A 65-year-old male and his life partner for 33 years have just moved to this area and have yet to establish primary care.  The patient’s only medical history is asthma, and he takes an albuterol inhaler as needed. The patient was doing well at home until about 2 months ago when he noticed shortness of breath on exertion thought to be related to anxiety and recent inactivity with a 20-pound weight loss (current height 68″ and 148lbs). One week ago, the patient fell on the left side due to weakness, and since then, his pain and shortness of breath have continued to increase and are persistent with rest.  He went to the ED and was diagnosed with a closed left hip fracture and mediastinal lymphadenopathy with moderate pleural effusions. Lab tests were unremarkable. The patient was admitted for further evaluation.  He underwent a biopsy of the mediastinal lymphadenopathy and left hip repair (open hip with internal fixation) but has struggled to work with physical therapy due to pain treated with intravenous morphine and shortness of breath.  In addition, he was diagnosed with advanced stages of metastatic non-small cell lung cancer. He was very frightened and angry when he was told about the biopsy results. The patient and his partner wanted to get all possible treatments done. They met with the oncologist to discuss the possible treatment options and were told: “the patient has no treatment options available due to advance stages of the disease.”  The patient states, “I don’t want to die.”                                                 1.What symptoms management options can you order for this patient?                                  2. What would have been the patient’s perioperative risk for the hip surgery?

3. What would the appropriate discharge setting be for this patient?

4. How would you approach discussing end-of-life care with the patient and his partner? How would you educate on establishing DPOA-HC?

5. Do you have a code status designation form (POLST, MOLST, DNR, etc.) in florida  state?

6. Are Nurse Practitioners allowed to review these forms and sign these forms?

ANSWER

Comprehensive Care Approach for a Patient with Advanced Lung Cancer

As a nurse practitioner, providing comprehensive care for a patient with advanced lung cancer requires a holistic and patient-centered approach. The case of a 65-year-old male with metastatic non-small cell lung cancer presents a complex scenario that necessitates addressing symptom management, perioperative risk assessment, discharge planning, end-of-life discussions, and legal documentation. This essay will discuss each aspect of care, highlighting the considerations and interventions that a nurse practitioner should take into account.

Symptom Management Options

Pain Management: To address the patient’s pain from both the hip fracture and the cancer, a multimodal approach can be employed. This includes administering analgesics such as opioids, non-opioids, and adjuvant medications. Additionally, ensuring regular pain assessments and titrating medications based on the patient’s pain level is crucial.

Dyspnea Management:The patient’s shortness of breath should be managed with interventions such as supplemental oxygen therapy, breathing exercises, and positioning. Nebulized bronchodilators and corticosteroids can also help alleviate respiratory distress.

Perioperative Risk for Hip Surgery

The patient’s perioperative risk for hip surgery involves assessing factors such as age, comorbidities, and overall health status. Given his advanced lung cancer and associated symptoms, he may be at a higher risk for complications related to surgery and anesthesia. The risk of infection, delayed wound healing, and respiratory complications should be carefully considered.

Appropriate Discharge Setting

Due to the patient’s complex medical condition and need for ongoing medical care, a skilled nursing facility (SNF) may be the most appropriate discharge setting. The patient will require specialized nursing care, physical therapy, and pain management while recovering from hip surgery and managing his lung cancer symptoms.

Discussing End-of-Life Care

Approaching end-of-life discussions requires sensitivity and empathy. Openly addressing the patient’s fears and concerns while providing information about his prognosis is essential. Educating the patient and his partner about establishing a durable power of attorney for healthcare (DPOA-HC) helps ensure that his wishes are respected if he becomes unable to make medical decisions. These discussions should be ongoing and patient-led.

Code Status Designation and Nurse Practitioner’s Role

In Florida, there are various forms for code status designation, including POLST (Physician Orders for Life-Sustaining Treatment) and MOLST (Medical Orders for Life-Sustaining Treatment). Nurse practitioners may be authorized to review and sign these forms in collaboration with a physician, depending on state regulations. It’s crucial for the nurse practitioner to understand their scope of practice and state laws regarding these forms.

In conclusion, caring for a patient with advanced lung cancer involves addressing a multitude of physical, emotional, and legal considerations. By managing symptoms, assessing perioperative risk, planning appropriate discharge settings, facilitating end-of-life discussions, and understanding code status forms, nurse practitioners play a pivotal role in ensuring that patients receive compassionate and comprehensive care that aligns with their values and preferences.