Case Study 1

Mr. Wiggins is a 78-year-old African American male with chronic kidney disease, which requires dialysis. The etiology of his renal disease was multifactorial—long-standing uncontrolled HTN and DM nephropathy. He has been on hemodialysis for the past 10 years and has done relatively well. Four weeks ago, he had a major CVA and is minimally responsive. His condition is not expected to change, and the family is having a difficult time with his recent health changes. Advanced directives were discussed with them, and his wife is a durable power of attorney for his health care. The wife hates to see her husband this way and understands this is not how he would want to go on, but their children and many of the family members (his brothers and sisters) think the patient will return to himself. They want everything done in terms of life support measures—full code status. His family wanted a feeding tube placed, and he is now receiving 24-hour tube feedings. You are the NP caring for Mr. Wiggins. You have known and cared for him and his wife for several years. The wife pulls you aside, shares her dilemma, and asks you to make the decision regarding continuing medical care/support for her husband. How will you respond?

Case Study 2

Mrs. Adams is a 96-year-old Caucasian female who has recently been diagnosed with colon cancer. She was admitted to the hospitalist service through the ED with dehydration and rectal bleeding. The bleeding resolved, and she received 2 units of PRBs and fluid/electrolyte replacement. She is stable and ready to be discharged home.

Mrs. Adams is in remarkably good health, and other than arthritis and mild HTN, she has no significant medical or surgical history. She is able to carry out all of her essential daily living activities. She pays her own bills, is competent, and has good functional abilities. She was driving up until last year. Now, she has neighbor’s assist with weekly shopping and transportation to church. Her sensory, functional, and cogitative abilities were evaluated this admission and remain intact. She has been offered palliative surgical intervention, but deferred all treatment. Her only son is in agreement with his mother’s decision. Her parents and husband are deceased. You have been asked to obtain advanced directives. What will your discharge treatment plan be for Mrs. Adams?

Case Study 3

Mr. Pierce is an 82-year-old East Indian male, recently widowed 6 months ago. He fractured his left hip 2 months ago attempting to climb his backyard fence to get his cat out of a tree. His children live internationally and have been taking turns caring for him. His eldest son brought him in through the ED last night because Mr. Pierce started having shortness of breath and his lips turned blue. In addition, his son noticed his left leg was very swollen compared to the right. The ED nurse practitioner ordered a thin cut cat scan (CT) with pulmonary embolism (PE) protocol and deep vein thrombosis (DVT) scan. Mr. Pierce has a large DVT that is obstructing circulation and multiple pulmonary emboli. His condition is life threatening and he is only expected to live a few weeks. He has a living will and advanced directives and has requested to be able to die in the comfort of his home. “I hate hospitals.” You have been consulted at the patient and family’s request because you are Mr. Pierce’s primary care provider. What additional services can be offered to ensure his care/comfort at home and to give him peace of mind regarding his estate?

To prepare:

• Select one of the three case studies. Reflect on the provided patient information.
• Think about potential outcomes for the patient in the case study you selected.
• Consider how care, treatment, and/or support might be facilitated for the patient. Reflect on how you might also address the needs of the family.

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