Mrs. Keating is an emaciated 97-year-old white female with dementia who lives with her son and daughter-in-law. According to the son, until recently she needed some assistance with eating but had no swallowing difficulties. In recent weeks, she began choking on food and now has aspiration pneumonia. Her son brought her to the hospital. Once she was admitted to the medical unit a consult was placed for a wound ostomy continence nurse (WOCN). The nurse, Jennie Reardon, discovered a Stage IV sacral ulcer with exposed bone, tendon and muscle. A surgical consult also was placed and the surgeon is quick to schedule a surgical repair. Jennie wants a more comprehensive evaluation of Mrs. Keating before she has surgeryone that will assess her age, quality of living, goals, etc. At this stage of dementia it is appropriate to transition to purely palliative goals, and surgery may increase Mrs. Keatings pain and suffering without offering any additional benefit. The surgeon sees a problem that needs to be fixed and will not countenance delay. The son is eager to consent to the surgery.
Provision 3 of the ANA Code of Ethics for Nurses states, The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient. In this case the surgeon sees a stage IV sacral ulcer that needs repair. The nurse sees a 97-year-old woman with end-stage dementia, who may need an advocate to ensure that her treatment respects her inherent dignity and promotes her well-being and peaceful end of life since cure is not an option. The 2014 Institute of Medicine report, Dying in America, states, providing high quality care for people who are nearing the end of life is a matter of professional commitment and responsibility.
Jennie decides to be a team player and does not question the surgeons order. She mentions to the charge nurse that a more comprehensive assessment is indicated but does nothing to follow up herself. She is sad when she returns to work after a two-week vacation to see the wound care orders for Mrs. Keating following the surgery. Not surprisingly, Mrs. Keating is now receiving IV antibiotics for sepsis aggravated by her poor nutritional status. Mrs. Keating is now unresponsive and has had no family or other visitors. Jennie feels remorse, but once again tamps this down, less it interfere with her ability to get the days work done.
Jennie immediately shares her concerns with the charge nurse and then contacts Mrs. Keatings attending with whom she has a good working relationship. She recommends involving palliative care, ethics and the legal department. Since there is a possibility that neglect or worse has contributed to Mrs. Keatings situation, a call to adult protective services may be indicated. She wants to ensure that whatever treatment plan is developed honors Mrs. Keating and what would be her values and preferences were she able to articulate them. Jennie wants to find out if there are other family members or friends who know Mrs. Keating and who might be better able to speak on her behalf. Within 36 hours, Mrs. Keating is on a comfort measures only order and is being seen by palliative care. Protective services are evaluating her home environment. Jennie took some heat from the surgeon for sticking her neck out, but celebrates her ability to be the critical difference for one vulnerable patient. I would want someone to advocate for me if I were Mrs. Keating! she said.
Institute of Medicine. (2014). Dying in America. Improving Quality and Honoring Individual Preferences Near the End of Life. Key Findings and Recommendations. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf