Case Study on End-of-Life Care
Despite studies showing the majority of people would prefer to die outside the hospital setting, there are those who
find comfort in a more structured environment. Death in the hospital need not be a terrible or frightening event, as
evidence in this case study
Jake is a 90-years old male, diagnosed with end-stage dementia. He has been living in the home of his daughter and
son-in-law, who are retired in their 60s. His daughter is a power of attorney-health care representative. He has a
living will in which he indicates an intentional non-decision about artificially supplied nutrition and hydration. In the
past 2 years, he has become progressively weaker, unable to ambulate, unable to carry on a meaningful
conversation, and increasingly incontinent of bowel and bladder. He was admitted to the hospital with dehydration
and lethargy. A hydration Intra-venous has been started at 75 cc/hr. The physician has mentioned the possibility of a
G-tube for feedings in the family so wishes. The Certified Nursing Assistant reports Jake moaned when she turned
him during his bath, and he did not arouse when she attempted to feed him his breakfast.
You are the nurse caring for this patient. The daughter is in a quandary, stating “I don’t think Dad would want a tube
in his stomach, but he never told me that for sure. My brother thinks we should do it so dad doesn’t starve to death. I
tried to feed him his oatmeal this morning, but he seemed to choke. He’s been coughing when he eats for a couple of
months now.” Your physical assessment reveals crackles throughout the lung field, respiratory rate of 44 breath per
minute, edema to lower extremities, decreased level of consciousness, an irregular apical pulse, and a blood pressure
of 76/48
Questions:
1. What active symptoms affect the decision making for Jake?
Active symptoms that affect the decision making are the end-stage-dementia which is severe state in
which the patient requires help for everyday activities, because Jake is 60 years old and he needs more
care and help more than ever. He also has decreased level of consciousness. Age related factors like
weakness, unable to walk or initiate a conversation and has an increasing incontinent of bowel and
bladder. He is unable to eat properly because he chokes a lot when given food. And for his physical
assessment it was discovered that he has crackles throughout the lung field.
2. What quality-of-life issues might also be involved in the decision making?
The quality-of-life issues may involve are health, food quality, standard of living, safety.
3. How would you help Jake’s daughter understand the benefits and burdens of tube
feeding?
I would explain to the patient and to the family about the benefits of having the g-tube
insertion and what are the negative. First, G tubes can be great for the elderly who are
struggling to get enough calories or liquids especially those with terrible reflux and
vomiting, older adults who aspirate and inhale their food; and older adults who cannot or
will not eat for other reasons. The tube is a long-term solution to safely feed an older
adult, helping them gain weight and get all the calories and nutrients they need, to help
them be well-nourished throughout their life. G tubes can be managed at home by parents
or caregivers. As long as the tube area is kept clean and dry, care is relatively easy. Many
liquid medicines can be given through the tube so it doesn’t matter if your little one balks
at swallowing meds that means Jake may not need to swallow anymore. The cons that I
would explain to them are G tubes must be kept clean and dry to avoid infection or
complications. Jakes caregivers have to be vigilant about ensuring the tube site gets
cleaned. Jakes caregivers have to purchase medical supplies to manage the tube, which
may be expensive. Some items you might need include replacement G tubes every six
months, gauze and medical tape, extension sets, large syringes for bolus feeds, feeding
bags and feeding pump rental or purchase, protective belts and ointment to keep the
surgical site dry.
4. How would your hospital-based team address the son’s differing opinion?
Effective communication and explanation would be done to the patient’s family. Hearing out
their comments answering them respectfully and address assurance of the patients benefit and
ensure trust and care for the patient and his family for better health relationship.
5. What treatment would be appropriate for Jake’s pain? His shortness of breath? The
crackles in his lungs?
Teach the caregiver the proper ways of coughing and breathing, which is to take a deep breath,
hold for 2 seconds, and cough two or three times in succession. Educate the patients caregiver on
the optimal positioning (sitting position), the use of pillow or hand splints when coughing. A
doctor may prescribe diuretics which are medications that are developed to reduce levels of fluid
in the lungs and may also require antibiotics if the crackles have resulted from bacterial
pneumonia or bronchitis. Doctors may also prescribe steroids to decrease inflammation in the
lungs. Inhaled steroids can be given to reduce airway inflammation, bronchodilators can also be
given to help relax and open Jakes airways. Oxygen therapy may be recommended to help
breathe better.
