This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
Case
The patient is illustrative. Mrs. E., 81, has severe chronic obstructive pulmonary disease and has been admitted three times in six months with exacerbations. She uses home oxygen and can walk only a few steps before stopping to breathe. She has never discussed what she would want if she became too ill to speak for herself. Her son assumes "everything should be done," while her daughter says her mother told her she never wants to be "on a breathing machine."
Why advance care planning matters
Advance care planning helps people reflect on their goals, values and beliefs, consider future treatment preferences, choose a surrogate decision-maker, and document their wishes. In a randomized trial of 309 medical inpatients aged 80 or older in Melbourne, Australia, half were offered facilitated advance care planning. Among the 56 patients who died within six months, end-of-life wishes were known and respected for 86% of those in the intervention group compared with 30% in the control group. Family members of patients in the intervention group who died had less stress, anxiety and depression, and patient and family satisfaction was higher (Detering et al., 2010).
Palliative care also works alongside treatment, not only at the end of life. In a trial of 151 patients with newly diagnosed metastatic lung cancer, those who received early palliative care alongside standard oncology care had better quality of life, fewer depressive symptoms (16% vs. 38%), and less aggressive end-of-life care, and their median survival was longer (11.6 vs. 8.9 months; Temel et al., 2010). Mrs. E. has a different illness, but the principle of integrating palliative care early applies.
The conversation
The nurse arranges a family meeting with the provider while Mrs. E. is well enough to take part.
| Step | What the nurse says or does |
|---|---|
| Prepare | Confirms Mrs. E. wants her children present; books a quiet room; checks her understanding of her illness |
| Ask about understanding | "What do you understand about where your lung disease is now?" |
| Ask about goals | "If your health gets worse, what matters most to you?" Mrs. E. says being at home and not suffering |
| Ask about fears | "What worries you most about the future?" She is afraid of feeling she can't breathe |
| Talk about trade-offs | With the provider, explains what intubation and ICU care would involve for her, and what comfort-focused options exist |
| Choose a surrogate | Mrs. E. chooses her daughter, and asks her son to support her decision |
| Document | Helps her complete an advance directive and records her goals in the electronic record; the provider completes any medical orders that reflect them |
Nursing care that follows
- Refer to the palliative care team for help with breathlessness, such as opioids at low doses, a fan, positioning and breathing techniques.
- Make sure the advance directive goes home with her and is shared with her primary care provider.
- Revisit her wishes at each admission, since preferences can change.
- Support her son, who is struggling with the decision, and offer the chaplain or social worker.
Reflection
The family disagreed because no one had asked Mrs. E. directly. A planned, structured conversation let her speak for herself while she still could, and it gave her children a shared understanding of what she wanted.
References
Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ, 340, Article c1345. https://doi.org/10.1136/bmj.c1345
Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., Dahlin, C. M., Blinderman, C. D., Jacobsen, J., Pirl, W. F., Billings, J. A., & Lynch, T. J. (2010). Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine, 363(8), 733–742. https://doi.org/10.1056/NEJMoa1000678
