Jenny is a 93-year-old widowed female with multiple comorbidities. Her husband died 30 years ago and since that time she has lived alone. Her past medical history includes recurrent episodes of congestive heart failure, junctional rhythm, TIAs, diverticulitis, arthritis and cerebral vascular disease. She has a pacemaker, two knee implants and dental implants.
She is oriented to time, place and person. She is the beloved matriarch of a large family and is cared for by her two daughters, one son and five grandchildren — none of whom live close to her. She is insistent on continuing to live in her own home and has had personal care attendants 24/7 for the past two years when family isn’t present. She is mobile, but needs help with showering, meals and taking her medications. A woman with a deep faith, Jenny is ready to die and prays to die soon. She has outlived her peers and deeply misses the daily telephone conversations she had with her sisters before their deaths. Jenny’s children all work full time. As problems increase with her personal care attendants, her daughters begin to explore moving Jenny to an assisted care facility. The daughter closest to Jenny finds a small, excellent quality facility 10 minutes from her home, which would allow frequent visits. Plans are made to move Jenny.
Guidance from the ANA Code of Ethics
Provision 1.4 of the ANA Code of Ethics for Nurses addresses the nurse’s responsibilities to promote the patient’s right to self-determination. The importance of carefully considered decisions regarding resuscitation status, withholding and withdrawing life-sustaining therapies, foregoing nutrition and hydration, palliative care and advance directives is widely recognized. Nurses assist patients as necessary with these decisions. Nurses should promote advance care planning conversations and must be knowledgeable about the benefits and limitations of various advance directive documents (ANA, 3).
Sandy McCloskey is the nurse who does the admission history to the assisted nursing facility. While she spends a great deal of time discovering how the nursing assistants can facilitate Jenny’s activities of daily living, there is no discussion of advance care planning. Her daughters do provide a copy of Jenny’s advance directives, which specify “no heroic measures.” Sadly, three months into Jenny’s stay at her new residence, she goes into heart failure and first responders bring her to the local ED. By the time Jenny’s children arrive at the hospital, she is in the ICU and on ventilator support. Jenny can no longer speak for herself, and Jenny’s children are divided about how to proceed. Jenny spends one month in the ICU before a decision is made to extubate her and transition to purely palliative goals. One of Jenny’s critical care nurses had finally called for an ethics consult and asked the basic question, “If Jenny could wake up and speak to us, would she want us to continue the current level of treatment or would her goal now be to prepare for a comfortable and dignified death?” When the family concurred that Jenny would definitely want the latter, the decision was made to transition to palliative goals. Finally, Jenny dies and is at rest.
Jim Watkins was the nurse who admitted Jenny to the assisted facility. In addition to discovering what types of assistance would be most beneficial to Jenny, he asked questions about Jenny’s beliefs and values and learned Jenny was ready to die. She had prepared an advance directive specifying under what conditions she would not want life-sustaining technologies. Jim spoke with her daughter who was the valid legal surrogate, and asked whether “do not attempt to resuscitate,” or “allow natural death,” or “do not hospitalize” orders were appropriate. Jenny’s daughter was clear. If you can treat a problem, and she can return home to good functioning, please hospitalize her. But if she stops breathing or her heart stops, please allow her to die peacefully. A DNR was put in place. When Jenny went into heart failure three months into her new residence and was found pulseless by first responders (Jenny was wearing a life-alert necklace), no efforts were made to resuscitate her.