NRP/556 Week 8: Comprehensive Older Adult Case Built Around Goals of Care, sample paper

A Granddaughter's Wedding in June: Patient Priorities Care for an 86-Year-Old Woman With Heart Failure, Kidney Disease, Diabetes and Eleven Medications

[Student Name]

University of Phoenix

NRP/556: Adult and Geriatric Management II

Week 8 Assignment

[Instructor Name]

[Date]

The patient and family are composites written for a model paper.

Mrs. O., 86, lives with her daughter. Her conditions include heart failure with preserved function, stage G3b kidney disease, type 2 diabetes, atrial fibrillation, osteoarthritis and mild cognitive impairment. She takes 11 medications, has four specialists and has had seven medical appointments in the past month. She has fallen twice this year. Her A1C is 6.3%. At today's visit she says she is "tired of doctors" and that what she wants most is to dance at her granddaughter's wedding in June. This paper describes how her care was rebuilt around that goal.

A Serious Illness Conversation

Bernacki and Block (2014) reviewed evidence on communication about serious illness goals and found that such conversations are often late, clinician-led and focused on procedures rather than values, yet when done well they are associated with care more consistent with patients' wishes and better quality of life. They recommend asking patients about their understanding of illness, goals, fears and what tradeoffs they would accept. I asked Mrs. O. these questions. She understands her heart is weak and she will not get better. Her goals are to attend the wedding, to stay at home and to be less tired. She fears falling and being sent to a nursing home. She would accept higher blood sugar if it meant fewer finger sticks and less dizziness.

The Problem of Stacked Guidelines

Boyd et al. (2005) worked through what would happen if every relevant guideline were followed for one imagined older woman with several common diseases, and the result was a long medication list, likely interactions and advice that pulled in different directions. Mrs. O.'s regimen reflects this: each specialist added treatments reasonable for one disease, and together they produce fatigue, dizziness and falls that threaten her goals.

Every drug on her list was defensible on its own; together they stood between her and the dance floor.

Patient Priorities Care

Tinetti et al. (2019) compared patient priorities care with usual care among older adults living with several chronic diseases and found that, compared with usual care, it was associated with a greater reduction in self-reported treatment burden and with more medications stopped, and priorities-based decisions appeared in visit notes for about two-thirds of participants. The approach identifies each patient's specific, actionable health outcome goals and care preferences and uses them to decide what to start, stop or continue.

Reviewing Each Condition Against Her Goals

Diabetes: an A1C of 6.3% on glipizide and insulin places her at high risk of hypoglycemia, which can cause falls and confusion. For an 86-year-old with multiple conditions, a less stringent target is appropriate. I stop glipizide and simplify insulin, aiming for an A1C around 7.5% to 8% and fewer finger sticks.

Heart failure: she needs her diuretic for breathlessness, but dizziness on standing suggests overdiuresis. I reduce the dose slightly with daily weights and a plan for adjustment.

Blood pressure: her standing blood pressure falls to 102/60 mm Hg. I stop amlodipine.

Atrial fibrillation: anticoagulation protects against stroke, which would end her goal of staying at home. After discussion, she chooses to continue apixaban at the correct dose for her age, weight and kidney function.

Osteoarthritis: pain limits walking; I add scheduled acetaminophen and physical therapy focused on balance and strength before the wedding.

Cognitive impairment: her daughter manages her pills with a blister pack.

Why a Relaxed Glucose Target Is Not Neglect

Mrs. O.'s daughter worried that allowing higher blood sugar meant giving up. I explained that tight glucose control helps prevent complications that take years to develop, while low blood sugar causes harm now, including dizziness, confusion and falls. For an 86-year-old whose goals are near-term, avoiding hypoglycemia matters more than an A1C below 7%. The change reflects her priorities, not a lower standard of care.

Continuing Anticoagulation

Not every decision reduced treatment. Anticoagulation for atrial fibrillation adds bleeding risk, and some might stop it to lower pill burden. But a stroke would take away both of her goals, staying at home and attending the wedding. When I explained this tradeoff, she chose to continue. Patient priorities care is not simply deprescribing; it is aligning each decision with what matters to the person.

Coordinating With Specialists

I called her cardiologist and nephrologist to explain her goals and the proposed changes. Both agreed. Sharing the reasoning, rather than simply reporting changes, helped them support the plan and reduced the risk that another visit would add back what was removed.

Measuring Success

Success will be measured by her own goals: fewer appointments, fewer falls, less fatigue and dizziness and, most of all, being at the wedding in June. I will ask her at each visit how close she feels to that goal.

Reducing Burden

With her cardiologist's and nephrologist's agreement, I consolidate follow-up so that she has one primary care visit a month and specialist visits every three to six months, with laboratory work drawn at the same visit. Her medications fall from 11 to 8.

Falls

Physical therapy, stopping amlodipine and glipizide and reducing the diuretic address her falls. A home safety evaluation adds grab bars and night lights.

Her Heart Failure Monitoring

To avoid both fluid overload and dehydration while reducing her diuretic, her daughter will weigh her each morning and call the clinic if the scale climbs by a kilogram overnight, or by two across several days, or if her breathing or ankle swelling worsens, so the diuretic can be adjusted before a crisis.

Physical Therapy Goals

Physical therapy will focus on leg strength, balance and endurance, with a specific goal she chose: standing and swaying to music for the length of one song by June.

Documenting Priorities

I document her goals and preferences prominently in the chart and share them with her specialists, so that future decisions, such as hospitalization or new medications, can be weighed against them. We also discuss an advance directive and name her daughter as her health care agent.

What Her Daughter Needs

Her daughter carries much of the care. I ask about her own health and stress, provide information about local caregiver support and respite options and make sure she knows whom to call with questions between visits, which reduces unplanned emergency visits.

Revisiting the Plan After the Wedding

Goals change. After June, I will ask Mrs. O. what matters next, since her priorities may shift toward comfort, independence or another family event, and the plan will be revised accordingly.

Follow-Up

Visits every four weeks until the wedding, reviewing energy, dizziness, falls, glucose and weight.

Conclusion

Mrs. O.'s care had been built disease by disease, producing a heavy burden that threatened her goal of dancing at her granddaughter's wedding. A serious illness conversation identified her priorities, and patient priorities care, associated with reduced treatment burden, guided a plan that relaxed glucose targets, reduced medications, consolidated visits and addressed falls while preserving treatments she valued, such as anticoagulation.

References

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. https://doi.org/10.1001/jamainternmed.2014.5271

Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA, 294(6), 716-724. https://doi.org/10.1001/jama.294.6.716

Tinetti, M. E., Naik, A. D., Dindo, L., Costello, D. M., Esterson, J., Geda, M., Rosen, J., Hernandez-Bigos, K., Smith, C. D., Ouellet, G. M., Kang, G., Lee, Y., & Blaum, C. (2019). Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: A nonrandomized clinical trial. JAMA Internal Medicine, 179(12), 1688-1697. https://doi.org/10.1001/jamainternmed.2019.4235