Assessment-and-Treatment-Plan-Paper

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Assessment & Treatment Plan Paper

The following is a case scenario of a hospice patient and family. After reviewing the following case, write a minimum of three-page paper (excluding title and reference page) providing assessment and treatment plan for the patient and primary caregiver on each issue listed on the table (11 issues).

The following is how you should organize the paper! It is very important to follow the instruction.

The paper should be organized by 11 issues provided below; use first level headings as the 11 issues. Under each issue, discuss assessment and treatment plan for the patient and primary caregiver. The paper should be formatted in accordance with APA 6th ed. style.

CASE

Mary, 70 year old seriously ill patient

David, 50 year old son, lives with mother, travels a lot

Michael, 45 year old son, lives with mother much of time

Susan, 40 year old daughter, lives in Florida

Dorothy, 35 year old daughter, lives locally, has been designated as the primary caregiver.

The patient, a Caucasian protestant widow, is diagnosed with end stage chronic obstructive pulmonary disease and has a history of asthma. She has shortness of breath with minimal exertion, and uses oxygen most of the time. Two years ago she was on a ventilator after respiratory arrest, but now has a living will that states her wish for comfort care only – she doesn’t want any death delaying procedures. She also has a Do Not Resuscitate Order, and has designated her son David as power of attorney for health care decisions and finances. Her physician predicts she has six months or less to live, according to concrete guidelines developed for determining prognosis.

Mary lives with her son David, who travels a lot and isn’t home much. Her other son Michael also lives with her much of the time. The patient feels that she lives in an unsafe neighborhood, and keeps a gun in the house for that reason. The Dept. of Aging has provided an aide to do housework 2 hours per week. She has two daughters, one is Susan in Florida whom she doesn’t see very often. The other daughter, Dorothy, lives close by, but works, and visits on Mondays. Dorothy is the primary caregiver and has slowly been taking over her mother’s care and responsibilities. Mary’s husband died many years ago when he was in his 20’s, and she appears to have coped well with this loss. She was divorced due to her alcoholism. She raised four children alone, and now enjoys her grandchildren. She was an LPN, but became disabled and retired on Social Security Disability at age 62. She has Medicare and the Medicare Hospice Benefit.

Her children say that due to her alcoholism, she was not there for them as children. The patient complains that her son David insults her, but Dorothy reported that the patient has 8 always insulted David. Dorothy is resentful about her mother’s abuse toward her children and their father. Dorothy also complains of a lack of support from her siblings, who leave the care of the mother to her. She is glad, though, that her sister Susan has been looking into hospices in Florida.

Mary states that she wants to stay at home and die in her own bed, but has been afraid she will panic when she gets short of breath. She has had difficulty with the idea of calling hospice instead of 911 at times like this. She has expected that she would want to go to the hospital, and would be afraid to be home alone during respiratory arrest. Her family also is not used to the hospice philosophy of dying at home. Dorothy was able to make an agreement with hospice staff, though, that she would call the hospice nurse first, before calling 911. If the nurse is not able to be there immediately, and she is really afraid her mother will choke to death, she will call 911.

Mary has portable oxygen tanks, a wheelchair, bedside commode, and a home alert system. She states that her home is arranged the way she wants it. She is obese and has diabetes. She takes medications for shortness of breath and anxiety. She says she has been shaky on her feet lately, feeling “hyper” from all the meds, and has difficulty breathing. Staff is concerned that she smokes. She is concerned about finances. She has many unpaid medical bills, and wants to be able to keep her house so that her children can sell it to pay for her funeral.

Mary needs help with bathing, dressing, feeding, transfers from bed to wheelchair, and ambulation to the commode. She complains that her children will assume no responsibility for her. She wants to be able to get out of the house for outings. She went to a nursing home temporarily in 2/07, and did well there according to staff, but did not consider it good quality of life and would not stay. She does not want to return to the nursing home. Mary is fearful of thinking about death, but is capable of open discussion of thoughts and feelings. She has discussed dying a peaceful death in bed. Funeral plans have been discussed – patient knows funeral home, wants cremation, wants private memorial service only.

She copes through focusing on the positives, and staying involved with her children’s lives. She does worry about leaving her children behind. Although she takes medication for anxiety, she has coped fairly well and denies any thoughts of ending her life.

She felt close to God the last time she was sick. She says she is not religious, though, and has no belief in life after death. Her philosophy of life has been to have fun all her life. Her life has been carefree, she has partied, drunk alcohol, she says she has basically done whatever she wanted in her life. Her one regret is that she wishes she could have been a better mother. She recognizes that she did the best she could – has forgiven herself.

When Dorothy was asked about her beliefs, she stated that she no longer believes in God. If there was a God, He wouldn’t have let her be abused, let her father die so young, and let her mother die in this painful way.

ISSUE

DESCRIPTION

TASKS TO BE ACCOMPLISHED

1.End-of-life decisions consistent with their religious and cultural norms

Patient self-determination is a key aspect of hospice philosophy and an important social work value. The ability to make one’s own choice promotes self-determination.

Legal and ethical questions may be involved, as well as cultural and religious beliefs and preferences regarding end-of life care.

Social worker discusses end-of-life preferences with clients, advocates for patient self-determination with team.

Helps clarify values, assesses whether there are concerns. Refers to religious leaders for specific religious questions. Provides resources if needed. Develops practice approaches and policies that make room for differing beliefs and preferences, leads the way in developing cultural competence.

2. Patient thoughts of suicide or wanting to hasten death

Practice wisdom suggests that suicidal ideation, request for assisted suicide, or a suicide attempt may be an issue for a patient. Often unmet needs, death anxiety, a need to control the circumstances of death, or other emotional distress create a desire to hasten death.

Meeting the needs leading to suicidal ideation may address the issue: counseling regarding complicated anticipatory grief, pain and symptom control, obtaining resources to support the family in caregiving, addressing financial needs, advocating for patient self-determination.

3. Anxiety about death

Elements of death anxiety are fear of loneliness, fear of personal extinction, fear of suffering, and fear of the unknown.1 Much of this entails questions about the afterlife, thus death anxiety may overlap with spiritual issues. Death anxiety leads to lack of awareness of prognosis, or denial.

Allow patient to openly discuss spiritual issues, clarify own beliefs. Spirituality and social support reduce death anxiety. Coming to a sense that one’s own life has been valuable as it is, and a sense of oneness with all may decrease death anxiety.

4. Preferences about environment (e.g., pets, own bed, etc.)

Patient self-determination regarding preferences about the environment is an important part of hospice philosophy. Preferences may include where the bed is located, the desire for pets in the room, preferences about who visits and when, having treasured objects close by, music, books, etc.

Preferences should be elicited and explored. Social workers act as advocates for patient preferences with family members and the hospice and palliative care team.

5. Social support

Informal and formal support, patient’s environment, family, significant others, friends, and resources. Better social support predicts a preference for home hospice care. Spirituality increases social support.

Help promote open discussions, remove barriers to intimacy and help maintain intimacy. Provide insight into family strength, needs, and adjustment to terminality.

6. Financial resources

A major concern is the adequacy of health insurance to cover end of life care expenses, medications, medical equipment. Other issues may be a need for caregivers in the home and a loss of income due to the illness.

Assess how well clients’ financial resources meet their needs; referring to formal supports when needed.

7. Safety issues

Client safety becomes an issue when activities of daily living become more difficult. Clients who live alone, or with family members in denial about the patient’s condition, may be in danger of injury in the home.

Assess client safety and obtain informal and formal supports as needed. Provide counseling if family denial is leading to an unsafe situation.

8. Comfort issues

Patient’s physical comfort is influenced by the psychosocial and spiritual dimensions. Increased social work services are associated with decreased pain control costs.

Assess for non-physical pain control interventions, including relaxation and meditation techniques.

9. Complicated anticipatory grief (e.g., guilt, depression, etc.)

Some factors interfere with resolution of anticipatory grief.

These include guilt about one’s past actions, anger and depression in response to the terminal illness, spiritual questions. Patient cannot die in peace.

Assess patient’s beliefs and concerns, provide counseling, opportunities to resolve conflicts or ask for forgiveness, refer to religious leaders for specifically religious questions.

10. Awareness of prognosis

Lack of awareness of terminality although being informed of it.

Denial is a way of coping with death anxiety, but one cannot accomplish tasks of dying while in denial. Denial compromises patient self-determination. Denial of patient’s terminality by primary caregiver can lead to unsafe home conditions or lack of support for patient end-of-life decisions.

Avoid confronting the patient and stripping them of their denial. A little bit of denial is considered positive. Intervene when harmful situations develop. Patients go in and out of denial, and will bring up questions about their terminality during periods when they are ready to address it. Death anxiety leads to denial; reducing death anxiety by addressing spirituality will reduce denial.

11. Spirituality (e.g., higher purpose in life, sense of connection with all)

Different concept from religion. Religion has to do with a certain belief system, affiliating with an organized religion. Spirituality applies to everyone, regardless of religious or non-religious path. Finding meaning and purpose in life, sense of connection with all (nature, others, God, ultimate reality, according to one’s own belief system). Spirituality was the most frequently addressed issue in home visits to clients in a study of a Midwestern hospice. Addressed by all team members; refer to appropriate chaplain for specifically religious issues.

Help patient discover a higher purpose in life and a sense of connection or oneness with all. Encourage patient to resolve spiritual issues connected with the meaning of life and suffering, unfinished business, clarifying his/her belief system, relationship with the Ultimate, isolation, and transpersonal experiences. These may include reconciling with someone, praying for forgiveness, or forgiving oneself and asking for forgiveness from another.

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