Case Study on Palliative Care: Example Answers

Carol is a 48 year old woman who lives with her husband Dean and three children. Carols three children, Josephine (15 years), Harry (12 years) and Sarah (8 years) are aware their mother has cancer, but have not been told of the development of secondary disease or the implications this carries. The family run a small general store in an outer suburb of Perth. Carol was diagnosed with breast cancer three years ago, originally undergoing a right lumpectomy with adjuvant chemotherapy. Last year Carol was diagnosed with bone secondaries. Since that time she has been receiving tamoxifen and attending the oncology clinic for follow-up. The community palliative care nurse visits Carol once a month to monitor her progress and provide emotional support.

While visiting Carol the nurse notes that she appears to be in considerable discomfort, though she denies any pain. On questioning Dean, the nurse learns that Carol has been found crying and holding her hip, but refuses to seek medical attention.

Why do you think Carol is reluctant to seek medical attention and acknowledge her pain?

ANSWER: Carol is reluctant to seek the medical attention because she is fed up with the medical checkups and also she receives no positive improvement in her health so she herself concluded to not to waste the money on her health and let them safe for her three children (Matthews, 2008).

As Carol begins to receive palliative care, which members of the palliative care team do you think need to be involved in her care? Briefly describe the role of each.

ANSWER: The family members of Carol play an important role in the team of palliative care and especially the role of Dean was very crucial because he is the person who could fill the strength in Carol to fight against this dangerous disease ( Foley, 2001).

Investigations of Carol’s pain revealed bony secondaries. She was offered a course of radiotherapy, but refused as this would mean going to the city (55km away) every day, and she would be away from the shop at the busiest time of the year. Carol agreed to recommencing chemotherapy, and was commenced on regular panadeine forte (two every four hours) for her pain. Carol has been troubled by nausea and vomiting after each course of chemotherapy. On a follow up visit five days after Carol’s last chemotherapy, the community nurse discovers that Carol is constantly nauseated, vomiting several times a day and unable to keep any fluids down.

Identify the possible causes of Carol’s nausea and vomiting.

ANSWER: Chemotherapy involves the killing of cancerous cells from the patient’s body thus due to these heavier operations on Carol’s body would make her uneasy and thus she has nausea and vomiting (Ferrell, 2006).

Describe the management strategies for the various probable cause(s) of Carol’s nausea and vomiting.

ANSWER: Management strategies should be in order to give her strict instructions to be away from strong odours, not to lay flat after eating, have some light exercise after eating, to eat in smaller amounts and most importantly keep her mind relaxed and try to forget about the chemotherapy (Hesketh, 2005).

On a follow-up visit, the community nurse discovers that Carol is only achieving two hours pain relief after her tablets and is taking them more frequently, but is reluctant to consider changing to stronger medication.

Identify the appropriate steps for assessing Carol’s pain.

ANSWER: She should be checked to take medicines on her own i.e. someone from her family should take the responsibility to fetch her with medicines; also management should maintain a regular chart of the total amount of daily doses and the time span of pain she have(McMann, 2009).

After consultation with the general practitioner, the community nurse discusses changing Carol’s analgesia to something stronger. Carol is very reluctant as she feels she will only become addicted to ‘hard drugs’ if she uses them now. Carol expresses concerns about having this type of medication in the house with young children around.

What are the possible reasons for Carol’s reluctance to change her medication, and how could this be overcome?

ANSWER: Carol main reason for reluctance was that she wants to be with her family also she wants to save money as she could not afford the hospital’s expenses and hence she wants the whole medication to be done at her home. This can be overcome if and only if the management gives some relaxation in the expenses (Visel, 2006).

Carol reluctantly agrees to a trial of oral morphine, initially in short-acting form until the dose is titrated. She is commenced on 10mg of oral morphine 4th hourly.

What education should the nurse give Carol about commencing and taking morphine?

ANSWER: The nurse should tell her to handle some pain and extend the period of taking the morphine from 2 hours interval to 4 hours interval so that she could develop some resistive powers in herself (Bruera, 2003).

When should Carol be considered for conversion to controlled (slow) release morphine, and how would the dose be calculated for this?

ANSWER: As soon as Carol feels that she has generated enough resistive power then the controlled doses of morphine should be given and the period should be increased rose to the power of 2 i.e. 2, 4, 8, 16 and finally it should be stopped (Bruera, 2003).

Identify adjuvant medication that may be helpful in Carol’s case.

ANSWER: Herceptin drug can be used as the adjuvant medication because it interferes with growth of cancer cells and slows their growth and spread in the body (Knox, 2004).

Carol is reluctantly taking morphine 30mg every four hours and Naprosyn 500mg b.d. for her pain. When visiting Carol one day the community nurse finds Carol vomiting and complaining of catching a ‘gastro’ bug from one of the children. On questioning Carol states she has had small frequent amounts of diarrhoea for 5-6 days, and has not had a normal bowel motion for two weeks. Carol is notably dry, complains of thirst, has a coated tongue, and a distended abdomen.

What nursing investigations would you carry out?

ANSWER: The infection is been spreading in her family due to the contact of virus released by the vomiting of the Carol. Hence personal hygiene should be maintained (Yarbro, 2005).

What nursing strategies would you implement to relieve Carol’s symptoms?

ANSWER: For relieving Carol’s symptoms the basic nursing strategies should ensure that the toiletry area should properly cleaned using diluted bleach, she must wash her hand after using the toilet, her clothes must be washed in warm water, and lastly the nurse should suggest her the BRAT food i.e. Banana Rice Applesauce and Toast as the main food from time to time and drink as much liquid as she discharges in her stools (Yarbro, 2005).

Carol’s appetite has decreased and she is eating only very small amounts of food. She is not nauseous. Dean is finding it hard to accept that Carol doesn’t need food and worries that without food Carol will die.

What will you tell Dean about Carol’s loss of appetite?

ANSWER: We will tell him not to panic because this loss of appetite is only due to the gastro effects and it will be removed as soon as the medicines perform their proper function (Ko, 2008).

What strategies can you use to help Carol increase her intake?

ANSWER: After giving her enough liquid food we will ask Carol to perform light exercises which could help her to burn more calories and so she will feel a good hunger for receiving a good nutrition (Ko, 2008).

Carol has become increasingly bedbound and is spending many hours sleeping, and at times becomes restless. She has refused all further chemotherapy and blood tests and is aware her time is limited. Carol has told Dean that she would like to die at home.

What do you need to consider to ensure that Carol can be cared for at home (eg. equipment, care needs etc)?

ANSWER: The main consideration would be based on finding ways so that she must not get any complication in terms of medical facility. Hence important equipments must be installed with a good experienced nurse who remains with Carol in her house for 24 hours (Keir, 2002).

The community nurse is called late at night because Carol has become semi-conscious, but is calling out and very restless. On arrival the nurse finds Carol agitated and restless in bed, with an increased respiratory rate, an obvious frown and unable to respond to questions. On questioning Dean states that he was unable to administer her last two doses of morphine slow release tablets. Carol has not taken fluids for several days, nor passed urine for eighteen hours.

Identify the possible cause(s) for Carol’s restlessness and suggest treatments.

ANSWER: Carol’s restlessness is only due to improper metabolism of her body so she should be given liquids as much as she could take and finally she must be made to discharge the urine (smith, 2006).

The community nurse suggests insertion of a subcutaneous butterfly needle to administer Carol’s morphine for pain control. Dean becomes distressed, questioning the need for morphine when his wife is almost unconscious. He accuses the nurse of trying to “hurry things along”.

What is an appropriate nursing response to Dean’s concerns?

ANSWER: Nurse should send Dean outside the room and tell him to keep patience and keep faith, she will do the appropriate nursing of Carol (Kearny, 2006).

Carol remains unconscious for several days. Josephine expresses concern that her mother has not had any fluids for several days and questions whether she should be admitted to hospital so intravenous fluids could be commenced. Josephine questions if it is cruel to let her mother die of dehydration?

What explanation could the nurse give in response to Josephine’s concerns?

ANSWER: Nurse should give condolence to Josephine and not to worry because she will take care of her mother in every aspects of medical concern (Alexander, 2000).

What nursing actions will ensure that Carol is comfortable despite no oral intake?

ANSWER: The basic nursing action that a nurse should check Carol’s pulse rate and blood pressure, if everything is normal then there it is ensured that Carol is comfortable despite of having no oral intake (Alexander, 2000).

Dean approaches the palliative care nurse for assistance the next day. He states the children, in particular Sarah, are asking questions he doesn’t know how to answer. Sarah asks detailed questions about what will happen to Carol before and after she dies, and appears to have a morbid interest in the details of death.

Identify strategies to assist children dealing with death.

ANSWER: While assisting children dealing with death the children of small age should be taken away from the house and make them busy in some games while elder children should understand itself how to manage with the condition (Schaefer, 2002).

Carol died at 4.30 p.m. on a Sunday afternoon, with Dean, the three children and her mother by her side. Her death was described by the palliative care nurse as peaceful, but her dying as a struggle.

What bereavement follow up could be put in place for this family?

ANSWER: Carol was a strong fighter and she fights with her disease with silence and lots of courage, this death would keep soul free from the struggles that she had faced during her illness. God bless her soul Amen (Schaefer, 2002).