Elderly Man Tom's Palliative Care: Deciding Morphine & Guardianship - Case Study

Introduction

This case involves an elderly man Tom who is receiving palliative care at a hospital. Tom has had pain and trouble breathing caused by lung cancer and multiple metastases. Some of the issues presented here and that require resolving are:

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• Whether to use morphine on Tom or not
• Whether to stop the usage of morphine and use "something better" as per Carina's request
• To determine which takes precedence between the power of the attorney and enduring guardianship in this case

The nurse advises Tom to use morphine, but he does not like to air his objection. However, the nurse makes use of proper communication strategies by explaining to Tom about the benefits of using morphine and confirming to him that it does not have side effects. Due to the nurses' good communication strategies and persuasive skills, Tom and the family members present assent to the use of morphine, albeit in smaller amounts to manage his condition without making him drowsy. Tom suggests that he does not want to get drowsy and wants to be in control of everything and the nurse agrees to his concerns.

Establish Goals

• In dealing with this case as a Registered Nurse, I would be determined to achieve the following goals;
• Make it known to the entire family Tom's wishes
• Explain to the family what power of the attorney means and enduring guardianship mean and which takes precedence
• Ensure that Tom receives the best palliative care at this crucial stage
• Ensure care provided to Tom and his family is culturally safe

Review Progress Notes Before Advising the Family

Hannan (2018) observed that in nursing, the decisions for palliative care should be made as soon as possible so that the terminally ill patient can participate in the decision-making process. In making these crucial decisions, the patient and family members should be involved, but the nurse should offer professional advice on these issues. I am aware that it might not be an easy task given that there is a division in the family concerning which direction I should take concerning Tom' health and communication challenges due to cultural differences. While the family is supposed to provide the best environment for the patient in palliative care, the management of the patient can be made difficult where there exists a family conflict (Eagar, 2004). It is true that there exists a conflict between Tom's family members. He had discussed his wishes with a section of the family members but in the absence of some of them such as his daughter Carina. The daughter refuses to agree with the decisions that were made in her absence and come armed with the Power of the Attorney. In this case, one of my primary goals as a Registered Nurse is to unite the family by use of communication strategies. According to Tasmanian legislation on nursing and palliative care, the need of the patient needs to be prioritized over those of the family (Martin & Barkley Jr, 2016). As such, I will inform the family of Tom's wishes and especially on the use of morphine in smaller amounts.

Tom needs utmost peace at this time. Cultural and psychological communication strategies would be best at this stage. I would ensure that cultural demands are adhered to during the communication with both the family and the patient. For example, Tom feels that Uncle Joe who is a traditional healer should be part of the decisions made and I would honour his request. Psychologically, I would ensure that I focus on the issue at hand, health of Tom, so that every family member may be convinced and be determined to take any step as long as it is aimed at ensuring Tom has the best care and peace at this critical stage of his life.Select a Course of Action (what are you going to do)

One of the decisions that is of conflict, in this case, is whether to withdraw the morphine treatment or not. Family conflicts can affect the care given to a patient (Lichtenthal & kissane, 2008). Carina demands that the morphine treatment be replaced with a better option. While Carina may be concerned and empathetic of his father's condition, I will explain to her that morphine is the best solution for her sick father at the time. I will explain to her the benefits that morphine has and explain to her that it is used in small amounts so that her father does not become drowsy. I will explain to her that the current medication order for morphine is 2.5mg -5mg SC every 2 hours PRN. Besides, I will inform her that before arriving at this decision, I had discussed with her father and the present family members who agreed to it.

The other thing I will do is invite the family together and try to assess every side so that they can agree on one thing. In case such as this, there is a need for me as a Registered Nurse to help the family members reach a consensus on decisions about the patient's care. In this case, I would explain to the family that the most concerning aspect at this time is to ensure that Tom is given the best care and attention by the entire family. Besides, I would encourage the family to open up on their preferred choices and why they consider them essential and then use that information to come to a consensus. Since this is an Aboriginal family, I will ensure that my communication is in line with the cultural expectations of the community so that the message is clear to all. I would avoid using complicated words such as technical and medical jargon to ensure that they can understand well. Words such as Power of the Attorney and Enduring Guardian may be difficult to understand, and therefore, I would break them down to make them understandable. Besides, as per the Aboriginal and Torres Strait Islanders, I would avoid asking personal questions but use indirect questions.

Nurse Engaging Patient and Family to Make a Decision (Matzo & Sherman, 2019)

I will make it known to the family what power of attorney and enduring guardianship means and which should be adhered in such a case. To begin with, I would inform the family that an Enduring Guardianship is a person that you appoint who makes essential treatment and lifestyle decisions on your behalf during palliative care. In this case, Tom's Enduring Guardian (EG) is his mother, Cec. According to Tasmanian law, the EG has the absolute role in making decisions about the support services that the patient requires but does not have the power to make decisions about the patient's finances and estates ("Enduring Guardianship," 2014). He or she is also supposed to act in accordance with the wishes the patient gave. If the patient fails to set out any conditions for the EG, then the EG bears full power as specified in section 25 of the Guardianship and Administration Act 1995. According to Tasmanian law, an Enduring Power of Attorney is appointed to deal with property and finances but not health issues ("Enduring Guardianship," 2014). Thus, in Tom's case, his mother, Cec, bears the responsibility of making health-related decisions for Tom. While this is the legal standing, I will communicate it to the family in the best manner possible so that neither of the parties becomes aggrieved (Montague, 2015).

Carina's preference of other options other than morphine may not be possible since the progressive notes from Tom's medical registrar indicate that "not-for-resuscitation (NFR), not for CPR, and not for ICU admission." This limits the options available for Tom. As such, I would make the progressive notes available to the family and explain to them what they mean since they are written in technical language. The note bearing these writings is tagged with a red dot. The presence of the red dot, in this case, may mean that Tom may only be treated following the notes written and any change should involve further consultations. As such, there are very limited pharmacological options for Tom other than the use of morphine.

References

Eagar, K. (2004). Palliative care in Tasmania: current situation and future directions. Wollongong, N.S.W., University of Wollongong, Centre for Health Service Development.

Enduring Guardianship. (2014). Retrieved from: https://www.guardianship.tas.gov.au/__data/assets/pdf_file/0010/251776/Infosheet_Enduring_Guardians_Jan_2014.pdf

Hannan, T. J. (2018). Bedside stories: a journey built by patients, learning to listen. Tasmania: Dr Terry J. Hannan

Lichtenthal, W. G., & kissane, D. W. (2008). The management of family conflict in palliative care. Progress in Palliative Care. 16, 39-45.

Martin, EM, & Barkley Jr, TW. (2016). 'Improving cultural competence in end-of-life pain management', Nursing 2019, vol 46, no. 1, pp. 32-41.

Matzo, M., & Sherman, D. W. (2019). Palliative care nursing: quality care to the end of life. New York: Springer Publishing Company

Montague, A. (2015). Death and dying in Aboriginal and Torres Strait Islander Culture (Sorry Business). Northern Sydney Local Health District.