What is case
based discussion and what areas it focus on?


Positive indicators

Medical record keeping

Legible; signed; dated; appropriate to the problem;
understandable in relation to and in sequence with other entries; helps the
next clinician give effective and appropriate care.

Clinical assessment

Understood the patient’s story; made a clinical assessment based
on appropriate questioning and examination.

Investigation and

Discusses the rationale for the investigations and necessary
referrals; understands why diagnostic studies were ordered or performed,
including the risks and benefits in relation to the differential diagnosis.


Discusses the rationale for the treatment, including the risks
and benefits.

Follow-up and future planning

Discusses the rationale for the formulation of the management
plan including follow-up.


Discusses how the care of this patient, as recorded,
demonstrated respect, compassion, empathy and established trust; discusses
how the patient’s needs for comfort, respect, confidentiality were addressed;
discusses how the record demonstrated an ethical approach, and awareness of
any relevant legal frameworks; has insight into own limitations.

Foundation Programme – Homepage”, 2018)

In the table
above we can see that the case based study in medical field focuses on various sectors,
but for this particular assignment we will be looking more into the
professionalism side. This table also provide a good insight of the things
expected from the student in order to successfully complete the CBD (Case Based
Discussion) of a chosen field.

professionals need to develop analytic and diagnostic thinking therefore CBD has
been used in the medical field for this particular reason. CBD will allow students
to be exposed to the ethical/management problems, medical problems and
different problems associated with the patient, this will in return helps them
to develop analysing abilities. By such exposure students will also improve
their interpreting and problem-solving skills and in the course of doing this
they will develop interest in the subject. CBD can be used in future, if we get
similar scenario we would be aware of the policies and law in place.

Considering the
importance of Case Based Discussion, I have decided to look upon the key
aspects of intervention that needs to be followed by the nurse and health professionals
when looking after reduced capacity patient. I will also be looking at the
ethical implications on the topic and how this can be set in to safeguard and
promote the interest and well-being of the patient.


























Background of the patient



For the purpose
of patient and staff confidentiality and to protect patient’s identity all the
names will be altered and provided pseudonyms. Consent has been obtained from
the patient’s families and the nurse (who was looking after the patient) to
carry out this case study (NMC 2015). The patient will be referred as pseudonym

James is a 76-year-old
gentleman who has been married to his second wife for 22 years. James has been
diagnosed with many long-term conditions and lives with Arthritis, Stroke,
Gout, Vascular dementia and benign prostate cancer as well as other
illnesses.  His needs and care are very
complex and requires input from different healthcare professionals.  This assignment will focus on ethical or
management problems in delivering James’s care and also the importance of
working in partnership with all the healthcare professionals to provide the
better quality of care. Living with stroke can affect the patient’s decision-making
capabilities and it is a important job to ensure that this complexity is
entirely addressed.

James has been
chosen for this assignment because over the placement, I was involved with his
care and had an opportunity to know James and his families closely. I have
selected this topic to research for my assignment because stroke is one of the most
common health problems among UK population and also this case was very unique
and had lots of management problems and this will help me gain more knowledge
on this sort of problems and management issues that is linked with the patient.
I believe this case base study will increase my understanding which will
benefit me with all the evidence based information in my future career. This
will also develop my further understanding of health professional’s role when
caring for patients with complex care issues which will influence in my

who suffer from chronic illness often requires complex needs, their illnesses
or diseases have a prolonged course that do not resolve spontaneously and
cannot be completely cured but could only manage the symptoms of the illness to
ensure they receive a quality of life and care throughout their journey” (Smeltzer
et al 2010).




































Overview of case


During my
placement, I was involved with a team providing care for James.  His general condition kept deteriorating over
the weeks of my placement.  James communication
with his families and staffs decreased, before he used to respond and
communicate even with a few words or showed facial expression or gestures such
as a nod or shake of the head.  His mobility
was drastically changed, as his pain and increased muscle spasm restricted him
to transfer on a recliner or any other chair. He was bedridden as per GP (general
practitioner) and OT (occupational therapist) decision for his own safety. On
consultation, GP reviewed James and was aware about of his pain and
deterioration on his condition. 
Referrals were made by the nurse for speech and language therapist
(SALT) for dysphagia. A referral to the dietician was made to review the
massive weight loss that James had endured within a short period of time,
whilst the occupational Therapist (OT) was referred to review for an
appropriate chair for James. He also established grade 2-3 pressure ulcer in
his sacrum and was referred to tissue viability nurse.

The assessment
was carried out by the SALT team about his ability to eat and it was decided
that dysphagia presentation was due to his history of stroke which was exacerbated
by reduced physiological reserve and low mood. The diet was changed from fork mash
able to soft diet and syrup consistency fluids. SALT advised that James should
be encouraged and assisted with his diet and fluids. They advised for James to
receive nutritional and well balanced diet to maintain a healthy weight.

visited James regarding his weight loss and asked to try out nourishing drinks
made with full cream milk such as Ovaltine, Horlicks, etc. The dietician
advised to provide the patient with monounsaturated olive oil varieties of spreads
such as cheese, butter, cream and custard to add good sources of calories to
monitor his weight.

Tissue viability
nurse visited and applied some dressing on James sacrum; she also carried out
the care plan for James dressing. She advised that James should be rolled over
every 2 hours to ensure that pressure relief is maintained. The wound showed
signs of improvement after few weeks. 

According to NMC
(2015) it is paramount that all the practices and information should be
accurately and completely documented.  The nurse informed wife about all the
situation and outcomes that the MDT (multidisciplinary team) made regarding about
his general health condition and managing his illness. GP requested the nurse
to discuss with his wife about the ‘Do not resuscitate’ form as the patient
health was not improving. His wife fully understood about the situation and
signed the form and was happy with all the decisions and plans that were set up
by MDT.

“A do-not-resuscitate order, or DNR order,
is a medical order written by a doctor. It instructs health care providers not
to do cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or if
the patient’s heart stops beating.” (order, 2018)
















MCA is defined
as “The Mental Capacity Act (MCA) is
designed to protect and empower individuals who may lack the mental capacity to
make their own decisions about their care and treatment. It is a law that
applies to individuals aged 16 and over.” (“What is the Mental
Capacity Act? – NHS.UK”, 2018)

Thus, when
looking after the patient who has reduced capacity this might affect the acts
in connection with their care plan or treatment and should always be ensured that
all the actions taken by the professionals should be merely in the best
interest of the patient. It can be found in MCA as “If someone is found to lack the capacity to make a decision and
such a decision needs to be made for them, the MCA states the decision must be
made in their best interests.” .”  (“What
is the Mental Capacity Act? – NHS.UK”,
2018). NMC (2015) suggests that nurses should use different communication
skills in promoting wellbeing and preventing ill health of

patient and
meeting the changing health care needs of the individual. Therefore, the use of
the care plan is essential, for nurses to be able to recognise the needs of the
patients. The documented nursing intervention in the care plan of patients’
needs will help the healthcare professionals recognise the unique needs of an
individual and will help to improve patient outcome.

Case management
focuses in delivering holistic health and social care to fulfil the needs of
the vulnerable clients who have complex needs and whose care is not actively
managed by the whole system (Carrier 2009).  According to NMC (2015) the nurse has to gain
informed consent from the patient to share any information with other
healthcare professionals. The nurse gained consent from James and informed him
about the current situation. As James has cognitive impairment and according to
mental health capacity (2005) if someone is appointed to make decision on their
behalf they must act in patient’s best interest and still involve patients in
making decision as much as possible. Consent was gained from James wife as well
and all the information was shared and made transparent. Collaborative and
successful information could only be made possible through gaining consent from
the patient and their family member (NMC 2015).

“Consulting with others is a vital part of
best interest decision-making. People who should be consulted include anyone
previously named by the person concerned, anyone engaged in caring for them,
close relatives, friends or others who take an interest in their welfare, any
attorney appointed under a Lasting Power of Attorney or Enduring
Power of Attorney, and any deputy appointed by the Court of Protection to
make decisions for the person.”  (“What
is the Mental Capacity Act? – NHS.UK”,

The core of caring
patient applies same for all patients based on professional and ethical principles.
NMC (2015) states that patient’s respect and dignity should be always maintained,
therefore James’s other parts of the body were covered throughout the treatment.
In the given scenario, I felt that all the teams worked effectively and in
collaborative manner recognising each other’s roles and skills in making
informed decision at the best interest of the patient which aimed to improve
the quality of life and wellbeing of the patient.









Patient prospective



James used to
respond and communicate even with a few words or showed facial expression or
gestures such as a nod or shake of the head but his communication with his
families and staffs was deteriorated. Hence it was really hard to communicate
with him and he also suffers from cognitive impairment which didn’t help with
the communication, therefore it was very difficult to tell how he was feeling
throughout the event. I could only assume how he was feeling, he must have felt
very confused, depressed and helpless.


















I feel that the
case management should be designated more in UK healthcare system as its key
aspect is to provide personalised care and recognise the changing needs of the
people living with long term condition. This Case Based Discussion has
highlighted that patient and families’ involvement in decision making in
planning, intervening and reviewing in delivering safe care is an integral aspect
of individualised care plan. The assignment has highlighted the importance of
adapting the care plans for reduced capacity patients in delivering safe practice
of administration. The professional guidelines and policies are adhered equally
for all the patients no matter if they have reduced capacity or not. The importance
of individualised care plan could differ with the patients that allows the care
to be implemented accordingly and helps in recognising their unique needs.
























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