Case study of acute mental status change in a 55-year-old female

¶ … Life Care

Difficult Situations as a Nurse Practitioner

The scenario for the nurse practitioner centers on Angela Smith and her family. Angela is a 55-year-old who suffered a stroke and admitted after neighbors noticed some really odd behaviors. The situation was further complicated when Angela suffered a respiratory arrest and required mechanical ventilation and after a second CT scan the team found that she bleed into the ventricles and brainstem which may have caused irreversible brain damage. Her condition is quite serious and there must be a decision made about how to proceed with the care for Angela. It is likely that she will need long-term ventilation and PEG and the neurological team suspects that the brain damage is irreversible.

The most difficult aspect to this scenario is that there is no advanced directive and the family is being indefensibly optimistic regarding the potential for recovery. In fact, the patient's family, her two daughters, have stated that they believe that God will provide a miracle cure and that their mother would somehow beat the odds with divine intervention. While it may be good to have a sense of optimism through a difficult period, it is also necessary to temper these impulses with objectivity. Furthermore, as a nurse practitioner, it is critical to provide the family with an objective interpretation of the patient's situation and have a conversation about the best way for the family to proceed under such trying circumstances. This analysis will identify some of the themes that a nurse practitioner will want to address in their conversations with the family and try to guide them towards a consensus about treatment goals and their options.

End of Life Care

This case deals with one of the most important aspects to nursing. End-of-life care encompasses a broad and sensitive aspect of the nursing practice in which the nurse must deal with death and the dying process. Generally, the family will be emotional throughout this transition and great care must be taken to comfort them in the grieving process. Yet it is equally important to be truthful and honest about the challenges that lie ahead for them. Mechanical ventilation and PEG has advantage of giving the patient more time to live when determining the likelihood of the patient's condition improving. However, the patient's odds for improvement are extremely low and by needlessly waiting she will suffer significantly. If there is not hope, prolonging the inevitable will lead to more pain for the patient.

Advanced directives are a set of requests that the patient has made beforehand in the event that they cannot speak for themselves. Nurses can use advanced directives to guide the treatment plan for the patient based on their plan that they have previously created before they lost the mental capacity to do so. Having set of advanced directives is the ideal means of deciding treatment options in such situations. Without advanced directives, it can complicate the situations because of the emotional factors that nurses must consider but also there are many legal considerations to be made.

Once the diagnosis of the terminal condition is made, the family can create a palliative and end-of-life plan that can guide the treatment plan that the team will use during the patient's last phase of life. Patients who are terminal should have the ability to die with dignity during the final stage of their life and sometimes families can strip their loved one's of this right based on emotional factors. The palliative care plan is a compressive plan that may include spiritual care, social workers, hospice care, and many other parties to address the patient's fears, provide support, and honor any final requests. Nurses play a critical role in helping to guide families through this process.

Cultural Competences

The patient's family in the case is deeply religious and their faith is apparently driving their decision about how to proceed with their mother's care. Although a nurse will probably not generally base a treatment plan recommendation on the patient experiencing a "miracle," it is important to recognize cultural differences in others to improve communications and the possibility of reaching consensus quickly. One model, Campinha-Bacote's model of cultural competence in health care delivery is defined as process of Cultural Competence in the Delivery of Healthcare Services (Campinha-Bacote, 2002). This model views cultural competence as the ongoing process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community) which is an ongoing process involves the integration of cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (Campinha-Bacote, 2002). Other sources also propose that it is best to define cultural competence as a nonlinear and dynamic process that is never ending and ever expanding in its quest for increasing knowledge and developing skills (Burchum, 2002).

Despite all the different approaches and models that are dedicated to cultural understanding, at the root of many of these are maintaining a sense of humility. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals (Tervalon & Murray-Garcia, 1998). The first objective when discussing the patient's options should be to remain cultural humble and build empathy with the family. Based on this foundation, the second objective would be to truly understand their position and beliefs. Once the family's positions are clear, the next objective would be to design a communication plan that is based on the family's individual concerns and issues related to a treatment plan. Having a level of humility can prevent professionals from making rash generalizations and position them better to engage in effective communications.