Decision Making

Case Study

AJ is a 22-year-old male, whose family has recently located to south Florida from Colombia. AJ has had a high-speed motorcycle crash and sustained life-threatening injuries, including multiple rib fractures, a pelvic fracture, and a severe traumatic brain injury (TBI). He had difficulty breathing at the scene and was endotracheally intubated by paramedics en route, but only after much difficulty during which he experienced a 5-minute hypoxic period. He arrived at the trauma center with a Glasgow Coma Score (GCS) of 3. He is admitted to the intensive care unit with respiratory distress, anemia related to bleeding from his pelvic fracture, and altered mental status from his TBI. His primary nurse is Kevin, a Caucasian male from upstate New York. Kevin has 10 years of experience as an RN in critical care, and 5 years in his current position. Kevin is keenly aware of the long and complicated hospital course that AJ will likely experience.

AJ’s family arrives at the trauma center. They are brought to the intensive care unit to see AJ for the first time. His family consists of his mother, 52, his father, 54, two younger sisters ages 12 and 14, and an uncle (his father’s brother). They speak only Spanish, as they have been in the country for only 6 months. AJ’s parents do not allow his sisters to see him, as they are afraid they may be overwhelmed and faint. His father, mother, and uncle proceed to the bedside. They are shocked by the sight of AJ, whose body is swollen and has multiple severe skin abrasions and lacerations. AJ’s family is greeted by Kevin, his nurse. Kevin speaks some Spanish and he is able to communicate basic information to the family. AJ’s mother is very emotional, crying, and unable to focus well on what Kevin is telling them. 

Kevin, NP B, the social worker, an interpreter, and AJ’s mother, father, and uncle meet in the unit conference room. NP. B, through the interpreter, describes AJ’s prognosis, multiple injuries, and what needs to be done at present. The prognosis for functional recovery is very poor, because of anoxic brain damage from the prolonged period when AJ was not able to breathe well. His other injuries are severe but likely survivable in a young healthy person. His pelvic fracture would need surgical repair, but because of AJ’s poor neurological prognosis, NP B recommends not doing the surgery. He explains that this is because AJ will not walk due to his brain damage and the surgery would be extensive and has risks. AJ’s family appears overwhelmed and tearful, and his mother is repeating prayers aloud in Spanish through her tears. Kevin provides emotional support. NP. B, knowing that the family will need time to process the prognosis, says he must leave but schedules another meeting in 2 days. The family asks if they may bring other family members to the next meeting, and the team agrees to the request.

AJ’s father has been appointed his health care surrogate. Further diagnostic testing has confirmed that AJ has significant anoxic brain damage, and his prognosis for neurological recovery is nil. As the interpreter relays this message from NP. B to the family group, many break out in tears and exclamations. AJ’s mother repeats, “No, no, no, it is not true” in Spanish while wringing her hands over and over. AJ’s father appears stoic but grim faced.

1. Who will make decisions about AJ’s care in the above scenario? Support response
2. Identify 2-3 factors that may influence the health care decision making in AJ’s situation?
3. Describe and apply provider decision-making behaviors that would be useful in the above situation.
4. What plans of care should be presented to the family and why? What priorities or elements should be the goal of care conferences for seriously ill patient’ such as AJ?
5. What are some effective communication strategies the APN should employ and consider in this situation?
6. Identify sources of conflict in health care decision making
7. Might the APN experience moral distress related to AJ’s family’s decision in the above scenario? Why or why not?