In Part 1, we introduced PE, a 68-year-old former Navy member diagnosed with Motor Neurone Disease (MND) in July 2023, and outlined how Mega Nursing & Care established a tailored, compassionate care plan to support his physical, emotional, and social needs. As PE’s condition progressed, his care requirements intensified, demanding an adaptive and empathetic approach. Part 2 explores how Mega Nursing & Care responded to these challenges, ensuring PE’s dignity, comfort, and wishes remained at the heart of his care journey while providing robust support to his family.
As PE’s MND advanced, his symptoms worsened, with increased muscle weakness, shallow breathing, and fatigue becoming prominent. Using the Rockwood Frailty Scale, his score escalated from level 7 to level 9 by December 2023, reflecting severe frailty. The colour-coding tool shifted from amber to red, signalling a critical phase in his condition. In response, the district nursing team introduced a syringe driver in December to manage symptoms effectively, aligning with NICE guidelines and the Five Priorities of Care.
Mega Nursing & Care prioritised the PE’s comfort through meticulous symptom monitoring. Carers used a cough assist machine regularly to clear mucus and prevent respiratory infections, a common risk with MND. The NIPPY machine (non-invasive ventilator) continued to support his breathing, with carers trained by the home ventilation team to ensure proper use. Medications, including antibiotics for chest infections, antidepressants, and sleeping tablets, were prescribed by PE’s GP to manage symptoms and enhance his quality of life. Any changes in PE’s condition, such as increased breathlessness, were promptly documented and communicated to the care team and relevant health professionals.
PE’s Advance Care Plan (ACP), dated 03/02/2024, remained the cornerstone of his care. As his condition deteriorated, Mega Nursing & Care facilitated his transfer to Cransley Hospice, as per his wishes. The Do Not Attempt Resuscitation (DNAR) order, dated 27/05/2024, was respected, ensuring interventions aligned with PE’s preferences. Despite communication challenges due to his ventilator mask, carers promptly removed it when needed, enabling PE to express himself clearly and maintain his voice in care decisions.
PE’s identity as a Navy veteran continued to shape his care. Carers organised his day around watching documentaries and films about naval history, which brought him joy and a sense of connection to his past. A standout moment was PE’s participation in the Remembrance Sunday march in November 2023, honouring the Armistice. This meaningful event, facilitated by Mega Nursing & Care, allowed PE to engage with his community and celebrate his legacy, demonstrating our commitment to enriching his life beyond clinical care.
PE’s wife and family were integral to his care journey, and Mega Nursing & Care provided comprehensive support to ease their emotional and practical burdens. Regular updates kept the family informed about PE’s condition, and they were encouraged to participate in decision-making. As PE’s prognosis became clearer, his wife was sensitively supported in discussions about funeral arrangements, with resources like counselling services and hospice care made available.
Initially hesitant to accept help, PE’s wife gradually welcomed assistance with tasks like washing, cooking, and cleaning, reducing her stress as a carer. Mega Nursing & Care collaborated with Marie Curie, the district nursing team, and the palliative care team to provide pain relief and symptom management, ensuring a seamless support network. Emotional companionship from community resources, such as PE’s Facebook friends, further bolstered the family’s resilience, creating a compassionate environment for both PE and his loved ones.
Mega Nursing & Care maintained a structured care routine to provide stability for PE. His dedicated team of five carers—two for night shifts and three for daytime—ensured continuity and trust. Detailed care plans outlined precise instructions for managing PE’s medical equipment, meals, and exercises, with daily stretches at midday to preserve mobility. Regular meetings with the GP, palliative care team, and home ventilation team kept all parties aligned, while updated Gold Standards Framework (GSF) paperwork ensured care remained responsive to PE’s evolving needs.
Clear documentation and proactive reporting were critical to PE’s care. Any changes in his symptoms were promptly shared with the office and health professionals, allowing for swift adjustments to his care plan. This systematic approach ensured consistency, minimised disruptions, and upheld PE’s dignity throughout his journey.
Mega Nursing & Care’s support for PE and his family exemplifies our commitment to compassionate, person-centred care. By adapting to PE’s progressing needs, honouring his wishes, and supporting his loved ones, we created a care experience that prioritised dignity, comfort, and connection. From facilitating cherished moments in the garden to enabling PE’s participation in Remembrance Sunday, our team went beyond clinical care to celebrate his life and legacy. PE’s story reflects the heart of Mega Nursing & Care: delivering holistic support that empowers clients and their families during life’s most challenging moments.
