a change back to her real area of passion caring for the elderly geriatric population. She has spent the last two years working at an Assisted Living Facility (ALF) and has continued to grow her skill set including the treatment of residents’ wounds under the direction of a doctor specializing in Wound Care.

Gaining an in-depth understanding of End-Of-Life (EOL) care is very important for care providers, especially nurses. Often, those facing death have many questions and concerns, and their families or those close to them have needs a nurse can address. The Clinical Measurement Model (CJMM) is an effective nurse thought-process tool for new nurses as they begin patient care on their own. Updated: 06/22/2022

Hospice Care in a Hospital Setting

In this Case Study, Daryl has decided to let God determine when his time is up on earth. His health is failing, and his pain is increasing, but he believes he has a reason to be here, to support his wife and children. Nurse Amber is a hospice nurse in the local hospital and notes that upon admission, Daryl has realized he likely only has a few more days to live; he is self-determined, meaning he made his own decision to go to a hospice facility. He doesn't want to burden his family with dying at home, and his family supports his choice. Amber realizes he will need physical and emotional support as he proceeds through the process of dying, CJMM Layer 0, and believes he is in the Acceptance stage of grief, CJMM Layer 2.

Daryl has his Healthcare Proxy and Living Will in a folder for Mary to share with Amber. All is in order, and his driver's license indicates he does not want to be an Organ Donor. Amber asks if either Daryl or Mary has questions about the documents and their decisions. They state they have worked through everything and have no further questions (CJMM Layer 4).

Physical Care

Amber attends to Daryl's needs in the hospital hospice room, doing as much as possible when the family is absent, and working quietly, gently, and quickly when they are with him. She adjusts his pillows, gets him a warm blanket, refreshes his ice water, offers mouth care, and empties his catheter bag as needed (CJMM Layer 1). He quietly accepts her help and appreciates her kindness. His 16-year-old daughter Suzie cries off and on, and Amber looks for an opportunity to connect with her to listen and see if there is anything that might comfort her (CJMM Layer 2).

Emotional, Cultural, and Spiritual Care

Anna offers to get the family food or drinks as needed and makes sure they know where the restrooms are. Suzie asks where the chapel is, and Amber walks her there. Once they step inside the empty chapel, Suzie asks to be left alone, so Amber returns to Daryl's room. Daryl asks about Suzie and appears to be comforted, knowing Suzie is getting comfort from her Lord (CJMM Layer 4). He asks if the chaplain might be able to come and see him or maybe the pastor from his church. Amber offers to find a way to contact one of them, and Daryl looks relieved (CJMM Layer 3). She asks if Daryl and his family have customs or cultural needs, and he states he will talk with his wife Mary and let Amber know.

Later, Daryl and Mary let Amber know they don't have other cultural needs but would like to play some of their favorite music and bring in some books or movies they both like. Amber assures them that they can be done and assists in getting them what they need through other staff and the IT department when the technology had issues (CJMM Layers 3 and 4).

Gaining Insights into Family Dynamics

Anna chats with Mary, Daryl's wife, who looks weary. Mary states that Daryl has done everything he can to leave things in order and reviewed everything with her. She is thankful she can focus on him now and doesn't have to worry about legal or financial issues. Letting go of things has been very hard for Daryl. He is used to taking care of his share of the responsibilities and has had times of frustration and depression as his health continues to decline. Mary is already grieving but is spending the time she can with her husband. Mary states that these last few months have been hard but good, as they have worked through what living without Daryl will be like in the practical areas. Missing him will override most everything else. She is worried about Suzie even more than her two adult sons who have wives and children of their own. Both sons live in nearby towns, and she is hopeful they will be able to step in for Daryl when Suzie needs them. Suzie returns from the chapel, looking sad but calm, and her brothers, Paul and Sam, arrive. Greetings, hugs, prayers, and tears follow. Amber continues her care and observations of Daryl and his family, looking for ways to help give them comfort (CJMM Layers 2 and 3).

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