Anorexia/Depression/Anxiety

Ms. Smith is an 85-year-old woman with end-stage cardiac disease in a home hospice program. She has been very comfortable, not experiencing any other symptoms, and has been quite functional until the last two weeks. Her family contacts the home hospice nurse concerning her lack of appetite, “continual sadness,” and anxiety which they feel is affecting her ability to function. During a routine home visit by the hospice nurse, the patient relates she has no appetite and is quite comfortable just having occasional “snacks” when she pleases. However, her family remains adamant that she requires better nutrition, and they request an IV be inserted. In addition, the family believes Ms. Smith is depressed and “too antsy,” and these contribute to her lack of appetite. Mrs. Smith states that she has had trouble with depression for many years, but has always tried to find “the brighter side” to fight off the sadness. She also acknowledges that she becomes anxious when her children come to visit, as they “don’t want to admit I am dying,” she says. She reports that she does not always sleep well at night, because she is afraid to die and leave her family behind. She says, “I wish I had raised my children better. If I had, there might not be all of this fighting going on about my care. I wish they would leave me alone, so I can die the way I want to.” Discussion Questions: How might the hospice nurse incorporate interdisciplinary care for this patient? What additional assessments would be needed? What interventions might be considered?

Sample Solution

Ms. Smith's Hospice Care: A Case for Interdisciplinary Intervention

Introduction:

Ms. Smith, an 85-year-old woman with end-stage cardiac disease, presents with declining appetite, sadness, anxiety, and sleep disturbances. While her family expresses concerns about her nutrition and emotional state, Ms. Smith desires a peaceful and dignified end. This case requires a holistic approach to address her physical, emotional, and spiritual needs through interdisciplinary care.

Full Answer Section

Interdisciplinary Care:

Ms. Smith's situation necessitates collaboration between various healthcare professionals to provide optimal care. The hospice nurse should be the central communication hub, coordinating with the following:

Physician: To assess Ms. Smith's physical condition, manage pain and other symptoms, discuss prognosis, and address family concerns about her nutrition.
Social worker: To provide emotional support to Ms. Smith and her family, address family dynamics and conflict, and assist with grief counseling and anticipatory mourning.
Chaplain: To offer spiritual support and guidance to Ms. Smith and her family, address any existential concerns, and facilitate discussions about death and dying.
Dietitian: To evaluate Ms. Smith's nutritional needs and preferences, suggest appropriate food options, and ensure she receives adequate hydration and comfort measures.
Palliative care specialist: To provide additional expertise in pain and symptom management, psychosocial support, and advance care planning.

Additional Assessments:

To develop a comprehensive care plan, the following assessments are necessary:

Physical assessment: Evaluation of Ms. Smith's vital signs, weight, pain level, presence of other symptoms, and medication side effects.
Nutritional assessment: Evaluation of Ms. Smith's dietary intake, nutritional deficiencies, and ability to swallow.
Mental health assessment: Screening for depression, anxiety, and sleep disturbances using validated tools.
Family assessment: Evaluation of family dynamics, coping mechanisms, support systems, and communication patterns.
Spiritual assessment: Exploration of Ms. Smith's religious beliefs, values, and spiritual needs.

Interdisciplinary Interventions:

Based on the assessments, the interdisciplinary team can implement a range of interventions:

Symptom management: Medications for pain, anxiety, and insomnia.
Nutritional interventions: Offering high-calorie, nutrient-rich snacks and fluids, ensuring hydration, and respecting Ms. Smith's preferences.
Emotional support: Individual and family counseling to address grief, anxiety, and guilt.
Spiritual support: Chaplain visits, prayer, and spiritual rituals.
Family education: Providing information about end-stage cardiac disease, hospice care goals, and pain and symptom management.
Advance care planning: Facilitating discussions about Ms. Smith's wishes for her care at the end of life and ensuring advance directives are in place.
Family communication: Mediating family discussions to address conflicting opinions and promote respectful communication.

Addressing Specific Concerns:

Lack of appetite: Respect Ms. Smith's wishes regarding her food intake. Focus on comfort measures and hydration. Offer high-calorie snacks and fluids frequently.
Sadness and anxiety: Provide individual and family counseling. Address Ms. Smith's concerns about dying and leaving her family behind. Offer emotional support and reassurance.
Sleep disturbances: Address underlying causes like anxiety and pain. Implement relaxation techniques and sleep hygiene measures.
Family conflict: Mediate family discussions and encourage respectful communication. Address guilt and anger towards each other.
Fear of death: Provide spiritual support and discuss coping mechanisms. Encourage Ms. Smith to share her feelings and concerns.

Ethical Considerations:

Patient autonomy: Respect Ms. Smith's right to make informed decisions about her care.
Beneficence: Provide care that promotes her comfort, well-being, and dignity.
Non-maleficence: Avoid interventions that may cause harm or suffering.
Justice: Ensure Ms. Smith receives fair and equitable care, regardless of her family's opinions.

Conclusion:

By incorporating interdisciplinary care and addressing Ms. Smith's physical, emotional, and spiritual needs, the hospice team can help her achieve a peaceful and dignified end of life. Collaborating with her family, respecting her wishes, and providing holistic care are essential for ensuring a positive experience for Ms. Smith and her loved ones during this challenging time.

Word Count: Approximately 790 words

Note: This response provides a general framework for discussion and intervention. Specific plans and approaches may vary depending on Ms. Smith's individual situation and preferences.

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