- What priority problem(s) did you identify for Julia Morales and Lucy Grey?
- What teaching measures and what other members of the health care team should be included in the home health nurse visit for Julia Morales and Lucy Grey?
- What potential barriers might Julia Morales and Lucy Grey encounter that would hinder active participation in Julia’s care?
- What appropriate assessments were made to help you decide what interventions Julia Morales and Lucy Grey needed?
- What appropriate strategies could be implemented to empower Julia Morales and Lucy Grey in the management of Julia’s care?
- What potential problems does Julia Morales face if the symptoms of her disease progression are not recognized and if actions are not initiated in a timely manner?
- What is the role of the home health/hospice interprofessional team, and what is the importance of teamwork and collaboration in the case of Julia Morales and Lucy Grey?
- What potential environmental/safety hazards need to be assessed in the home care setting?
- Reflecting on Julia Morales and Lucy Grey’s case, were there any actions you would do differently?
- How would you apply the knowledge and skills that you obtained in the case of Julia Morales and Lucy Grey to an actual patient care situation?
vSim for Nursing | Gerontology
Julia Morales and Lucy Grey Part 1
Julia Morales and Lucy Grey Part 1
Patient: Julia Morales
Diagnosis: Lung cancer, stage 4
This scenario is part of the Julia Morales and Lucy Grey Unfolding Case. The scenario can be used as a standalone scenario or as part 1 of the case.
The Unfolding Case
Julia Morales, age 65, and Lucy Grey, age 73, are partners who have been together for more than 25 years. They are retired and have spent the past several years traveling together. Julia has lung cancer, which has been treated with chemotherapy and radiation, and now she wishes to stop treatment. Lucy is supportive and feels she will be able to care for Julia in their home. Lucy’s past medical history includes a knee replacement. Their support system includes Julia’s son, Neil.
The simulation scenarios begin with the home health nurse evaluating Julia after she has decided to stop treatment for her lung cancer. Her partner Lucy wishes to care for her in their home. In the second scenario, the end of Julia’s life is near and she is surrounded by her loved ones and the hospice nurses. Julia dies during this scenario. The learners are introduced to supportive measures for both the patient and the family during this process. The final scenario concentrates on Lucy and the difficulties she has adjusting to her new life after Julia is gone. The objectives focus on the students’ assessment of Lucy’s grieving process, how well she is coping, and the physical changes that she has experienced over the past few months.
Brief Summary of Present Scenario
This scenario involves a visit by the home health agency nurse. The students are expected to do a physical and functional assessment of Julia and her nursing care needs. Julia inquires about hospice services, but her son Neil urges her to try one more round of chemotherapy. Lucy is supportive of Julia’s decision and tries to comfort Neil. The students should assess Lucy’s caregiver preparedness, and articulate what hospice care means for the patient and family. The assessment tools recommended for this scenario include the Katz Index of Independence in Activities of Daily Living (ADL), and Informal Caregivers of Older Adults at Home: Let’s PREPARE!
Upon completion of the scenario, the student should be able to:
· Provide care for the terminally ill older adult and her family in the home setting
· Perform physical and functional assessments of the older adult, using standardized tools, to include:
· Katz Index of Independence in Activities of Daily Living (ADL)
· Assess caregiver preparedness using the Informal Caregivers of Older Adults at Home: Let’s PREPARE! assessment tool
· Identify purpose of hospice care and services provided
· Explain advance directives and durable power of attorney
· Relate the importance of providing individualized care unique to each individual and family
Patient Case Introduction to Students
Report from home health agency manager:
Julia Morales is a 65-year-old woman who has stage 4 lung cancer. She has been treated with chemotherapy and radiation but now wishes to forgo further treatment. She is living together with her partner, Lucy Grey, age 73. They have been together for more than 25 years. Julia and Lucy both want Julia to spend her remaining days in their home, and Lucy wishes to care for Julia. The oncologist nurse practitioner has asked the home health agency to do a home visit to assess client needs for comfort, safety, and other support. Julia has questions about hospice care and what that comprises, especially related to pain treatment. Lucy and Julia’s son, Neil, will also be present at the visit. Please make sure to assess Lucy’s preparedness to care for Julia. I think she has some questions related to the caregiver role.
Patient data: Female – Age 65 years. Weight 56 kg (123 lbs). Height: 163 cm (64 inches)
Allergies: No known allergies
Past Medical History: Adenocarcinoma of the lung, diagnosed 4 years ago, treated with radiation and chemotherapy.
History of Present Illness: Julia was seen in her oncologist’s office yesterday. Julia, Lucy, Dr. Davis and the nurse practitioner (Laura Johnson) discussed at length Julia’s decision to stop chemotherapy, which at this point would have no documented benefit for Julia. Laura, the nurse practitioner, recommended a home health agency referral to assess and to support family’s needs.
Social History: Retired from work at a local nursery/garden center. Lives with partner Lucy. Son Neil, age 42, lives 20 miles away. Private insurance.
Primary Medical Diagnosis: Adenocarcinoma of the lung, stage 4.
Surgeries/Procedures & Dates: Hysterectomy at age 44.
· Home health agency visit
· Diet as tolerated
· Oxygen per nasal cannula at 2 liters per minute as needed for comfort
· Docusate 100 mg: 1-2 capsules PO daily as needed for constipation
· Morphine sulphate, controlled release, 100 mg PO every 6 hours as needed for pain
· Chronic Pain related to metastatic lung cancer
· Readiness for Emancipated Decision Making related to end-of-life care
Overview of Proposed Correct Treatment
· Introduce self and explain purpose of visit
· Wash hands
· Identify patient
· Address Neil’s concerns, using therapeutic communication
· Educate on available family support
· Explain purpose of hospice
· Obtain vital signs
· Assess pain
· Begin general assessment
· Assess patient using Katz Index of Independence in Activities of Daily Living (ADL)
· Assess caregiver preparedness using Informal Caregivers of Older Adults at Home: Let’s PREPARE!
· Assess patient concerns
· Provide patient education regarding role of hospice
· Explain advance directives
· Explain durable power of attorney
· Provide patient education about:
· Pain management
· Medical equipment, including use of portable oxygen
· Community resources
During this scenario, the nurse should assess Julia’s functioning and Lucy’s ability to care for her in their home. It is important to look at the individual aging patterns by using standardized assessment tools, because this will help to ensure a comprehensive approach to the assessments. In this case, The Katz Index of Independence in Activities of Daily Living (ADL) should be included in the initial assessment, as well as analysis of the prefilled SPICES: An Overall Assessment Tool for Older Adults for an evaluation of Julia’s current condition. The nurse should assess the family’s understanding of expectations for hospice care and Julia’s dying at home. It is also important to assess Julia’s caregiver preparedness to be able to develop an individual plan of hospice care. The assessment tool: Informal Caregivers of Older Adults at Home: Let’s PREPARE! should be used for that purpose. The Modified Caregiver Strain Index may also be used for assessing the family’s preparedness for their loved one to enter hospice care.
Julia has extensive needs for physical and emotional care, which will certainly increase with time because her condition is bound to deteriorate. The nurse should use knowledge of hospice care to enlist the aid of others on the team as appropriate. It is important to ensure that Julia and her family are aware of each team member’s role, as well as whom to call and where to get the equipment and support needed. A plan of comfort and pain relief should also be made with the family on this first visit. Support should be given to the family and education provided about medication, activities, and hospice care to give Julia and Lucy a complete understanding of the possibilities and limitations of home care.
Hospice care and end-of-life care in general are important roles for nurses. A nurse should be skilled in helping families cope with death, even if the patient is not in hospice. It is important for nurses to acknowledge their own feelings and be comfortable in dealing with the deaths of patients.
The nurse should assess Julia’s and Lucy’s level of understanding of what will likely happen as Julia faces death. The nurse will need to prioritize actions based on listening closely to the patient’s and family’s priorities, and meeting needs as they arise. Education on advance directives, durable power of attorney, available support resources, and family support are also important elements of this visit.
© Laerdal Medical 1
©Laerdal Medical 2