Patient Falls and End of Life Care

Q1. Given the two pieces of evidence, what are the key clinical questions to consider when caring for this patient?

First, given the patient’s fragile health, age, and that the care given to the patient is primarily palliative, there is the need to ease pain, discomfort, and pressure ulcers. There is a high level of quality evidence to suggest that using higher-specification foam mattresses can reduce the risk of pressure ulcers and thus improve the patient’s current quality of life. Second, although lower quality evidence is available, there is a suggestion that reducing the use of urinary catheters is preferable, and that difficulties in managing incontinence should not justify automatically resorting to this device to deal with the patient’s issues.

Q2. If you are going to take a patient-centered approach to caring for this patient, what further information do you need?

One accepted definition of patient-centered care is care which “honors patients’ preferences, needs, and values; applies a biopsychosocial perspective rather than a purely biomedical perspective; and forges a strong partnership between patient and clinician” (Greene et al., 2012, par.2). Asking the patient about her feelings regarding her care, including her comfort level in bed, her pain threshold, and her personal feelings about her dignity regarding her toileting situation, is essential.

Q3. What questions would you ask of the patient and family? Of the physician?

Asking the patient how she feels most comfortable positioned in bed, her end-of-life care plans, and also her pain threshold and management are all critical. It is also important to ask the family about how loss of mobility and pain has affected the patient’s quality of life. If they are her primary caregivers, investigating how she fell, how to prevent this in the future, and how to improve her toileting situation (perhaps with additional nursing support) may be useful. Speaking to the physician about the risks regarding the patient’s pain medications (if they need to be increased), life expectancy, and how to decrease discomfort without increased risk of side effects from increased doses is likewise critical.

Q4. If the evidence of meaning existed, what questions related to the meaning of a patient’s experience would you ask?

According to Oben (2020), “patient experience is recognized as an independent dimension of health-care quality, along with clinical effectiveness and patient safety” (par.2). The patient has experienced significant loss of mobility and dignity, as well as is experiencing significant pain. The patient should, to the maximum extent of which she is capable, offer feedback about her personal experience, and how she would like to maximize the quality of her life safely (minimizing falls, for example, while still moving enough to reduce pressure ulcer risk).

Q5. What are the areas of ambiguity related to clinical decisions that need to be made relative to the two areas of evidence?

There is little ambiguity regarding the patient’s need for a better mattress to reduce pressure ulcers, or the need to maximize mobility in bed while minimizing the patient’s risk of falls. There is ambiguity regarding the use of a catheter, although the weak evidence-based literature, combined with the patient’s fall risk, suggests that increasing assistance to the patient when moving independently without the use of a catheter is likely to be preferable.

Q6. What are the potential conflicts between the decision that the evidence would point to and what the patient may desire?

The patient may desire to have greater mobility, despite the risk of falls. The patient may also express a desire to end her suffering, or more pain medication than is safe. Conversely, some patients are reluctant to move as much as is necessary to reduce pressure ulcer risk, although that the patient experienced a significant fall, despite her fragility, suggests she is still desirous of some physical autonomy.