management of a chronic health condition

The Case:
Patient profile:
Age: 69
Ethnicity: Caucasian
Marital status: Married for 47 years, to Phil.
Occupation: Retired book keeper.
Children: 5 children, 11 grandchildren and 2 great grandchildren.
Medical Hx: COPD, CVD, angina, ex-smoker, depression and osteoarthritis.
Social Hx: Multiple hospitalisations over past 12 months, due to COPD exacerbation. Nancy’s ability to manage her activities of daily living has been progressively worsening.
Religion: Dedicated Catholic, who used to attend church regularly and volunteer in her spare time. Since Nancy has been unwell, a priest from her church has been providing home visits weekly, for her spiritual comfort and encouragement

The Scenario:
‘I just feel so exhausted…’
Nancy is 69 years old. She has been suffering from Chronic Obstructive Pulmonary Disease (COPD) for many years. Her primary carer is Phil, her husband of 47 years, over the last 12 months Nancy has had multiple admissions to hospital with acute exacerbation of her COPD. The disease progression is causing Nancy to become increasingly fatigued. Nancy reports that when she is at home, she feels so exhausted that she often remains in bed throughout the day.
Three days ago, Nancy was readmitted to hospital for the third time in the past four months. On this occasion Nancy has presented with an exacerbation of COPD secondary to pneumonia. Whilst on the ward Nancy has had her medications reviewed, her new medication regime includes the following drugs- MS Contin 20mgs BD, PRN Ordine liquid 1ml (5mgs) 4 hourly for breathlessness, Ativan 0.5-1mg sublingually PRN for anxiety, Endep 50mgs nocte for depression, anginine 600mcgs PRN for angina, Cardizem 180mgs daily, Voltaren 25mgs daily, Flucloxacillin 500mgs TDS p.o, Coloxyl with Senna 2- 3 tablets nocte, Paracetamol 1000mgs TDS.
As her breakfast tray is delivered Nancy states she is “exhausted” and says she “no longer wants to go on”. From her charts it is clear that she has been refusing meals and most medications.

Nurse: Nancy, I see you haven’t eaten your breakfast… I have some tablets here for you to take. Do you want to have them now with your brekky?
Nancy (in a weak and breathless voice): I …. don’t …  want   …  anything…
Nurse: Is it the food? Don’t you like Weetbix? I can get you something else if you would like.
Nancy: No.. I don’t   …  want   … anything…Please understand.. I’m exhausted… I don’t …  want   … anything to eat… I just don’t ….want to… go on …anymore!
Nurse: Oh, Nancy, I can see how you might feel that way – you’ve been through so much this year.
Nancy (sighing): I’m …  just so… tired… And I worry…. about Phil… I… I.. think it is hard… for him.. having to watch… me …We both know… I’m dying… it’s only a matter of time… (She struggles to breathe, begins to weep, and coughs)
Nurse: I know… Coming to the end of your life isn’t easy. It’s a very difficult time for you – and for Phil. But you know you aren’t alone in this. We have many people who can help support you and your family while you work out this phase of your care. I can call in the social worker to chat with you and Phil. I can also arrange for pastoral care to be here to support you spiritually if you would like.
Nancy: That would… be nice, dear… I have my own priest,… I’d rather see him.. is that ….OK?
Nurse: That is even better, and I can arrange that for you. Do you have some ideas about your ongoing care? I ask because I notice that you don’t have any documentation about what you would want to happen in the event that you take a turn for the worse.
Nancy: No, no, I don’t… Can I do that?… Can I say…. what I would like… to happen to me?
Nurse: I will let the doctor know. He will come to see you and talk to you about what we call ‘Advance Care Directives’. That way he will be able to make sure that this phase is exactly as you would like it to be. And we will need to have a meeting with everyone to ensure that we are all on the same page.
Nancy: Will I ….be…. involved?
Nurse: You are the most important person! It’s essential that you – and you family – are involved. But you try to get some rest now, and leave it with me to organize.
(The nurse leaves the room, and Nancy closes her eyes.)

The story continues…
The nurse immediately calls the doctor and explains the situation.
Nurse: Dr Field? It’s Vicky the RN on Ward 11B. It’s about Nancy Gray. Yes, she’s been admitted again. I’m afraid she doesn’t have much time left and she would like to talk with you about decision making and her end of life care…
(Vicky then contacts Nancy’s priest and phones the social worker to discuss a referral for ongoing support for Nancy and Phil).
The meeting
Doctor Field initiates a case meeting to determine Nancy’s ongoing care. This meeting includes Nancy, her  family members, medical staff, nursing staff, the social worker, Father Missenden from Nancy’s local parish, and other allied health staff involved in Nancy’s care.
A few days later, following the meeting, all arrangements have been made for care during  Nancy’s end of life phase.
The beginning of the end…
Nancy’s condition quickly begins to deteriorate, and palliative measures are put in place. Nancy is commenced on a “Palliative Care Integrated Clinical Pathway for End of Life Care” to facilitate care during the dying phase

The Question:
The management of Nancy’s chronic health condition will require the involvement of many interprofessional team members. Provide a 500 word discussion on the interprofessional management of Nancy during the self-management. Your discussion should focus on the roles and responsibilities of the various interprofessional team members and provide evidence based references to support your discussion