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Case Study - Fred Wisp

Fred is an 87 year old retired bus driver. His wife Pam visits him every day, and he has always enjoyed her visits. Over the past 12 months, Fred has gradually deteriorated and now spends most of his time in bed. He sleeps most of the time and has stopped responding verbally and non-verbally to Pam when she visits him. Care staff report difficulty maintaining his skin integrity because he always wants to lie on his right side. His advance care directive indicates he is not to be transferred to hospital if his condition deteriorates but that ‘full treatment’ is to be provided within the facility.

Trigger:

Reduced responsiveness, worsening skin integrity

Assessment:

Comprehensive nursing assessment including skin and mouth care
Assessment of pressure injury risk - Waterlow scale
Functional Assessment Screening Tool (FAST) to establish severity of dementia and inform discussions over time regarding progression.

Practice Points

Link to Listening to Family's concerns

Listening to family's concerns

Attendance:

  • Fred and Pam 
  • GP to provide a medical perspective on prognosis and the need for a palliative approach within the context of his continuing therapeutic relationship with the whole family
  • Care staff to give insights into everyday functioning and needs
  • RN to facilitate the case conference and provide a perspective on Fred’s recent medical history 

Key Discussion points: 

Possible reasons for Fred’s increased drowsiness are discussed. GP and nursing assessments indicate that Fred’s dementia has progressed, and that this is a continuation of a gradual decline. The RN indicates that a range of factors may contribute to Fred’s risk of pressure injury, including poor hydration and oral intake and his preferred positioning in bed.

Strategies to encourage alternative positioning are discussed. Care staff suggest that Fred may like to face the door and that changing the position of the bed would assist.

When Pam is asked what her concerns are regarding Fred’s current condition, she indicates that she is worried she won’t be there when Fred dies, and that he will be alone. Comfort is provided to Pam by the case conference facilitator who also take the opportunity to provide education about the dying process. While assurances can’t be made that Pam will be present, the signs of approaching death are discussed and Pam is reassured that death in the facility will not be a lonely process for Fred.

Outcome:

A plan of care is developed to reduce risk of pressure injury, including repositioning of the bed, pressure cushions, and the use of hydrating skin creams.

Strategies to increase oral intake of food and fluids including offering more frequent sips of thickened fluids.Pam is encouraged to visit early in the morning when Fred is usually most alert.

Handouts are provided to Pam explaining what to expect in the final days/hours.

Arrangements are made for Pam to speak with the case conference facilitator later in the week for ongoing support and to answer any further questions.

Last updated 04 December 2015