CASE STUDY THREE
83 year old man now resident in a nursing home following a long hospital
admission initially presenting from home following a hip fracture. Now transfers
with a rotunda and two carers, has a long term catheter and is unable always to
express his needs due to vascular dementia and previous strokes. He usually
enjoys company and his food! The carers are concerned as one of his legs had
become very swollen.
Discuss possible next steps.
Notes from From PACE Document:
3.0 Main diagnosis:
Vascular dementia
Hip fracture
Ischaemic heart disease and atrial fibrillation
Diabetes on oral medication
Benign prostatic hypertrophy requiring catheter for outflow obstruction
Osteoarthritis
3.4 Discussion summary regarding End of Life Care
Discussion took place with Mr Robert’s son during a discharge planning meeting from hospital as with his increased care
needs it was recognised that he would be unable to return home and would need nursing home placement. Mr Roberts
lacked capacity to take part in health and welfare decisions. With his immobility, increasing frailty, recurrent in-hospital
infections and high care needs, it is thought that Mr Roberts is likely approaching the end of his life. His family were in
agreement that once he was settled in a nursing home that all effort should be made to manage his care needs in the
community.
3. 5 Spiritual needs of the patient at the end of life: Nil specific
3.6 Preferred place of death
1
Nursing Home
Patients name
4.0 Assessment
Possible Developments specific to the person Action Category Comments
(see 4.1 below) Please also see supplementary notes for
care
e.g.“chest infection”
(e.g.” Hospital” home staff (appendix 2)
or “Home”)
e.g. “oral antibiotics appropriate”
1
Mr Roberts is at high risk of developing Home
chest infections
Consider oral antibiotics if feverish or
unwell. Morphine may help with
symptomatic breathlessness
2
Mr Roberts has had recurrent urinary
tract infections associated with a long
term catheter
If becomes feverish, oral antibiotics
maybe helpful. Try to keep well
hydrated. Catheter needs changing every
six weeks.
3
Breathlessness due to heart failure. This Home
is usually associated with worsening
ankle swelling.
May need to ask GP to review his
medication.
4
Poor blood sugar control maybe result
from infection
Home
Ask GP to review medication.
5
Serious unexpected event eg
Fall and broken bone
Hospital
Hospital assessment and management of
pain
6
Has had several small strokes affecting
speech and memory. At risk of having
further stroke
Home and call
GP to consider
hospital
Can be managed at home and kept
comfortable until assessed by GP.
7
Patient has no signs of life.
Home
Has DNAR form in place
Home
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