Case Study - John Alland

Practice Point

Futile Treatment

John has been a resident at Clearview for 3 years. Previously he was an active man who played tennis 3 times per week. Over the past 6 months his physical condition has declined. He is now requiring full assistance for personal care and has had three falls in the last week while using his walker. His advance care directive indicates he is for ' full active treatment' including transfer to hospital.

Trigger:

Decline in functional status – increase in falls

Assessment:

Physiotherapists assessment of John's strength, balance and mobility.
Medication review.
Functional assessment by RN.

Attendance:

  • RN as case conference chair
  • John and his daughter Sue
  • GP via telephone
  • Physiotherapist to provide input on change in functional ability

Key discussion points:

Using the ‘Ask tell ask’ strategy, John and Sue are asked about how they feel John’s condition has changed recently, and in what situations they feel that going to hospital would be helpful. John’s daughter expresses that the change in his care needs has been difficult, including her father’s discomfort regarding assistance for showering. The case conference facilitator turns to John and acknowledges this must be difficult. She then suggests that they think through some ways that John can have more privacy yet be safe during his showers. Sue feels that there may be a medical reason for why things have changed, and asks if an assessment in hospital could identify a way to fix these problems. The case conference facilitator acknowledges Sue’s concerns for the best care for her father, and seeks permission to explain more about the current situation and what strategies could be utilised at the facility.

The case conference facilitator provides information about the gradual decline in physical function that usually occurs with dementia and asks Sue what she thinks should be done if John were to have another fall. Sue indicates that her father “didn’t want any heroics”. Confirmation of what this means is discussed and a plan is made to review John’s advance care plan. The physiotherapist is encouraged to provide information on his physical function and ongoing falls risk, advising that John is at high risk of further injury if he continues to walk unsupervised. The GP suggests stopping John's night time sleeping tablet to see if his mobility and balance improves.

Outcomes:

  • Physiotherapist to provide an exercise program and short supervised walks.
  • Change in medication with GP follow up in 2 weeks.
  • Advance care plan is revised, to indicate that John should not to go to hospital if his condition continues to gradually deteriorate. In the case of an acute emergency (fracture) he would agree to a short admission for assessment and management and then return to the facility.

Last updated 07 December 2015