End-of-Life Simulation: Monica Jones

Source: raw/nsg210_wk09_SIMULATIONPATIENTNURSE.doc. “Nursing Care at the End of Life: Introductory Concepts.” Scenario time 15 to 25 minutes.

Learning Objectives

• Discuss how death and dying affect the family structure
• Describe end-of-life nursing care across the lifespan, including care specific to the person’s developmental stage
• Describe what family caregivers can do to help with end-of-life care
• Explore challenges of end-of-life care across ages
• Scenario-specific: use therapeutic communication to meet the patient’s needs

Patient

• Monica Jones, 45-year-old female, admitted to acute care from the cancer center
• Chief complaint: chest wall and abdominal pain, constipation. She says, “I have pain.”
• History: metastatic breast cancer with bone metastasis (metastases found 5 years ago), hypertension, anxiety
• Prognosis poor. Over the past week, increasing sternal pain causing more shortness of breath
• 5 ft 7 in, 100 lb
• Married; son 18 and daughter 12; was a CEO; enjoys her kitten and TV; quit smoking 12 years ago; no alcohol or drugs
• Valid living will, comfort care only, DNR
• Palliative Performance Scale 25% (100% is fully well; 0% is death)
• No known allergies

Symptoms

Loss of appetite, weakness and fatigue, insomnia, anxiety, upper chest pain, abdominal pain, constipation, shortness of breath.

Pain: upper chest and abdomen, “intolerable,” 10+ out of 10, no relief from any intervention; lowest is 5-6. Constant ache with sharp episodic spikes in the chest. Changes somewhat with position. Does not radiate. No headache.

Medications

Current Management

Pain: fentanyl patch, breakthrough hydromorphone, bed rest, positioning, equipment, staff support. Shortness of breath: bed rest and positioning. Poor appetite: diet of choice. Weakness: bed rest and positioning. Insomnia: Ambien, pain control, support. Psychosocial and spiritual needs still need to be addressed.

Inconsistencies in the Scenario

• The summary says the fentanyl patch was increased from 200 to 300 mcg/h two weeks ago and the medication list says 300, but both assessment paragraphs say 200. Verify the actual dose before giving breakthrough medication.
• The listed date of birth (11/22/1967) does not match age 45.

Likely Nursing Priorities

These are study notes, not from the source file.

• Uncontrolled pain (10+/10) despite a high-dose opioid regimen: full pain assessment, give breakthrough hydromorphone as ordered, reassess, and notify the provider that the regimen is not working; nonpharmacologic measures (positioning, environment)
• Opioid-induced constipation: assess last bowel movement and abdomen; a scheduled bowel regimen is usually needed with opioids rather than only as-needed laxatives
• Dyspnea: high Fowler’s or position of comfort, fan, calm presence; watch for oversedation with opioids plus lorazepam plus zolpidem
• Very low weight (BMI about 15.7) with poor intake: comfort feeding, mouth care, skin care and turning for pressure injury risk
• DNR and comfort-care-only wishes: respect the living will; focus on comfort
• Psychosocial and spiritual: anxiety, fear, loss of role (CEO, mother); use the questions in nsg210-dd-talking-with-dying-patient
• Family: husband and two children (a teenager and a 12-year-old) need support and age-appropriate explanations (see the lifespan table in nsg210-dd-slides); consider hospice or palliative referral, social work, and chaplain

Role Prep: Playing the Husband

These are study notes, not from the source file. The source gives no husband script or name; “Mr. Jones” is used here. Background beyond the scenario facts is improvised to fit it.

Who He Is

• Married to Monica, about her age (mid to late 40s). Two kids at home: son 18, daughter 12. A kitten the family loves
• Monica was a CEO, the organized one who ran things. He is now the caregiver, the decision maker, and a single parent in waiting, and feels unprepared for all three
• Has lived with her cancer for 5 years since the metastases were found, so he knows the vocabulary, but this admission feels different: she is thinner, in more pain, short of breath, sleeping less
• Knows there is a DNR and living will for comfort care only. Agreed with it on paper; living it is harder

Emotional State

• Exhausted, has not slept, may not have eaten
• Frustrated and protective: “She is still in pain. Why is nothing working?” This is the main pressure point, since her pain is 10+/10 on a high-dose regimen
• Scared of the opioids too: worries more medicine will “knock her out” or speed up death, while also demanding she be comfortable. Holding both at once is realistic
• Some denial or bargaining: asks about another round of treatment, a second opinion, a feeding tube because she is “wasting away”
• Grief and guilt underneath: did they miss something, should he have brought her in sooner
• Worried about the kids: does not know what to tell the 12-year-old; the 18-year-old is angry or withdrawing

Lines to Use

Pick a few; the point is to give the students openings to practice therapeutic communication.

• “She keeps saying she has pain. You gave her something an hour ago. Why isn’t it working?”
• “If you give her more of that, is it going to stop her breathing?”
• “She hasn’t eaten in days. Can’t you put in a feeding tube or an IV?”
• “Is this it? Is she dying? Nobody will give me a straight answer.”
• “How long do we have?”
• “What do I tell our daughter? She’s twelve.”
• “Our son won’t even come in the room.”
• “I signed the DNR, but I don’t know if I can just watch this.”
• “I should have made her come in last week.”
• “She always handled everything. I don’t know how to do any of this.”
• “Can she come home? She’d want to be with the kids and the cat.”

How to React to the Nurse

Reward good technique by calming down and opening up; push back a little on poor technique so the students feel the difference.

• If the nurse uses open-ended questions, silence, reflection (“It sounds like you’re exhausted”), or validates feelings: soften, share more, maybe cry or admit fear
• If the nurse gives false reassurance (“She’ll be fine,” “Don’t worry”), changes the subject, uses jargon, or answers only with facts: get more frustrated or shut down
• If the nurse explains the comfort plan clearly (breakthrough dose, repositioning, notifying the provider that the pain is not controlled): accept it, ask a follow-up
• If the nurse offers concrete help (chaplain, social work, hospice or palliative team, how to talk to the kids, ways he can help with her care): show relief

What the Students Should Be Doing (Good Responses to Watch For)

• Acknowledging his feelings before giving information
• Explaining that her pain will be reassessed and the provider notified, and that opioids given for comfort at end of life are appropriate (the goal is comfort, not hastening death)
• Explaining that loss of appetite is part of the dying process and that forced feeding does not add comfort, consistent with her comfort-care wishes; offering mouth care and favorite foods instead
• Inviting him to help with care: mouth care, lotion, repositioning, holding her hand, talking to her
• Age-appropriate guidance for the kids: honest, simple language for the 12-year-old; including the 18-year-old as a near adult; see the lifespan table in nsg210-dd-slides
• Offering chaplain, social work, hospice or palliative referral, and asking about his own support and rest