Running head: HEARTLAND HOMECARE AND HOSPICE 1 Heartland Homecare and Hospice Katie J. Wohlfert Lansing Community College, MI HEARTLAND HOMECARE AND HOSPICE 2 Heartland Homecare and Hospice According to Heartland home care's public website, their goal is "to create a positive difference every day, to make a personal connection, and to create memorable moments that will enrich your life" (HCR_ManorCare). Heartland home care understands that every patient has a unique set of needs and wishes and has the services to provide such care. Heartland provides disease management programs that will help individuals become educated about their illness and learn how to maintain their independence for longer. Heartland provides specialty services that include care for patients with heart and pulmonary illnesses, Parkinson's disease, those who have experienced a stroke, and care for patients who received a hip or knee replacement. Heartland home care is accredited by ACHC, the Accreditation Commission for Health Care ensuring patients receive the highest quality care. There are numerous benefits to home health care; patients recover faster, become more independent, manage their conditions better, and experience reduced anxiety, stress, and feelings of isolation. Heartland works with a team of highly trained caregivers from a variety of disciplines including physical, occupational, and speech therapy, social work, dieticians, and pharmacists to ensure every patient's needs are met. Personal History Julia Morale is a retired 65-year-old woman who received a diagnosis of stage four lung cancer four years ago. She smoked cigarettes for about 10 years but quit shortly after college. She underwent numerous rounds of chemotherapy and radiation to treat her cancer, however, now wishes to stop treatment. She is in search of home hospice care so that she can peacefully pass in her home surrounded by her loved ones. Julia's support includes her partner and primary caregiver Lucy, who has lived with Julia in their home, "home walkthrough 1", for about 20 HEARTLAND HOMECARE AND HOSPICE 3 years. Lucy is in support of Julia's decision to stop treatment and wishes to care for Julia in their home during her final weeks to months. Also, Julia's 42-year-old son Neil lives in the area and visits regularly. Neil wishes for his mother to try one more round of chemotherapy. However, Julia is certain of her decision to halt treatment of her lung cancer stating, "When I look back on my 65 years on this earth, I am happy and proud of what I've accomplished, I don't need any pity" (Julia Morales audio file). She explains that she tried all the treatments and even received complimentary treatment from a naturopath doctor but states her cancer has only gotten worse. She says that the treatments make her feel sick and she now experiences a lot of pain, fatigue, and increased weakness. Julia reiterates that she is most comfortable in her home and wishes to let go and pass naturally in the place and with the people she is most comfortable. Upon entering Julia and Lucy's home it is noted that it is quite cluttering and includes many antique-looking furniture and decorations. A biased statement regarding Julia's home condition would be "The patient's home is dirty and outdated". An unbiased way of describing Julia's home condition could be "It appears that the patient may need assistance with the upkeep of her home". Another biased statement regarding Julia and Lucy's living situation would be "The patient is lesbian". Assuming the patient's sexual orientation based on who she lives with is wrong, instead, it would be best for the nurse to describe what she knows unbiasedly by explaining "Julia and Lucy have lived in their home together for more than 20 years". Documenting information accurately and without bias is crucial for a nurse to formulate an appropriate assessment. Medications HEARTLAND HOMECARE AND HOSPICE 4 The medication regimen for a patient who is passing is quite simple; only medications that provide comfort are typically used. Table 1 lists the medications that this patient receives daily and as needed upon initial home hospice assessment. Table 2 lists the medications that Julia now receives after being on hospice for six weeks. Table 1: Patient’s Medication Regimen – Initial Hospice Assessment Generic/Trade Dose Expected/Unexpected Rationale/Indications Morphine sulfate controlled-release capsules (Avinza) 100mg every 6 hours orally as needed Higher dose Treat pain Docusate sodium (Colace) 100mg: 1-2 capsules orally as needed Usual dose Treat constipation Oxygen 2 liters/min via nasal cannula as needed Usual dose Maintain oxygen levels and promote comfort Table 2: Patient’s Medication Regimen – Six Weeks of Hospice Care Generic/Trade Dose Expected/Unexpected Rationale/Indications Fentanyl patch (Duragesic) 50 mcg/hr every 72 hours transdermal Usual dose Prevent pain Scopolamine patch (Maldemar) 1.5 mg every 72 hours transdermal Slightly higher dose Prevent nausea and vomiting HEARTLAND HOMECARE AND HOSPICE 5 Morphine sulfate (Roxanol) 50 mcg/hr oral liquid drops as needed every 2-4 hours for pain; not to exceed 100mg in 24 hours Higher dose Treat breakthrough pain Docusate sodium (Colace) 100mg: 1 -2 capsules orally as needed Usual dose Treat constipation Oxygen 2 liters/min via nasal cannula Usual dose Maintain oxygen levels and promote comfort Physical Assessment Upon initial home health assessment, Julia is an alert and oriented patient with stage four lung cancer. She has no known drug allergies, and her diet is as tolerated. She is currently mobile but will likely need assistance with activities of daily living as time progresses. Weeks later, the on-call hospice nurse assesses Julia. Julia has been on home care hospice for six weeks and is not expected to live much longer. She has been in bed and has not been communicating verbally for the past few days. She is being repositioned every two hours and her skin is intact. Julia's respiratory rate is eight breaths per minute and is irregular and has a heart rate around 80 beats per minute. Lucy is present and states that she believes Julia is comfortable and is aware that she will be passing very soon. Interventions The hospice nurse repositioned Julia so that she is now lying on her left side. Julia continues on two liters of oxygen via nasal cannula. Additionally, the nurse assessed Julia's vital signs and HEARTLAND HOMECARE AND HOSPICE 6 completed a pain assessment. The nurse is continuing to assess Julia for any outward signs of discomfort and is prepared to notify the physician in the event of Julia's passing. Evidence-Based Research The article "The Role of Nutritional Support for Cancer Patients in Palliative Care" analyzes how improved nutrition may increase life expectancy, improved quality of life, decrease hospital admissions for cancer patients in palliative care. The authors explain the importance of assessing nutritional deficiencies in all patients regardless of the use of anticancer medications or not. Such nutritional deficiencies are linked to "low-performance status, impaired quality of life (QoL), unplanned hospitalizations, and reduced survival" (Cotogni et al., 2021). Oral intake must be monitored regularly. For patients who experience inadequate oral intake dietary counseling and oral nutrition supplementation is recommended. To improve oral intake the first step is managing unpleasant symptoms like nausea, changes in taste and smell, and loss of appetite. Next, the focus is on finding and encouraging the intake of food that is better tolerated and optimizing energetic and protein intake. For those who still experience inadequate nutrition despite counseling, enteral nutrition or home parental nutrition is recommended. In conclusion, sufficient nutritional support leads to better patient outcomes and improved life expectancy for cancer patients in palliative care. Following Guidelines Upon initial assessment from the home health nurse regarding admission to hospice care the nurse documented very little concerning Julia's nutritional status. The only documentation noted is that at the time Julia was on a "diet at tolerated", meaning she can essentially eat anything she wants as long as it does not cause her an issue. I believe this nurse could have done HEARTLAND HOMECARE AND HOSPICE 7 a better assessment of Julia's nutrition. As explained in the paragraph above, poor nutrition may result in decreased life expectancy and quality of life which may have impacted Julia's final weeks to months. The nurse could have easily asked Julia a few simple questions about her favorite foods or what a usual day of eating looks like for her. These questions could have alerted the nurse of a possible nutritional deficit that could have been corrected and led to a better outcome for her. Barriers The potential barriers that could have impacted Julia's nutritional status include decreased access to healthy meals, difficulty eating due to pain or trouble swallowing, and/or loss of appetite due to medications. Julia does seem to have many support persons in her life; Neil visits regularly and Lucy lives with her. However, it's possible that if Neil isn't available and with Lucy's increased knee problems it may not be feasible for either Julia or Lucy to get to the grocery store and be able to prepare a healthy meal. There is no information about where the two live in proximity to a store but access the nutritionally dense meals could potentially be a challenge. As Julia's condition declines, she will likely continue to experience increased pain and possible trouble swallowing. Additionally, being in pain may impact her appetite and ability to feed herself. Having problems swallowing would cause her to have to make changes to her diet to foods possibly less appetizing, decreasing her nutrition. Lastly, medications like opioids can cause nausea, vomiting, constipation, dry mouth, and loss of appetite for some patients, all of which could influence Julia's nutritional status. Culture HEARTLAND HOMECARE AND HOSPICE 8 There are numerous differences as well as some similarities among cultures regarding viewing death, paying respects, and mourning. Some cultural practices reflect those of western practices. According to "Death Across Cultures" edited by Selin and Rakoff, In American Indian cultures, they also hold a wake ceremony where the family and community come together to share memories and help one another grieve. However, unlike in western cultures where there is importance on speaking highly of those that have passed and cherishing their memories, "In the Navajo tribe, members do not speak the name of the person after he or she is buried so as not to summon the person's spirit back to earth" (Selin & Rakoff, 2020, p. 340). In India, many believe in Hinduism which contains a belief in karma and reincarnation. Karma is the belief "that all deeds done by a living being will lead to the accumulation of good or bad karma and will have good or bad consequences" (Selin & Rakoff, 2020, p. 20). These consequences can be experienced in the present life or in a life to come. Not all beings are reborn and if they are it may be in several ways; "Living beings can be reborn as human beings, but also as animals, insects, or plants. They may go to heaven or hell or become a ghost or pitṛ (forefather). The deceased might obtain liberation from the cycle of death and rebirth. Such liberation is called Mukti or moksha" (Selin & Rakoff, 2020, p. 20). There are varying interpretations as to what moksha truly entails but for a Hindu it is the goal in every life to achieve. In western cultures, there is a belief in an afterlife which also reflects the person's choices on earth. If someone is a good person on earth and a believer in God then that person's afterlife would be a pleasant one in heaven. On the contrary, if one made poor choices, treated others badly, and did not believe in God then their afterlife would result in hell. Many cultural beliefs concerning death and dying have some similar aspects. However, there are key features concerning death and dying practices that are specific to that of a particular culture. HEARTLAND HOMECARE AND HOSPICE 9 Conclusion To conclude, Julia is prepared and ready to pass peacefully in her home after a long battle with lung cancer. Hospice agencies like Heartland Homecare and Hospice work to serve individuals and families like Julia's to make such a challenging decision and transition easier and with as little discomfort as possible. The nurse closely assessed Julia and implemented pain-relieving interventions. Included in the documentation of a patient's assessment and history should be factual and unbiased data. According to evidence-based research, a focus on a patient's nutrition can have a positive impact on a person's independence and quality of life; a detail that the home care nurse could have better assessed. Julia's nutrition may be impacted by her diagnosis and the decline in her physical health. As her condition declines there is more emphasis on comfort, coping, and mourning. Such topics are often determined by one's cultural beliefs which are highly variable amongst individuals and communities. HEARTLAND HOMECARE AND HOSPICE 10 References Cotogni, P., Stragliotto, S., Ossola, M., Collo, A., & Riso, S. (2021). The role of nutritional support for cancer patients in Palliative Care. Nutrients, 13(2), 306. https://doi.org/10.3390/nu13020306 HCR_ManorCare. (n.d.). Patient services - PROMEDICA home health serving Greater Lansing and Jackson. ProMedica Home Health. Retrieved February 3, 2022, from https://promedicahomehealth.org/find-an-agency/promedica-home-healthmason/?contentIdString=14479&contentNameString=Patient+Services National League for Nursing [NLN]. (2019) Advancing Care Excellence for Patients and Caregivers (ACES). http://www.nln.org/professional-development-programs/teachingresources/ace/unfolding-cases Selin, H., & Rakoff, R. M. (Eds.). (2020). Death across cultures: Death and dying in non western cultures. SPRINGER NATURE. Retrieved from https://link-springercom.lcc.idm.oclc.org/content/pdf/10.1007%2F978-3-030-18826-9.pdf.
