Nursing, Palliative Care & Death: A Natural Progression Of Life. Presented by Veronica Gordon, MSN, RN

Transcription

1 Nursing, Palliative Care & Death: A Natural Progression Of Life Presented by Veronica Gordon, MSN, RN

2 Disclosures Presenter, Veronica Gordon have no interest to disclose.

3 Learning Objectives At the conclusion of this activity, the participant will be able to: 1. Identify the Benefits Palliative Care Consultations have on Improving End of Life Care 2. Identify the Quality of Life Model by addressing the Four Dimensions of Assessment and Care of patients to Improve End of Life Care 3. Recognize Indicators of Imminent Death and the Death Event 4. Describe How Palliative Nursing Impacts Quality End of Life Care

4 What is Palliative Care Palliative care is specialized care for individuals with serious or terminal illnesses. The main goal is to ease pain and discomfort from symptoms and stress of a serious illness. Palliative care aims to enhance quality of life Get Palliative Care, 2016

5 Palliative Care Team Members Palliative care is provided by a specially-trained team of doctors, nurses, social workers and other specialists who work together with a patient s doctors to provide an extra layer of support. Massage therapists, pharmacists, nutritionists, chaplains and others may also be part of the team. The palliative care team works in partnership with the patients doctor to provide an extra layer of support for the patient and their family. The team provides expert symptom management, extra time for communication and help navigating the health system. Palliative patients identified hospitals as a safer place than home, offering relief to the Get Palliative Care, 2016 Taylor, & Chadwick, 2015

6 Identifying Patient s Need for Palliative Care Palliative care is needed if a patient suffers from symptoms due to a serious illness. This may include cancer, cardiac disease, respiratory disease, kidney failure, Alzheimer s, HIV/AIDS, ALS, MS, and more. Symptoms include pain, stress, depression, shortness of breath, fatigue, constipation, nausea, loss of appetite, difficulty sleeping and much more. Palliative care is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Get Palliative Care, 2016

7 Benefits of Palliative Care at the End of Life Expert Physical, Pain, and Symptom management Psychosocial/Emotional support Spiritual and Cultural support Discussion, Negotiation, Advance Life Planning, End of Life Goals Early education and execution of advanced directive allows patient preferences to be honored and decreases decision- making burdens on the family. Guidance in appropriate disposition (inpatient or community hospice) Holistic and supportive care regardless of palliation or curative intent Bailey, Harman, Bruera, & Arnold, 2016 Finestone & Inderwies, 2008 McAteer, R., & Wellbery, C,2013

8 Fast Facts: U.S. Statistical Data 2014 registered deaths: 2,626,418 Patients received hospice service: 1.6 to 1.7 million Deaths while under hospice care:1,200,000 Leading causes of death: Non- Cancer: 63.4% Cancer: 36.6% Veterans deaths: One of every four Americans who die each year is a Veteran Hospice Care in America,2015 Shreve, 2016

9 Fast Facts Hospice and Palliative Care Department of Veterans Affairs Annual Report-FY15 73% of all inpatient deaths received palliative care More inpatient deaths occurred in VA inpatient hospice units than inpatient ICU and Acute Care combined 84% of the families of the inpatient decedent, rated care in the last 30 days as Excellent or Very Good Earlier palliative care consultation continues, with now 41% occurring more than 30 days prior to death Shreve, 2016

10 Palliative Care Metric Report VISN Definitions and Terms Workload Complexity- All inpatient and outpatient completed palliative care consults with an encounter. Level minute consult minute consult Level minute consult hour or longer consult hour or longer consult OR admission to hospice or palliative care Palliative Care Reporting, 2016

11 Palliative Care Metric Report VISN Definition and Terms Treating Specialty- Inpatient Hospice Admission (TS96/1F) 1F- Patients with hospice admission to Acute Care Setting TS96- Patients with hospice admission to Community Living Center Inpatient Palliative Care Summary = Inpatient deaths w/completed PCC within 12 mo. of death OR hospice adm. Inpatient deaths Palliative Care Reporting, 2016

12 MEDVAMC Palliative Care Data FY13 FY14 FY15 FY16 FY17 TD* Completed Consults, Level Completed Consults, Level Total Consults, total Average days between completed initial PCC and death Level 3-5 consult within 12 mo. prior to death Hospice admission - TS96 or 1F w/i 12 mo. prior to death Level 3-5 consult w/i 12 mo. prior to death OR hospice admission Inpatient deaths % inpatient deaths with completed PCCT consult within 12 months prior to death OR hospice admission

13 1200 MEDVAMC Palliative Care Workload Complexity 100% 88% 86% 86% 90% 86% 90% % % 60% 693 Consults, Level % Consults, Level % 30% Total Consults Percent Level % 10% FY17 data: through March 26; 48% of year 0 FY13 FY14 FY15 FY16 FY17 TD* 0%

14 Transitioning to Comfort Care % % % % 70% 60% % 50% Hospice admission or TS changed 250 Inpatient deaths % % 30% % Inpatient Deaths with hospice admit or TS changed % 10% Houston VA FY17 data: through March 26; 48% of year FY13 FY14 FY15 FY16 FY17 TD* 0%

15 Hospice is not about GIVING UP! It is about receiving specialized care at end of life my story

16 Hospice Hospice is not a place, but a concept for healthcare delivery to those dealing with life-limiting illness. Hospice focuses on creating a natural and comfortable end-of-life experience for those confronted with a terminal condition. Through a range of palliative, medical, nursing, psychosocial, and spiritual care provided by an interdisciplinary team of experts, hospice seeks to manage symptoms and provide comfort when cure is no longer possible. WebMD LLC

17 Impact of Transitioning to Comfort Care on Quality End-of-Life Improved pain and symptom management Improved quality of life and mood Prevent suffering and unnecessary hospitalization Prevent invasive and burdensome procedure and treatments Decreased hospitalization costs with improved utilization of supportive and health care resources Increased decision making and a sense of control Caregivers, family, and friends report greater satisfaction Improved end-of-life care and increase survival rate Communicate end-of-life wishes; reduce confusion about goals of care Ahluwalia et al., 2014 Bailey, Harman, Bruera, Arnold, & Savarese, 2016 McAteer, R., & Wellbery, C Temel et al., 2010

18 DEATH

19 Quality of Life Model: Four Dimensions of Assessment and Care Physical Well-Being Activities of daily living, Appetite, Strength, Pain, Fatigue, Nausea Psychological (Mental) Well-Being Stress, Fear, Cognition, Depression, Anxiety, Relief Social Well-Being Relationships, Finances, Sexual Function Spiritual Well-Being Religion, Hope, Loss, Meaning

20 Death a Fearsome Subject Death Cafe s goal: help people make the most of their lives, their finite lives, by giving them a chance to talk about death. It s something family and friends often refuse to contemplate. Cafe.html#storylink=cpy The Kansas City Star: May 23, 2014

21 DEATH, a Natural Process Two dynamics at work Physical plane Emotional-Spiritual-Mental plane Body Final process of shutting down Maintaining comfort enhancement measures Spirit Final process of release from the body, its environment, and all attachments Support and encourage this release and transition Hospice, 2016

22 Indicators of Nearing Death and Clinical Death o Decreased level of consciousness, Palliative Performance Scale 20%, o Dysphagia of liquids appeared at high frequency and >3 days before death and had low specificity (<90%) and positive LR (<5) for impending death. o apnea periods, o Cheyne-Stokes breathing, o Death rattle o Peripheral cyanosis, o Pulselessness of radial artery o respiration with mandibular movement o decreased urine output occurred mostly in the last 3 days of life and at lower frequency. Five of these signs had high specificity (>95%) and positive LRs for death within 3 days, including pulselessness of radial artery (positive LR: 15.6; 95% confidence interval [CI]: ), respiration with mandibular movement (positive LR: 10; 95% CI: ), decreased urine output (positive LR: 15.2; 95% CI: ), Cheyne-Stokes breathing (positive LR: 12.4; 95% CI: ), and death rattle (positive LR: 9; 95% CI: ). Non-reactive pupils Decreased response to visual stimuli Decreased response to verbal stimuli Inability to close eyelids Drooping of the nasolabial fold (which makes the face

23 Clinical Death Clinical DEATH-The cessation of all vital functions of the body including the cessation of all vital functions of the body Heartbeat Brain activity (including brain stem) Breathing The irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart, respiration, and the brain activity: The End of Life

24 How Palliative Nursing Impacts Quality End of Life Special Training Interdisciplinary services Cultural Competence Providing physical care Psychosocial/Emotional Distress Social Distress Spiritual Distress Values and Hope Avoid delay the introduction of a palliative approach

25 Special Training Social Distress Rehabilitation Special Equipment Psychosocial/Emotional Distress Limited Disability Spiritual Distress Values and Hope Existing long-term relationship

26 Nursing Responsibility Health professionals often delay the introduction of a palliative approach by waiting for a clearly terminal event. By doing so, the dying patient may have a poor quality of life, suffering unnecessarily from preventable symptoms (Wilson, Avalos, & Dowling, 2016). It is important that providers and caregivers review the four dimensions in order to provide proper care and support. Assess all dynamics in relation to the closure of the patients life. Poor management of these four dimensions may hasten death by increasing stress, pain, anxiety, and diminishing spiritual meaningfulness. Enlist help of interdisciplinary services such as chaplain, social worker, psychologist, pain management specialist, and etc. Make accommodations.

27 Nurses Preparing for Palliative Readiness includes: Being knowledgeable Caregiving - Learning through actively seeking updated information, trial and error, earlier experience and guidance by others. - Be able to provide knowledge to the family on preparedness to include expectations on emotional and physical wellbeing. Giving emotional support - Knowing not only what to do, but also feeling ready to manage the demands of the caregiver role. - Providing support to family caregivers is an important aspect of both palliative care and nursing. Dealing with the stress of the role Åhsberg & Carlsson, 2014 Janze & Henriksson, 2014

28 Cultural Competence Nurses who lack understanding of a dying patient s cultural and spiritual needs at this difficult time can make that person s death an even more traumatic experience for his or her family members. Minoritynurse.com, 2016

29 Self-Determination Patient Self-Determination Act (1991) Right to facilitate own health care decisions Right to accept or refuse medical care Right to make their own advanced healthcare directive Living Will Power of Attorney Cipolletta & Oprandi, 2014

30 Thanatophobia: Fear of Death Religious Issues Beliefs may be wrong Straight and Narrow path, deviations?? Fear of the Unknown Cannot be unequivocally proven Fear of Loss of Control Utterly outside anyone s control Fritscher, L. 2014

31 The Fear of Death Concerns about Relatives Who will care for them, finances, what will happen Fear of Death in Children Don t fully understand time, some people leave and come back again Healthy part of normal development, lack defense mechanisms Fear of Pain, Illness or Loss of Dignity Do not actually fear death itself Fritscher, L. (2014)

32 References: Åhsberg, E., & Carlsson, M. (2014). Practical care work and existential issues in palliative care: experiences of nursing assistants. International Journal Of Older People Nursing, 9(4), p. doi: /opn Ahluwalia, S., Ettner, S., Pantoja, P., Lorenz, K., Tisnado, D., & Walling, A. (2014, February 2). Early Care Planning Discussions Are Associated with Less Hospital Care at End of Life in Veterans with Advanced Cander (TH336-C). Journal of Pain and Symptom Management []. Retrieved May 23, 2016 from: Bailey, A.F., Harman, S.M., Bruera, E., Arnold, R.M., & Savarese, D.M. (2016). UpToDate [Peer commentary on the journal article Palliative Care: The last hours and days of life ] by Wolters Kluwer, Retrieved June 6, 2016 from: Bombard, T. (2014). Neurotrauma Review Series PART 4: Autonomic Dysreflexia. EMS World, 43(4), Cipolletta, S., & Oprandi, N. (2014). What is a Good Death? Health Care Professionals Narrations on End-of-Life Care. Death Studies, 38(1), p. doi: / Finestone, A.J., & Inderwies, G. (2008, September 3). Death and Dying in the US: the barriers to the benefits of palliative and hospice care. Clinical Interventions in Aging, 3(3), Retrieved Juen6, 2016 from: Fritscher, L. (2014). Thanatophobia: Fear of Death, American Psychiatric Association, Retrieved from: Get Palliative Care. (2016). Retrieved from Hospice (2016). Hospice, Preparing for approaching death. Retrieved from: Janze, A., & Henriksson, A. (2014). Preparing for palliative caregiving as a transition in the awareness of death: family carer experiences. International Journal Of Palliative Nursing, 20(10), p. doi: /ijpn McAteer, R., & Wellbery, C. (2013, December 15). Palliative Care: Benefits, Barriers, and Best Practices [Letter of editor]. American Family Physician, 88(12), Retrieved June 3, 2016 from: Medical-dictionary.the freedictionary.com (2016). Clinical death / definition of clinical death by medical dictionary. Retrieved April 19, 2016 from: Merriam-Webster.com (2015). Death: Medical Definition of DEATH, Retrieved from: Minoritynurse.com (2016). Nurses, culture, and cancer minority nurse, Retrieved 03/11/2016 from:

33 NATIONAL HOSPICE AND PALLIATIVE CARE ORGANIZATION. (2015). Retrieved August 6, 2016 from In-line Citation:( NATIONAL HOSPICE AND PALLIATIVE CARE ORGANIZATION, 2015) National Spinal Cord Injury Statistical Center Annual Statistical Report for the Spinal Cord Injury Model. Systems Public Version. University of Alabama at Birmingham: Birmingham, Alabama. Retrieved August 6, 2016 from Last access: December O Gorman, S.M. (1998), Death and dying in contemporary society: an evaluation of current attitudes and the rituals associated with death and dying and their relevance to recent understandings of health and healing, Journal of Advanced Nursing, 27, , Retrieved from: Palliative Care Reporting. (2016, February). Retrieved August 9, 2016 from Shreve, S.T. (2016). Enhancing Access to Quality Care for Seriously Ill Veterans, Veterans Affair Central Office (VACO): FY 15 Hospice and Palliative Care Annual Report [Discussion group comment]. Retrieved June 27, 2016 from? Employee computer via , online VISN 16 Palliative Care Agenda group meeting. Spinal Cord Injury (SCI) Facts and Figures at a Glance. (2015). Retrieved August 06, 2016, from National SCI Statistical Center, Taylor, R., & Chadwick, S. (2015). Palliative care in hospital: Why is it so difficult?. Palliative Medicine, 29(9), doi: / Temel, J.S., Greer, J.A., Muzikansky, A., Gallagher, E.R., Admane, S., Jackson, V.A., Lynch, T.J. (2010, August 19). Early Palliative Care for Patients with Metastatic Non-Small Lung Cancer. The New England Journal of Medicin, 363(), Retrieved June 17, 2016 from: TheFreeDictionaly.com (2015). Clinical death / definition of Clinical death by Medical dictionary. Retrieved from: The Kansas City Star (May, 2014). Appreciating life at death café, Retrieved 05/06/2016 from: Wilson O, Avalos G, Dowling M. Knowledge of palliative care and attitudes towards nursing the dying patient. British Journal Of Nursing [serial online]. June 9, 2016;25(11): Wong, P. (2002). From death anxiety to death acceptance. Retrieved May 6, 2016 from: Veronica Gordon has no interest to disclose.

34 Self-Determination Patient Self-Determination Act (1991) Right to facilitate own health care decisions Right to accept or refuse medical care Right to make their own advanced healthcare directive Living Will Power of Attorney Cipolletta & Oprandi, 2014

35 Nursing, Palliative Care & Death: A Natural Progression Of Life QUESTIONS Honoring Veteran s and Patients Preferences for Endof-Life Care

36 Nursing, Palliative Care & Death: A Natural Progression Of Life QUESTIONS Honoring Veterans Preferences for End-of-Life Care