Gladys attends the GP surgery for regular warfarin testing. Recently the practice nurse noticed that her hands were very swollen and that she was more breathless than usual. In addition, Gladys has a cataract on her left eye that appears to be getting worse and her family and friends think she is going deaf, as she sometimes fails to hear the phone ringing. In fact, the police were called by her friends recently when she did not respond to their phone call, as they were concerned she had fallen or was unwell. Gladys is single and lived and cared for her parents for many years whilst continuing to work full time. She has lived alone for the past 25 years but has always been a very independent and sociable person who regularly attended her local church and music group where she played the piano. She refuses any help with her housework, cooking or washing, which she does by hand, as she has no washing machine. However, she has become quite isolated since her best friend and neighbour of 20 years recently moved to be closer to her daughter. Gladys has not left the house for the last 18 months except to visit the surgery for her regular blood tests. She has a niece who visits weekly with her shopping and who now accompanies her to the surgery. The niece is concerned about Gladys and feels that she has become very withdrawn, and is increasingly anxious about maintaining her small Victorian terrace house. At her request, the family moved Gladys’s bed to the downstairs front room some time ago when she reported having difficulty climbing the stairs due to pain in her knees and the breathlessness. The bathroom and only toilet are on the ground floor. She has begun to discuss her wish to move to sheltered accommodation with her family so that she could have more company nearby but does not feel that she is ready for nursing care yet. When the nurse asks Gladys about her swollen hands, painful knees and breathlessness, Gladys seems reluctant to speak to the doctor but eventually agrees to see him. On examination, the GP diagnoses osteoarthritis and gout and refers Gladys to the rheumatology department at the local hospital.
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1. How would you go about initiating conversations about what is currently concerning Gladys about her healthcare and social care?
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Gladys has regular contact with her local surgery and in particular the practice nurse. She has been able to develop a trusting relationship with the nurse and this should allow an opportunity to ask her questions about any concerns she have regarding her well-being. These regular contacts also provide a good opportunity for the nurse to get to know more about Gladys’s life and the things that are important to her in addition to her physiological condition. When the situation changes (e.g. when Gladys presents with swollen hands), it is an opportunity for the nurse to identify with Gladys if she is still able to take part in the activities and events in her life that have meaning for her or if the physiological changes she is experiencing are limiting her sense of well-being.
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2. What would need to be taken into account when planning Gladys’s care?
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Gladys’s physical, psychological and spiritual needs should be assessed. Any medication for her osteoarthritis and gout will need to be continually reviewed with her and non-pharmaceutical interventions considered. Psychological/social support such as asking if Gladys would like a volunteer befriender to visit her at home or suggesting she might like someone to accompany her on a trip out or to a day centre could be considered. A visit to an assisted or sheltered housing complex might help Gladys to explore the longer-term options of moving. As Gladys approaches the end of life, care may be impeded by poor symptom control and lack of psychological and emotional support. There needs to be open communication between all involved in her care to promote symptom control, discuss treatment decisions and place of on-going care or preferred place of death.
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3. What opportunities are there to begin discussing end-of-life care with her?
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Gladys’s osteoarthritis has become much worse, and she has now also been diagnosed with gout. This will involve additional medical and nursing appointments and possible interventions. Such transition periods are often a good time to review what is important to Gladys and to begin the possibility of discussing how she would like to be cared for. In addition, Gladys has begun to acknowledge that life is getting more difficult at home and that she would like more company, so this could again be an ideal opportunity to begin to discuss with her and her family how she would like to be treated if she can no longer manage at home alone.
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4. How would you recognise the signs that she might be approaching end of life?
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There are a number of indicators that could highlight signs that Gladys might be approaching the end of life. These include poor appetite, weight loss, apnoea, physiological symptoms such as oedema, recumbency, lassitude, progression of disease, anticipatory grief, sleeplessness, increasing pain and agitation, depression and anxiety. Gladys is demonstrating some of these symptoms at present (such as increasing pain, depression and anxiety, possible progression of her disease). However, it is important when considering the implication of these symptoms to be aware of other factors that might be impacting on Gladys experience at this time. We know that she is somewhat socially isolated and that she recognises a need to have more accessible support nearby. Therefore, it is important to identify and offer treatment for amenable symptoms (such as her osteoarthritis and gout) and also acknowledge and consider ways that any social and psychological support required are also managed if possible.
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5. How might you include the niece in conversations about any future decisions concerning Gladys’s care?
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Gladys’s niece is clearly involved in her care and support and is now attending medical appointments with her. However, Gladys remains fiercely independent and likes to be in control of her life and decision-making regarding her healthcare choices. Therefore, it is important to establish with Gladys and her niece the extent of the support required and available as well as the expectations that Gladys and her niece may have about managing this relationship. Gladys is aware that her niece has a busy family life of her own, and it is important for Gladys that she is not a nuisance to her niece, but at the same time, she is aware that she needs additional support. The niece wishes to support Gladys but sometimes finds her inflexibility in making changes difficult to understand, especially if this would make life easier for her. As a nurse, you need to establish the extent of involvement that both parties are comfortable with before any care decisions can be made that might impact on them as individuals. Facilitating both Gladys and her niece to have an open discussion regarding their expectations about any future care needs could be the first step in this process and would help to reduce any future tensions about what they are both comfortable undertaking.
