CASE STUDY FOUR
Mr Williams has a progressive neurological condition thought to be Progressive
supranuclear palsy and has become increasingly frail in a Nursing Home. He
can transfer with a zimmer frame and two carers although needs a standing hoist
to get back to bed. He uses bottles and is usually continent. His speech is
becoming difficult to understand but his cognition has been good. He has
expressed a wish to die with dignity and has declined artificial feeding tubes.
He was found on the floor three days ago and hoisted back to bed. He had some
pain in the right hip but there was no external rotation and the GP thought
unlikely a hip fracture and prescribed simple analgesia. He is now unable to
weight bear through that leg and the carers are concerned that there may be a
fracture.
Discuss possible next steps.
Notes from From PACE Document:
3.0 Main diagnosis:
Likely supranuclear palsy
Postural hypotension
3.4 Discussion summary regarding End of Life Care
A discussion took place with Mr Williams, his wife and the GP. He has previously expressed a wish to die with dignity in
the Nursing Home and has declined a PEG insertion. He understands that his prognosis is likely weeks to months and
without a feeding tube he is unlikely to meet his nutritional requirements. He has had several boughts of probable
aspiration pneumonia which have been treated in hospital with intravenous antibiotics. He would rather not go back to
hospital and community based treatment has been agreed. His wife and daughter are fully supportive. He has been
written up for end of life drugs on his chart should he need them. He has a DNAR in place.
3. 5 Spiritual needs of the patient at the end of life: Catholic. Has already had last rights when in hospital
but would wish a priest to be called if he is nearing the end of his life.
3.6 Preferred place of death
1
Nursing Home
Patients name
4.0 Assessment
Possible Developments specific to the person Action
Category
(see 4.1 below)
e.g.“chest infection”
(e.g.” Hospital”
or “Home”)
Comments
Please also see supplementary notes for
care
home staff (appendix 2)
1
Has had recurrent aspiration pneumonia
Home
If sounding chesty consider
glycopyronium to dry up secretions. If
feverish may benefit from oral
antibiotics.
2
Weight loss, increasing weakness and
lethargy
Home
All part of progressive disease.
3
Coughing when eating / drinking
Home
Encourage small amounts of pureed diet
and snacks regularly. Ideally while
sitting up out of bed. review by SALT
regarding appropriate thickening of
fluids.
4
At risk of pressure sores
Home
Monitor and ensure appropriate mattress
/ cushion.
5
Prone to dizziness on standing and has
fainted several times. Is on medication
to try and prevent further episodes
Home
Encourage fluid intake. If feels dizzy or
looks pale hoist back to bed
immediately. If faints in chair, slide to
floor and lift up legs.
6
Serious unexpected event eg
Fall and broken bone
Hospital
Hospital assessment and management of
pain
7
Patient has no signs of life.
Home
Has DNAR form in place
e.g. “oral antibiotics appropriate”
4.1Action categories
Intensive:Transfer to hospital for treatment if appropriate. Intubation, ventilation etc. should be considered.
Hospital:Transfer to hospital for treatment if appropriate.
Home:Treatment, medication and comfort measures with support from GP.
Comfort:Palliative Medication by subcutaneous, oral or per rectal route, positioning, wound care and other measures to
relieve suffering. Admission to hospital would be avoided unless comfort measures fail (e.g.: fractured neck of femur).
2
Patients name