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A critique on the care of a patient in a case study.

Institution affiliation

Student’s name
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In Australia, advanced care planning (ACP) refers to discussing the treatment choices and
achievable care goals at the end of life. This is done with the consideration of patient's wishes
about medical care in case they cannot be engaged in such discussions. An advanced directive is
an oral or written statement that illustrates the patient's wishes on future health care and personal
care. Advance directives are legally binding in Australia and become effective as soon as
patients cannot make decisions by themselves (Poveda‐Moral at. al., 2021).Advance care
planning (ACP) is important as it assists the patients to die according to their outlined wishes,
gives their family time to prepare for the patient's death and helps to avoid inappropriate
interventions at the end of life (Department of health, 2014). This paper entails a critical analysis
on how end of life care was carried out on a patient by the name Tyler James Morton. It will
focus on whether the clinical practice guidelines and standards concerning end life care of a
patient were followed or not, thereby having both positive and negative aspects of the care
provided.

In Tyler's care, he was issued with an advanced care directive following his diagnosis in
which he outlined his wishes and needs. This was essential in ensuring that his needs and desires
were clearly outlined in case he was unable to communicate later on. According to the Australian
Government Department of Health (2022), advanced care directives have been shown to have
many benefits in end of life care management. These include minimizing unnecessary
interventions such as ventilation, cardiopulmonary resuscitation (CPR) and tracheotomy as
outlined in Tyler's case. Advance care directives also increase the possibility of care as per the
patient's wishes, for instance having family present at the time of death and being visited by a
minister or a priest. It also increases bereavement outcomes for the family however this was not
reflected in the case of Tyler's care (Buck et. al., 2019). In addition, it helps in increasing the
patient sense of preparedness for death and decreases the burden of making decisions for the
family (Registered Nurse in Palliative Care).

As per the care provided to Tyler Morton, the family was not involved in his advanced
care planning. Upon Taylor's diagnosis, a family meeting was not conducted. This is contrary to
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the practice guideline for the care of dying patient. According to palliative care Australia (2021),
family involvement is critical when offering any advanced care to any dying patient and the
discussions with the family should be documented in the medical notes. The conversation with
the family should entail the prognosis of the patient, what to expect as the patient deteriorates
and explain on how symptoms such pain will be managed (Hemsley et. al., 2019). In addition,
the family should also be engaged in determining whether the ongoing treatment should be
continued or not with the assistance of medical staff. Also the family should be involved in
establishing whether the patient's end of life wishes were earlier documented and followed
accordingly. Moreover, the family should document to what extent they wish to be involved in
the care of the dying patient and how they would like to be contacted in case of emergency
(Macauley, 2018). Since no meeting was held with Tyler's family, the outlined issues were not
met on the patient thus undermining his care towards the end of life.

Tyler Morton's wishes were not advocated for by the nursing staff thus curtailing their
fulfillment. According to his advanced care directive, he wanted his family with him at the end
of life and also did not to die in his family but in a hospice. However, this was not actioned.
According to advanced practice (Nursing) standards and requirements, standard 4 outlines that it
is the responsibility of registered nurse to standard up for the patient's wishes, beliefs, and rights.
However, this was not the case in the care provided to Taylor. As stated in the standard 4.4, the
registered nurse should utilize information technology in documenting procedures followed in
the advanced nursing care (Jones, Curtis & Shaban, 2020). Contrary to this guideline
documentation was incomplete and not detailed, portraying that there was failure in the
provision of appropriate care to Tyler James Morton.

During the provision of end of life care to Tyler, the follow up was poor, as demonstrated
in the case where he was wheezing and inappropriate actions were taken, and his deterioration
should have been assessed and realized earlier. Also the medical officer noted that he was in an
unstable state; however no action was taken—all these hindered achievement of his advanced
care directive needs. According o the Australian Commission on Safety and Quality in Health
Care (2014), standard 2, the registered advanced care nurse should utilize and apply their
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advanced skills and knowledge in patient care. The guideline under standard 2.4 further states
that the nursing staff should have comprehensive knowledge on pharmacological actions to
manage any symptoms as arises in the patient (Jones, Curtis & Shaban, 2020). This guideline
was clearly not applied in Tyler's case as symptoms such as wheezing were noted, and no action
was taken to manage it. Also, nursing staff did not fully their skills in assessing his deterioration
in time to optimize his care (Cheluvappa & Selvendran, 2022). In as much as they knew his
wishes as outlined in the advanced care directive, little effort was made towards ensuring that
they were fulfilled.

Tyler's Deterioration should have been assessed and realized earlier which could have
helped Tyler achieve his advanced care directive wishes. According to National Safety and
Quality Health Service, recognizing and responding to acute deterioration is key in end of life
care. The nursing staff should promptly detect acute deterioration in the patients thereby
providing timely and appropriate care to the patient. According to Australian Commission on
Safety and Quality in Health Care (2013), acute deterioration involves physiological changes as
well as mental and cognition changes of the patient. The care provided to Tyler was not up to
this standard since his deterioration was not timely and promptly recognized to optimize his
advanced care. If this was done in a prompt and timely manner he could have been taken to a
hospice as per his advanced care directive.

Grief support and bereavement was not mentioned anywhere in the advanced care plan.
Tyler's wife was in denial and struggling while little to no interventions were done. The process
of dying was also not mentioned, which could have aided the family, especially the wife is
coming to terms with the forthcoming death of her husband. His children were not involved in
their father's dying process which attributed to their complex grief. As per the clinical practice
guidelines, the family should be prepared when death is imminent. According to the Australian
Medical Association (2007), it is the responsibility of the medical team to provide necessary
support to the family. To make the family feel heard and cared for in the provision of care to the
patient. This ensures the family is prepared and is protected from possible distress. It is important
to assess a family's need for support and make referrals where necessary such as to a grief
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counselor. In accordance to the clinical practice guidelines, it is the responsibility of the nursing
staff to explain the process of dying of the patient to the family and manage the moment of death
and its aftermath. The struggle and grief experienced was largely due to the failure of medical
personnel in provision of the support needed as per care of the dying person- health professional
guidelines( Boyd & Murray ,2010).

During Tyler's care pain assessment was completed however not formally with the
appropriate tools. According to palliative care outcome collaboration (PCOC), the assessment of
pain on dying patient should be carried out using five tools. These tools are palliative care phase,
system assessment scale (SAS), palliative care problem severity scale (PCPSS), Australia-
modified karnofsky performance status (AKPS) scale and resource utilization group- Activities
daily living (RUG-ADL). These are important in palliative care as they are easy to use in routine
care and also give exact results in clinical settings. They are also accurate in showing the
characteristics and needs of patients ( O’Mahony et.al., 2020). The medical team involved in
Tyler's should have utilized these PCOC tools in assessing his pain to optimize his care.

Concerning the advanced care plan in Australia, there are limitations in the
provision of care to the dying patients. These include patient's change in their needs and wishes
as per the advanced care directive, and therefore there is a need to update it regularly. There
exists confusion among the health professionals due to the existence of multiple forms and
varying legislation for documenting ACP discussions in different states in Australia. Health care
professionals in Australia lack confidence having ACP discussions, lack knowledge about ACP
processes and the medical legal aspect in honoring patients wishes (Morrison, Meier & Arnold,
2021). In addition, there is a lack of electronic recording and fragmentation of information
thereby the information may not be available in case of emergencies, and patient's wishes may
not be honored (Mitchell et. al., 2021).

In conclusion, Tyler's end of life care was not optimal as per clinical practice guidelines,
the practice guideline on end of life care, national safety and quality health service standard and
others. According to the afore mentioned guidelines and standards, there was failure in Tyler's
end of life care such as failure to recognize and respond to deterioration in a timely manner,
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failure of nursing staff to advocate for care, failure to assess his pain using appropriate PCOC
tools, failure to conduct a family meeting upon his diagnosis, failure to explain the process of
dying and offering grief support. Advanced care directive is essential for a palliative patient and
helps to ensure that patient's wishes and needs are outlined in case they are unable to be engaged
in discussions concerning their end of life care. Although Tyler James Morton had outlined his
wishes and needs on the advanced care directive they were not all met. These include dying in
hospice and having his entire family with him which were not actioned as stated. The advanced
care planning in Australia is limited due to regular changes on patients wishes and needs which
need to be regularly updated, lack of confidence and time constraints of health care professionals
in conducting ACP discussions and lack electronic recording of ACP discussions. The advanced
care plan can be improved by overcoming these limitations and by ensuring health care workers
follow the set guidelines and standards.

REFERENCES

Australian Commission on Safety and Quality in Health Care (2014) National Consensus
Statement: Essential Elements for Safe High-Quality End-of-Life Care in Acute Hospitals-
Consultation draft. Sydney: ACSQHC
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Australian Commission on Safety and Quality in Health Care. (2013) Safety and quality of end-
of-life care in acute hospitals: A background paper. Sydney: ACSQHC

Australian Government Department of Health. (2022). Advance Care Directive.

https://www.health.gov.au/health-topics/palliative-care/planning-your-palliative-care/
advancecare-directive

Australian Medical Association (2007) Position statement on the role of the medical practitioner
in end of life care. Retrieved October 17, 2022, from https://ama.com.au/position-statement/role-
medical-practitioner-end-lifecare-2007

Boyd K. & Murray S. (2010) Recognising and managing key transitions in end of life care,
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Buck, K., Detering, K., Sellars, M., Sinclair, C., White, B. P., Kelly, H., & Nolte, L. (2019).
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Cheluvappa, R., & Selvendran, S. (2022). Palliative Care Nursing in Australia and the Role of
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Department of Health (2014) Advance care planning: have the conversation. A strategy for
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Jones, T., Curtis, K., & Shaban, R. Z. (2020). Academic and professional characteristics of
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Macauley, R. C. (2018). Ethics in palliative care: A complete guide. Oxford University Press.

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