Course Objectives being assessed:
4. Explain the role of advanced care planning in contemporary society.
5. Explore innovative practices to support the older person living with chronic and complex conditions and their families/support networks.

CASE STUDY: This assignment is based on the case study of Gavin outlined below:

You are working in ED when Gavin (aged 60) arrives at the ED via ambulance, experiencing moderate dyspnoea, lethargy and decreased responsiveness (GCS 13-14). He was initially saturating in the high 80’s when picked up by the ambulance, and with high flow oxygen was reaching 93-94% only. An ECG is conducted and is reviewed by the medical officer in charge of the shift. Regular observations are taken and Gavin also has IV antibiotics administered as required. He is observed closely to ascertain whether the treatment being conducted is effective.

Gavin’s saturation level slowly decreases and after a chest x-ray it is discovered that he has a poor prognosis given his diagnosis of severe pneumonia compounded by his other conditions: lung metastases and co-morbidities related to COPD.

Gavin has a long history of chain smoking and he also has been diagnosed with Schizoaffective disorder. He has also not taken good care of himself for many years and he has previously discharged himself numerous times refusing treatment for other serious illnesses. He has lost contact with his family many years ago and subsequently a guardian was appointed for him under the SA Guardianship and Administration Act 1993, to make health, accommodation and lifestyle decisions for him.

The medical team is discussing his case and a high priority is the need for his guardian to be contacted so the team can be directed as to the type care that Gavin would choose at this time.

The team decide to continue with the current treatment while they wait for a phone-call from the guardian. In the meantime they decide to set up a Bi-Pap machine for Gavin.
The Bi-Pap has been in place for 2 hours and Gavin is saying continually that he does not want the mask and is constantly trying to remove it. The team is now meeting to determine whether or not Gavin condition is such that intubation is indicated. The team all agree that given the current state of his health he is not a good candidate for intubation and even if he receive ongoing Bi-Pap in the High Dependency Unit, he may not have much longer to live.
One hour later, the patient’s guardian has made contact and confirmed that Gavin has expressed that he does not want any medical intervention demonstrated by Gavin’s premature discharges from hospital. In consultation with the guardian, the medical team decide that further active measures will cease as indicated by Gavin. The Bi-Pap mask is removed and O2 is applied by nasal cannula. Gavin’s oxygen saturation progressively deteriorates over the next 20-30 minutes and he dies an hour after the Bi-Pap mask was removed. You are with him during the whole episode.

Your reaction to Gavin’s situation is that you can only think that he had no family or friends with him and no one in the team offered comfort other than analgesia. You are not certain that Gavin knew his prognosis or was aware of his impending death. You wish you had offered Gavin something more, for example a chaplain or a counsellor to stay with him and you wish you had held his hand and comforted him more. On reflection you think you avoided this because he was acting so aggressively when he first arrived in ED. You and the other staff were apprehensive about getting too close to him. However he was mostly conscious during the whole episode until the last 10 minutes before his death. When he became semi-conscious the doctor in change decided to ask Gavin if he wanted to speak to anyone and by this time is was too late to tell him about what happening and check to see if he really wanted no further treatment.

Acknowledgement: Thank you to student DF (2014) who gave us permission to adapt her student assignment for this case study.

Now you have examined Gavin’s story, address the following aspects in your case study analysis justifying your discussion with current academic resources:
1. Discuss the holistic assessment strategy for Gavin and comment on the implications of the institutional context, guiding the team in their planning of Gavin’s care,
2. Discuss the triggers for advanced care planning and your role in this process including the discussion with patients and family/guardian,
3. Examine the issues arising out of Gavin’s social, medical and mental health history and how this might impact on the decision-making process in relation to advanced-care planning. Include and justify the options that might have been available for Gavin.
4. Apply the Nursing and Midwifery Board of Australia (2013) Nursing Decision Making Framework (DMF) to Gavin’s care including everyone in the multi-disciplinary team the MD team to manage Gavin’s complex health and social problems.

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