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Palliative Care Management

Situation: An adolescent with incurable cancer had been hospitalized for three weeks, spending the past eight days in the intensive care unit. His physical deterioration and suffering created anguish in his father and in the health care team. The attending physician discussed, with the father, the likelihood of the adolescent having a cardiac arrest. He described the actions the team would take for a full resuscitation as well as the varying levels of resuscitation approved by the treatment setting (which included a do-not-resuscitate option) and asked the father to express his preferences regarding resuscitation. The father initially chose the do-not-resuscitate status for his son and completed all of the official paperwork to implement that decision. During the next 12 hours, the father actively solicited from nursing, allied health and medical staff their definitions of do-not-resuscitate. He then contacted the attending physician to rescind his decision, choosing instead to have a full resuscitation order in place. He explained his decision change, "When I saw that the staff did not all define resuscitation in the same way, I decided that I would not leave that in their hands. I am my son's father and I will be his father to the end." This new decision was enacted and over the next four days, the young patient showed clear signs of dying. His father stayed with him in the intensive care unit and witnessed the changes in his son's physical appearance. He began commenting on those changes and on his son's obvious suffering. Within two hours of his son's death, the father told the nurse that he did not want his son to be resuscitated. This information was immediately conveyed to the health care team and a brief discussion with the physician, father, and nurse was convened to affirm this decision.

Questions
1.Define/describe do-not-resuscitate status? What has contributed to this definition? How would you work with the father in describing and deciding on the various resuscitation options? How do you imagine the description of what occurs at the varying levels of resuscitation might effect the father's decision? What communication skills could have been employed to facilitate this discussion/decision-making?

2. What constituted suffering for the son? The father?

3.What members of the interdisciplinary health care team do you think could participate in this case—i.e. members that you see as having a contribution unique to this case?

4. As a member of the health care team, what would be the source of any personal distress or anguish in this case?

5. As a health practitioner, think about what the father meant when he rescinded the DNR stating, "I am my son's father and I will be his father to the end." How might the introduction of palliative care and/or hospice at an earlier point in the son's illness have changed this story for the son, father, and health care team?

Solution Preview

1. Do not resuscitate status is essentially the status that a patient is placed upon due to the wishes of the patient or the individual that has power of attorney in respect to that patient. This is essentially a status in which the patient or the individual that has power of attorney for that patient has formally requests(written), that the hospital staff not attempt CPR or other resuscitation techniques in order to resuscitate that individual in the event that their heart stops or that they stop breathing. What has contributed to these definition is the fact that this status has previously received negative connotations, as well as there being lawsuits filed against hospitals and their staff by other family members etc. This has resulted in an exact definition of this status so that the hospital and its staff are legally protected upon basically allowing an individual to ...

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