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Advance Care Planning Model Case Study

Info: 3511 words (14 pages) Nursing Case Study
Published: 12th Feb 2020

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Carla’s Case study

Advance care planning is the process that helps people to plan for their future medical treatment and end-of-life care in advance when they are healthy and able to make thoughtful decisions. It enables individuals to express their wishes, priorities, beliefs, values and life goals to their doctors, family, friends and carer before any healthcare crisis occurs. Advance care planning ensures that patient’s preferences are known, understood and respected which influences the treatment and client-centred care (Holman & Hockley, 2010). Carla is a 54-year-old woman with metastatic ovarian cancer. Carla’s disease progression allowed her to be dependent upon her family. Conflicting views within the family arise when Carla discuss her wishes and preferences related to end-of-life care. The following assignment describes three nursing care plans related to Carla’s case study which includes patient’s assessment data, nursing diagnosis, goals, interventions and rationales, and evaluations. It also includes referrals needed for the client and family members to facilitate client-centred care. Moreover, it explains the barriers and facilitators related to Carla’s case study and advance care planning model in order to provide effective client-centred care.


Chronic pain due to the progression of the disease (metastatic ovarian cancer) prevents Carla from performing her daily self-care activities. In addition, Carla has expressed her wish to be kept pain free at the end of life. Carla may show the signs and symptoms of chronic pain such as fatigue, anxiety, depression, irritability, restlessness and crying or moaning at the end-of-life. Carla has undergone multiple therapies including surgery and chemotherapy.






Chronic pain related to disease progression as evidenced by patient expressed her desire to be kept pain free (Ackley, Ladwig, & Makic, 2016).

Within 4 hours of nursing interventions, Carla’s feels comfortable due to the decrease in pain level.

Within 8 hours of increasing sense of comfort, the patient will not show any signs or symptoms of pain (Gulanick & Myers, 2013).

Perform regular pain assessment including quality, severity, location, characteristics, onset, duration, frequency, precipitating factors and patient’s expression of pain to develop the baseline information of the pain through systematic assessment and documentation of pain that provides direction for a pain management plan (Lee, et al., 2015; Linl et al., 2011; Pasero and McCaffery, 2011). Assess the client for signs or symptoms of chronic pain such as such as fatigue, anxiety, restlessness, irritability, or depressed because it is associated with disease progression which leads to physiological and behavioural changes to ensure that the patient is treated for symptoms accompanying pain or its management (Wilkie & Ezenwa, 2012). Non-pharmacological pain management strategies such as distraction, imagery, music therapy, simple massage, positioning, relaxation, and application of heat and cold to help control pain level and to provide comfort (Hökkä, Kaakinen, & Pölkki, 2014). Administration of analgesics as ordered around-the-clock for continuous pain and PRN medication for intermittent or breakthrough pain as may be experienced by clients with cancer pain to provide a consistent level of pain relief and to reduce sufferings and improve the quality of life (Mashaqbeh & AbuRuz, 2017). Assess patient’s sedation level and respiratory status at regular interval during pain management with opioid analgesics to check any sign of opioid-induced respiratory depression and oversedation (VanItallie & Plante, 2011).


Palliative care nurse to improve patient’s quality of life by reducing symptoms of pain and providing comfort during pain management.

GP or palliative care physician to monitor the overall health of the patient. Pain medicine specialist if pain is not controlled (Howie & Peppercorn, 2013).

Within 4 hours of nursing intervention, Carla appears to be relaxed and comfortable as result of the decrease in the level of pain.

Within 8 hours of increasing sense of comfort, Carla showed no signs and symptoms of pain (Gulanick & Myers, 2013).


Lack of knowledge and understanding of Carla’s disease, treatment plan, and advance care planning result in arguments within the family. Carla expressed a lack of support from daughter and husband as they refused to accept her wishes. There are conflicting views and expectations of the family towards Carla’s treatment and care. Her husband could not tolerate the thought of her dying and want everything possible done for her in the hospital. Both, her daughter and husband want her to receive all possible treatment to see the birth of their granddaughter. Carla communicated about her fear to Josey that she will be forced to have more treatment by her husband and daughter.






Ineffective family coping related to patient’s wish to discontinue further acute care treatment as evidenced by patient expressing the fear that her husband and daughter are against her wishes and want her to receive continuous care and treatment to see the birth of their first granddaughter (Ackley, Ladwig, & Makic, 2016).

Within 2 hours of nursing interventions, family members will demonstrate an understanding of a patient’s disease and treatment.

Within few hours of nursing interventions, patient’s family members will cope and support her wish to not to continue any acute care treatment at the end-of-life (Gulanick & Myers, 2013).

Provide education and knowledge to the family members related to the patient’s progressive disease and end-of-life care treatment to ensure a better understanding of patient’s wishes (Washington, Meadows, Elliott, & Koopman, 2011). Palliative care nurse or GP should assist patient to make advance care directive to avoid any future conflicts among family members (Palliative Care Australia, 2017). Schedule meeting to facilitate open communication with family members and patient to help the patient to express her wishes and preferences at end-of-life care. Thus, reduces fear and stress within the family (Walshe et al., 2017). Providing palliative care at home will allow patient and family members to spend quality of time and share meaningful moments together (Dhiliwal & Muckaden, 2015). Discuss patient’s needs and reason of not continuing acute care treatment with family members to allow family members to understand, respect and support patient’s preferences (Moir, Roberts, Martz, Perry, & Tivis, 2015). Palliative care nurse should increase home visits to ensure the safety of the patient and to provide support and reassurance to the family related to end-of-life care (Lang et al., 2015). Promote family relaxation and stress-reduction strategies to reduce stress and enhances coping (McMillan, et al., 2015).


Medical social support for the family that serves as an advocate to provide information related to advance care planning for care needed by the client. Grief and bereavement support that allow family members to cope with grief after the death of the client.

Psychiatric home health care service for family counselling to allow family members the ability to support patient’s treatment plan (Ackley, Ladwig, & Makic, 2016).

Within 2 hours of nursing interventions, family members demonstrated an understanding of a patient’s disease and treatment.

Within few hours of nursing interventions, Carla’s family members understood, respected and supported her wish to not to continue any acute care treatment (Gulanick & Myers, 2013).


Carla is unable to perform activities of daily living due to her disease progression and cancer pain, which allowed her to be dependent upon her family in order to meet her daily needs such as bathing, grooming, toileting and eating.

The patient had undergone surgery and chemotherapy for ovarian cancer in the past.






Activity intolerance related weakness from cancer as evidenced by the patient being increasingly depended upon her family to meet her care needs (Ackley, Ladwig, & Makic, 2016).

Within 4 hours of nursing interventions, the patient will be able to recognise techniques to enhance activity tolerance and to participate in desired activities.

Within 6 hours of nursing interventions, the patient will maintain skin integrity (Gulanick & Myers, 2013).

Establish trust to allow the patient to cooperate and to reduce anxiety related to lack of self-care activities. Assess patient’s level of mobility to identify the capability of the patient to perform activities. Assist patient with activities of daily living to allow conservation of energy and to enhance patient’s self-esteem. Provide emotional support to the individual to gradually increase activity (Brown, Winters-Stone, Lee, & Schmitz, 2012). Nurses should position the patient every two hourly to reduce the development of pressure ulcer and to maintain skin integrity. Support patient with pillows during positioning and air mattress to provide comfort to the patient (Stephen-Haynes, 2012).


The physiotherapist will assist patient with the passive range of motion exercises to increase blood circulation and to promote comfort to the patient. Home support and assistance that will allow caregivers (family members) and patient to adjust to the changes in living patterns (Ackley, Ladwig, & Makic, 2016).

After 4 hours of nursing interventions, patient recognised techniques to enhance activity tolerance and participated in desired activities.

After 6 hours of nursing interventions, patient maintained skin integrity (Gulanick & Myers, 2013).

Some barriers and facilitators are identified related to Carla’s case study and advance care planning model in order to provide effective client-centred care. Understanding these barriers and facilitators are helpful in the development of interventions which aimed at implementation of advance care planning in practice. Carla’s husband William and Daughter Penny are the main barriers who can impact the implementation of the advance care planning. In fact, Carla’s husband William is in denial of Carla’s impending death and want her to receive every possible treatment in the hospital to keep her alive. On the other hand, Penny is pregnant and wants to prolong her mother’s life for as long as possible for her to see the birth of her first granddaughter. Both Carla’s daughter and her husband do not support or accept her wish to discontinue any further acute treatment. Unfortunately, this leads to the family conflict and arguments among the family members which might impact Carla’s decisions. Another barrier that can impact the effective facilitation of advance care planning is Fear. Carla’s fear in relation to her current family situation might concern her about distressing her family members by making decisions in regards to end-of-life care rather than continuing all possible treatment. Lack of knowledge of advance care planning can be defined as a barrier. Lack of patient knowledge in particularly related to the processes involved in making advance care directives. Also, no clear understanding or misinterpretation of palliative nurse and GP’s explanation related to advance care planning (Lund, Richardson, & May, 2015; Pung, 2011; Kononovas & McGee, 2017; De Vleminck, Houttekier, Pardon, Deschepper, Van Audenhove, Vander Stichele, & Deliens, 2013).

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However, Carla’s son Harry is one of the main facilitators who can help to implement the advance care planning. Moreover, Harry supports her mother’s wish to discontinue further acute care treatment and to remain at home during her end-of-life. Carla will be able to appoint Harry as her substitute decision-maker who can speak on her behalf with healthcare teams and family members in the event of loss of capacity to communicate or to make decisions. Carla’s palliative nurse Josey and GP’s can assist Carla to facilitate the advance care planning model. The knowledge and experience of Carla’s palliative nurse and GP will allow Carla to identify the suitable time for initiating discussion and open communication with family members in regards to expressing and documenting her wishes for future care or treatment. Patient Centred Care can also be linked to the facilitators as it focuses on patient’s wishes and preferences for future care or treatment. As in the case study, Carla has already expressed her decision related to her treatment and end-of-life care. She stated that she does not want to continue any future acute care treatment and would prefer to stay at home and to be kept pain free. She will be able to bring an open communication with family member and health practitioners about her wishes and preferences discussed and documented in advance care planning. Thus, patient centred care will help Carla to get her wishes and preferences to be understood and respected by everyone. This will increase the patient’s satisfaction with the care received (Kononovas & McGee, 2017; De Vleminck et al., 2013; Paladino, Bernacki, Hutch, Billings, & Block, 2014).

In conclusion, Advance Care Planning will help patient to overcome family conflicts, relieves burden from family or healthcare teams to make decisions in stressful situations, improve patient and family satisfaction with care and treatment, and reduce stress, anxiety, and depression within family. Nursing care plans will help patient to achieve quality of life and ensure patient wishes and preferences are understood and respected by everyone during end-of-life care. Nursing diagnosis is implemented by keeping patient at the centre of care to provide better quality of care according to patient’s wishes documented in advance care directives. Moreover, barriers and facilitators related to Carla’s case study and advance care planning helped to implement effective client-centred care.


Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2016). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (11 ed.). USA: Elsevier Health Sciences.

Palliative Care Australia (2017). Advance Care Planning. Retrieved March 6, 2017, from Palliative Care Australia Organisation: http://palliativecare.org.au/support-and-services/advance-care-planning/

Brown, J. C., Winters-Stone, K., Lee, A., & Schmitz, K. H. (2012). Cancer, Physical Activity, and Exercise. Comprehensive Physiology, 2(4). doi:10.1002/cphy.c120005

Dhiliwal, S. R., & Muckaden, M. (2015). Impact of Specialist Home-Based Palliative Care Services in a Tertiary Oncology Set Up: A Prospective Non-Randomized Observational Study. Indian Journal of Palliative Care, 21(1). doi:10.4103/0973-1075.150170

Gulanick, M., & Myers, J. L. (2013). Nursing Care Plans: Nursing Diagnosis and Intervention (8 ed.). Philadelphia: Elsevier Health Sciences.

Hökkä, M., Kaakinen, P., & Pölkki, T. (2014). A systematic review: Non-pharmacological interventions in treating pain in patients with advanced cancer. Journal of Advanced Nursing, 70(9). doi: 10.1111/jan.12424

Howie, L., & Peppercorn, J. (2013). Early palliative care in cancer treatment: rationale, evidence, and clinical implications. Therapeutic Advances in Medical Oncology, 5(6). doi:10.1177/1758834013500375

Kononovas, K., & McGee, A. (2017). The benefits and barriers of ensuring patients have advance care planning. Nursing Times, 113(1).

Lang, A., Toon, L., Cohen, S., Stajduhar, K., Griffin, M., Fleiszer, A., Easty, T. and Williams, A. (2015). Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. Safety in Health, 1(1). doi:10.1186/2056-5917-1-3.

Lee, J. J., Lee, M. K., Kim, J. E., Kim, H. Z., Park, S. H., Tae, J. H., & Choi, S. S. (2015). Pain relief scale is more highly correlated with numerical rating scale than with visual analogue scale in chronic pain patients. Pain Physician, 18(2).

Linl, C., Kupperl, A., Gammaitonil, A., Galerl, B. and Jensenl, M. (2011). The frequency of chronic pain descriptors: Implications for assessment of pain quality. European Journal of Pain, 15(6).

Lund, S., Richardson, A., & May, C. (2015). Barriers to advance care planning at the end of life: an explanatory systematic review of implementation studies. PLoS One, 10(2). doi:10.1371/journal.pone.0116629

Mashaqbeh, M., & AbuRuz, M. E. (2017). Pain Management: A systematic review. Journal of Nursing and Health Science, 6(1). doi:10.9790/1959-0601017580

McMillan, S. C., Small, B. J., Weitzner, M., Schonwetter, R., Tittle, M., Moody, L., & Haley, W. E. (2015). The impact of coping skills intervention with family caregivers of hospice patients with cancer. American Cancer Society, 106(1). doi:10.1002/cncr.21567

Moir, C., Roberts, R., Martz, K., Perry, J., & Tivis, L. J. (2015). Communicating with Patients and their Families about Palliative and End of Life: Comfort and Educational Needs of Staff RNs. International Journal of Palliative Nursing, 21(3). doi:10.12968/ijpn.2015.21.3.109

Paladino, J., Bernacki, R., Hutch, M., Billings, J. A., & Block, S. (2014). Facilitators and barriers to advance care planning in oncology. Journal of Clinical Oncology, 32(31). doi:10.1200/jco.2014.32.31_suppl.84

Pasero, C. and McCaffery, M. (2011). Pain assessment and pharmacologic management. 1st ed. St. Louis, Mo.: Elsevier/Mosby.

Pung, L. J. (2011). Addressing Barriers to Advance Care Planning (ACP). Journal of the American Medical Directors Association, 9(3). doi:10.1016/j.jamda.2007.12.058

Stephen-Haynes, J. (2012). Pressure ulceration and palliative care: prevention, treatment, policy and outcomes. International Journal of Palliative Nursing, 18(1). doi:10.12968/ijpn.2012.18.1.9

VanItallie, T. B., & Plante, G. E. (2011). Opioids for cancer pain: the challenge of optimizing treatment. Metabolism, 59(1). doi:10.1016/j.metabol.2010.07.010

Walshe, C., Roberts, D., Appleton, L., Calman, L., Large, P., Lloyd-Williams, M. and Grande, G. (2017). Coping Well with Advanced Cancer: A Serial Qualitative Interview Study with Patients and Family Carers. PLOS ONE, 12(1).

Washington, K. T., Meadows, S. E., Elliott, S. G., & Koopman, R. J. (2011). Information needs of informal caregivers of older adults with chronic health conditions. Patient Education and Counseling, 83(1). doi:10.1016/j.pec.2010.04.017

Wilkie, D. J., & Ezenwa, M. O. (2012). Pain and Symptom Management in Palliative Care and at End of Life. Nurs Outlook, 60(6). doi:10.1016/j.outlook.2012.08.002


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