Michael and Carol

Karen GlaetzerNurse Practitioner – Palliative Care Southern Adelaide Palliative ServicesLecturer (B) – Flinders University

Michael

> 39 year old man with cerebral palsy and intellectual impairment

> Lives with parents Carol and Donald> Presented to local medical surgery March 07

with headache> CT showed – posterior fossa lesion> Thought to be GBM> Excision and biopsy – histology inconclusive> Developed thyroid mass > Obstruction and tracheostomy> Histology – Medullary Ca Thyroid

Michael

• Treatment options – Surgery, XRT, Chemo • Family declined• 4 month hospital admission• First seen in ICU, family wanted to explore

home care options• Prognosis thought to be 2 weeks• Arrangements made for transfer home• No regular GP• Palliative Care Plan and Crisis Orders

Carol

> Mother of Michael> Diagnosed with large breast mass 2 months ago> Currently undergoing chemo pre mastectomy> Keen to have Michael return home> Went on to have mastectomy, then further chemo

and radiotherapy

NP Role

> Case Coordination role> Organised local GP > Visited fortnightly or weekly in later stages> Clinical/Psychosocial assessment> Support to parents> Reviewed and titrated medications as required

(dexamethasone and analgesia)> Phenytoin levels as needed – eventually changed

to Clonazepam so monitoring not needed> Arranged in home respite for when Carol having

chemo and radiotherapy

Outcome

> Michael died at home 9 months after discharge from hospital

> Cared for at home by his parents> Did not require any hospital admissions> Was seen twice by GP in 9 months, no

other medical contact> Carol presented 2 days after Michael’s

funeral with a pleural effusion

Outcome

> Admitted for drainage and further staging> Found to have widespread lung

metastases> Went home for 3 weeks> Did not want to put her husband through

another death at home> Died at Daw House 5 weeks after Michael> Bereavement follow up provided to Don

Tessa

Tessa

> 80 year old lady> Lives with husband and son> Presented with 2-3 week history of weight loss and

abdo pain> CT showed AAA, pancreatic mass and liver

metastases> Emergency AAA repair and biopsy of mass – adeno

ca pancreatic primary> Reviewed by Oncology – declined chemotherapy> Referred to Palliative Care Service

Tessa

> Assessed through Triage Process> Sent appointment for NP Clinic> First seen 11/8/09> Seen with husband and daughter> Full history taken, physical and

psychosocial assessment > Still independent> Not needing any increased community

supports at this stage

Issues Identified/Outcomes

> Constipation an issue – gave advice> Only using Endone 5mg once daily> Concerned by 3 stone weight loss –

referred for Megesterol/Dexamethasone Study

> Arranged referral for Wheelchair> Follow up appointment 6 weeks

Second Appointment

> 22 September 2009> Came with husband> Stable> Completed Megesterol Study> Now taking Endone 3 times a day –

commenced on Oxycontin 10mg bd> Physical Examination – right calf swelling,

warm and tender> Sent for Ultrasound – DVT confirmed –

commenced Clexane

3rd Appointment

> 1 December 2009> Increasing pain - Oxycontin increased to

20mg bd> Appetite poor> Obvious weight loss> Problems with constipation - Movicol> Epigastric mass larger> Continues on Clexane – mild ankle

swelling> Family still managing care

4th Appointment

> 2 March 2010> Pain increasing – needing to take regular

breakthrough in afternoons – Oxycontin increased to 20mg tds

> Appetite slightly improved> Further weight loss evident> Showering with husband nearby> Still not requiring any additional home

supports> Discussed respite options, but declined> Next appointment 2 months

OPD Clinics> Opportunity for regular review> Needs based > Strengths identified> Encourages independence > Empowers individuals to take control> Resource efficient

Essentials:> Constant reinforcement about what might

happen and contingencies> Opportunity to respond with a home visit

if/when the need arises> Communication back to GP and other

relevant providers