Question: Caring For Patient At End Of Life Case Study Mrs. W. Is A 66-year-old Woman With A 20-year History Of Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, And Insulin-dependent Diabetes Mellitus. She Has Been Admitted To The Hospital Multiple Times During The Past 5 Years For Pneumonia, Exacerbations Of Her COPD, And Heart Failure. She Is Weak …

Caring for Patient at End of Life Case study Mrs. W. is a 66-year-old woman with a 20-year history of chronic obstructive pulmonary disease (COPD), heart failure, and insulin-dependent diabetes mellitus. She has been admitted to the hospital multiple times during the past 5 years for pneumonia, exacerbations of her COPD, and heart failure. She is weak and constantly short of breath at home, which has caused her to be increasingly unable to care for herself. Mrs. W. has two adult sons who live in other states, with whom she has regular phone contact and occasional visits. Her husband died a year ago from a myocardial infarction, and now she lives alone. She is currently admitted to the critical care unit with pneumonia and heart failure and is on mechanical ventilation but awake and alert. After 2 weeks with minimal improvement, a tracheostomy is performed with the patient’s consent. She remains dependent on the ventilator, and little to no weaning progress has been made after 3 weeks. She is receiving ventilation in the pressure support mode with 15 cm H2O of pressure support, positive end-expiratory pressure of 8 cm H2O, and fraction of inspired oxygen of 0.5. With these ventilator settings, her arterial oxygen (PaO2) level is only 72 mm Hg. She is receiving a continuous intravenous infusion of an inotropic agent to treat the heart failure and has decompensated during previous attempts to change from the intravenous infusion to oral therapy. Mrs. W. has a “sunny personality, and many critical care staff members have come to know and like her during the course of her multiple admissions. Her admitting pulmonologist knows her well, and he has been regularly treating her as an outpatient. Despite her multiple medical problems, Mrs. W. remains alert and oriented and communicates with the staff by mouthing inotropic agent to treat the heart failure and has decompensateu change from the intravenous infusion to oral therapy. Mrs. W. has a “sunny personality, and many critical care staff members have come to know and like her during the course of her multiple admissions. Her admitting pulmonologist knows her well, and he has been regularly treating her as an outpatient. Despite her multiple medical problems, Mrs. W. remains alert and oriented and communicates with the staff by mouthing words or writing notes. On hospital day 28, Mrs. W. expresses to her evening nurse that she would like to discontinue ventilator support and “let nature take its course.” Her nurse is surprised but supportive and contacts Mrs. W.’s pulmonologist to convey the patient’s wishes. The next day, the pulmonologist visits Mrs. W. In his conversation with her, attended by her nurse, the pulmonologist expresses his opinion that Mrs. W. is unlikely to ever be weaned from the ventilator. However, he also states that because of his personal religious beliefs, he is unable to carry out her request to withdraw ventilator support, and he would like to transfer Mrs. W. to a long-term acute care (LTAC) facility to continue her care. Mrs. W. becomes visibly upset and insists that her ventilator support be discontinued or “she will call her lawyer.” Her physician leaves without further comment. Mrs. W. has no prior written advance directive. Questions What immediate actions should the nurse take? to carry out her request to withdraw ventilator support, and he would like to transfer Mrs. W. long-term acute care (LTAC) facility to continue her care. Mrs. W. becomes visibly upset and insists that her ventilator support be discontinued or “she will call her lawyer.” Her physician leaves without further comment. Mrs. W. has no prior written advance directive. Questions What immediate actions should the nurse take? What subsequent actions could the nurse take to advocate for the patient? 1