Would you consider the death a “good death”?  Why or why not?  Were the patient’s and family’s wishes followed?

QUESTION

Jennifer is a 26-year-old woman who gave birth three days ago to a healthy 9 pounds 2 ounce baby girl. The vaginal delivery was uneventful. Two hours after the birth, Jennifer began to complain of an “excruciating headache.” Within one hour of receiving acetaminophen for her headache, Jennifer became unconscious and suffered from a respiratory arrest. She was coded, placed on a ventilator, and sent to the ICU. A CT scan revealed that she had suffered from a massive cerebral hemorrhage. After it was determined that the damage to the brain was irreversible and that Jennifer would be unable to breathe on her own, her husband, Brett, made the decision that his wife should be removed from life support. “Our neighbor had Lou Gehrig’s disease and Jennifer would go visit with him and his wife. She always said she would never want to live like that,” stated Brett. However, Brett was not quite ready to have the ventilator removed. The Palliative Care team was called to visit with Brett, and also Jennifer’s parents. It was decided that Jennifer would be moved from the ICU down to one of the two new palliative care suites, and have the ventilator removed there.

Upon arriving to the palliative care suite, Brett and Jennifer’s parents were introduced to Nancy, the nurse that would be taking care of Jennifer and her family. Nancy was sensitive in talking with the family and had a great desire to find out what they wanted. The family agreed that the ventilator would be removed at noon the next day, to give family and friends an opportunity to say good-bye. Throughout the rest of the day, evening, and the next morning, over 75 people came to say good-bye to Jennifer.

Brett’s mother requested to stay with the new baby in the newborn nursery. Brett was so torn between spending time with his new baby girl and his wife. Nancy agreed that it was a good plan to have Brett’s mother care for the baby, while Brett concentrated on making decisions regarding Jennifer. Per Brett’s request, his mother brought the baby to the palliative care suite two times.

Jennifer’s pastor came by to spend time with Brett. He supported Brett in this very difficult decision. The hospital chaplain was also present. Nancy suggested some memory-making rituals such as taking a clipping of Jennifer’s hair, so her baby girl would have for later on. Footprints and handprints were made of Jennifer, per her parent’s request. A hand mold of the baby’s hand in her mother’s hand was made. Both Jennifer and the baby’s hospital name bands would be removed and placed in a memory box. Jennifer’s mother requested to bathe her. Brett brought in Jennifer’s favorite college sweatshirt to put on her. CDs of some of Jennifer’s favorite music were brought in and played.

The next day, as per the request of the family, the palliative care team reviewed with Jennifer’s family how they would extubate her. They talked about possible symptoms and how they would treat those. Brett, Jennifer’s parents, two brothers, and 12 other close friends were all together with Jennifer in the palliative care suite. The nurse from the newborn nursery brought the baby and laid her on Jennifer’s abdomen, per the family’s request. They were all reminiscing and telling Jennifer how much they loved her and how much she had meant to all of them. The palliative care nurse, physician, and chaplain were all present in the room and encouraged the family to take as much time as they needed. At 2 pm, the family reluctantly requested that the ventilator be removed.

When Jennifer was extubated, she turned cyanotic and began gasping for air. The team administered supplemental oxygen and morphine. Jennifer continued to gasp for air, and the morphine was doubled. This was repeated one last time until Jennifer was no longer dyspneic. Unfortunately, Jennifer remained cyanotic. Jennifer died 15 minutes, after she had been extubated. The palliative care team stayed with the family during the entire process.

The palliative care nurse made arrangements for Jennifer’s body to be picked-up by the funeral home directly from the palliative care suite. The family had requested that she not be taken to the hospital morgue. The team remained with the family, until the funeral home came. Once Jennifer’s body was removed by the funeral home, Brett left the palliative care suite to visit his new daughter in the newborn nursery. “One life so precious is gone, and yet, God has blessed me with another new life.”

Discussion Questions

1. Would you consider the death a “good death”?  Why or why not?  Were the patient’s and family’s wishes followed?  Were pain and other symptoms well-controlled?  How were ethical and/or legal issues handled?
2. Discuss the collaboration among team members.  Who else could have been collaborated with and how would that have improved the death?
3. Was there anything that could have been improved?  Were there issues that could have been prevented?

ANSWER

Evaluating the End-of-Life Experience: A Critical Analysis

Introduction

The case study presents the end-of-life journey of Jennifer, a 26-year-old woman who suffered a massive cerebral hemorrhage following childbirth. This discussion aims to evaluate whether Jennifer’s death can be considered a “good death” by examining the adherence to patient and family wishes, the management of pain and symptoms, and the handling of ethical and legal issues. Additionally, the collaboration among the healthcare team will be analyzed, along with potential areas for improvement and prevention of issues.

Assessing the Death as a “Good Death”:

 Patient and Family Wishes: Jennifer’s family and her husband, Brett, actively participated in decision-making and expressed their desires regarding end-of-life care. The decision to remove life support aligned with Jennifer’s previous statements about not wanting to live in a debilitated state, indicating that her wishes were respected.

Pain and Symptom Control: The narrative suggests that Jennifer’s respiratory distress was effectively managed through the administration of supplemental oxygen and morphine (Sinha, 2023). Although there were initial challenges with cyanosis, the palliative care team adjusted the medication dosages until Jennifer’s distress was alleviated.

Handling of Ethical and Legal Issues

End-of-life Decision-Making: Brett, as Jennifer’s spouse, made the decision to remove life support after considering her expressed wishes. This decision was supported by the presence of the palliative care team and the involvement of a pastor and chaplain, ensuring the ethical and emotional aspects were addressed.

 Respect for Autonomy: The team respected Jennifer’s autonomy by involving her family in decision-making and memory-making rituals. The creation of mementos, such as hand molds and memory boxes, demonstrated a thoughtful approach to honoring Jennifer’s legacy.

Collaboration Among Team Members

The case highlights effective collaboration among the healthcare team, including nurses, physicians, and chaplains (Pfaff & Markaki, 2017). However, the involvement of additional team members could have further improved the death experience:

 Mental Health Professionals: Including psychologists or grief counselors could provide emotional support to both Jennifer’s family and the healthcare team during and after the process.

 Social Workers: Involving social workers would ensure comprehensive support for Jennifer’s family, addressing practical matters such as funeral arrangements, financial concerns, and connecting them with appropriate community resources.

Areas for Improvement and Issue Prevention

While the case presents a generally positive end-of-life experience, a few areas could be improved to enhance future scenarios: a) Clear Documentation: Ensuring that Jennifer’s end-of-life wishes were documented in advance could have facilitated decision-making and prevented potential uncertainties or disputes.

Earlier Engagement of Palliative Care: Integrating palliative care earlier in Jennifer’s journey, especially when she developed an excruciating headache, might have prevented or minimized the severity of her cerebral hemorrhage (Devi, 2011). Timely palliative interventions could have improved symptom management and provided psychosocial support.

 Cultural Sensitivity: The case does not explicitly address cultural or religious considerations. Future improvements should include recognizing and accommodating diverse cultural practices and beliefs to ensure a culturally sensitive and inclusive end-of-life experience.

Conclusion

Overall, Jennifer’s death can be considered a “good death” based on the fulfillment of patient and family wishes, effective pain and symptom management, and the ethical handling of the situation. The collaboration among the healthcare team members was commendable, although involving additional professionals could have further enhanced the process. Identifying areas for improvement, such as clear documentation, early palliative care involvement, and cultural sensitivity, can lead to more comprehensive end-of-life experiences in the future, fostering a compassionate and patient-centered approach to care.

References

Devi, P. S. (2011). A timely referral to palliative care team improves quality of life. Indian Journal of Palliative Care, 17(4), 14. https://doi.org/10.4103/0973-1075.76233 

Pfaff, K. A., & Markaki, A. (2017). Compassionate collaborative care: an integrative review of quality indicators in end-of-life care. BMC Palliative Care, 16(1). https://doi.org/10.1186/s12904-017-0246-4 

Sinha, A. (2023, February 26). End-of-Life Evaluation and Management of Pain. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK568753/