8/31/2010. ELNEC- For Veterans. Hospice Education Network - ELNEC - For Veterans Module 1 - Introduction to Palliative Care

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1 ELNEC- For Veterans End-of-Life Nursing Education Consortium Palliative Care For Veterans Module 1: Introduction to Palliative Nursing Care Veterans Affairs Motto to bind up the nation s wounds, to care for him who shall have borne the battle and for his widow, and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations. President Abraham Lincoln 2 nd Inaugural Address Mission of the Department of Veterans Affairs Hospice and Palliative Care Program To honor Veterans preferences for care at end of life. Department of Veterans Affairs Office of Geriatrics and Extended Care 1

2 Demographics of Veterans Projected Over 5,000,000 Veterans cared for at VA facilities/year US Veterans: 23,442,000 Deaths of WW II Veterans/day: 900 % of Veterans over the age of 65: 39.4% National Center for Veterans Analysis and Statistics, 2009; Casarett et al., 2008a The Facts About Veteran Deaths More than 50,000 Veterans die a month (600,000/year) 23,000 die in VA inpatient settings/year Veteran deaths account for almost 28% of all deaths in the US Approximately 85% do not receive care in a VA facility Only 4% die in a VA facility NHPCO, 2010 Veterans in the Community Nearly 40% of enrolled Veterans live in rural communities 121,000 Veterans are without shelter or healthcare, hence no access to hospice/palliative care NHPCO,

3 Nurses Caring for Veterans at the End of Life Must Understand the Culture Enrolled Veterans Social isolation Lack L k of ff family support Low income Military camaraderie Culture of stoicism US Department of VA Affairs, VA Health Administration, 2005 Characteristics of VHA and Unique Characteristics of Enrolled Veterans The largest integrated healthcare system in the US Multi-layered layered benefits system Large elderly population Multiple co-morbidities Higher percent of homelessness than in general population Back et al., 2005; Casarett et al., 2008a; Finlay et al., 2008 Various Experiences Can Affect a Veterans Dying What branch of service? Enlisted? Drafted? Rank? Age? Combat and/or POW experience? PTSD (assess for social isolation, alcohol abuse, anxieties)? Stoicism Department of Veterans Affairs, VA Health Administration,

4 We Do Not Always Die the Way We Would Prefer Care at home Fear of pain Financial burden Invasive, painful treatments Dependence on others Role changes Finances Elderly caring for the sick Boni-Saenz et al., 2005; Egan-City & Labyak, 2010 Hospice and Palliative Care HOSPICE Most intense form of palliative care Less than 6 months to live Agrees to enroll in hospice program Chooses not to receive aggressive care PALLIATIVE CARE Ideally begins at the time of diagnosis Can be used to complement treatments NCP, 2009 Hospice and Palliative Care cont. BOTH Interdisciplinary care Provide pain and symptom management Physical, emotional, social and spiritual care 4

5 Palliative Care NCP, 2009 Death and Dying in America: Today Over 4700 hospice programs in the US Average length of stay in hospice is 20 days In 2007: 1,400,000 patients received hospice services 38.8% of all deaths in the US were under the care of a hospice program Patients with chronic illnesses make up the majority of hospice patients (i.e. heart disease, dementia, etc) NHPCO, 2005 & 2009 Barriers to Quality Care at End of Life Failure to acknowledge limits of medicine Lack of training for healthcare providers Hospice/palliative care services are misunderstood Many rules and regulations Denial of death Glare et al.,

6 History of Palliative Care in VA 1992: Policy All Veterans should be provided access to a hospice program : VA Faculty Leaders Project for Improved Care at the End of Life 2001: Training i and Program Assessment for Palliative Care (TAPC) : 2003: TAPC launched the VA Hospice & Palliative Care Initiative (VAHPC) VAHPC Launched Hospice-Veteran Partnership (HVP) NHPCO, 2010 History of Palliative Care in the VA (cont.) 2003-Present: Palliative Care Consultative Team (PCCT) and Accelerated Administration & Clinical Training (AACT) Comprehensive End of Life Care Initiative (CELC) PROMISE Palliative Care in the VA Today VA provides palliative care consultation services at ALL of its medical centers Many Community Living Centers (CLC) And contracts with community-based hospice programs to enhance VA s ability to meet the end-of-life services of its Veterans Over 60% of all Veterans who die in VA facilities receive care from a palliative care team Department of Veteran Affairs, VA Pubic Affairs,

7 Benefits of Palliative Care Consultation Teams (PCCT) in VA Veteran s goals of care are identified Less likely to be admitted to ICU Laboratory and technological tests decreased Communication between PCCT and Veteran allow goals to be honored Penrod et al., 2006 Differences in Cause of Chronic Illness and Death by Wars World War II Korean War Vietnam Gulf War Operation Enduring Freedom/Operation Iraqi Freedom Eligibility for VA Hospice Benefit Included in the Medical Benefits Package (both inpatient or home settings) Eligible for both VA and Medicare may elect to have hospice paid for under Medicare Hospice Benefit Department of Veterans Affairs, Veterans Health Administration,

8 Providing Hospice Services to a Veteran who Becomes an Inpatient GENERALLY, VA provides needed inpatient hospice care at a VA facility (preferred option) VA may utilize Community Nursing Home (CNH) contracts VA may purchase inpatient hospice services from a community provider Department of Veterans Affairs, VA Health Administration, 2005 Prognostication: May Be Used to Establish Goals of Care Performance status ECOG and Karnofsky are poor indicators Multiple symptoms Biological markers Albumin, etc. Would I be surprised if this Veteran died within the next 6 months? Glare et al., 2010; Lamont & Christakis, 2007; Lynn et al., 2000 Two Palliative Care Frameworks for Assessing Patients Making Promises Document: Begin g by envisioning what a better care system would look like Quality of Life Model: Identify physical, psychological, social, and spiritual aspects of care 8

9 Making PROMISES: Changing Systems of Care Good Medical Treatment Never Overwhelmed by Symptoms Continuity, Coordination, & Comprehensiveness Well Prepared, No Surprises Customized Care, Reflecting Your Preferences Consideration for Patient and Family Resources Make the Best of Every Day Americans for Better Care of the Dying, 1999 QUALITY OF LIFE MODEL: Addressing Four Dimensions of Care Physical Functional Ability Strength/Fatigue Sleep & Rest Nausea Appetite Constipation Pain Psychological Anxiety Depression Enjoyment/Leisure Pain Distress Happiness Fear Cognition/Attention Quality of Life Social Financial Burden Caregiver Burden Roles and Relationships Affection/Sexual Function Appearance Spiritual Hope Suffering Meaning of Pain Religiosity Transcendence Adapted from Ferrell et al., 1991 Role of the Nurse in Improving Palliative Care for All Patients More time at the bedside than other healthcare providers Some things cannot be fixed Use of therapeutic presence Maintain a realistic perspective Keep Veteran s goals first in all communication with the team 9

10 Maintaining Hope in the Midst of Death Experiential processes Spiritual processes Relational processes Rational thought processes Ersek & Cotter, 2010 Extending Palliative Care for Veterans Across Various Settings Nurses are the constant caregivers In-patient settings Clinics Community living centers Expand the concept of healing Become well-educatededucated Willing to be a change agent Final Thoughts Quality palliative care addresses quality of life for ALL patients Increased nursing knowledge is essential Being with Interdisciplinary care is vital 10

11 Consider. What steps do you need to take to improve palliative care at your institution so that you and other members of the team are prepared to care for him who shall have borne the battle? 11