Case Study Reflection on Community Based Palliative Care and DNAR Decision Making
Added on 2023-06-09
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Running head: CASE STUDY REFLECTION
Case study reflection
Name of the student:
Name of the University:
Author’s note
Case study reflection
Name of the student:
Name of the University:
Author’s note
1CASE STUDY REFLECTION
So what:
In the context of Ahmed’s case scenario, it is seen that Ahmed was receiving palliative
care in a community care setting. Community based care can be defined as coordinated
integrated care provided in community setting such as health care clinics, patient’s home,
hospices and any public health units. Patient centred and population centered care is a priority in
community based care and it is responsive to social, language, cultural and gender difference of
client (Kogan, Wilber and Mosqueda 2016). Community based care includes various types of
care services such as primary care services, treatment and management of chronic illness,
rehabilitation support and end-of-life care. In the context of patient with life limiting illness,
palliative care in the community setting is provided through established delivery systems such as
electronic palliative care delivery and utilization of different technologies to meet increasing
palliative care needs (Daubman, Rosenberg and Kamdar 2017). The main goal is to enhance the
quality of life of people (Walshe and Luker (2010). Rosenwax et al. (2015) argued that the
advantage of palliative care in patients with cancer is that it significantly reduced the number of
emergency department visits in the last year of life. However, for Ahmed, the need to discuss
about DNR request came up because he was at the end stage of metastatic lung cancer.
Community nurse is one member of the palliative care team who has specialized skill in
providing physical care, coordinating work of others and dealing with emotional and
psychological issues of patient (Seow et al. 2014). Specialist palliative care nurse also support
community nurses depending on the complexity and needs of patient and family. Community
nurse are involved in the assessment, planning and coordination of care for dying patients
(McIlfatrick et al. 2017). A study done in 2010 provided a detailed account of the role of the
So what:
In the context of Ahmed’s case scenario, it is seen that Ahmed was receiving palliative
care in a community care setting. Community based care can be defined as coordinated
integrated care provided in community setting such as health care clinics, patient’s home,
hospices and any public health units. Patient centred and population centered care is a priority in
community based care and it is responsive to social, language, cultural and gender difference of
client (Kogan, Wilber and Mosqueda 2016). Community based care includes various types of
care services such as primary care services, treatment and management of chronic illness,
rehabilitation support and end-of-life care. In the context of patient with life limiting illness,
palliative care in the community setting is provided through established delivery systems such as
electronic palliative care delivery and utilization of different technologies to meet increasing
palliative care needs (Daubman, Rosenberg and Kamdar 2017). The main goal is to enhance the
quality of life of people (Walshe and Luker (2010). Rosenwax et al. (2015) argued that the
advantage of palliative care in patients with cancer is that it significantly reduced the number of
emergency department visits in the last year of life. However, for Ahmed, the need to discuss
about DNR request came up because he was at the end stage of metastatic lung cancer.
Community nurse is one member of the palliative care team who has specialized skill in
providing physical care, coordinating work of others and dealing with emotional and
psychological issues of patient (Seow et al. 2014). Specialist palliative care nurse also support
community nurses depending on the complexity and needs of patient and family. Community
nurse are involved in the assessment, planning and coordination of care for dying patients
(McIlfatrick et al. 2017). A study done in 2010 provided a detailed account of the role of the
2CASE STUDY REFLECTION
district nurse in providing palliative care. Realist review of literature from electronic databases
gave idea regarding different dimensions of their role.
Nurses had confident in providing physical care. However, literature revealed that many
district nurse struggled with psychological aspects of care and they fail to understand patient’s
and family’s perspective regarding going through the trauma of being diagnosed with a life
limiting illness. Difficulty in effectively communicating with a dying person is also a challenge
for them. The strength of the study is that as large number of qualitative studies were reviewed, it
provided rich data on experience of district nurse in providing care to dying person. However,
the study is limited by small sample size and poor quality research methods used in many
qualitative studies (Walshe and Luker 2010). It has also been argued that community nurse fail
to address dignity and other concerns for people with life limiting illness McIlfatrick et al.
(2017).
The failure to address dignity creates issues related to patient and family’s dissatisfaction
with care (Pringle, Johnston and Buchanan 2015). During the decision making process for DNR,
I noticed that community nurse did not followed a patient centred care approach to first assess
patient and determine the necessity of DNR for the patient. Communication process was
compromised because patient’s consent related to the DNR process was not taken. According to
Woo et al. (2013) nurses should act as an advocate while caring for patients with DNR. Hence,
actions like evaluating patient’s perspective about DNR would have enhanced the likelihood of
provding patient centered care. Improving communication at the stage of Ahmed’ care was
important as it has the potential to address patient’s need and preferences and support community
nurse to provide transparent care. Research evidence also suggest that collaborative practice can
flourish when health care staffs respects and values the opinion of patients and their family
district nurse in providing palliative care. Realist review of literature from electronic databases
gave idea regarding different dimensions of their role.
Nurses had confident in providing physical care. However, literature revealed that many
district nurse struggled with psychological aspects of care and they fail to understand patient’s
and family’s perspective regarding going through the trauma of being diagnosed with a life
limiting illness. Difficulty in effectively communicating with a dying person is also a challenge
for them. The strength of the study is that as large number of qualitative studies were reviewed, it
provided rich data on experience of district nurse in providing care to dying person. However,
the study is limited by small sample size and poor quality research methods used in many
qualitative studies (Walshe and Luker 2010). It has also been argued that community nurse fail
to address dignity and other concerns for people with life limiting illness McIlfatrick et al.
(2017).
The failure to address dignity creates issues related to patient and family’s dissatisfaction
with care (Pringle, Johnston and Buchanan 2015). During the decision making process for DNR,
I noticed that community nurse did not followed a patient centred care approach to first assess
patient and determine the necessity of DNR for the patient. Communication process was
compromised because patient’s consent related to the DNR process was not taken. According to
Woo et al. (2013) nurses should act as an advocate while caring for patients with DNR. Hence,
actions like evaluating patient’s perspective about DNR would have enhanced the likelihood of
provding patient centered care. Improving communication at the stage of Ahmed’ care was
important as it has the potential to address patient’s need and preferences and support community
nurse to provide transparent care. Research evidence also suggest that collaborative practice can
flourish when health care staffs respects and values the opinion of patients and their family
3CASE STUDY REFLECTION
including their cultural and ethical perspectives (Hileli et al. 2014). According to Nice guideline,
ensuring good communication and shared decision making is necessary to reduce complaints
over care at the end of life (NICE 2015).
By witnessing the decision making process of DNR, I could identify many gaps in such
decision making process for Ahmed. DNAR or Do Not Attempt Resuscitation decision is centred
around the decision to withhold cardiopulmonary resuscitation (CPR) during the event of sudden
cardiopulmonary arrest of people (Mockford et al. 2015). Although DNAR decision making are
common in palliative care, however it is associated with many ethical and legal challenges
(Brogan, Hasson and McIlfatrick 2018). This is because the decision involves withholding CPR
instead of providing it to patient. Hence, many people go against DNR process because it is a
violation of patient’s autonomy (Altin and Stock 2016). However, the DNR process is favoured
by many because it saves people from invasive treatment which ultimately yield no benefit for
the dying patient (Downar et al. 2011). Although during cardiopulmonary arrest, the decision to
resuscitate or not to resuscitate depends on the clinician’s decision making, however patients and
family are involved because of the futility of the treatment in end-of-life patient (Salins et al.
2010). DNR decision making process became a subject of conflict in case of Ahmed’s case
scenario. This was mainly because of different perspective of Ahmed’s wife and his family
regarding well being and no step taken to assess Ahmed’s wish regard DNR. This occurred
because of cultural gap and difference in values between the two parties. Ahmed’s family were
from Arab and according to religious beliefs of Arabs, they do not favour taking their lives by
themselves (Hileli et al. 2014). In contrast, Ahmed’s wife was more liberal in thinking because
of her cultural background and she prioritised comfort ahead of religious values.
including their cultural and ethical perspectives (Hileli et al. 2014). According to Nice guideline,
ensuring good communication and shared decision making is necessary to reduce complaints
over care at the end of life (NICE 2015).
By witnessing the decision making process of DNR, I could identify many gaps in such
decision making process for Ahmed. DNAR or Do Not Attempt Resuscitation decision is centred
around the decision to withhold cardiopulmonary resuscitation (CPR) during the event of sudden
cardiopulmonary arrest of people (Mockford et al. 2015). Although DNAR decision making are
common in palliative care, however it is associated with many ethical and legal challenges
(Brogan, Hasson and McIlfatrick 2018). This is because the decision involves withholding CPR
instead of providing it to patient. Hence, many people go against DNR process because it is a
violation of patient’s autonomy (Altin and Stock 2016). However, the DNR process is favoured
by many because it saves people from invasive treatment which ultimately yield no benefit for
the dying patient (Downar et al. 2011). Although during cardiopulmonary arrest, the decision to
resuscitate or not to resuscitate depends on the clinician’s decision making, however patients and
family are involved because of the futility of the treatment in end-of-life patient (Salins et al.
2010). DNR decision making process became a subject of conflict in case of Ahmed’s case
scenario. This was mainly because of different perspective of Ahmed’s wife and his family
regarding well being and no step taken to assess Ahmed’s wish regard DNR. This occurred
because of cultural gap and difference in values between the two parties. Ahmed’s family were
from Arab and according to religious beliefs of Arabs, they do not favour taking their lives by
themselves (Hileli et al. 2014). In contrast, Ahmed’s wife was more liberal in thinking because
of her cultural background and she prioritised comfort ahead of religious values.
4CASE STUDY REFLECTION
The DNR request can be made by any patient according to DNAR policy. The DNAR
policy lays out procedure which ensures that high quality CPR will be available to those patients
who will benefit from it. The policy applies to registered nurse, doctors and allied health care
professionals and provides the correct process for making, documenting and implementing
DNAR decisions (NHS Foundation Trust 2016). While appraising the DNAR policy, there is a
need to consider different legal and ethical issues related to DNAR decision making process.
This may help to understand the reason behind the conflict that occurred during Ahmed’s
decision making process. The ethical questions arising while going with the DNAR process is
related to patient’s autonomy and ethical values of beneficence and non-malificence (Salins et al.
2010). While providing care to patient, patient’s autonomy should be a major part of care
delivery (Hess et al. 2015). This is also important as part of patient and family centred care.
Patient centred care provides the scope to increases patient’s trust and satisfaction with care
(Altin and Stock 2016). It is a care provision that is respectful of patient’s preferences, needs
and values. While taking any care decisions for patient, validating with patients regarding their
care needs is a responsibility for all health care professionals (Epstein and Street 2011).
According to patient’s autonomy principle, patient must be informed regarding all decisions
related to treatment and care. However, the extent to which this is fulfilled during DNR process
is doubtful. Azimzadeh et al. (2013) argues that providing patient-centred care in a cancer ward
becomes difficult as all patients’ need cannot be met. Hence, care of patient with cancer brings
unique challenges for health staffs. Similar kind of ethical challenges was witnessed while taking
DNR decision for Ahmed too as he was in the end stage of metastatic cancer.
According to the above mentioned DNAR policy, DNAR order can be issued by a care
provider or a physician only when the order is addressed by a fully informed patient with
The DNR request can be made by any patient according to DNAR policy. The DNAR
policy lays out procedure which ensures that high quality CPR will be available to those patients
who will benefit from it. The policy applies to registered nurse, doctors and allied health care
professionals and provides the correct process for making, documenting and implementing
DNAR decisions (NHS Foundation Trust 2016). While appraising the DNAR policy, there is a
need to consider different legal and ethical issues related to DNAR decision making process.
This may help to understand the reason behind the conflict that occurred during Ahmed’s
decision making process. The ethical questions arising while going with the DNAR process is
related to patient’s autonomy and ethical values of beneficence and non-malificence (Salins et al.
2010). While providing care to patient, patient’s autonomy should be a major part of care
delivery (Hess et al. 2015). This is also important as part of patient and family centred care.
Patient centred care provides the scope to increases patient’s trust and satisfaction with care
(Altin and Stock 2016). It is a care provision that is respectful of patient’s preferences, needs
and values. While taking any care decisions for patient, validating with patients regarding their
care needs is a responsibility for all health care professionals (Epstein and Street 2011).
According to patient’s autonomy principle, patient must be informed regarding all decisions
related to treatment and care. However, the extent to which this is fulfilled during DNR process
is doubtful. Azimzadeh et al. (2013) argues that providing patient-centred care in a cancer ward
becomes difficult as all patients’ need cannot be met. Hence, care of patient with cancer brings
unique challenges for health staffs. Similar kind of ethical challenges was witnessed while taking
DNR decision for Ahmed too as he was in the end stage of metastatic cancer.
According to the above mentioned DNAR policy, DNAR order can be issued by a care
provider or a physician only when the order is addressed by a fully informed patient with
5CASE STUDY REFLECTION
decision making capacity or a patient’s family member with decision making capacity or legal
guardian with decision making authority (Griffith 2015). When the spouse or children or parent
is more than one, then all must agree to the decision. However, this provision mentioned in the
policy is questioned for end-of-life patients as they may not have the capacity to take such
decision because of their illness. As per the ethical directive of patient’s autonomy and informed
consent, a physician need to discuss about the proposed intervention, risk and benefits with
patient to take best decisions regarding resuscitation and end-of-life (Shaw et al. 2018). In
contrary, while working with seriously ill patients, clinical seldom discuss advanced care
directive with patient. This is also understood from a research done by Gibbs, Malyon and Fritz
(2016) which conducted an exploratory international investigation into the resuscitation decision
making process. Survey questionnaires related to DNAR decisions were collected from 143
medical professionals. Specific guidelines related to DNAR decisions where followed by 88% of
respondents and 90% of them discussed DNAR decision with patient at least half of the times.
However, the response of participants differed based on difference in cultural attitude towards
death, role of family and medical education. However, the research can be generalized because
large number of respondents from one particular country was taken. Evaluating perceptions
related to DNAR process for countries with diverse culture was important. During Ahmed’s
decision making process, difference of opinion between his wife and family member arose. At
this point, it was essential for community nurse to openly discuss about end-of-life preference
with Ahmed’s family members. As Ahmed was in coma, the possibility of assessing Ahmed’s
wish related to the DNAR decision was also not there.
The complexity in DNR decision making process is also understood from numerous
ethical, legal and biopsychosocial issues in care (Bjorklund and Lund 2017). Medico legal issues
decision making capacity or a patient’s family member with decision making capacity or legal
guardian with decision making authority (Griffith 2015). When the spouse or children or parent
is more than one, then all must agree to the decision. However, this provision mentioned in the
policy is questioned for end-of-life patients as they may not have the capacity to take such
decision because of their illness. As per the ethical directive of patient’s autonomy and informed
consent, a physician need to discuss about the proposed intervention, risk and benefits with
patient to take best decisions regarding resuscitation and end-of-life (Shaw et al. 2018). In
contrary, while working with seriously ill patients, clinical seldom discuss advanced care
directive with patient. This is also understood from a research done by Gibbs, Malyon and Fritz
(2016) which conducted an exploratory international investigation into the resuscitation decision
making process. Survey questionnaires related to DNAR decisions were collected from 143
medical professionals. Specific guidelines related to DNAR decisions where followed by 88% of
respondents and 90% of them discussed DNAR decision with patient at least half of the times.
However, the response of participants differed based on difference in cultural attitude towards
death, role of family and medical education. However, the research can be generalized because
large number of respondents from one particular country was taken. Evaluating perceptions
related to DNAR process for countries with diverse culture was important. During Ahmed’s
decision making process, difference of opinion between his wife and family member arose. At
this point, it was essential for community nurse to openly discuss about end-of-life preference
with Ahmed’s family members. As Ahmed was in coma, the possibility of assessing Ahmed’s
wish related to the DNAR decision was also not there.
The complexity in DNR decision making process is also understood from numerous
ethical, legal and biopsychosocial issues in care (Bjorklund and Lund 2017). Medico legal issues
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