Management of Chronic Co-morbid Conditions – The Case of Mr. Bale


 The current case involves an elderly Spanish patient (Mr. Bale) who is suffering from Chronic Obstructive Pulmonary Disorder (COPD), Congestive Heart Failure (CHF), and hearing loss. COPD is a combination of several distinct but related illnesses that are characterized by difficulty in breathing (Aksenova & Burduli, 2016). The condition can impact the quality of life of a patient considerably, necessitate long term medical care and frequent admissions, and result in premature death if inappropriately managed. CHF is a progressive condition that affects the ability of a heart to pump blood efficiently (Rasmussen et al., 2017). It is often referred as Heart Failure. It is also important to note that Mr. Bale has a history of smoking. His smoking habits are so severe that he has not stopped smoking despite having signed an agreement of cessation just before the initiation of his oxygen therapy. Although he receives care from a Western healthcare model, he still relies on Mexican cultural remedies. He currently lives in his son’s family home.

Mr. Bale’s treatment plan will be implemented in accordance with the Chronic Care Model (CCM), which is based on the application of interventions at different levels of care comprising the patient, provider, and the healthcare system (Horwitz, 2015). Therapy will be effected in accordance with the patient’s conditions and a collaborative approach that draws in evidence-based practice, quality improvement, communication, and interaction between members of the inter-professional team.

Medical Treatment

            COPD does not have an instant cure but it can be managed through the control of symptoms, reduction of complications and exacerbations, as well as the improvement of the quality of life of the patient. In the case of Mr. Bale, smoking cessation is a necessary remedy as it is the only way of restricting the condition from advancing to a worse stage. If he has had a hard time quitting, it is necessary for the nurse to consider nicotine replacement products and medications such as bupropion and varenicline.

The type of medications to be used in the control of COPD will rely on the available regimens but the ones that are commonly applied normally incorporate the use of bronchodilators, phosphodiesterase-4 inhibitors, and theophylline (Currie et al., 2008). Bronchodilators usually come in an inhaler and aid in the relaxation of the muscles around the patient’s airways, allowing them to breathe easily and comfortably. Bronchodilators may be long-acting or short-acting in nature with the former serving as an endorsed remedy for severe cases of COPD. Phosphodiesterase-4 inhibitors decrease airway inflammation and relax the patient’s airways, but nurses should consider the side effects, which may include weight loss and diarrhea. Theophylline woks in the same way and side effects rely on the dosage. In addition, the nursing team should apply a pulmonary rehabilitation program and confer with Mr. Bale’s family about the matter in order to shorten hospitalization, increase independence, and improve his quality of life. This will consist of exercise training, education, nutrition advice, and counselling. Mr. Bale should continue with his oxygen therapy in order to maintain a stable level of oxygen in his blood.

            Like COPD, CHF needs lifelong management. Treatment can alleviate symptoms and help the patient live longer, as well as reduce the chance of sudden death. In the case of Mr. Bale, the nurse will choose one or more categories of medication from the following pool: angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, diuretics, aldosterone antagonists, inotropes, and digoxin (Rasmussen et al., 2017). These drugs generally increase the wellness of the CHF patient by either widening blood vessels, reducing blood pressure, reversing the damage of the heart, reducing the risk of abnormal heart rhythms, reducing fluid in the lungs, or increasing the pumping function of the heart.  

Safety Concerns and Risk Factors

            The major safety concerns and risk factors in the treatment of Mr. Bale relate to his elderly status and smoking habits. At 85 years old, he faces the risk of experiencing severe complications. Age is a major risk factor for many prevalent chronic conditions especially those associated with cardiovascular functions. The aging process tends to decrease fitness with time and usually involves the consequence of declining health (Niccoli & Partridge, 2012). Early living conditions and life experiences are also significant in the health of the elderly, meaning that Mr. Bale’s case has a potential of worsening owing to his lifelong smoking habits.

             According to Burns (2000), the disease consequences of smoking among the elderly are fatal although they occur disproportionately in the population. Consistent with research, older smokers like Mr. Bale are less likely to quit smoking. In fact Mr. Bale has already violated an agreement he had signed during the beginning of his oxygen therapy, promising to quit his smoking habits. The dangers of smoking whilst using oxygen therapy cannot be underestimated. Smoking around oxygen can cause hair and clothes to ignite and burn more vigorously than in normal air (Chang, Lipinski, & Sherman, 2001).

Ethical Dilemma and Solutions

            The most noteworthy ethical implication of incorporating palliative care in Mr. Bale’s treatment plan concerns his separation from his family. It is evident that the current setting cannot guarantee provision of maximum care due to the aforementioned risk factors. In relation to the principle of autonomy, a competent adult can accept or refuse treatment, drugs, surgeries according to their will, and their decision should be respected by everyone, including the inter-professional team (Gillon, 1994). This principle can get in the way of the current plan since Mr. Bale may wish to remain in his son’s home under the care of the family. However, the principle of beneficence demands healthcare providers to improve the patient’s health and go good in every situation.

            The ultimate solution to this ethical dilemma is to engage all members of the inter-professional team in a progressive conversation that takes full advantage of communication, interaction, education, and empowerment. This will give the nursing team a chance to convince Mr. Bale and his family that the current plan is reasonable and is only aimed at improving his wellness. The nursing team should draw in the principles of justice and non-maleficence (Gillon, 1994) while maintaining enough autonomy and benevolence.

Appropriate Course of Action

There is a need to place Mr. Bale on palliative care in order to ease symptoms and improve his quality of life. Notably, the manifestation of comorbid poses a risk at his age. Implementation of palliative care may demand his relocation to a medical setting and the involvement of a collaborative care nurse and a geriatric nurse alongside the primary care provider.

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