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Week 2 Discussion

Grief Group Case Studies (Group I)

You have received a hospice referral for Mr. Jones, age 54, who has ALS (amyotrophic lateral sclerosis). He and his family (wife and 3 children—ages 9,16, 19), who are confused and anxious, listen to you as you describe what they should expect from the hospice experience. The family does not seem to understand why you are discussing end-of-life issues with them. You call Mr. Jones’ family physician, who tells you that the patient assured him that he talked to his family about his prognosis. You determine that Mr. Jones has, in fact, not told his family. You talk with Mr. Jones, who admits that he has told his family he is very stable and expected to have many years of life remaining. He asks you to help him break the reality of his poor prognosis to his family.

Initial Post Requirements

What is your role now?

What communication gaps do you recognize?

What strategies would promote continuity of care and improve team communication?

How might a family meeting be helpful in this case?

What special needs would you perceive the children having at this time? How would you meet these needs?

Grief Group Case Studies (Group 2)

Cindy is a 36-year old female with pancreatic cancer, has been hospitalized for two weeks. She has been in the intensive care unit for the past 5 days. Her physical deterioration and suffering had created anguish in her husband and the health care team. The attending physician discussed with the husband the likelihood of his wife having a cardiac and/or respiratory arrest, described the actions the team would take for a full resuscitation as well as the varying levels of resuscitation approved by the treatment setting, which included a do-not-resuscitate option, and asked the husband to express his preferences regarding resuscitation. The husband initially chose the do-not-resuscitate status for his wife and completed all of the official paperwork to implement that decision. During the next 12 hours, the husband actively solicited their definitions of do-not-resuscitate from nursing and medical staff. He then contacted the attending physician to rescind his decision, choosing instead to have a full resuscitation order in place. He explained his decision change as, “When I saw that the nurses and doctors did not all define resuscitation in the same way, I decided that I would not leave that in their hands. I am my wife’s husband, and I will be her husband to the end.” This new decision was enacted, and over the next four days, the patient showed clear signs of dying. Her husband stayed with her in the intensive care unit and witnessed the changes in his wife’s physical appearance. He began commenting on those changes and his wife’s obvious suffering. Within two hours of her death, the husband told the nurse that he did not want his wife to be resuscitated. This information was immediately conveyed to the health care team, and a brief discussion with the physician, husband, and nurse was convened to affirm this decision.

Initial Post Requirements

What were the barriers to effective communication in this case?

How might these barriers have been eliminated?             

Grief Group Case Studies (Group 3)

Max Klein is an 84-year-old retired plumber who has brought his 83-year-old wife, Mary, to the E.R. complaining of chest pain. Mary’s condition declines, she experiences cardiac arrest, and full resuscitation is attempted. During this time, Max communicates to the social worker and chaplain that “This can’t be. Mary is healthy as an ox.” He doesn’t want to notify his children who live out of town “until she’s stable because I know they’ll get her straightened out – they’re really good here at Methodist Hospital.” Max seems anxious but distracted and talks incessantly about how Mary’s been sick before but “always gets better before you know it.” After 2 hours of numerous procedures and attempts, Mary dies.

Initial Post Requirements

What are useful communication strategies while Mary is still receiving aggressive care to communicate her status?

How should Max be told of Mary’s death?

What is the role of the interdisciplinary team in communication in this case?

Grief Group Case Studies (Group 4)

Valenzio Quartera is a 56-year-old man with widely metastatic prostate cancer. He is currently undergoing radiation therapy for bone metastasis. His wife died one year ago from breast cancer. He now lives at home with his twin daughters, age 15 years. As you, the radiation oncology nurse, enter the treatment room, Mr. Quartera asks you, “Susie, you don’t think I’m going to die do you?” “What would happen to my daughters if I die?”

Initial Post Requirements

How would you respond?

How would you address his concern about his daughters?

What would you recommend that he discuss with his daughters at this time?

What would other healthcare team members be appropriate to contact to help Mr. Quartera with his daughters?

Grief Group Case Studies (Group 5)

Mr. Ahmed is a 49-year-old with a recurrent brain tumor currently hospitalized after experiencing seizures. Mr. Ahmed was diagnosed at age 44 and has had extensive surgery, chemotherapy, and radiation therapy. Three months ago, his oncology team advised him and his family that there were no further treatment options and recommended palliative care. The family was not interested in palliative care, and they requested that “everything is done.” He has experienced weight loss, increasing severe headaches, nausea, and now seizures. Following a severe seizure last week, his wife brought him back to the cancer center seeking possible new treatments and wonders if he can receive palliative care, too. As Mr. Ahmed waits in radiology for a scan, you, the oncology nurse, come to see him as you heard he was in radiology. He tells you he is so tired of treatment and being taken far away and wishes his family would “give up and just let me be at home so I can play with my dog and be with my friends.”

Initial Post Requirements

How would you respond to Mr. Ahmed?

Is it possible for Mr. Ahmed to receive treatment and palliative care at the same time? If so, how would you describe this to Mr. and Mrs. Ahmed?

How could you use attentive listening and presence with this patient and his wife?

How would you describe palliative care to this family?


Week 3 Discussion

Grief Group Case Studies (Group I)

A 45-year-old woman is caring for her mother, who has had a cerebrovascular accident. The patient is aphasic and remains in a persistent vegetative state. The patient’s daughter has periods of crying and states she is angry with herself for not checking on her mother. She is experiencing anticipatory grief.

Initial Post Requirements

Describe anticipatory grief.

Identify interventions to support her in her grief.

Grief Group Case Studies (Group II)


McKenzie Pierce is a 16-year-old woman who is brought to the emergency department following a motor vehicle accident. She is diagnosed as brain dead. Her parents are informed, and they decide to make her an organ donor. The mother is crying uncontrollably and suffering from complicated grief.

Initial Post Requirements

Describe complicated grief.

Identify interventions to support the parents in their grief.

Grief Group Case Studies (Group III)

A 78-year-old widow was experiencing chronic grief since her husband’s death last year.

Initial Post Requirements

Describe chronic grief.

Identify interventions to support her in her grief.

Grief Group Case Studies (Group IV)

Andrew Tobias has only days to live related to lung cancer. He is married to Trina Tobias and has three adult children from his first wife. Jenny Tobias has come to the home to support her children. She states to the hospice nurse that she never wanted to divorce and still loves her former husband. She is experiencing disenfranchised grief.

Initial Post Requirements

Describe disenfranchised grief.

Identify interventions to assist Jenny with her disenfranchised grief and to assist her children in the grieving process.

Grief Group Case Studies (Group V)

Lisa Parson’s mother died when she was 14 years old. Her father remarried six months after her mother’s death. Soon after their marriage, Lisa was admitted to the adolescent psychiatric facility due to the practice of cutting herself. She is diagnosed with exaggerated grief.

Initial Post Requirements

Describe exaggerated grief.

Identify interventions to assist Lisa in overcoming her exaggerated grief.



Week 4 Discussion

DQ1 Articles on Pain Management

Utilizing the CINAHL Links to an external site.or Medline Links to an external site.databases, find an evidence-based practice article on pain management at the end of life.

DQ2 Articles on Complementary and Alternative Therapies

Utilizing the CINAHL Links to an external site.or Medline Links to an external site.databases, find an evidence-based practice article on complementary and alternative pain management therapies at the end of life.



Week 5 Discussion

Case Studies Involving Ethical and Legal Issues (Group I)


Joleen Wright, an 87-year-old woman, living in a nursing home, had been pleasantly convivial and moderately demented for some time. No family or friends were known. It was tough to discern her preferences, as she “lived in the present” and did not trouble herself about future possibilities. She had chronic hypertension and hearing and motion deficits.

Over a few weeks, she gradually started doing “poorly,” walking less, eating less, and seeming more distant. Over the next two weeks, a comprehensive evaluation in her nursing home setting turned up very little. Blood tests, physical exams, and chest x-rays were all normal, but she then became short of breath and was hospitalized. By the time she arrived at the emergency room, her blood pressure had declined to dangerous levels. She had mild problems with oxygenation, probably due to pulmonary edema, and was started monitoring and careful fluid balance. Within 24 hours, she had multiple interventions (e.g., IV, cardiac monitor, urine catheter) for monitoring and treatment and was restrained in bed to keep the connections in place. Her skin was breaking down on her shoulder blades. She indicated “yes” or “no” to questions about her comfort but showed little insight or attention. No definite reversible diagnoses surfaced despite appropriate work-up. Her condition worsened, and she faced the need for mechanical ventilation. The care team anguished over whether to continue intrusive care in the intensive care unit to establish a precise diagnosis or shift toward a primarily palliative approach. Her condition continued to deteriorate, and she became minimally responsive.

After a team meeting, the care team decided to institute hospice-type care and not seek a court’s involvement in getting a guardian. Joleen Wright died comfortably 36 hours later. Because no consent to autopsy could be obtained, the diagnosis remained a mystery.

Initial Post Requirements

hould age be a deciding factor in the provision of care? Why or why not?

Should we allow people to die from aging without knowledge of a primary terminal disease process?

What care would you want if this were you? How do your personal values influence your preferences?

What role could a nurse play in addressing the ethical issues in this case?

Case Studies Involving Ethical and Legal Issues (Group 2)


Ms. J.F. is a 48-year-old woman in apparent good health until 2 months before consulting her physician when she reported progressive abdominal swelling and weight gain. Associated symptoms included fatigue, loss of appetite, gastric fullness, nausea, diarrhea, and intermittent leg swelling. She had become unable to perform her usual activities as a legal secretary and mother of a 19-year-old autistic son. She is divorced and has had a stable relationship with Robert, a school director, for 5 years.

On physical examination, she is afebrile, alert but pale, and in obvious discomfort. There is dullness and decreased breath sounds at the left lung base. She has marked abdominal distention with a fluid wave. There is moderate non-localized abdominal tenderness to palpation. Rectal and pelvic examination demonstrates a non-tender mass in the cul-de-sac. She is admitted to the hospital for further evaluation and management.

Laboratory and diagnostic results include the following: CBC, electrolytes, serum calcium, and liver function tests are normal. Serum albumin is decreased. The chest X-ray demonstrates a small left pleural effusion. Pelvic ultrasound shows ascites and a regular-sized uterus; the ovaries are not visualized. Abdominal CT scan reveals no organomegaly, but retro-crural adenopathy is present. Bone scan and esophagogastroscopy with biopsy are normal. Colonoscopy confirms an extrinsic, compressing mass at 5 cm. There is diverticulosis but no intrinsic mass.

Paracentesis cytology is positive for undifferentiated adenocarcinoma. The tumor marker results are as follows: CA 15:3: normal; CA 125: slightly increased; CA 19:9: moderately increased; CEA: normal.

During the first week of admission, Ms. J.F. becomes weaker with increasing diffuse abdominal pain and a sensation of pressure on the perineum. She also develops moderate dyspnea and persistent nausea and vomiting. It is thought that she does not have a bowel obstruction; instead, her symptoms are explained by ascites and involvement of the parietal peritoneum. The ascites reaccumulate, requiring repeated paracentesis. It is decided to give her an albumin transfusion replacement, morphine, intravenous metaclopromide, and dimenhydrinate.

An interdisciplinary group meets to discuss her care and determine what limits should be placed regarding further investigations relative to her condition and likely prognosis, i.e., the benefit of identifying the adenocarcinoma’s primary site vs. the projected poor outcome and excess burden to the patient.

Initial Post Requirements

As a team member, how would you proceed, and what would you consider in the decision-making process?

What factors will assist you in determining the limits in this case?

How does the issue of futility influence your opinion?

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Case Studies Involving Ethical and Legal Issues (Group 3)


As recommended by the interdisciplinary team, the attending physician proposes to Ms. J.F. the option of an empiric chemotherapy trial. The physician explains that the malignancy is widely disseminated, that chemotherapy might slow down the ongoing process, and that she might experience some side-effects from the therapy. He is vague regarding the prognosis and potential value of the treatment. The physician does not want to needlessly alarm the patient or her companion, who is anxious and confused by the rapid progression of her condition. The physician wants to maintain their morale, saying “they have enough to deal with at this moment.” Consent is obtained from the patient for chemotherapy.

Initial Post Requirements

Why is consent a necessary component of therapy?

What variables can influence consent?

What are the requirements for consent?

How do you evaluate the competency of the patient?

Do you think that the consent was valid and without influence? Further explain your answer.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Case Studies Involving Ethical and Legal Issues (Group 4)


Ms. J.F. does not respond to chemotherapy. Her pain increases to the point that she can assume no comfortable position and is in constant pain despite all analgesic therapy, including increasing doses of morphine. She becomes more nauseated despite receiving different anti-emetics. Her ascites continues to accumulate rapidly and requires repeat paracenteses to help alleviate increasing pain and dyspnea. Her serum albumin continues to drop despite replacement. She develops thrombophlebitis, for which she receives heparin therapy. At this point, the patient is fatigued, dyspneic, and restless and must sleep in a sitting position. However, she remains conscious, alert, and oriented. Her competency is never in question, although she is partly sedated with lorazapam.

One morning she speaks to the attending physician. After inquiring about her disease’s extent and outcome and being reassured that everything possible is being done, she asks that all treatments be stopped. She states she is at the ‘end of the road’ and does not wish to go further. “I can’t bear it anymore. Please help me be comfortable. Make me sleep.”

Throughout her illness, she is supported by her companion, who loves her dearly. He has wanted everything done to restore her health. However, when confronted by her demand, he agrees that the situation is complicated and very painfully shares her decision. The patient asks to see her son, who is taken to the hospital for a brief visit.

Initial Post Requirements

ow would you clarify this request? Is this withholding of treatment?

Is sedation an acceptable treatment for relieving Ms. J.F.’s symptoms?

What is the ethical rationale for your decision?

How are sedation and withdrawal of treatment different from assisted suicide or euthanasia?

Ms. J.F. is reassured that everything will be done to make her comfortable. The intravenous line and heparin are discontinued. She is put on higher doses of continuous subcutaneous infusion of morphine; midazolam and haloperidol are given subcutaneously twice daily. She remains comfortable and dies peacefully 2 days later. She is conscious but sleepy until her death. During this difficult time, she is accompanied by her loved ones. Everyone is at peace because they have the impression they could express their feelings and discuss issues freely. The door is left open for communication and support. Bereavement counseling is made available to both Robert, her companion, and Ms. J.F.’s son.

Adapted from: Lesage, A.D. & Latimer, E. (1999). An approach to ethical issues. In N. MacDonald (Ed.), Palliative medicine: A case-based approach (p. 253-277). New York, NY: Oxford University Press. Reprinted with permission.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Case Studies Involving Ethical and Legal Issues (Group 5)


Mr. B. is a 21-year-old African-American male who has been treated over the last year at your hospital for widely metastatic Burkitt’s Lymphoma. Mr. B. had lived at home with his mother, but a few months ago, against his mother’s wishes, he married his long time 17-year-old girlfriend, the mother of his 2-year-old son. His mother does not get along with the patient’s wife. The couple has a small apartment, and his wife has been trying to keep working nights as a nurses’ aide to support them. He’s applied for disability, but they currently have no consistent financial support source except her part-time job.

Unfortunately, after his first course of chemotherapy, he became septic and nearly died in the ICU. His disease has continued to progress through second and third-line treatment. He has been hospitalized almost continuously for dehydration and fevers for the last two months, among other problems.

He has been evaluated for a bone marrow transplant but has steadfastly refused it because “I don’t want my family to lose everything because it’s probably not going to work at this point.” He has told you that he was pressured by his mother to have the evaluation – “It’s really hard to say ‘No’ to her. Mom told me she’d take the hospital to court if they don’t do a full-court press. She’s already contacted a lawyer. My wife can’t stand up to her, so I guess I’ll end up doing it even though I don’t want to.”

Initial Post Requirements

What ethical principle/principles are at issue in this case?

Does this situation warrant ethics consult from the hospital ethics committee? If so, who should initiate it?

What, if any, legal issues should be examined?

What should patient/family issues be addressed?

What advocacy role do you have as the oncology nurse taking care of this patient?

Adapted from: ELNEC Core Curriculum, Module 4: Ethical Issues in Palliative Care Case Studies (January 2013).

ach member of the group will discuss this case, respond to the questions, and participate in the initial post.







Week 6 Discussion

DQ1 The Last Lecture

You will be asked to write a 2-3 page reflective paper on what you learned in The Last Lecture for Assignment 6.1: The Last Lecture Reflection.

Initial Post Requirements

In addition to submitting the reflection, I would like you to upload your reflection to this forum.

Responding to Your Peers

To receive full credit for this discussion, you are required to respond to at least one of your peers.

Examine the opposite position. For example, if they posted a positive benefit, try to counter with a potential challenge.

Those responses should show thoughtful reflection and critical thinking. Please be constructive and descriptive in your reply comments.

You must make an initial post before you can view the posts of your peers.

DQ2 Congenital Heart Failure Case Presentation

Initial Post Requirements

After viewing the Congenital Heart Failure Case Presentation (embedded above), post a case scenario and identify strategies to care for the patient experiencing cardiac failure.

Comment on the most important aspects of care you learned while watching the Case Presentation and how you will implement this into your care.

Responding to Your Peers

To receive full credit for this discussion, you are required to respond to at least one of your peers.

Examine the opposite position. For example, if they posted a positive benefit, try to counter with a potential challenge.

Those responses should show thoughtful reflection and critical thinking. Please be constructive and descriptive in your reply comments.

You must make an initial post before you can view the posts of your peers.



Week 7 Discussion

Group Case Studies on Various Diseases (Group I)

Stanley is a 42-year-old man with amyothrophic lateral sclerosis. He was diagnosed 1 year ago. His condition is declining. He is married with two school-age children.

Initial Post Requirements

What is the treatment for ALS?

How will you address the subject of enteral feedings, ventilation, and advanced directives?

How will you assist in promoting sleep in this patient?

How will you assist the family in preparing for the worsening of Stanley’s ALS and ultimate death?

Identify the care you will provide to Stanley at the end of life.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Group Case Studies on Various Diseases (Group II)


Jenny Ellison is a 28-year-old woman. She has completed genetic testing, which revealed she would develop Huntington’s Disease.

Initial Post Requirements

What is the epidemiology of Huntington’s Disease?

You need to explain to Jenny the trajectory of the disease process. What are the clinical features of Huntington’s Disease?

Identify the pathophysiology of Huntington’s Disease.

What are the recommended treatments for the management of Huntington’s symptoms?

Determine a plan of the care of the patient dying of Huntington’s Disease.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Group Case Studies on Various Diseases (Group III)


Anthony Peronetti is a 78-year-old patient with Parkinson’s Disease. His symptoms began 8 years ago. His medications have been increased steadily over the last 8 years as his symptoms worsened.

Initial Post Requirements

Identify the medications used for the treatment of Parkinson’s Disease. Describe their actions and adverse effects and the aspects of patient education you should provide to the patient and his family.

Anthony is having difficulty swallowing. His family would like him to begin enteral feedings. What patient education will you provide?

What is the pathophysiology of Parkinson’s Disease?

What nursing interventions are important to implement with Anthony at the end of life?

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Group Case Studies on Various Diseases (Group IV)


Mr. J. is an active 71-year-old Hispanic gentleman whose home health nurse calls you to tell you about his symptoms, which include an increase in lethargy, constipation, and questionable altered mental status. The patient is known to have widely metastatic prostate cancer, including bone metastasis. A recent MRI of his brain was positive for metastatic disease. He is a very proud and private man, she tells you, and he doesn’t always listen to what the doctor tells him.

As the nurse in the medical oncology clinic, you have cared for this patient and family for several months. He has been on long-acting morphine at 200-mg q 12 hours po with morphine sulfate immediate-release tablets 10mg to be taken q 2-3 hours po prn for pain. His pain has been well managed on this regimen for the last month. He has been on an effective bowel regimen until the last week. The oncology nurse instructs the home care nurse to have the patient come to the clinic.

Initial Post Requirements

Discuss the physical assessment that would be conducted on Mr. J.

What laboratory or radiographic studies might be ordered? Why?

Discuss the differential diagnosis for these complaints and how might these be managed?

What education would you provide to the patient/family?

Describe the strategies you would review with the home care nurse in promoting a comprehensive plan of care for this patient.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Group Case Studies on Various Diseases (Group V)

Review           Mrs. Paul is a 48-year-old woman dying of end-stage liver disease and chronic renal failure. She is fatigued and has experienced significant weight loss, despite significant edema. She was diagnosed with colon cancer three years ago.

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