Comprehensive Care Planning for Mrs. A: Needs, Issues, and Support

This report presents a comprehensive analysis of Mrs. A's case, a patient diagnosed with late-stage ovarian cancer, focusing on her care needs and potential challenges. The report details the process of establishing Mrs. A's care needs, considering both actual and potential issues, and proposes goals of care using relevant models and frameworks, particularly the Roper-Logan-Tierney model. It emphasizes the importance of the palliative care social worker's role in implementing the care pathway, reflecting on the social worker's experience using Kolb's reflective cycle. Furthermore, the report explores the author's skills in assessing care needs, referencing relevant theory and discussing methods for sharing good practice. The report underscores the significance of care planning in providing quality patient care, considering the patient's family and overall well-being.

Meeting the Needs of Service
Users
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Contents
INTRODUCTION...........................................................................................................................3
Question 1:.......................................................................................................................................3
Discuss how the care needs of Mrs A were established and the actual and potential problems
that may arise, with suggested goals of care making use of the relevant models and
frameworks which enable this................................................................................................3
Reflect on the importance of the role of the palliative care social worker in the
implementation of the care pathway for Mrs. A using the Kolb framework to do so............6
Question 2:.......................................................................................................................................7
With reference to theory, explore your own skills of assessing care needs of patients’/service
users that you care for. Include reference to how your own good practice is shared or could be
communicated to others..........................................................................................................7
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10
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INTRODUCTION
Care plan is a crucial aspect to administering standard quality care to the patient. It not only
assists in defining the support as well as role of care workers in administering consistent care,
but it also makes the care team able to customise types and levels of support for each individual
according to their needs (Allum, Connolly and McKeown, 2018). This report is based on the
Case study of Mrs. A who was diagnosed with late stage ovarian cancer and her health is
gradually deteriorating due to the disease. She has the responsibility of her five children and one
grandson and was worried about who would look after her children in future. This report covers
care needs of Mrs A along with the potential and actual issues that may arise due to her situation.
Apart from this, it also covers reflection on significance of palliative care social worker role in
implementation of care pathway by using Kolb’s reflective model. At last, it explores own skills
of assessing care needs of service users and the way good practice can be communicated to
others.
Question 1:
Discuss how the care needs of Mrs A were established and the actual and potential problems that
may arise, with suggested goals of care making use of the relevant models and frameworks
which enable this
Care plan is defined as the written statement of individual assessed needs of a person
which are identified during the assessment of community care. This plan covers what support an
individual must get, why and when along with details of who is meant to render it. In care
planning, the individuals who are involved includes the patient, family members, individual who
carry out assessment including social worker, occupational therapist, district nurse or other care
professional, friend or relative. The care plan needs a systematic review of areas of need of an
individual, collecting and sharing stories of patients to whom care provider work with, exploring
as well as discussing information to assist establish what is most important, allow goal setting
and assisting to work out accomplished from individual care plan, action planning and risk
management (Back, Friedman and Abrahm, 2020).
In case of Mrs. A, she was diagnosed with advanced ovarian cancer and refer to palliative
care team. The social worker team has the responsibility to check whether the family were doing
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well or if they need anything. Mrs. A was suffering from Life threatening illness and was in the
advanced stage of cancer. At this time, the palliative care social worker provides wide variety of
support to her family. They provide them advice around debt, accessing other services, help with
housing and offering psychosocial support. The care planning of Mrs. A, it includes the
communication between her and her loved ones, substitute decision makers in future and give
providers regarding these wishes and values (Duckworth, Iezzi, and Carlson, 2018).
There are some standards relevant to care planning which needs to be considered by health
care professionals while providing treatment to Mrs. A of advanced ovarian cancer. These
professional standards include assessment, diagnosis, outcome identification, planning,
execution, coordination of care, health teaching and Health promotion, consultation, evaluation,
ethics, education, practice quality, evidence based practice and research, communication,
leadership, collaboration, resource utilisation, professional practice evaluation and environmental
health. All these standards must be considered by the hospice care professionals so that effective
care and support can be provided to Mrs. A. The care planner has a responsibility to perform
comprehensive information collection to the health care of patient and unique situation. The care
planner then analyses the information to a certain diagnosis and issues (Haigh, and et. al., 2019).
The expected outcomes are then identified and a plan is developed which includes interventions,
strategies and alternatives to accomplish projected outcomes. The developed plan is executed
and the care planner administers for coordination of planned care throughout the lifespan. They
work in collaboration with healthcare providers, consumers and others to provide effective, safe
and financially responsible care services to patients.
Professional standards define the competent care level in every phase of practice. Care
planning impacts positively on professional practice as it helps health care providers in providing
appropriate support and care to the patient and family of Mrs. A. This helps in managing the
chronic disease of Mrs. A in more appropriate way. As Mrs. A was in the late stage of ovarian
cancer, there are some actual and potential issues which may arise due to the disease. The
advanced ovarian cancer is the cancer which has spread outside the ovary (Hao, and Helo, 2017).
In the late stage of cancer, it may spread within abdomen or pelvis or away to other parts like
lungs. There are four stages of ovarian cancer among which this stage 4 is the last stage. In this
stage, cancer has spread to other organs, beyond reproductive system and pelvis. These other
organs can be brain, lungs, liver and skin. There are two sub stages in which the stage 4 of
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Cancer is divided, i.e., 4A and 4B. In the 4A stage, the cells of cancer are found in fluid which is
surrounding to the lungs, called as malignant pleural effusion. In this, the cancer has not spread
the locations outside peritoneal cavity or pelvis. In the 4B stage, cancer is spread to the areas
which is outside the peritoneal cavity (Katz, 2017).
One of the issue which may arise because of advanced ovarian cancer is infection.
Chemotherapy is used to destroy rapid divide of Cancer cells in body. However, in this process
sometimes the healthy cells also destroy. One kind of healthy cell which often damaged by
chemotherapy is responsible for developing white blood cells which helps in fighting from
invading germs and bacteria. The risk of infection increases when the white blood cell count in
the blood is low. The another risk is associated with kidney pain which is hard to detect in late
stage of cancer as it just feels like back pain. Sometimes, the cancer can spread and influence
urinary system and can block uterus which is responsible for moving waste between kidney and
bladder. Due to this, patient may experience swelling and pain and this eventually leads to
kidney damage. In this situation, the main goal of care providers is to provide adequate support
to Mrs. A and her family (Malhotra, Radich, and Garcia-Gonzalez, 2019).
The Roper-Logan-Tierney Model of care is referred as the nursing care theory based on
daily activities. The purpose of this model is an assessment utilise throughout the care of patient.
It attempts to define the meaning of living and categorise discoveries into living activities by
complete assessment. This leads the care providers to interventions which support in
independence in areas which may be complex for individual to address alone. This model
involves 12 activities including communication, maintaining safe environment, eating and
drinking, breathing, elimination, mobilisation, controlling temperature, washing and dressing,
sleeping, working and playing. In case of Mrs. A, she was suffered from advanced ovarian
cancer and faced many difficulties due to it. She is a single mother and have responsibility of 5
children. She is also guardian for her old grandson. Her health was deteriorated gradually and
she became frailer. In this situation, execution of Roper Logan Tierney model helps Health Care
professional in measuring the ability of Mrs. A to accomplish independence at every care stage.
All the 12 activities mentioned above utilised as framework for assessment, planning, execution
and evaluation process in care provision (Price, and Reichert, 2017). The model is assistive in
ensuring that the needs of patients are considered. Maintaining safe environment is very
necessary to make sure mental, psychological and physical wellbeing of patient while reducing
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infection risk. It is a very important aspect of recovery of Mrs A. Due to deteriorating health of
Mrs. A, she may also face difficulties in mobility. Execution of Roper Logan Tierney model help
health care professional in developing appropriate intervention which aid Mrs. A in mobility.
Reflect on the importance of the role of the palliative care social worker in the implementation of
the care pathway for Mrs. A using the Kolb framework to do so
The role of palliative care social worker in execution of care pathways for Mrs. A is very
significant. I am a palliative care social worker and assigned the responsibility to provide care
and support to an old woman, Mrs. A who was 51 years old and suffering from advanced ovarian
cancer. It is a late stage of cancer in which the cancer spreads outside the ovary. In this type of
cancer, the survival rate of women is only 17 % (Ringash, and et. al., 2018). For reflecting on my
own experience during the situation, I make use of Kolb's reflective cycle which involves four
stages, execution of which helps in learning effectively. When I visited to Mrs. A's home, I
found that she has ovarian cancer and she is in the last stage. I have the responsibility to provide
care and support to her.
The lady had five children and a 13-year-old grandson and she had the responsibility to all.
Her daughter also had ovarian cancer and she was died due to this in hospice settings. Because of
this, the family initially completely refused to get support from social work team. That made it
very difficult for me to engage with her but later, everything was fine and she was ready to take
help and support. I have the responsibility to check it family needed anything and how they were.
I helped Mrs. A to support in discussions regarding her illness, future, death and dying. I was
also able to work with the schools of children, provide advice and support to teaching staff.
While working with the family, I also got to know about the wish of Mrs. A. She wanted that her
elder daughter takes guardianship of children when she died. The guardianship required to be
legally transferred to elder daughter of Mrs. A which increased my involvement in the situation
(Sandsdalen, and et. al., 2015).
As a palliative care social worker, my role is to provide support to the family as well as
Mrs. A and help her in fulfilling her wish. In the overall scenario, initially I was not able to
understand the situation but, later when I interact with Mrs A and her family, I was able to
completely understand their situation and this allowed me to provide them adequate support and
care. I coordinator with the family of Mrs. A so as to ensure that appropriate care can be
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provided to her. Apart from this, I also worked in coordination with medical team and other
human service professionals so as to provide care in an effective way. In the overall situation, I
learnt many things and learn that how to handle such kind of situation effectively. It also assisted
me in understanding my roles and responsibilities as a social worker in more appropriate way
and make me able to perform my roles and responsibilities more effectively in future (Saracino,
and et. al., 2018).
Question 2:
With reference to theory, explore your own skills of assessing care needs of patients’/service
users that you care for. Include reference to how your own good practice is shared or could
be communicated to others
There are several skills which are required to possess by a healthcare professional for
assessing the needs of patient. These skills involve communication skills, negotiation skills,
listening skills, teamwork, coping skills, consistency, recording skills and emotional intelligence.
In developing the therapeutic relationship with the patient, it is necessary to have good
communication and listening skills as this helps in interacting with the patient and family in an
effective way and understanding which type of care and support they required. The main purpose
of developing professional relationship is to render adequate care and support to the patient
which help in improving their health and well-being (Sihra, Gibson, and Bradley, 2017). In case
of Mrs A, good communication skills helped me interacting with her and her daughter in an
effective way and knowing the entire situation. It also assisted developing good care plan for
Mrs. A which includes appropriate interventions and strategies which are assistive in improving
the health condition of Mrs. A.
The main purpose of therapeutic communication is to assist care user to feel cared for as
well as understood and developed a relationship which make the patient able to feel free and
express their concerns appropriately. The purposeful communication health care provider to
develop and maintain helping relationship with Mrs. A and her family. Shannon and Weaver
model of communication is designed to ensure effective communication between two persons.
Execution of this model in care practice is highly useful in communicating the information about
condition of Mrs. A clearly to medical team and other healthcare professional. The noise concept
of this model assist in making the communication influential by removing the barriers causing
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noise. The main agenda of National Health Services is to provide quality care services to the
patient (Swisher, and et. al., 2020).
The palliative care social worker has to work with different other people to provide
appropriate care and support to the patient. For this, they required to work collectively in team.
In providing appropriate care and support to Mrs. A, the different team members includes social
care workers, medical team and other professionals. For performing effectively in the team, the
team requires to assess the team role behaviour stated in Belbin team roles model. This will
assist in ensuring development of high performing team. According to Belbin team roles model,
the roles are categorised into three groups involving thought oriented, action oriented and people
oriented. The action oriented roles include shaper, implementer and completer finisher. People
oriented roles includes resource investigator, teamwork and coordinator. And the thought
oriented roles includes monitor evaluator, specialist and planter (Warraich, and Meier, 2019).
In context of the case of Mrs A, the social care worker requires to perform the role of an
implementer. They turn the concepts and ideas of team into practical actions and are disciplined
people to work efficiently and systematically in an organised way. Apart from this, as a
professional, the role of coordinator is also very important as their responsibility is to guide the
team towards accomplishment of care objectives set out previously to provide effective care to
the patient. Coordinators are the excellent learners and are able to recognise the value of
members in the team. In case of Mrs. A, coordination skills assist in developing good therapeutic
professional relationship by interacting with the patient and other team members and get good
understanding about the care needs of the patient.
Apart from this, the another role is the role of team worker, the individuals who render
support and ensure that individuals within the team are working collectively in an effective way.
They fill the negotiator role in team and are perceptive, diplomatic and flexible. In analysing the
and evaluating the ideas, monitor evaluator is the best role (Wieser, and et. al., 2017). These
individuals are critical thinkers and are strategic in their approach. The another role is role of a
specialist, who are the individuals with specialised knowledge which is very much required in
getting the job done appropriately. They have the specialised skills and abilities and have
expertise in their area of work. In relation to the case of Mrs A, the role of specialist is very
much essential in order to improve her health status. Mrs A was suffering from advanced ovarian
cancer and in order to provide her with appropriate care and support, it is necessary for the health
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care professional to have expertise in his or her area of practice. This assist in providing adequate
care to Mrs. A and help her in supporting in her end of life stage.
My own good practice can be communicating and shared by others with the help of using
appropriate communication channel. By developing an appropriate plan and communicating it
effectively to share good practice, healthcare professionals get benefit from it. Communicating
effectively enable the health care professionals to take better decisions regarding providing care
to Mrs. A. It improves competencies and efficiency level and assistive in improving the quality
of care (Sihra, Gibson, and Bradley, 2017).
CONCLUSION
As per the above mentioned report, it can be concluded that care planning is a significant
aspect of rendering standard quality of care to the service user. Meeting the needs of patient is
very necessary to ensure better outcomes regarding their health. Palliative social care worker has
several responsibilities including providing advice to patient and their family members, offering
them with psychological support and help them in accessing other services. There are some
standards which required to be considered by the social care workers at the time of care planning
including assessment, diagnosis, planning, execution, outcome, coordination of care etc. The
health care professional required to have appropriate skills and expertise to provide high quality
care to the patient.
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REFERENCES
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Oncology Practices: Meeting the Palliative Care Needs of Patients With Cancer and Their
Families. American Society of Clinical Oncology Educational Book, 40, pp.14-22.
Duckworth, M.P., Iezzi, T. and Carlson, G.C., 2018. Meeting the care needs of patients with
multiple chronic conditions. In Behavioral Medicine and Integrated Care (pp. 195-228).
Springer, Cham.
Haigh, M.M., and et. al., 2019. Cancer support services: Are they meeting the needs of rural
radiotherapy patients?. European journal of cancer care, 28(1), p.e12904.
Hao, Y. and Helo, P., 2017. The role of wearable devices in meeting the needs of cloud
manufacturing: A case study. Robotics and Computer-Integrated Manufacturing, 45,
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Katz, M.H., 2017. Meeting the Needs of Patients for Specialty Care. Jama Internal
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Malhotra, H., Radich, J. and Garcia-Gonzalez, P., 2019. Meeting the needs of CML patients in
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meeting the needs. In Seminars in radiation oncology (Vol. 28, No. 1, pp. 64-74). WB
Saunder
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studies review. Palliative medicine, 29(5), pp.399-419.
Saracino, R.M., and et. al., 2018. Geriatric palliative care: Meeting the needs of a growing
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Sihra, N., Gibson, S. and Bradley, L., 2017. Meeting the clinical needs of patients with
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Swisher, A.K., and et. al., 2020. Bridging the gap: identifying and meeting the needs of lung
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Warraich, H.J. and Meier, D.E., 2019. Serious-Illness Care 2.0-Meeting the Needs of Patients
with Heart Failure. The New England journal of medicine, 380(26), p.2492.
Wieser, J.L., and et. al., 2017. Use of a very high protein enteral nutrition formula assists in
meeting the protein needs of patients receiving intravenous sedation with propofol.
In Poster Session ASPEN Clinical Nutrition Week Annual Conference.
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