What is the general role of tumor necrosis factors in the body? Strengthen the joint capsule O Decrease the symptoms of autoimmune disorders O Stimulate inflammatory response Lubricate the joints in healthy individuals 3. How does Enbrel (entanercept) work?

Jean – Assisting suicide or supporting autonomy? Jean is a 28-year-old woman who has had juvenile onset diabetes since age 5. While she has
been a nearly ideal patient, her condition has been quite brittle. Consequently, she is now near
blind, has significant peripheral neuropathy and increasing renal compromise. She was admitted
to the hospital 10 days ago for amputation of her right foot due to vascular compromise and
infection. Jean’s parents are dead and she has no siblings. She is unmarried but has a long-term
significant other. Jean used to be a modern dancer and agreed to the amputation of her foot only
with the understanding that she would be able to walk again with prosthesis.

After 10 days, the stump is not healing due to poor circulation and must be revised to above the
knee. In addition, the condition of her left foot has worsened with inactivity and the stress of
surgery. The surgeons recommend amputation of that foot as well. After listening carefully to the
explanation about the surgery, Jean replied to her primary physician (who she has known for 9
years), “I will not consent to further surgery. I am clearly at the end of this. I want to have my
insulin drip discontinued tomorrow after I have had a chance to say goodbye to David and my
friends. I’m smart enough to know that it will be a heck of a lot quicker and less painful to die of
ketoacidosis than this septic foot.”

Jean’s physician is shocked. He says he feels like he would be helping her to commit suicide.
Some of the nurses caring for Jean also are very distressed by this request. Other nurses think
Jean is doing exactly what they would do if they were in a similar situation. What is the right
thing to do? What issues are important here?  Adapted from a local case.

 Is Jean requesting assistance with suicide or withdrawal of life-sustaining therapy?

Do you agree with the example explanation below? If so, why? If not, why not? Please
provide a descriptive, thoughtful response.

Example Explanation: This case is to illustrate the patient’s right to refuse life-sustaining
therapy – even when the patient would not readily be identified as terminal and the therapy be
considered life-sustaining. In this case, based on a real situation, the woman was eventually
supported in her decision and died peacefully and quickly with her loved ones at her bedside.
The patient had clearly decided that her quality of life no longer met her minimum level and that
she was beginning the final phase of her chronic condition.

Reflect on the 3 most challenging patient encounters and discuss what was most challenging for each. What did you learn from this experience? What resources did you have available?

• What evidence-based practice did you use for this patient?
• What new skills are you learning?
• What would you do differently?
• How are you managing patient flow and volume?

Communicating and Feedback
Respond to the following reflective questions:

• How might I improve on my skills and knowledge, and how to communicate that back to my Preceptor?
• How am I doing? What is missing?
• What type of feedback am I receiving from my Preceptor?

Clara is an 89-year-old African American female who comes to see you in the clinic today. She describes a new complaint of Heartburn after doing housework . You are concerned these new symptoms might be cardiovascular in etiology and would continue your review of symptoms with her by asking which questions (list at least three ROS questions)?