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Refractory symptoms case study

See the Statement of Assessment Methods or Key Dates for further information. Submit at: Assessment 1: refractory symptoms case study assessment task Case Study Case Study 1 Bill Smith is a 48-year old man with end-stage cirrhosis secondary to chronic active hepatitis. He is not eligible for hepatic transplantation as he is hepatitis B surface antigen positive. Over the last three weeks, his sleeping patterns have changed. He is asleep all-day and awake most of the night, when he is restless, fidgety and wanting constantly to get out of bed, even though he is too weak to walk. He is reaching out with his arms, and says he is seeing killer penguins in the room. He believes his family is trying to poison him whenever they attempt to give him medications. His wife and young adult children are caring for him at home, and they are distressed and very tired. Case Study 2 Mrs Mary Jones is an 81-year old widow who is admitted to your palliative care unit, due to escalating pain. She has diagnoses of advanced lung cancer, chronic renal failure, hypertension, osteoarthritis and vision impairment. Mrs Jones was independent with ADLs prior to the onset of severe pain. Her opioid and adjuvant doses are increased after admission and by day 4 her pain appears to be improving, although she is not able to give you a numerical rating scale for her pain today. She is quiet and vague in her verbal responses, and needs prompting to undertake activities such as showering. She sleeps for intervals during the day and is sometimes slow to rouse, and awake often during the night. In the evening, Mrs Jones’s son speaks to the nurse on duty to report that his mother has told him that she can see a dead man in the corner of the room, and that it has been there since she arrived on the ward. He also reports that his mother is not as clear in her speech and thinking as is usual for her. Discussion questions 1. Initial assessment of patient and family needs a. What are the signs and symptoms of concern for these two patients, and what do they signify? Frame these patients’ signs and symptoms within the diagnostic criteria/definition of a commonly occurring syndrome in palliative care populations. b. What are the likely needs of these patients’ family? 2. What predisposed these patients to these changes? What are likely precipitants? Are symptoms likely to be reversible for Bill and Mary? Frame your response within the Why framework questions (Resource 1.3 in the study guide): 1. Why has a change in condition occurred? 2. What is the time-frame for the change? 3. What else has changed in or around the same time period? 3. What is the first line and second line management of delirium? Please justify your reasons for this ordering. Identify which interventions you are most likely to use to help Bill and Mary, and their families. 4. Having not had a response to interventions, is there a role for sedation in refractory delirium? Consider the different levels of sedation, the evidence for its efficacy and safety, and whether it may be appropriate for Bill or Mary. 5. If there is a role for sedation, what processes would you go through before offering it? 6. How do we ensure that we are effectively and safely treating the patient, not responding to the pressure of family or staff distress? 7. How can family or staff distress be effectively addressed?

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