Case study

Rose Silva is an 84-year-old cis-gender woman presenting to the emergency department after having an unwitnessed fall. She prefers to be called Rose. Her only son found her lying on her left side on the floor next to her bed during one of his biweekly visits and is unsure how long she has been on the floor. Rose’s native tongue is Portuguese and the nurse obtains most of her medical history from her son during assessment. According to her son, Rose was unable to stand after the fall. Rose is usually able to shower, groom and dress independently; however, she needs help with laundry, grocery shopping and meal prepping, which is what her son helps with during his biweekly visits.

Rose has a past medical history of osteoporosis, and colon cancer treated in 2013 and 2015, she has been in remission since her last treatment. She recently had her colonoscopy screening postponed due to the COVID-19 pandemic. Upon physical assessment, Rose has a cachexic appearance, alert and oriented to person, place and time, pain is 7/10, has a purplish bruise to her left hip, and a distended and firm abdomen. After the Nurse Practitioner assesses Rose, she orders blood work (CBC, electrolytes, calcium, magnesium, phosphate, CK), a bladder scan with insertion of Foley if over 300 ml, brain, neck and abdominal CT scan, and a left hip x-ray. A bladder scan shows 650 ml, you then insert a Foley catheter. Rose is diuretic; however, her abdomen remains distended and when asked Rose states she has not had a “good” bowel movement in 1 week (as translated by her son).

The results of the diagnostic tests are a hairline left hip fracture and a mass in her right colon. Rose is admitted to the hospital for further investigations, nutritional and hydration support, conservative management, and potential rehabilitation of her left hip.

After admission, additional investigations show that she has metastases to her liver and kidneys. Rose’s oncologist proposed a plan of care, which was translated by her son, including chemotherapy and resection with a likely chance of the insertion of a permanent ileostomy. Rose denies treatment and states to her son, “I can’t do any more chemo and if I have to learn how to deal with the ileostomy…I just can’t…I don’t want to die lying in a hospital bed”. Rose’s son then translates this to the oncologist. The oncologist believes that Rose may feel overwhelmed and may not fully understand the plan due to language discordance. He also believes that she may not understand the intention of treatment. The oncologist then decides to use the hospital-designated translation line to explain further by stating that the chemotherapy and ileostomy will not cure cancer rather it will extend her life expectancy and improve her nutritional status. Rose replies to the hospital translator that she understands, but still does not wish to move forward with treatment and the oncologist suggests Rose meet with the palliative care team. Rose’s son then intervenes and asks for time to consider the treatment plan. As Rose’s son objects to her decision, she then expresses to her son and the hospital translator that she has “lived her life”, accepted her diagnosis and is at peace with God. The oncologist ends his conversation with Rose and leaves the room. Rose assures her son that this is her final decision; however, she is apprehensive about meeting with the palliative care team as she believes they only assist in speeding up the process of dying and seeks more information. After her son translated the information from the medical-surgical nurse on the services provided by palliative care, Rose decides to move forward with meeting the palliative care team. After completing bedrest, Rose is then discharged to a rehabilitation center for her left hip with palliative support in place to follow her care.