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Case #4: Julia Morales and Lucy Grey
Author: Mary L.Cato, MSN, RN
Lead Simulation Faculty
Oregon Health & Science University
Portland, OR

Overview: Julia Morales, age 65, and Lucy Grey, age 73, are partners who have been together for more than 25 years. They are retired and have spent the past several years traveling together. Julia has lung cancer, which has been treated with chemotherapy and radiation, and now she wishes to stop treatment. Lucy is supportive and feels she will be able to care for Julia in their home. Lucy's past medical history includes a knee replacement. Their support system includes Julia's son, Neil, and Lucy's niece, Nora.

Monologue: The introductory monologue takes place in Julia's home prior to an initial home health nurse visit. In the monologue, Julia discusses her life, including raising a son to adulthood, then meeting Lucy. She reviews her history with cancer and relates her understanding of home hospice care and her desire to die at home. She expresses concern about leaving Lucy alone.

Simulation Scenarios 1, 2, and 3: The scenarios begin with the home health nurse evaluating Julia after she has decided to stop treatment for her lung cancer. Her partner Lucy wishes to care for her in their home. In the second scenario the end of Julia's life is near and she is surrounded by her loved ones and the hospice nurses. Julia dies during this scenario. The learners are introduced to supportive measures for both the patient and the family during this process. The final scenario concentrates on Lucy and the difficulties she has adjusting to her new life after Julia is gone. The objectives focus on the students' assessment of Lucy's grieving process, how well she is coping, and the physical changes that she has experienced over the past few months.

Julia's Introductory Monologue

Click here to download an audio file.
Click here to download the script for the audio file.
Click here for Instructor Toolkit ideas for use with Julia's monologue.

Simulation Scenario 1 involves a visit by the home health agency nurse. Learners are expected to do a physical and functional assessment of Julia and her nursing care needs, as well as an assessment of the home with a focus on safety. Julia inquires about hospice services, but her son Neil urges her to try one more round of chemotherapy. Lucy is supportive of Julia's decision and tries to comfort Neil. Learners will assess Lucy's caregiver strain, and articulate what hospice care means for the patient and family. The assessment tools recommended for this scenario include SPICES: An Overall Assessment Tool of Older Adults, the Katz Index in Activities of Daily Living, and Informal Caregivers of Older Adults at Home: Let's PREPARE!

Click here for Simulation 1 Template

Click here for chart materials appropriate for Simulation 1

Simulation Scenario 2 takes place in the home two months later. Julia is barely responsive and has Fentanyl patches for pain. Nursing care consists primarily of performing an appropriate patient assessment and ensuring patient comfort. Julia dies during this scenario and the learner provides support the family. During debriefing, discussions may include how nurses manage their own emotions and self-care after the death of a patient.

Click here for Simulation 2 Template

Click here for chart materials appropriate for Simulation 2

A second monologue occurs three months after Julia's death. Lucy is in the emergency room. She is grieving and wants to talk about Julia and their life together. She feels very lonely, but has had some contact with her neighbor Adele and her niece, Nora. There have been other instances where she became anxious and dizzy and slightly confused, stating that her heart was pounding and she feels like she "can't walk or do anything." Lucy thinks she has called 911 "about once a month since Julia died" and was transported by ambulance to the emergency department.

Lucy's Monologue

Click here to download an audio file.
Click here to download the script for the audio file.
Click here for Instructor Toolkit ideas for use with Lucy's monologue.

Simulation Scenario 3 takes place in the emergency department. Lucy called 911 once again after another fall at home. Her blood pressure is slightly elevated. Otherwise, Lucy is found to be in good health. Objectives relate to assessing her safety, her fears, the grieving process, and her need for assistance at home. The assessment tools recommended for this scenario include SPICES, The Hendrich II Fall Risk Model, the Geriatric Depression Scale, and the Generalized Anxiety Disorder 7 (GAD-7).

 Click here for Simulation 3 Template

 Click here for chart materials appropriate for Simulation 3

Click here for Instructor Toolkit ideas for use with all simulations


Finish the Story Assignment
Learners have now seen Lucy at four snapshots in time. What do they think her life will be like three months from now?

Click here for ideas on how this assignment could be implemented

 

 

 

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