Case Study 3 - Ada

Ada was admitted to the Home in June 2011 with a history of Dementia, hypertension and diverticulitis and was coded `A’.  She had limited cognition and verbal communication but had previously written memoirs outlining the care she would wish to receive when she could no longer voice her opinions or choices. Her daughters were aware of this, enabling them to honour her wishes. As a lifelong member of a church, faith was very important her.

As she slowly deteriorated, following a coding review meeting Ada was coded `B’. Best interest meetings were held and ACP, PPC, PPD and DNACPR were all in place.

In June 2015 Ada deteriorated during the night. The agency nurse called the Manager as she knew after reading the admission details and the GSF section in her notes, that Ada did not want to be hospitalised. The daughter was called and the out of hours doctor. The coding was changed to `D’. The OOH Doctor explained that Ada was in atrial fibrillation and this could be pre-terminal. It was agreed that she would stay and be cared for in the Home. Her daughter stayed with her and the GP was contacted to review. Oromorph was prescribed. The family took it in turns to sit with her and hymns were played in the background. The night staff also took it in turns to sit with her and when she was awake to read the bible to her. A Minister also visited and said prayers and administered communion. As she continued to deteriorate all nonessential medications were stopped and anticipatory medications prescribed. The family were informed about what was happening. As she continued to deteriorate the family were supported enabling them to stay and be offered refreshments.

Over the following days Ada began to improve, she was less breathless and began to tolerate more fluids and diet. Her daughters were very confused and anxious. One had a holiday planned and didn’t know what to do now. After long discussions she did go and the grandchildren visited daily.

Over the next few weeks Ada’s condition was variable, and she continued to have regular reviews from the GP and visits from her Minister. However in July she deteriorated again, and was unable to take oral fluids or medications. The GP reviewed and coded `D’ and subcutaneous injections were commenced. The family were informed and updated. Ada was kept comfortable with regular mouth care and hymns playing softly in the background. An End of Life Care plan was written and the Minimal protocol introduced.  Anticipatory medications were administered via a line to reduce discomfort. Staff sat with her to ensure she wasn’t alone when her daughter needed a break. A butterfly was placed on her door in recognition of her being in the dying phase.

Ada died peacefully with her daughter present at 0400hrs. The Care staff informed the Manager as she had requested as Ada had been a resident for six and a half years.  The Manager then visited the room as soon as she arrived and spent some time with Ada and her daughter.

When the Funeral directors arrived, the staff lined the hallway in silence and the daughter and Manager escorted Ada out of the Home hand in hand.

At the next coding meeting a Significant Event analysis was completed and a time of reflection followed. Several of the staff attended the funeral and messages of thanks to the Home were read out by the daughter during the Eulogy.


Updated 13/4/2016