End of life care in Residential Care Homes for the Elderly- challenges and rewards

Transcription

1 HKEC Symposium on Community Engagement IX 2014 End of life care in Residential Care Homes for the Elderly- challenges and rewards Presented by Dr. Sharon N C SHUM Specialist in Geriatric Medicine HKEC Community Geriatrics Assessment Team Department of Geriatrics Ruttonjee Hospital & Tang Shiu Kin Hospital 12/07/2014

2 End of life care is a Global Health Issue Hospital Authority Annual Plan Ran k Disease Group No. of registered deaths 1 Malignant neoplasms (31%) 2 Disease of heart 6316 (15%) 3 pneumonia 6131 (14.5%) 4 CVA 3325 (8%) 5 Chronic lower respiratory diseases 6 External causes of morbidity and mortality 7 Nephritis, nephrotic syndrome and nephrosis 1963 (4.6%) septicaemia dementia DM 457 All other causes 6349 All causes Ten leading causes of death in Hong Kong in 2011 Department of Health, HKSAR 2012

3 3

4 End of life care is a Global Health Issue Institutionalization rate of elderly population (aged 60 or above): international comparison Chui, E.W,T. et al (2009) Elderly Commission s Study on Residential Care Services for the Elderly Final Report. Hong Kong: Elderly Commission

5 End of life care is a Global Health Issue 33.5% (~13,630) of all deaths in HA hospitals are RCHE residents Among all RCHE deaths, 34.7% (~4700) are those with 2 admissions into M&G during the last 6 months of life (excluding the death episode or those who died in hospice beds) HA statistic 2012

6 HKEC Community Geriatric Assessment Team (CGAT) Provides on-site medical care to the residents Cover 81 residential care homes for elderly (RCHE) ~ 5660 residents

7 Dec patients 81% from RCHES Nov 2011 Hospital EOL program in geriatric wards Program A Jan 2014 Community EOL program in RCHEs Program B Pitfalls of Program A

8 End of Life Care in RCHE OBJECTIVES: Improved Quality of Life Die in Dignity Continuity of Care according to the Advance Care Plan (ACP) Bereavement support to family members/old age home staff

9 OUR TEAM Geriatricians RCHE staff CGAT nurses Geriatric wards PT MSW OT Dietitian/ST

10 End of life care in RCHE PREPARATORY PHASE: Staff training Working and care protocols Meeting with HA/HKEC management team, AED, PC department and RCHE staff

11 Recruit suitable patients

12 Recruit suitable patients Meeting with family/ patient

13 Discuss prognosis Identify values, goals & preferences Provide options to patient/family Emphasize comfort and dignity Build up a care plan and reduce unnecessary therapies Advance Care Plan

14 Issue Admission Card

15 End of life care pathway in RCHE E Adm. Path C Adm. Path CGAT coordinate direct admission during office hours

16 End of life care in RCHE EOL patients under CGAT care up to 06/2014 Program A 201 patients Program B 8 RCHEs 22 patients

17 End of life care in RCHE 66 patient screened for EOL program B 26 of patient s family members engaged for ACP 7 patients died before discussion 33 patients excluded due to not fulfill inclusion criteria/refused/ hospitalization 21 ACP signed after discussion 5 ACP not signed after discussion

18 Demographic data of EOL patients in RCHE sex No of comorbidities ranged from 3-11 average: 7 reflect the underlying frailty AGE 23% 77% female male 91% Average age: 91.3 yrs old More than 90+: 14/22 young old yrs old yrs old-old >80 yrs

19 Principal Diagnoses of Patients recruited in EOL program 25% 10% 15% 55% 40% 50% dementia end-organ failure others dementia end-organ failure malignancy Woo J. et al. J Clin Nurs 2011;20:

20 CHALLENGES of implement EOL care in RCHE BARRIERS Health Care Team - Staff readiness - Time restraint - Communication skills - Discomfort with emotions from the patients / family members Patient/ Family - Not aware of the relevance of ACP - Assume clinician will initiate ACP discussions when they are needed

21 CHALLENGES of implement EOL care in RCHE Misconception DNR Do Not Care DNR is a choice of treatment option Lack of social awareness/gover nment support Practical limitation Chinese taboo No legislation Visiting hour/infection control issue Collaboration with working partners

22 REWARDS Health care team Holistic care Compassion, Empathy Clinical skills Patient and family Good death Good family closure

23 REWARDS

24

25 Acknowledgment HKEC CGAT team RH PC team RH geriatric wards RCHE staff Allied health teams Patients and their family members