By Mary Beth Kean, DNP. RN, ACNS

By Mary Beth Kean, DNP. RN, ACNS

Sixty years old Mrs. G was diagnosed with cancer and underwent surgery to attempt to remove tumor at time of diagnosis. Her doctors informed her she would need to reach an independent level of function in order to be considered a chemotherapy candidate. 

She felt hopeless causing her to be deeply depressed which complicated her chances of recovery.  Her pain was poorly controlled, she developed a poor appetite, she lacked the motivation to get out of bed, and she avoided conversation with her doctors, friends and family. She was transferred to a rehabilitation hospital as a trial to see if she could get stronger.

In rehab she struggled to work to reach independence with her husband’s assistance at her bedside around the clock. She wanted to have chemotherapy to improve her chances for long term survival. Advance care planning (ACP) was recommended by her doctors and she was encouraged to have a “goals of care” conversation with her family.

This “goals of care” discussion with Mrs G and her family identified four goals: 
improved pain management,  improved depression management,  strengthening so she could be independent again, hoping to live long enough to see her first grandchild due in 6 months. 
Mrs. G wanted resuscitation in the face of an emergency but with some limitations

Mrs. G and her husband completed their advanced directives together. During that discussion, Mrs. G and her family were coached on how to clarify her rehabilitation goals with her oncology and her rehab teams. The teams outlined concrete targets including weight, percent of meals consumed, and distance she had to be able to walk in order to be considered a chemotherapy candidate. Symptom management was initiated for pain and depression. With clear goals and symptom control she started to work hard to meet her rehabilitation targets and was able to discharge home with family.

She returned to see her oncologist for an outpatient appointment and she surprised the team with how well she looked and how independent she had become. The plan was for chemotherapy, however, before she could begin therapy she developed new symptoms. Her cancer had worsened.

When she was informed of her of the progression, her goals of care did not change allowing her to continue to live as well as she could despite her condition. She was able to be home with her family, go out to dinner with her husband and continues to anticipate the birth of her new grandchild. Mrs. G and her family agree that she wouldn’t be living as well as she is without having gone through ACP.