Comprehensive Analysis of Care Provision for James with a Complex Health Condition

In this reflective case study, the critical analysis and evaluation of care provision for James with a complex health condition are to be executed. In this purpose, the personal performance to care for the patient and its contribution in managing the situation is to be reflected. The local and national policies related to caring for the patient with the complex condition are to be discussed. Moreover, different theories and models used in planning care and maintaining care decisions are to be discussed.

The NMC Code of conduct mentions that the confidentiality and privacy of the patient is to be maintained under all condition to protect them from any harm (NMC, 2018). Thus, the pseudonym James is used to indicate the patient. James is a 70-year-old individual who has uncontrolled diabetes and suffers often from chronic obstructive pulmonary disease (COPD) exacerbations. He has a history of mild learning disability and is currently identified to suffer from mild dementia. At the present, James is admitted to the hospital with a leg ulcer which has worsened to the stage that the physician has predicted the need of amputating the leg ulcer in saving his life from ongoing pain and difficulty. The family history of James indicates that his father died due to heart attack and has diabetes whereas his mother had a normal death but used to suffer from dementia. James lives with his 65-year older sister who cares for him but has currently expressed hindrance in managing his care due to development of osteoarthritis and diabetes.

The current situation has made James vulnerable to abuse as there is no responsible individual available in taking his care apart from his sister who has mentioned inability to further continue supporting his care. All the interventions made for James is done in the best interest in line with Mental Capacity Act 2005 and Equality Act 2010 following his incapacity in managing own care out of his deteriorated health condition. The management of James’s care appears to be difficult due to different coexisting mental and physical health conditions which increases the complexity of the overall treatment for the individual (Bousquet et al., 2019). Forman et al. (2018) argue that irrespective of effective care, multimorbidity leads individuals to have reduced life expectancy, lower-quality living, increased risk of hospitalisation and need of excessive use of healthcare resources in availing effective treatment. Thus, multi-morbidity negatively impacts the sustainability of effective health and social care conditions in patients like James due to extensive healthcare challenges created by it.

Struckmann et al., (2018) states that multimorbid patients required increased personalised care and poses greater medical challenges to service providers This is because all the patients with multimorbid conditions are not affected by a similar condition as they have different co-occurring diseases that are to be managed. It leads the healthcare providers to incorporate dynamic and broader healthcare treatment strategies and cope with related polypharmacy (Pedersen et al., 2020). The Inverse Care Law mentions that the ability to avail good medical or social care vary inversely with the increased severe need of the population (Mercer et al., 2018). It indicates that the increased presence of co-morbid condition in James makes him at risk of availing poor medical or social care. However, the National Health Services (NHS) Five Year Forward Plan in 2014 was developed in resolving the gaps in care and promote enhanced good healthcare for the comorbid condition in patients. Therefore, James’s case is used to indicate the way good healthcare is achieved in multimorbid or comorbid patients by resolving the gaps in care as promised in the NHS plan for any patients.

A leg ulcer is chronic or long-lasting sore which develops within the leg above the ankle requiring more than two weeks for healing (Nie et al., 2021). However, the individuals with poor diabetic condition are seen to express slow healing of the leg ulcer which leads it required to be healed completely by weeks or months (Yammine and Assi, 2019). In the UK, out of 4.5 million people diagnosed with diabetes, nearly 10% of them that is around 450,000 patients develops leg or foot ulcer at some point in their life (NHS, 2017). The reports mention that nearly 9000 lower-limb amputations occur in people who have leg ulcers. This estimates that lower-extremity leg amputation to be 23 times more frequent in diabetic patients compared to non-diabetic individuals (Kerr, 2019). Thus, the presence of uncontrolled diabetes in James can be direct risk factor for the worsening of the leg ulcer leading him to be at risk of experiencing lower-extremity leg amputation.

Sutton et al. (2021) state that people with uncontrolled diabetes develop poor circulation which leads slowing down of the blood circulation creating a difficulty of the nutrients to reach the wounds to support their faster healing. Reardon et al. (2020) argue that peripheral neuropathy which is nerve damage caused by the increased presence of blood sugar in diabetic individuals contributes to their development of leg ulceration. This is because causes local parenthesis or overpressure in the footpoints which causes extended trauma, breaking of overlying tissues which eventually leads to ulceration. In case of James, the diagnosis revealed that he has develop peripheral neuropathy in his leg with the ulceration and further test reports that he has high level of blood sugar (230 mg/dL). This indicates that James’s diabetic condition has mainly contributed to his leg ulceration. The symptoms of diabetic leg ulcer are foul-smelling wound, skin discolouration, swelling of the leg, redness and discharge of pus (Walton et al., 2019). In case of James, all the symptoms are present indicating he is suffering from a diabetic leg ulcer.

The diagnosis of leg ulceration in James to determine its current worsened state is executed through X-ray imaging, blood tests, magnetic resonance imaging (MRI) and bone scans. Moreover, the health history of patients is analysed to observes and identify the duty of care to be met for the patients in resolving their biopsychosocial needs (Bui et al., 2019). Thus, healthcare professionals in case of James performed extensive diagnosis of the leg ulcer and develop holistic as well as a person-centred approach in meeting his biopsychosocial needs. The ethics in nursing states that nurses to follow the principle of beneficence where they are required to deliver the best care to the patients which benefit their health and improve their well-being (Bifarin and Stonehouse, 2022). Gordon et al. (2020) state that non-healing leg ulcer requires the patients to have their leg amputated because it causes increased damage to the bone and tissues on the existing area and spread to other areas. However, the problem with leg amputation to be caused to James is that high blood sugar level may lead him to experience slowed wound healing from the surgery. This is because high blood sugar in diabetic patients causes narrowing and stiffening of the arteries which slows down the chronic or post-surgical wound healing (Lin et al., 2020). Thus, there is a risk of lower post-surgical wound healing opportunity as a result of uncontrolled diabetes in case of James which would affect leg amputation for him. This is against the consequentialism theory which mentions that good action leads to positive actions (Macnamara, 2019). However, the good action of leg amputation may create problem of wound healing for James making him to suffer more.

Deontological ethics states that some actions are moral obligations of the individuals regardless of the consequence of welfare of the patients (Ţânţu et al., 2018). Since leg amputation would provide James with the opportunity to lower his suffering and pain from leg ulceration, its moral obligation according to the theory to execute the act. The wound healing in diabetes patients is promoted through lowering of the raised blood sugar with controlled intervention and actions (Davis et al., 2018). It indicates that more concerned care is to be provided to James for lowering his raised blood sugar to ensure steady post-surgical wound healing after the leg amputation surgery. Hughes et al., (2020) argue that COPD causes increased progression of metabolic disorders like type-2 diabetes and others. This is because the corticosteroids used in managing COPD exacerbation causes hyperglycaemia as it makes the liver less sensitive to insulin which promotes the increased release of glucose in the blood. In case of James, he is mentioned to be under high dose of corticosteroids in controlling COPD as it gets worse which may be due to inability of James to completely quit the habit of smoking. Thus, to control diabetes in James to promote his leg amputation ability, COPD exacerbation is also required to be managed so that it does not contribute to the worsening of metabolic symptoms.

The Mental Capacity Act 2005 states a statutory framework to be followed for empowering and protecting vulnerable people who are unable to make their own decision due to hindered mental health conditions (legislation.gov.uk, 2005). In case of James, he has a learning disability and has moderate dementia which makes him incapable in taking critical decisions regarding care. It indicates that it is the responsibility of the care authorities to involve his family members and others to take care decision on his behalf. McCarron et al. (2018) state that people with intellectual disability and dementia has limited understanding of everyday functioning in life. This is because the parts of the brain responsible in supporting analysis ability in individuals are damaged in people with learning disability and dementia which makes them incapable in critically deciding regarding aspects of care. Thus, James cannot independently take the decision regarding leg amputation and ways to control COPD, dementia along with high blood sugar level in leading a better life.

The study by Colarusso (2022) mentions that smoking exacerbates the COPD condition as the harmful chemicals in the smoke irritates the inner lining of the lungs making the alveolar air sacs to be inflamed. It causes difficulty in the exchange of gases and support the production of mucus leading to increased coughing and breathing problem. A similar condition was faced by James as irrespective of being diagnosed with COPD he was revealed to be smoking two cigarettes a day. The NICE guidelines mention that effective smoking cessation is to be achieved in COPD patients to avoid exacerbation of the condition and improved management of health (NICE, 2019). However, Robertson et al. (2020) argue that people with learning disabilities express difficulty in understanding the impact of the risk due to smoking on their health and COPD condition. Thus, the nurse caring for James understood the action of involving his sister in making him realise the risk due to smoking and mentally support him in cessation of the habit for controlling COPD and high blood sugar in diabetes. This is because the inclusion of family members in caring for learning disability patients and dementia makes them provide decision on the behalf of the patients and influences patients in abiding by the care provided as the patient trust and value the family member’s opinion (Andersen et al., 2018).

Patients with learning disabilities are often stigmatised in society to be presumed helpless and unable to care for themselves or taking own decision (Daley and Rappolt-Schlichtmann, 2018). In deciding James’s care, the family member which is his sister was not randomly involved in providing decisions regarding his care. However, the decision-making ability of James is evaluated through the use of Aid To Capacity Evaluation (ACE) tool which revealed him to have poor decision-making capability regarding medical care. This is because the ACE tool helps the clinicians systematically examine the capacity of patients in making any medical decision regarding their health (Barstow et al., 2018). The Equality Act 2010 mentions no individual is to be discriminated against any condition in the care or community (legislation.gov.uk, 2010). The people with learning disability and dementia are often stigmatised to be helpless and being the burden of care (Richards et al., 2019). However, regarding the Act, James was not stigmatised under the condition and was provided an opportunity through assistive devices in taking own care to enjoy care independence.

James requires steady medical assistance which he cannot receive at home as he cannot be made completely independent in taking his care due to dementia and learning disability condition after leg amputation. This is because with progressing dementia, the individuals experience hindered ability to balance and be at risk of fall (Oliveira et al., 2021). Moreover, the analysis of James’s worsening health condition has revealed his sister was not completely capable in providing him enhanced care as she expressed her reduced knowledge with wound management when communicated that also indicates James' leg ulceration was worsened due to lack of care. The sister also has currently revealed she is incapable to impart effective care to James due to age-related issues and osteoarthritis. In this condition, the nursing team developed communication with the sister to plan care for James in his best interest as she is the immediate family member who can provide care decisions on his behalf as he is unable to make decision due to learning disability and dementia.

The rational decision-making model is used in developing the care plan for James. This is because it helps in identifying the problem, develop decisions and weighting its impact, generating alternatives and selecting the best alternative care in framing best care plan for the patient (Bhui et al., 2021). Thus, the model was used to reach decision of performing lower-extremity leg amputation of James to help him overcome leg ulcer. There was no other alternative care found in this condition as the leg ulcer is seen to have affected the bones in the leg area. The decision made James’s sister avoid providing consent as she was worried regarding disability which would be caused to James. However, we as a team (physician and nurses) informed her regarding the benefit and risk of not performing leg amputation for James which led her to later provide consent for the action. James and his sister were involved in therapeutic sessions to make James understand the importance of cessation of smoking for his COPD and diabetes condition. In this purpose, the psychiatrist counsellor from the multi-disciplinary team (MDT) performed talk therapy with James and his sister to make James understand the way to quit smoking. Thereafter, the intervention was made as per NICE guidance in supporting smoking cessation in James.

In managing high blood sugar levels in James, as nurse, the attempt was made to regularise the intake of anti-diabetes medication. This is because the exploration of clinical history of James revealed his irregular intake of meal and medication led to uncontrolled diabetes state. Hong et al. (2021) states that regular intake of effective diet and anti-diabetic medication (Metformin) helps in lowering blood sugar because it promotes glucose uptake in the body, lower hepatic glucose production and increase glucose utilisation in the body. Saha et al. (2018) argue that diet high in simple carbohydrates and lack of regular intake of medication in diabetes contributes to hindered intestinal and peripheral glucose absorption and increased glucose production leading to hyperglycaemia. Moreover, communication was made with James and his sister to determine if he is to be cared at home with regular visitation from social worker or to be moved to care home permanently as she has mentioned to fail in continuing care to him. In this purpose, both agreed to allow James’s care to be arranged at home after discharge from hospital with the help of social workers and according manage was made for him. James is also trained in using assistive technology to experience some independence in taking care. This is because independence in care makes patients feel empowered and valued of avoiding being burden of care on others (Koumakis et al., 2019).

In managing dementia in James, donepezil is used as a pharmacological intervention because it enhances memory along with cognitive awareness in individuals and resolves confusion (Secnik et al., 2020). NIICE guidelines states that corticosteroids can be replaced with bronchodilators in controlling COPD condition (NICE, 2019). Thus, similar action is to be taken for James to help him develop better control of COPD and diabetes. In managing James’s care, the democratic management and transformation leadership is used. The democratic management helps in drawing different views from varied staffs and allow efficient problem-solving through teamwork (Bress et al., 2019). The multi-disciplinary team (MDT) consisting of dietician, psychiatrist counsellors, social workers and others are collaboratively involved with me as a nurse and communicated through meeting in deciding care plan for James. The transformation leadership was present because the leader was seen to motivate us as a team in learning and stimulating the care activities so that it meets the needs and demands of James.

The challenge faced in caring for complex health condition of James is non-compliance from him in executing leg amputation. This is because he fears that he will be mentioned as a disabled individual and bullied in the society due to the condition. Davis (2020) states that people with amputated body parts are regarded as disabled and helpless in society as they require support in executing their life. In this context, James was mentioned of the consequence to be faced for not performing the action with the help of his sister which gradually led him to comply in care. The other challenge faced is non-compliance of James is taking medication which is important in managing his steady health condition regarding dementia, diabetes and COPD state. Khezrian et al. (2020) argue that polypharmacy creates the risk of adverse drug effects and lower quality of life in the elderly population. However, it is important in James’s case to improve his health and thus effective drug-drug interaction and other adversities are evaluated before recommending ac medication for James.

The responsibility of acting as the nurse is vital for leading and managing complex care for multimorbid patients like James. Thus, as a nurse continuous assessment, planning, implementation and evaluation of care for James is performed as a part of the nursing process (Asmirajanti et al., 2019). The NMC Code of conduct mentions that the family members of the patients are to be involved in taking decisions on their behalf when they are unable to make decision. Moreover, the family members are to remain updated regarding care and health progress of the patient (NMC, 2018). As a nurse caring for James, his sister who was his key carer was always updated about each care plan and decision-making process for him. The NMC Code of Conduct mentions that nurses have the role to abide by ethical principles in care and uphold professionalism in all aspects of care which is to be delivered in the best interest of the patient (NMC, 2018). The role was effectively followed as all the care decision are made by keeping James in the centre of care and the decision were consulted with his family members as well as MDT to implement them in an ethical way.

The action led to improvement of James’s condition which was evident as effective control of the diabetes condition led to create no issue with wound healing after leg amputation of James. However, the post-surgical wound healing was slow and effective wound management was provided to ensure avoiding any further health deterioration. It was believed that effective management and leadership through the care led to create successful health improvement for James by the nurse. Moreover, the contribution of MDT is regarded as effective teamwork practice in supporting enhanced well-being of James at the hospital and post-discharge.

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