NURS 6910 Week 10 Palliative Case Analysis Example

One More Harvest: An Eight-Domain Palliative Care Case Analysis of a 70-Year-Old Farmer With Idiopathic Pulmonary Fibrosis

Student Name

College of Nursing, Walden University

NURS 6910: Introduction to Palliative Care: Principles of Hospice and Palliative Care

Instructor Name

Month Day, Year

One More Harvest: An Eight-Domain Palliative Care Case Analysis of a 70-Year-Old Farmer With Idiopathic Pulmonary Fibrosis

Case Presentation

The composite patient is a 70-year-old man who farmed corn and soybeans for fifty years and still lives on the farm, now rented to a neighbor. He was diagnosed with idiopathic pulmonary fibrosis four years ago. He uses oxygen at home continuously and was admitted to the hospital three times this winter, once to the intensive care unit for an acute exacerbation. He is not a candidate for lung transplantation because of his age and heart disease. On the Palliative Performance Scale he is at 50 percent: mainly sitting or lying, unable to do any work, needing considerable help with self-care (Anderson et al., 1996). On the modified Medical Research Council dyspnea scale he is grade 4, too breathless to leave the house or breathless when dressing (Bestall et al., 1999). His wife, 68, drives him forty minutes each way to the pulmonary clinic.

Idiopathic pulmonary fibrosis is a progressive disease with a poor prognosis, and current guidelines emphasize symptom management and attention to quality of life alongside antifibrotic therapy (Raghu et al., 2022). This analysis assesses him across the eight domains of the National Consensus Project guidelines (Ferrell et al., 2018), records the goals he set with the team and argues a plan.

Assessment Across the Eight Domains

1. Structure and processes of care. His care is divided among a pulmonologist, a primary care physician, a cardiologist and the hospital. No one coordinates it, and no one had discussed his goals before the third admission. The home palliative care team has now been involved for one month.

2. Physical aspects. Breathlessness dominates his days, worse with any exertion. He also has a persistent dry cough, fatigue, poor appetite and weight loss. His antifibrotic medication causes nausea, and he wonders whether it is still worth taking.

3. Psychological and psychiatric aspects. He describes episodes of panic when breathless, especially at night. He denies depression but says he feels useless now that he cannot work. His wife reports he has become withdrawn.

4. Social aspects. His wife is his only caregiver. Their two sons live in the city, two hours away. Neighbors check on them. The long drives to the clinic and the hospital are exhausting both of them.

5. Spiritual, religious and existential aspects. He is a lifelong Lutheran but attends rarely now. What gives his life meaning is the farm. He says he would like to see "one more harvest" from the porch.

6. Cultural aspects. He values self-reliance and dislikes asking for help, which has delayed his accepting home services. He speaks plainly and wants plain answers.

7. Care of the patient nearing the end of life. He is not yet imminently dying, but his decline and the pattern of admissions suggest limited time. He and his wife have not discussed where he wants to be at the end.

8. Ethical and legal aspects. He has a will but no advance directive and no named health care proxy. He has not been asked about intubation since his ICU stay, which he describes as "the worst week of my life."

His Goals

In a conversation with the palliative nurse and his wife, he named three goals: to stay on the farm, to avoid another stay in intensive care and to see the harvest this fall. He also said he did not want to be "kept alive on a machine" if his breathing failed again. His wife agreed but said she was afraid of being alone with him if he could not breathe.

Plan

Breathlessness. Breathlessness is the symptom most closely tied to all three goals. The plan uses non-drug measures first, a handheld fan directed at the face, pacing, positioning and a breathing plan for panic episodes, and asks the palliative physician to address medication for refractory breathlessness. Palliative care in interstitial lung disease is recommended alongside disease-directed therapy, with breathlessness and cough among the main targets (Kreuter et al., 2017).

Antifibrotic therapy. His question about stopping his antifibrotic medication will be discussed with his pulmonologist, weighing its expected benefit at this stage against the nausea that is reducing his appetite.

Avoiding intensive care. The team will complete an advance directive with him, name his wife as health care proxy and record his wish to decline intubation in a portable medical order form. This directly serves his goal of avoiding another ICU stay.

Staying on the farm. Home-based palliative visits will replace some clinic trips, and the team will arrange a home health aide, a shower chair and a plan for what his wife should do if he becomes very breathless at night. In a review of patients who died with idiopathic pulmonary fibrosis after care at one specialty center, more than half died in the hospital and few had ever received a formal palliative care referral (Lindell et al., 2015). A patient who wants to remain at home needs a plan for crises there, or the ambulance becomes the only answer to a bad night.

His wife. Her fear of being alone during a crisis will be addressed with a written crisis plan, the palliative team's around-the-clock phone number and training in what to do.

Hospice. He does not yet want to discuss hospice, and the team will revisit it if his function declines further or his admissions continue. His function score on the Palliative Performance Scale will be checked again every visit, so a drop is noticed rather than guessed.

Meaning and mood. His sense of being useless is a psychological and existential finding, not only a mood. The team will ask whether he would like his neighbor, who rents the land, to bring him updates on the crop or drive him slowly along the fields when he is able, so that he stays connected to the work that gives his life meaning. The chaplain will offer a visit, and the nurse will screen again for depression at the next visit, since withdrawal can signal it.

Conclusion

Across the eight domains, the most urgent gaps are in structure and in ethical and legal care: no coordination and no advance directive, despite a recent ICU stay he never wants to repeat. Addressing those gaps, and treating his breathlessness, is how the team can help him stay on the farm and see the harvest. The plan will be revised as his disease progresses and as his goals change.

References

Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative Performance Scale (PPS): A new tool. Journal of Palliative Care, 12(1), 5-11. https://doi.org/10.1177/082585979601200102

Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P. W., & Wedzicha, J. A. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax, 54(7), 581-586. https://doi.org/10.1136/thx.54.7.581

Ferrell, B. R., Twaddle, M. L., Melnick, A., & Meier, D. E. (2018). National Consensus Project clinical practice guidelines for quality palliative care guidelines, 4th edition. Journal of Palliative Medicine, 21(12), 1684-1689. https://doi.org/10.1089/jpm.2018.0431

Kreuter, M., Bendstrup, E., Russell, A.-M., Bajwah, S., Lindell, K., Adir, Y., Brown, C. E., Calligaro, G., Cassidy, N., Corte, T. J., Geissler, K., Hassan, A. A., Johannson, K. A., Kairalla, R., Kolb, M., Kondoh, Y., Quadrelli, S., Swigris, J., Udwadia, Z., ... Wijsenbeek, M. (2017). Palliative care in interstitial lung disease: Living well. Lancet Respiratory Medicine, 5(12), 968-980. https://doi.org/10.1016/S2213-2600(17)30383-1

Lindell, K. O., Liang, Z., Hoffman, L. A., Rosenzweig, M. Q., Saul, M. I., Pilewski, J. M., Gibson, K. F., & Kaminski, N. (2015). Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest, 147(2), 423-429. https://doi.org/10.1378/chest.14-1127

Raghu, G., Remy-Jardin, M., Richeldi, L., Thomson, C. C., Inoue, Y., Johkoh, T., Kreuter, M., Lynch, D. A., Maher, T. M., Martinez, F. J., Molina-Molina, M., Myers, J. L., Nicholson, A. G., Ryerson, C. J., Strek, M. E., Troy, L. K., Wijsenbeek, M., Mammen, M. J., Hossain, T., ... Wilson, K. C. (2022). Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults: An official ATS/ERS/JRS/ALAT clinical practice guideline. American Journal of Respiratory and Critical Care Medicine, 205(9), e18-e47. https://doi.org/10.1164/rccm.202202-0399ST