Instructional Strategies: Case Study

Chronic Obstructive Pulmonary Disease (COPD): Part 1

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Mr. Cha Yer Moua was a 67-year-old man with emphysema who was admitted from clinic to the adult hospital ward with exacerbation of chronic obstructive pulmonary disease (COPD). His admitting nurse, Ms. Sara Jones, met him and five people as they arrived on the unit. She greeted the man in English, but he seemed to ignore her, apparently focused on his breathing.

She then greeted the elderly woman at his side, which smiled but didn’t answer in English. Ms. Jones then turned to a middle-aged woman, and asked how Mr. Moua was feeling. A middle-aged man standing next to her replied, “My father is very sick. His doctor said he needs a private room, medicine, and oxygen.” The nurse acknowledged his need, and escorted them to a private room. She started oxygen, took his vital signs (O2 Sat =92%, RR= 20, HR=100) and then looked at the written orders that the son had brought with him. She called Respiratory Therapy for a STAT nebulizer treatment, and ordered his medications.

Once Mr. Moua’s breathing had improved, Ms. Jones went into the room and asked what language he spoke, so she could get an interpreter. Finding out that he spoke White Hmong, she called the telephone interpreter service and waited two hours for an interpreter to answer the call. She proceeded to ask the necessary questions to obtain a medical and socio-cultural history.
Even though she directed her questions to Mr. Moua and passed the phone to him, he refused to respond, saying he was too short of breath to talk.

Hence, his wife and son answered the majority of questions for him. Ms. Jones learned that he was born in Laos, had been in the U.S. for 2 decades, had had 2 wives (one of whom was living), had 12 sons and one daughter, had smoked two packs of cigarettes a day for 40 years, and was a respected shaman in the community.

When Ms. Jones asked about an advanced directive, the son intervened and said, “Don’t ask my father those questions. We want him to live, that’s why we brought him here. We want everything to be done as much as possible.” Concerned that she couldn’t get Mr. Moua’s personal opinion, she explained that it was hospital policy to ask each patient the questions, and not accept family members’ responses, so she had to ask him.

The son thought about it, and said, “I suggest then that you rephrase the questions using a quiet tone of voice. ‘Mr. Moua, I am glad you’re feeling a little bit better. We at the hospital can do lots of things to make you better so you can go home to be with your family and live to be 120 years old. Your doctor ordered many good medicines that will help you. Excuse me, sir, but it is hospital policy to ask each person two questions, even for those people who are strong and getting better like yourself. If I am not disturbing you, please may I ask you two questions?’”

Ms. Jones agreed to try this approach, and when she had repeated these words, Mr. Moua replied, “Yes, you may. I understand that the hospital has its own way of doing things.”

“Thank you, sir. If your heart should stop, do you want us to push on your chest to get it going again?”

He replied, “Yes, but don’t worry about that, as my heart is strong.”

“Thank you sir; I am glad to hear it. The second question: if you should stop breathing, do you want us to put a tube down your throat and put you on a machine to breathe for you?”

Mr. Moua paused, as though focusing on his breath. He replied, “No, I do not want that. I have seen that terrible machine on other people, and I do not want that.”

Ms. Jones answered, “Thank you for allowing me to ask you these questions.”

After Ms. Jones left, the wife, son and daughter-in-law came out to the desk to tell her that the family disagreed with what Mr. Moua had said. They asserted that he had not understood what Ms. Jones had asked, because his dyspnea and hypoxia were impeding his ability to make this decision.

Also, his fear of hospitals had kept him at home for three days, despite his needing help to breath, so he was speaking from his fear. However, as his family, they had finally brought him to the hospital where they wanted everything done for him, including the “breathing machine.”

Questions for Discussion

Questions for Discussion

1. What do you think about the words that the son told the nurse to use? How are those words similar to or different from the words you have used in similar situations?2. What dilemma is the nurse facing?

3. What cultural information do you want to know in order to better understand Mr. Moua’s response and his family’s assertions?

4. What would you do to resolve the dilemma?

5. Do you think that Mr. Moua’s assertions for do not intubate (DNI) should be followed, regardless of the family members’ opinions? Or do you think that you should follow the family’s recommendations for a full code?

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