2100 Years Ago Ask: What do you see in the picture? Explain that there are several generations in the picture and they all live in the little house in the back ground.Point out the little boy with the bike. I estimate his age to be around and he has already experienced the death of a loved one.100 years ago death was viewed a natural process.
3The Last 100 Years “Industrialization & Modern Medicine” 19002000Life Expectancy47.5 yrs.76.5 yrs.Causes of DeathPrimarily InfectiousPrimarily Chronic IllnessesDisease TrajectoryShortExtendedMedical FocusComfortCureCaregiversFamilyHealth Care ProvidersSite of DeathHomeHospitals & Nursing HomesDeath Rate1720 per 100,000860 per 100,000
4The Last 100 Years In 1900, the average life span was 47.5 years Leading Causes of DeathPneumoniaTuberculosisDiarrhea & EnteritisHeart DiseaseStrokeLiver DiseaseInjuriesCancerSenilityDiptheriaIn 2000, the average life span was 76.5 yearsLeading Causes of DeathHeart DiseaseCancerStrokeChronic Lung DiseasePneumoniaAccidentsDiabetesSuicideKidney DiseaseChronic Liver DiseaseAsk how did people die of Senility a 100 years ago…They left grandma who had senility with the little boy with the bike and what do you think he did? He played on his bike and Grandma wondered off.
6End of Life StatisticsIn 1997, most Americans died in one of three settings:Hospitals 53% Nursing Homes 24% Home 23%Most people surveyed preferred to die at home and pain free however,77% died in institutions50% died in pain (SUPPORT I)The number of people over 85 will double to 9 million by the year 2030 (CDC)Forty percent of all DNR’s are signed within 48 hours of death
7Mission StatementAt INTEGRIS Health, our Palliative Care Service Mission is:To improve the quality of life of the people and community we serve. We believe this mission extends to all stages of life. Accordingly, we believe in palliative care as a process to meet the needs of persons with chronic, life-limiting illnesses. Palliative care assists with pain and symptom relief; with education and support for patients and their family; and with transitions in care as the illness progresses.
8What Is Palliative Care? Palliative Care is:Quality medical care for those with a life-limiting or life-threatening illnessPursuing the goals as defined by the patientGuiding patients/families as care transitions from curative therapy to disease & symptom managementAddressing the patient’s needs in context of their own social systemPrevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems
9Why Palliative Care? Palliative Care is an option for anyone with: A life-limiting illness that includes the cascade of physical, emotional, psychosocial and spiritual needsA need to relieve sufferingFeelings of isolationFeelings of being less than a person (the disease has become their primary focus in life)A need for aggressive symptom managementA need to maximize their quality of life
10Who Provides Palliative Care? A multidisciplinary team of palliative care professionals – MD, RN, MSW, Chaplain in collaboration with the primary physician, nurses, healing touch therapists, pharmacist, dietician and all staff who provide care to this patient and familyThe Palliative Care Team provides consult services to in-patients with complex palliative care needs identified through the palliative care screening processEvery care provider has responsibility to address the palliative care needs of our patients
11What Services Are Provided? Pain and symptom managementCoordination of health care servicesDisease process informationCommunity resource informationSpiritual supportAssistance with communication and decision-makingSetting care goals that expand throughout the progression of illness
12What It Is and Is Not Palliative is not: Palliative care is: Expert care of pain and symptoms throughout illnessCommunication and support for decision makingAttention to practical support and continuity across settingsCare that patients want at the same time as efforts to cure or prolong lifePalliative is not:“giving up” on the patientWhat we do when there is nothing more we can doIn place of curative or life-prolonging careThe same as hospice
13Palliative Care Vs. Hospice Available while patient still receiving life prolonging or life saving therapiesBegins much earlier in disease trajectoryDisease treating professionals continue consulting servicesHospice CareThose in hospice always receive palliative care, but hospice focuses on a person’s final months of lifeTeam oriented approach to enhance comfort and improve quality of life with such therapies as symptom management, emotional, spiritual and bereavement support for the patient and families
14Symptom Management Pain Nausea Vomiting Shortness of Breath Lack of appetiteAnxietyDepressionFatigueDrowsinessWe do a good job of managing patients pain however, when people are dying they experience other symptoms as well. Lets look at each of these symptoms and determine what we can do to help alleviate them. These are things that do not take a doctors order.Nausea and vomiting…What do you think is causing it? (decreased blood supply to the stomach, side effect of medication). One of the easiest things we can do is before we take their tray into the room take the lid off of it. This allows the odors to dissipate before you enter the room and the patient does not get hit with the strong odor of broccoli. A cool wash cloth to the forehead or back of the neck helps some patients.Shortness of Breath….Elevate the head of the bed, place a fan so it blows directly on them…Research has shown that having a fan blowing on a COPD patient can increase their O2 Sat by a couple of points. This is huge when you can breath. Stay with the patient and reassure them. Sometimes giving a back rub while you reassure them will often decrease their anxiety and help with their SHOBLack of appetite….Offer 6 small meals instead of three large ones. Ask them what they would like to eat or drink, if it is something they can have contact dietary to see they can provide the patient with what they would like to eat.Depression is often experienced due to the patient facing their own mortality. What resources can you tap into that can assist with this symptom? Pastoral care and the social worker.Fatigue and drowsiness is often associated with the disease itself or a side effect of the medication. What can you do to help the patient with these symptoms?.....Patients are often reluctant to ask visitors to leave when they become tried. So it is helpful to work out a signal a head of time with your patient so he can let you know they are tired so you can ask the visitors to leave instead of the patient. It can be as simple as having the patient tell you they have a headache.
15Alert vs. Nonresponsive Patients who are alert or responsive should be able to participate in their own treatment as much as possibleNonverbal cuesGrimacingMoaningRestlessnessElevated blood pressure and/or heart rateSubtle cues interpreted by family
16Symptom Management Expect the presence of multiple symptoms All symptoms can have their severity measured with a simple scale of 1 – 10.Symptom severity is best scored by the patient. If the patient is unable, the family or nurse may be ask to provide a score.Measuring and recording symptom severity over time allows interventions to be adjusted and maximizes comfort and quality of life.The goal of symptom management is to control symptoms, promote meaningful interactions between patients and significant others and facilitate peaceful deaths.
17Symptom Management & The Family The dying patient’s family is often viewed as a third leg of a triad much like in pediatricsPatients and family members often have different stresses and are at different stages of grieving – leading to additional stresses and issues within the familyDenialBargainingAngerDepressionAcceptanceAnticipatory GriefSince the patient and family will often go through what is called anticipatory grieving (go over the 5 stages of grief) they will not want to burden each other with those feelings. It is important to provide the patient and family support separately since their support system may not be intact anymore. You can always contact pastoral care or social services to come and talk with the patient and family one on one.
18Death & Family Dynamics (Dys) Functional Family RolesITWBBTCI - YAGFTHPrevious family issues, “old baggage”, that were never resolved or dealt withMarital issuesAbuse issuesParent-child issuesEstranged relationshipsITWBBTCI-YAGFTH= If They Were Broke Before They Came In- Ya Aint Going to Fix Them Here.Cover old baggage.Tell the story of The Man with Three Ex-WivesA patient who was dying had been married and divorced three times. All three ex-wives wanted to be there for the patient. The only problem was they could not stand one another. The nurse staff worked out a visitation schedule so each ex-wife could visit. We put about min between each visitation. Well one day ex-wife number 1 stopped at the gift shop and meet ex-wife number 2 in the parking lot and scecurity had to be called. Now we could have barred them from the hospital but who would have suffered the most from this decision? The patient. So we sat all three ex-wives down and explained that this behavior would not be tolerated and that we understood that they wanted to be there for the patient. So we created a new visitation schedule with 30 minutes between each visitation with the understanding that when their visitation was over they were to leave the hospital grounds. This was a win-win for everyone.
19EducationPatients and Family Members usually have little or no health care trainingDisease ProcessDisease TrajectoryTreatment OptionsTreatment GoalsResources & Support for Patient and FamilyPatients and their families should be educated on all aspects of their disease and care.What are some resources for the patient and family?
20Spiritual AspectsSpiritual Distress by the patient may actually exacerbate physical symptomsSome cultures had specific rituals or beliefs dealing with death and dying such as Last Rights or bathing after deathWe can not know every patients cultural or religious beliefs as it relates to death and dying however, we can find out by simply asking them.What are some examples of specific religious or cultural beliefs related to dying?Muslims-must face east and have a window open.Catholics often want the last rights before deathWe had a Buddhist who died and the family placed a piece of Jade in his hand. When the staff came in to do post mortem care they removed the piece of Jade. This up set the family because as they explained it the Jade contained their loved ones soul and since we had removed the jade the soul was now permanently separated from the patient. The was no amount of service recovery or apologies that could fix this. So when in doubt ask.
21Hospital Resources Clinical Support Case Management Social Work NursingPhysicianPharmacyCase ManagementSocial WorkPastoral CareEthics Committee
22The Legal Forms Advanced Directive (AD) Living Will for Health CareHealth Care ProxyDurable Power of Attorney for Healthcare (DPOA)Do Not Resuscitate (DNR)Certificate of Physician
23Postmortem CareIs the care provided to the patients body after their death.Postmortem care is necessary to keep the body in proper alignment and prevent skin damage and discolorationCultural and religious beliefs often dictate how the body is to cared for after death and by whom.In some cultures the family members help to clean and prepare the body.Once the family leaves we will either take the body to the morgue or leave the patient in the room if we are not needing the bed. We also have a postmortem kit that has a gown, and cover that we put the patient in after the family leaves.I usually cover any strange things that people say has happened when a patient dies. Like they sat up in bed, they moaned, they came back to life etc.
24Postmortem Care Standard precautions are followed. The body is placed in proper alignment before rigor mortis occursPosition the body:Place the patient in center of bed with a pillow under the head.Close the eyes. Put a moistened cotton ball on each eyelid if the eyes do not stay closed.Replace the patient’s dentures
25Postmortem CareCleans the body. Often times the patient will loose control of bowl and bladder.Place a clean gown, sheets and blanket.Remove any trash or clutter from the room. Put bed in lowest position with all four side rails down. Move chairs around bed and have a box of tissue within reach.Allow the patients family enter the room.
26Postmortem CareAfter the patients family leaves the funeral home will be notified.If there is not a bed crunch the patient may stay in the room until the funeral home can come and pick the patient up.If there is a need for the room or if the funeral home will not be able to come for several hours the patient may have to go to the morgue.If you have to take the patient to the morgue:Call security and ask them to meet you at the morgue.Transport the body to the morgue. Security will have to unlock the door and then relock after you place the body in the morgue.
27Postmortem CarePostmortem Care for patient’s going to the Medical ExaminerDo everything that you would normally do except:Do not remove any tubes (foley, NG, Vent, etc) or IV/lines.These will go with the patient to the ME’s office.Patients who might go to the ME’s Office:Patient’s who die within 24 hours of admissionInjuries/death the result of violence (ie gang, domestic, robbery, etc)Death result of an automobile accident