Reference no: EM133867365

This clinical dilemma highlights the current code status of Mabel who has severe dementia and was recently extubated. She expressed to her husband years ago that she would not want to be kept alive long-term on a ventilator. Because of end-stage COPD, her primary care providers have communicated that if she required intubation for any reason in the future, she would likely remain on a ventilator the rest of her life. Her husband has not yet taken the initiative to honor Mabel's stated wishes and she remains a full code.

Code Status/Patient Autonomy

I. Scenario

History of Present Problem:

Mabel Miller is an 84-year-old woman with a history of senile dementia, COPD, and CVA with dysphagia requiring gastrostomy tube. She was admitted eighteen days ago to the ICU for respiratory failure due to COPD and influenza and was intubated and placed on mechanical ventilation. Mabel was successfully extubated after ten days on the ventilator and has been transferred to the medical floor where she is currently on oxygen per nasal cannula at 4 liters. Her husband has been told by the physician that if she needed to be reintubated, she would likely remain on a ventilator for the rest of her life.

Personal/Social History:

Mabel is unable to recognize any family members and is non-verbal. She resides in a skilled-care facility and would return to this setting after she is discharged. Jim, her husband of 58 years is active and involved in her cares at the hospital. He stays at the hospital and spends each night sleeping in a recliner in her room. He openly shows tenderness and kindness towards Mabel and asks appropriate questions of the nurse regarding her care.

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

RELEVANT Data from Present Problem:

Clinical Significance:

RELEVANT Data from Social History:

Clinical Significance:

II. The Dilemma Begins...

Current Concern:

Since Mabel has been extubated, she remains a full code. Jim acknowledges that Mabel communicated to him many years ago that she would not want to be kept alive on a ventilator, but he has been reluctant to change her code status from full code to do not intubate (DNI) despite what the primary care providers have told him.

What data from the current concern is important & RELEVANT; therefore it has clinical significance to the nurse?

RELEVANT Data from Current Concern:

Clinical Significance:

3.What additional members of the healthcare team could be used in this situation? Why?

4.What is the nursing priority?

III. Resolving the Dilemma

1.Identifying data that is RELEVANT, what is the essence of this current dilemma?

2.What additional information is needed by the nurse that would help clarify the current dilemma?

3.What additional members of the healthcare team could be used in this situation? Why?

4.What is the nursing priority?

5.What nursing interventions and/or principles can the nurse use to successfully resolve this clinical dilemma?

6. What is the expected response of the husband that indicate the nursing interventions were effective?

7. What response by the husband would indicate that a change in the plan of care and nursing interventions are needed?

8.What is the patient or family likely experiencing/feeling right now in this situation?

9.What can I do to engage myself with this patient's experience, and show that she matters to me as a person?

10.Does this scenario warrant a review by the medical ethics committee of the hospital? Why or why not?

11.What was learned from this case study that you will incorporate into your practice?