NR 579 Week 1 Reflection, Assignments of Nursing

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Student Name Week 1 Reflection NR Dr. Jackson

I work in the ICU and this is an issue that I encounter weekly. Sadly, code status and advance directives are one of the first questions that we ask upon admission to the ICU, and it is part of our admission paperwork. It is often that the patient is incapacitated, they have no known advanced directives, and their family members are unsure of the patient's wishes in end-of-life care, due to not having those conversations. In the setting in which the patient has capacity and is supported by their family at the bedside, I always like to paint the picture of the patients current health status and what we are doing to support them medically. I also highlight the barriers to the patient's progression if appropriate. Lastly, I share my concerns going forward. For instance, I had a patient with end stage alcoholic liver cirrhosis who continued drinking. His kidneys were also shutting down, and he was not a liver transplant candidate as he was still drinking alcohol up until his admission. The continues buildup of ascites secondary to the cirrhosis was impeding his ability to breathe and function in his daily life. He had made it clear that had he been eligible for the transplant, he wouldn’t want to take the medications for antirejection. He also made it clear he did not want to undergo weekly taps for his ascities. Nephrology stated they would not start him on dialysis as it was futile and would only prolong suffering as his liver was the problem. It was here that I highlighted the importance of a code status discussion and advance directives. I stated I was concerned that without dialysis, his potassium would potentially continue to climb from it’s already high value, and send him into a lethal cardiac rhythm. Thus highlighting the time sensitivity of these conversations. Sadly, he didn’t realize that when he came in for shortness of breath, he would be given a terminal sentence. We contacted palliative care to come see him, and they discussed DNR status and goals of care. In reading about advance directives, it appears that in the US, there is no real guidelines or minimum content that is included on the paperwork (Sedini et al., 2021). Highlighted in this article, and an issue that we see in the hospital when the patients do have advance directives is that sometimes they are too vague or ambiguous making the physician have to rely on the ideations of the health care surrogate or decision maker, negating the purpose of the advance directive (Sedini et al., 2021). This article did lend some tools that I had never heard of including The Conversation project which is a written tool kit with value based questions to help drive the advance care planning conversations, and the Making your Wishes Known tool which is a video with instructions on how to complete and advance directive (Sedini et al., 2021). To close, I personally feel that all PCP should discuss advance directives and code status at each routine appointment while the patients are still capacitated and able to take the time to plan and make their wishes known. Reference: Sedini, C., Biotto, M., Crespi Bel’skij, L. M., Moroni Grandini, R. E., & Cesari, M. (2021). Advance Care Planning and Advance Directives: An overview of the main critical issues. Aging Clinical and Experimental Research, 34(2), 325–