Care Coordination Scenario II Paper

In this simulation, you will recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family. Completing this exercise will help you develop a transitional care plan for Mrs. Snyder.

Care Coordination Scenario II

Rebecca Snyder case

From: Denise McGladrey, Preceptor

I’m sure you remember the Rebecca Snyder case that you worked on seven months ago. That was the first complex case that we assigned to you, and you did an excellent job sending Mrs. Snyder home with the resources and support she needed.

Mrs. Snyder is back in the hospital, and we are assigning this case back to you. Unfortunately, Mrs. Snyder’s ovarian cancer has spread. Her oncologist has recommended another course of chemotherapy, along with medications. The oncologist hopes this course of action could improve the quality of Mrs. Snyder’s life and also extend her life for another year.Care Coordination Scenario II Paper

However, Mrs. Snyder is in a good deal of pain and wants to discontinue treatment beyond palliative care. Her family is fighting her on this. As you may recall, Mrs. Snyder is very anxious about doctors and pain, and they think she is giving up treatment prematurely because she is afraid of it. They think she is not psychologically sound to make this decision.

As you know, this has been a challenging case, but I know you can handle it. As always, the CC team and I are available if you need to bounce some ideas off of someone.

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Thanks,
Denise

Mrs. Snyder is in her hospital room with her son, Avi. You have spoken to Avi before about Mrs. Snyder’s treatment, and he has been very helpful. You should meet with them to find out more about Mrs. Snyder’s current needs. Ask them as many questions as you like to get the answers you need.

Mrs. Snyder, how are you feeling?

Rebecca: Right this moment I’m doing okay because look at all this morphine they have me on!

Avi: Too much morphine in my opinion. It’s not good for her.

Rebecca: Oy, Avi, what does it matter if it’s not good for me? You should want your dying mother to be comfortable.

Avi: She isn’t dying yet. The doctor says she could live for a year or more if she gets more chemo. But she won’t listen.

Rebecca: It’s my time, Avi! I’m ready to go. And I’m sick of you and everyone else trying to keep me here when I’m in pain.

Why don’t you want to continue with chemotherapy?

Rebecca: I had a round of chemo and it was horrible! I threw up all the time and I was in so much pain. I refuse to go through that again.

Avi: But Mom, it will give you another whole year! At least!

Rebecca: Another year of what?

Avi: Look, my mother here is depressed and anxious. She’s terrified of pain. I don’t think she’s in the right state of mind to make a decision that’s going to end her life.

Rebecca: I most certainly am in the right state of mind!

Avi: My mother needs a psych consult.

Rebecca: How dare you speak as if I’m not in the room! I am an adult and I am perfectly capable of making my own decisions.

How are things going at home?

Rebecca: They’re okay. I can’t do everything that I used to do.

Avi: And that’s one of the main reasons she’s depressed. She’s used to doing things for everyone else.

Rebecca: I am not depressed. I’m just a little frustrated. There’s a difference.

Avi: She cleans, she cooks, she walks the dogs… she acts like nothing has changed. It’s no wonder she feels sick all the time when she won’t take a break. At least she finally relented and let us move her mother into a home.

Rebecca: I did. I don’t feel good about that.

Avi: It’s a very nice facility with kosher food and great nurses.

Rebecca: But it’s all the way on the other side of town. I don’t get to visit every day, especially now that I’m sick. I still feel like if I were a better daughter, I would have found a way to take care of my mother in my home.

Are you getting the help at home you need?

Rebecca: A lot of people have stepped in to help. Neighbors, people from the synagogue, cousins, you name it. It’s overwhelming.

Avi: And you need to let these people help you, Mom. She turns people away who want to do things like cook, which is ridiculous.

Rebecca: I can still cook for myself! I don’t want all these people around doing things that I’m perfectly capable of doing. It makes me feel guilty.

Avi: Guilty? Mom, you’ve been doing things for other people your whole life. It’s time for you to let other people take care of you.

Rebecca: I don’t want to be a burden! If I weren’t here anymore, people wouldn’t need to do these things.Care Coordination Scenario II Paper

Avi: Mom, stop talking like that! Do you hear her?

After you are discharged from the hospital, where would you like to go?

Rebecca: I want to go home. I am not going to die in some facility. I want to be surrounded by my family and die peacefully. And I want to be a burden to as few people as possible.

Avi: Mom, that’s fine eventually. But you’re not ready yet. There are still options for treatment.

Rebecca: There are no options that I can handle. No more pain, Avi, That’s all I ask. Send me with some good pain medications and let me fade away without suffering.

Avi: You are not in a psychologically sound position to make that decision.

Rebecca: Oy, Avi, you’ve gone meshuga! The whole family has gone meshuga.

What can we do to help you, Mrs. Snyder?

Rebecca: I just don’t want to be in pain anymore! And I don’t want to be a burden to my family. If the chemo didn’t hurt so much and make me so sick, then I would give it a try. Of course I would. Why wouldn’t I want to spend another year with my family? But there’s no way I can stand another round of that chemo. It was horrible! Please do what you can to get me sent home so I can die without pain.

What can we do to help you, Mr. Snyder?

Avi: Thank you for asking. I don’t know what to do anymore. I know my mother doesn’t have that much longer with us, but the doctor said there’s a really good chance she could live for a year or even more with another chemo treatment. If we could just find a way to get her through this treatment, then she could have months more to enjoy her last year. She deserves that. Please help me find a way to get through to her!

Mrs. Snyder is in her hospital room with her daughter, Devorah. Devorah is seven months pregnant. You should meet with them to find out more about Mrs. Snyder’s current needs. Ask them as many questions as you need.

How are you feeling today, Mrs. Snyder?

Rebecca: Well, the doctor just gave me six months to live. Otherwise, I’m peachy keen!

Devorah: They’ve adjusted the pain medications. So she’s feeling okay, at least for now.

Rebecca: I’m hungry. I could really go for a banana split.

Devorah: Mom, that’s not a good idea with your diabetes.

Rebecca: Oy, my diabetes. That’s what I want for my last meal, Devorah. A banana split.

Devorah: As you can see, she’s in a better mood. I think she actually feels relieved about the diagnosis.

Rebecca: I do feel relieved. Does that sound crazy? For months I’ve been worried about what’s going to happen next, and now I know.

What can I do to help you right now?

Rebecca: I just want to go home. I want to be in my own house surrounded by my family. That’s not too much to ask, is it?

Devorah: Of course not.

Rebecca: This palliative care… I can do that at home, right? You can send me home with pain medications? I don’t want to suffer.

Devorah: I’ve been reading about home hospice care. It definitely seems like the right option for our family. If we could have a home nurse to help out with some of the harder stuff, we can handle the rest.

If you choose home hospice, are there family members or others who can help?Care Coordination Scenario II Paper

Devorah: I can take care of my mother. And my brother Avi will help.

Rebecca: Oy, Devorahleh, I don’t want to burden you. There’s too much for you to do all by yourself, and Lord knows your father isn’t going to help. That baby will be here soon, and you have two other little ones at home to take care of.

Devorah: The baby won’t be here for another three months. And this pregnancy is going great—much better than the other two. My blood pressure hasn’t shot up in weeks. My mother-in-law has offered to help with the girls so I can take care of my mother.

Rebecca: But she works!

Devorah: But her schedule is flexible. At least most of the time it is.

Rebecca: And what if you have to go on bedrest? You did at the end of your other two pregnancies.

Devorah: That’s not going to happen, Mom. I feel great and my blood pressure has been close to normal. And Avi can help too.

Rebecca: Oy, Avi. Tell him to leave his liquor bottles at home.

Devorah: Avi’s been sober for months, Mom.

Rebecca: I wouldn’t say ‘months.’ When did he get out of rehab?

Devorah: He’s fine, Mom. And there’s a possibility that my aunt will come in from Florida and help out as well. She was here for a couple of weeks when mom first got diagnosed and that was a huge help.

Rebecca: Janet has health problems of her own now. Her back is really bad and I don’t think she’s supposed to fly.

Devorah: I’m pretty sure she can fly as long as it’s not too often. And there’s people from the synagogue who will be helping out too. We can definitely handle home hospice. We’ve been through worse!

How do you feel about hospice facilities?

Rebecca: They’re for old people who don’t have families. Not for someone like me.

Devorah: Hospice facilities seem like such lonely places. Why would anyone want to die in a facility like that when they could be in their own home?

Rebecca: Exactly. And I know that some hospices are actually pretty nice. But I don’t think I’d ever feel comfortable in a place like that. I want to be able to look at my old photo albums and put the twins to sleep at night. It’s bad enough that I’m not going to be able to be there for them anymore… I’m sorry. I want to be able to spend as much time with my children and my grandchildren as I can.

Devorah: You will, Mom.

Rebecca: And my dogs. I know that sounds crazy. I couldn’t stand the thought of having those farstinkehneh beasts in my house until the boys just begged me. And now I can’t wait to get home and cuddle with them! It’s not like I could bring my dogs to a hospice facility.

Devorah: You don’t have to go to a hospice facility, Mom. You took care of your mother for years. It’s my obligation and my honor to do the same for you.

If you had to stay in a hospice facility, do you have a preference for a particular type of facility?

Devorah: I don’t even want to think of that possibility.

Rebecca: Well, we should discuss this, I think. What if you go on bedrest again?

Devorah: Mom…

Rebecca: Just in case, Devorah, we should talk about it. There’s a Jewish hospice facility not far from our house. I visited people from the synagogue there a few times. They have kosher food and they even have religious services on Friday and Saturday.

Devorah: But that place looks so sterile.

Rebecca: It’s not so bad inside. I mean, it’s certainly not my first choice. But if I have to go to a facility, that’s the one I’d want. I definitely couldn’t go to a facility that wasn’t Jewish. I wouldn’t be able to eat the food and I certainly wouldn’t feel comfortable.

 

Rebecca Snyder case update

From: Denise McGladrey, Preceptor

To: you

Bad news. It turns out that Mrs. Snyder’s cancer has spread more than was initially discovered. Her oncologist no longer recommends another round of chemotherapy, and instead recommends palliative care. Her prognosis is six months or less, so as you know, she is now eligible for hospice care.

Mrs. Snyder now needs help coordinating end-of-life care. You should meet with her as soon as you can. Good luck, and thank you again for all your good work on this case.

Thanks,

Denise

Hospice Reccomendation

Mrs. Snyder asks you for your recommendation. Should you recommend home hospice care, or recommend a hospice facility?

Your Reccomendation

Recommend that Mrs. Snyder go to a hospice facility. There are too many red flags to recommend home hospice care.Care Coordination Scenario II Paper

Response from Mrs Snyder and her daughter Devorah

Rebecca: (adamant) No! That’s not what I want. I want to go home.

Devorah: I know it’s going to be a challenge to care for my mother at home. But we’re ready for the challenge. We’re a family, and we’re not going to send my mother away.

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You Responded by

You provide evidence to Mrs. Snyder and her daughter that a hospice facility would be a better choice. You ask them to imagine what would happen if Devorah had to go on bedrest, or if her mother-in-law were unable to watch the children, or if Avi started drinking again. You explained that families can still be very involved with their families and discussed all the resources that are available at hospice facilities.

Mrs. Snyder is very unhappy with this conversation and asks to think about it. Later in the day, she tells you she and her family have decided that the hospice is the right decision. Devorah and Avi tell you that they are relieved by this decision because they both doubt their ability to care for their mother adequately.

You Continue to recommend that Mrs. Snyder go to a hospice facility.

Response

Mrs. Snyder requests for a Jewish facility but non is available

You Recommended

Look for another hospice that might be able to accommodate an Orthodox Jewish patient.

Mrs. Snyder is not happy with your recommendation that she goes to a non-Jewish facility, and she threatens to go home. However, you promise her that you will do your very best to find her an appropriate facility where she can get kosher food and feel comfortable. She reluctantly relents.

Choosing a Hospice Facility

Let’s meet the hospice representatives

1st

Kathryn Marcus

Fern Hill Center Hospice

Audio Player

What can you tell Mrs. Snyder about your facility?

00:54

HIDE TRANSCRIPT

Kathryn: Mrs. Snyder, I know you’d prefer to go to a Jewish facility, but we’d be able to work with you and your family to meet your needs, religious and otherwise. At Fern Hill Center, we really pride ourselves in communicating with patients to make them as comfortable as possible, physically and emotionally. End-of-life care is definitely not a one-size-fits-all experience. We’ve had patients before who require a kosher diet…. actually, we have one now. We have kosher food brought in for him from a nearby Jewish hospice facility. If you’d like, I can see if one of this patient’s family members wouldn’t mind calling you and letting you know how their experience has been. Oh, and I see from your photos that you have a couple of dogs? They’re beautiful… I just love Golden Retrievers. If they’re well-behaved, we can arrange for them to visit you. We’ve just started doing pet visits recently, and our patients love that.

2nd

Father Miguel Rivera

St. Francis House Hospice Care Coordination Scenario II Paper

Audio Player

Select a question, and listen to the interviewee’s response.

What can you tell Mrs. Snyder about your facility?

00:59

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Father Rivera: Mrs. Snyder, we’d love to have you at St. Francis! We welcome people from many faiths and have had many Jewish patients. People who are not Catholic often choose St. Francis because we are a place that celebrates faith and spirituality. We have both a Catholic and a non-denominational chaplain on staff, and of course your rabbi can visit as well. We’re also one of the top-rated hospice facilities in the state. I brought you some pictures… would you like to see? You would have a beautiful and private room with a lovely view of the courtyard, and your room would be right outside of our aquarium. We have several cats that live in our facility and we bring in dogs almost every day to visit with the patients. Like I said, we’ve had many Jewish patients, although I don’t recall if we’ve had any Orthodox Jewish patients before who required a kosher diet. But I’m completely sure we can accommodate your dietary needs! We accommodate vegetarians, gluten free folks, a bunch of different kinds of allergies…kosher food won’t be a problem.

Hospice Facility Recommendation

Should you recommend St. Francis House or Fern Hill Center?

Great Choice!

You Recommended

Fern Hill Center Hospice

Mrs. Snyder and her family are very pleased with the care she receives at Fern Hill Center. The kosher food that is arranged for her is excellent. The staff does an outstanding job communicating with the family about Mrs. Snyder’s needs. As a result, the staff takes special care to help Mrs. Snyder with her anxiety. In addition, her dogs are welcomed into the facility as daily guests—and they provide comfort to other patients as well. After a few weeks, Mrs. Snyder’s daughter calls the hospital to thank you for recommending such an excellent facility.Care Coordination Scenario II Paper