This week we are to post a description of a situation experienced and explain how incorporating or not incorporating patient preferences and values impacted the outcome of their treatment plan. Patient D.P. is a 62-year-old, morbidly obese adult woman that resides in a nursing home. D.P is diabetic, unable to walk, and is dependent on insulin as well as many oral medications to control diabetes. “Diabetes-related long-term complications are one of the most important diabetes-related worries in people with diabetes type 1 and type 2” (Kuniss, Freyer, Müller, Kielstein, & Müller, 2019, p. 33). D.P has no desire to make changes to reverse the effects of diabetes. D.P and her husband were in a care plan meeting discussing her “code status.” Due to her young age, D.P decided she wants to be resuscitated in the event that she stops breathing. After explaining all the details of what can happen if being resuscitated at her size, D.P still decided that she would want CPR. An IPOST was created, signed by the doctor following her, and placed in her chart. “The medical profession has become much more technologically advanced and aware of the importance of prevention and detection of disease before symptoms appear and before treatment becomes imperative” (Telfer, 2018, p. 10).
That following Fall, D.P was found unresponsive in her room. CPR was initiated and she was brought back to a responsive state. Testing showed her blood sugar was 1200 and was unresponsive at least two hours from the last time anyone laid eyes on her would have been during last rounds. D.P suffered broken ribs from resuscitation efforts and never fully was in a clear mental state thereafter.
Then, we are to explain how including patient preferences and values might impact the trajectory of the situation and how these were reflected in the treatment plan. The lack of oxygen played a role in her permanent altered mental status. D.P then began dialysis and that is when the doctor following her had a “come to Jesus” talk with her regarding hospice care. “Hospice care aims to improve the quality of life for terminally ill patients and their families by relieving suffering and providing supportive care” (Park, Yeom, & Yong, 2019, para 2). D.P’s husband became irate when he found out this conversation was had and yelled at the doctor. Both D.P and husband were in denial about her health and she still was a full code in the event that she was to stop breathing. I spoke with the husband privately sometime after the explosion between him and the doctor. I calmly explained that what happened to D.P from resuscitation efforts last time with the broken ribs and her confusion that stuck around after the fact could happen again if CPR is performed yet again. This did not sit well with her husband and that is when it finally clicked that it will happen again and it is time to switch her IPOST to a DNR status.
I do not feel like I coaxed him but informed/educated him on what to expect as it had already happened once. For a woman that refuses dialysis two times per week and sleeps the rest of the week away it did not make much sense to keep her as a full code and put her through all of that again. I was glad her husband agreed as it was not a great moment in time for staff performing CPR on a 400 plus pound unresponsive woman either. I am glad we were all on the same page as the social worker, doctor, and administrator had spoken to the husband about her code status and had had no luck.
Next, we are to explain the value of the patient decision aid selected and how it might contribute to effective decision making. I think part of it was that her husband knew me from being employed there for four years and that I am knowledgeable. The others may not have approached him the right way about this topic. Had I known that this decision-making tree website existed then I would not have sent him that way. Some people are internet savvy while others are not. This particular gentleman had old-school ways about himself and a good old-fashioned conversation and a handshake is how he did his business.
Lastly, we are to describe how we might use this decision aid inventory in our professional practice or personal life. If a patient was undecided or even on the fence about a life changing procedure, I would refer them to this website to help decide. As mentioned above, not all patients or family members are going to be on board with finding out information on delicate subjects online. That is going to have to be a case by case judgement call.
Kuniss, N., Freyer, M., Müller, N., Kielstein, V., & Müller, U. A. (2019).
Expectations and fear of diabetes-related long-term complications in people
with type 2 diabetes at primary care level. Acta Diabetologica, 56(1), 33–38.
Park, M., Yeom, H.-A., & Yong, S. J. (2019). Hospice care education needs of
nursing home staff in South Korea: a cross-sectional study. BMC Palliative
Care. 18(1), 20. https://doi-org.ezp.waldenulibrary.org/10.1186/s12904-019-
Telfer, C. (2018). Patient perspectives: Exploring patient values and preferences.
Canadian Family Physician Medecin de Famille Canadien, 64(1), 10–11.