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Introduction

In this assignment, we delve into the case of Maureen, a 76-year-old woman with a complex medical history, focusing on the quality of care she received during her end-of-life journey. We will critically evaluate her care against high-quality evidence, considering the End-of-Life Care Clinical Practice Guidelines, the National Palliative Care (NPC) standards, the Nursing and Midwifery Board of Australia (NMBA) standards and the National Safety and Health Quality Service (NSQHS) standards. The analysis unfolds through four pivotal episodes of care: her initial hospitalisation for a urinary tract infection and subsequent diagnosis of vascular dementia, her discharge home with the discovery of her Advanced Care Directive, her second hospital admission due to a hip fracture, and finally, the decision to admit Maureen to hospice care. Each event will be carefully analysed concerning the pertinent clinical standards and guidelines to assess how much care aligns with best practices. The ultimate goal of this assignment is to find areas where end-of-life care for patients like Maureen can be improved, leading to a more sympathetic and patient-centred approach.

Episode of Care 1

In Maureen's case, the first episode of care contains both negative and positive aspects. Positively, Maureen's urinary tract infection (UTI) was swiftly diagnosed and treated by the medical staff. This is consistent with the End-of-Life Care CPG guidelines, highlighting the significance of quickly identifying and treating infections (ACU, n.d). In palliative care, controlling infections is essential since they can worsen a patient's symptoms and discomfort (Göl et al., 2022). The delay in revealing Maureen's diagnosis of vascular dementia is a noteworthy drawback of this episode. In palliative care, prompt diagnosis and communication are crucial since dementia is a degenerative disease that profoundly affects a patient's journey to death (Malhi & McElveen, 2021). The NPC Standards, which emphasise the value of precise and prompt evaluation and communication regarding a patient's condition, directly conflict with this delay. This discrepancy also violates the NMBA standard 2.7, which emphasises cultural sensitivity and person-centred care, which is essential, especially when it comes to coping with cognitive disorders, which, in Maureen's case, required early detection and support (NMBA, 2023).

There were numerous significant areas where the first episode of Maureen's care could have been improved to raise the level of quality following best practices and standards. First and foremost, it should have been a top priority to evaluate Maureen's cognitive condition promptly. This delay in diagnosing her vascular dementia directly contradicts the NPC Standard 4.5, emphasising the need for accurate and prompt assessments. The End-of-Life Care CPG highlights the significance of comprehensive assessments and effective communication, especially in cognitive decline cases (ACU, n.d). Moreover, per the NMBA standard 2.7, care should have been more person-centred. A more individualised approach would have considered Maureen's unique background, values, and cognitive health importance, ensuring her diagnosis was communicated in a manner that respected her preferences (NMBA, 2023). Additionally, fostering interdisciplinary communication among the healthcare team and adhering to the would have allowed for a more comprehensive and patient-centric approach to care, reducing the likelihood of overlooking the dementia diagnosis (Kwame & Petrucka, 2021). Lastly, as the NSQHS standard 1.20 emphasises, staff education and training should be prioritised to ensure that healthcare professionals are adequately prepared to recognise and manage cognitive conditions in palliative care settings (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2021).

Episode of Care 2

The second episode of care, involving Maureen's discharge home and subsequent second hospital admission due to a hip fracture, undeniably represents a negative element of care. It is characterised by a lack of coordination and communication that had dire consequences for Maureen. The failure to promptly recognise and act on her Advanced Care Directive and the absence of appropriate safeguards against falls ultimately led to her injury. This breakdown in communication and coordination is a clear violation of NPC Standard 4.1, which stresses the significance of timely and accurate communication regarding a patient's condition and concerns (Palliative Care Australia, 2018). Furthermore, it raises questions about adherence to the NSQHS standards 5.4b and 2.7, emphasising the importance of person-centred care and shared decision-making (ACSQHC, 2021). In Maureen's case, her concerns in her Advanced Care Directive were overlooked, resulting in a preventable adverse event. A more patient-focused approach that considered her directives and ensured better communication among the care team could have averted this negative outcome (Kwame & Petrucka, 2021).

In the second episode of care, involving Maureen's second hospital admission due to a hip fracture, several critical improvements could have enhanced patient-centred care and aligned it with best practices and standards. The primary change should have been a comprehensive review and adherence to Maureen's Advanced Care Directive, as the NPC Standard 4.1 outlined. This would have ensured that her documented preferences were diligently followed, promoting her autonomy and respecting her end-of-life wishes (Palliative Care Australia, 2018). Another crucial improvement would have been implementing robust fall prevention measures, particularly for patients with mobility issues like Maureen (Appeadu & Bordoni, 2020). Adhering to the NSQHS standard 5.25, which aligns with ensuring patient safety and preventing falls, would also have played an essential role (ACSQHC, 2021). This would have entailed creating a safe environment by utilising bed alarms, assistive devices, and non-slip flooring to mitigate the risk of falls and related injuries (Mileski et al., 2019). 

Effective interdisciplinary communication among the healthcare team, including Maureen's care providers, her family, and various support staff, was pivotal (Victorian Government Department of Health, 2021). As the End-of-life Care CPG emphasised, it would have ensured that everyone involved was informed regarding Maureen's care preferences and directives (ACU, n.d). Timely and accurate communication about her condition and wishes would have contributed to a more coordinated and person-centred approach to care (Rawling et al., 2019). Incorporating these improvements would have markedly enhanced the second episode of care, preventing adverse events and promoting a higher quality of patient-centred care consistent with the best practices and standards in palliative care.

Episode of Care 3

The third care episode involving Maureen's third hospital admission following a hip fracture represents a negative care element. It is characterised by inadequate pain management and ineffective communication regarding Maureen's condition. This is evident from Maureen's request to speak with her church minister and the nurse's assumption that her pain was solely attributable to the hip fracture. Inadequate pain management is a significant oversight that contradicts the End-of-life Care CPG guidelines. These guidelines emphasise the necessity of comprehensive pain assessment and management in palliative care to ensure the patient's comfort and overall well-being (ACU, n.d). Furthermore, this episode raises concerns about compliance with the NSQHS standards 8.6d and 2.10a, prioritising pain relief and effective communication to meet a patient's physical and emotional needs during end-of-life care (ACSQHC, 2021). The absence of a thorough pain assessment and timely, clear communication with Maureen contributed to a negative care experience. It compromised her comfort and fell short of the established standards and best practices in palliative care. A more patient-centred approach that prioritises pain management and open communication is essential to ensure the well-being and dignity of patients at the end of life (Sinha et al., 2021).

In the third episode of care, Maureen's third hospital admission following a hip fracture, several crucial improvements were needed to provide patient-centred care and align with established best practices and standards. Firstly, a comprehensive pain assessment should have been prioritised per the NSQHS Standard 5.7a (ACSQHC, 2021). Maureen's distress and request to speak with her church minister indicated unaddressed pain extending beyond her hip fracture. A thorough pain assessment, covering location, intensity, and characteristics, would have identified the source of her discomfort and enabled more effective pain management following the End-of-Life Care CPG (ACU, n.d). Secondly, there should have been timely, transparent, and empathetic communication with Maureen about her pain and overall condition, adhering to the NPC standard 2.6 (Palliative Care Australia, 2018). This would have allowed Maureen to express her concerns and needs, ensuring that her physical and emotional well-being were addressed, ultimately enhancing her care experience.

Furthermore, an effective interdisciplinary collaboration among the healthcare team, involving pain management specialists and palliative care experts, would have allowed for a more coordinated approach to Maureen's pain management (Connell et al., 2022). As highlighted by the NSQHS standard 5.6 and NMBA standard 2.6, this approach emphasises the importance of interdisciplinary collaboration to provide comprehensive care (ACSQHC, 2021; NMBA, 2023). Integrating these improvements in the third episode of care could have significantly enhanced Maureen's overall experience, ensuring that her pain was effectively managed, her emotional needs were addressed, and a more patient-centred approach was adopted, consistent with best practices and standards in palliative care.

Episode of Care 4

The fourth episode of care, involving the family meeting to discuss Maureen's prognosis and future care, is a negative element in her care journey. The deficiency lies in the lack of comprehensive understanding and communication with Maureen's daughter, Lisa, regarding the prognosis of Alzheimer's disease and the potential trajectory of her mother's condition. This shortcoming contradicts the NPC Standard 2.2, which underlines the significance of clear and empathetic communication with patients and their families. Such communication ensures they fully comprehend the patient's condition, prognosis, and the available care options (Palliative Care Australia, 2018).

Effective and caring interaction is crucial to facilitating collaborative decision-making and taking care of the emotional requirements of the patient's family, according to the NSQHS standard 2.6 (ACSQHC, 2021). A negative care experience for Maureen and her family was influenced by Lisa's uncertainty and apprehension during the family meeting due to the lack of thorough communication and understanding. This negative aspect of care could have been reduced by taking a more compassionate, family-centred approach that prioritised open, compassionate communication and ensured the family was well-informed, supported emotionally, and actively involved in decisions about Maureen's care and end-of-life preferences (Malenfant et al., 2022).

Several crucial changes should have been made to the fourth episode of treatment during the family conference to address Maureen's prognosis and future care to deliver more patient- and family-centred care and align with best practices and standards. First and foremost, Lisa, Maureen's daughter, should have received thorough and sympathetic information about the prognosis of Alzheimer's disease and the likely course of her mother's health. The NHSQS Standard 6.10 strongly supports this method, emphasising the value of open, considerate interaction between the patient and their family to thoroughly comprehend their condition, prognosis, and treatment options (ACSQHC, 2021). This allows the family to make knowledgeable decisions regarding the patient's care and attend to their emotional needs (Stalnikowicz & Brezis, 2020). Lastly, Lisa should have actively participated in decisions regarding her mother's treatment and final wishes. This would have aligned with End-of-Life Care CPG and ensured that the family's viewpoint is considered and that the care plan represents the patient's preferences and values fostering a more patient and family-centred approach and resulting in a more positive care experience for Maureen and her family (ACU, n.d).

Conclusion

Several key points emerge in the critical evaluation of Maureen's end-of-life care journey. Each care episode showcased positive and negative elements, reflecting the healthcare team's ability to adhere to clinical guidelines and standards. Notably, prompt identification and treatment of a urinary tract infection in the first episode aligned with best practices, demonstrating an understanding of the importance of addressing infections promptly in palliative care. However, the delay in diagnosing Maureen's vascular dementia was a significant shortcoming, directly contradicting national standards emphasising timely and accurate assessment and communication. This delay also raised concerns about person-centered care, given the importance of early diagnosis and support in cognitive decline cases.

The subsequent episodes of care, involving Maureen's discharge home, her second hospital admission due to a hip fracture, and her third hospital admission for the same issue, underscored a critical need for better coordination, adherence to advanced care directives, pain management, and effective communication. The failure to recognise and act on Maureen's Advanced Care Directive resulted in a preventable adverse event, highlighting the importance of honouring patient preferences. Inadequate pain management and insufficient communication further compromised Maureen's comfort and emotional well-being, a clear violation of established standards.

References

Appeadu, M., & Bordoni, B. (2020). Falls and fall prevention. StatPearls https://www.ncbi.nlm.nih.gov/books/NBK560761/

Australian Catholic University (ACU). (n.d). Practice Guidelines: End of life care.

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2021). National Safety and Health Quality Service Standards. https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Connell, N. B., Prathivadi, P., Lorenz, K. A., Zupanc, S. N., Singer, S. J., Krebs, E. E., & Giannitrapani, K. F. (2022). Teaming in Interdisciplinary Chronic Pain Management Interventions in Primary Care: a Systematic Review of Randomized Controlled Trials. Journal of General Internal Medicine 37 (6), 1501-1512. https://doi.org/10.1007/s11606-021-07255-w

Engle, R. L., Mohr, D. C., Holmes, S. K., Seibert, M. N., Afable, M., Leyson, J., & Meterko, M. (2021). Evidence-based practice and patient-centered care: Doing both well. Health Care Management Review 46 (3), 174-184. https://doi.org/10.1097/HMR.0000000000000254

Göl, M., Hoşoğlu, Y., & Türkbeyler, İ. H. (Eds.). (2022). Management of the infectious diseases during palliative care. Revista da Associação Médica Brasileira 68 (9), 1127-1129. https://doi.org/10.1590/1806-9282.20220768

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC nursing 20 (1), 1-10. https://doi.org/10.1186/s12912-021-00684-2

Malenfant, S., Jaggi, P., Hayden, K. A., & Sinclair, S. (2022). Compassion in healthcare: An updated scoping review of the literature. BMC Palliative Care 21 https://doi.org/10.1186/s12904-022-00942-3

Malhi, R., & McElveen, J. (2021). Palliative Care of the Patient with Dementia. Delaware Journal of Public Health (4), 92-98. https://doi.org/10.32481/djph.2021.09.012

Mileski, M., Brooks, M., Topinka, J. B., Hamilton, G., Land, C., Mitchell, T., Mosley, B., & McClay, R. (2019). Alarming and/or Alerting Device Effectiveness in Reducing Falls in Long-Term Care (LTC) Facilities? A Systematic Review. Healthcare (1). https://doi.org/10.3390/healthcare7010051

Nursing and Midwifery Board of Australia (NMBA). (2023). Registered nurse standards. https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Palliative Care Australia. (2018). National Palliative Care Standards. https://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/02/PalliativeCare-National-Standards-2018_web-3.pdf

Rawlings, D., Devery, K., & Poole, N. (2019). Improving quality in hospital end-of-life care: honest communication, compassion and empathy. BMJ Open Quality (2), e000669. http://dx.doi.org/10.1136/bmjoq-2019-000669

Sinha, A., Deshwal, H., & Vashisht, R. (2021). End Of Life Evaluation And Management Of Pain. StatPearls https://www.ncbi.nlm.nih.gov/books/NBK568753/

Stalnikowicz, R., & Brezis, M. (2020). Meaningful shared decision-making: Complex process demanding cognitive and emotional skills. Journal of Evaluation in Clinical Practice 26 (2), 431-438. https://doi.org/10.1111/jep.13349

Victorian Government Department of Health. (2021). An interdisciplinary approach to caring. https://www.health.vic.gov.au/patient-care/an-interdisciplinary-approach-to-caring

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