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Palliative Care & End of Life

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1 Palliative Care & End of Life
Integris health

2 100 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.

3 The Last 100 Years “Industrialization & Modern Medicine”
1900 2000 Life Expectancy 47.5 yrs. 76.5 yrs. Causes of Death Primarily Infectious Primarily Chronic Illnesses Disease Trajectory Short Extended Medical Focus Comfort Cure Caregivers Family Health Care Providers Site of Death Home Hospitals & Nursing Homes Death Rate 1720 per 100,000 860 per 100,000

4 The Last 100 Years In 1900, the average life span was 47.5 years
Leading Causes of Death Pneumonia Tuberculosis Diarrhea & Enteritis Heart Disease Stroke Liver Disease Injuries Cancer Senility Diptheria In 2000, the average life span was 76.5 years Leading Causes of Death Heart Disease Cancer Stroke Chronic Lung Disease Pneumonia Accidents Diabetes Suicide Kidney Disease Chronic Liver Disease Ask 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.


6 End of Life Statistics In 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 institutions 50% 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

7 Mission Statement At 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.

8 What Is Palliative Care?
Palliative Care is: Quality medical care for those with a life-limiting or life-threatening illness Pursuing the goals as defined by the patient Guiding patients/families as care transitions from curative therapy to disease & symptom management Addressing the patient’s needs in context of their own social system Prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems

9 Why Palliative Care? Palliative Care is an option for anyone with:
A life-limiting illness that includes the cascade of physical, emotional, psychosocial and spiritual needs A need to relieve suffering Feelings of isolation Feelings of being less than a person (the disease has become their primary focus in life) A need for aggressive symptom management A need to maximize their quality of life

10 Who 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 family The Palliative Care Team provides consult services to in-patients with complex palliative care needs identified through the palliative care screening process Every care provider has responsibility to address the palliative care needs of our patients

11 What Services Are Provided?
Pain and symptom management Coordination of health care services Disease process information Community resource information Spiritual support Assistance with communication and decision-making Setting care goals that expand throughout the progression of illness

12 What It Is and Is Not Palliative is not: Palliative care is:
Expert care of pain and symptoms throughout illness Communication and support for decision making Attention to practical support and continuity across settings Care that patients want at the same time as efforts to cure or prolong life Palliative is not: “giving up” on the patient What we do when there is nothing more we can do In place of curative or life-prolonging care The same as hospice

13 Palliative Care Vs. Hospice
Available while patient still receiving life prolonging or life saving therapies Begins much earlier in disease trajectory Disease treating professionals continue consulting services Hospice Care Those in hospice always receive palliative care, but hospice focuses on a person’s final months of life Team 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

14 Symptom Management Pain Nausea Vomiting Shortness of Breath
Lack of appetite Anxiety Depression Fatigue Drowsiness We 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 SHOB Lack 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.

15 Alert vs. Nonresponsive
Patients who are alert or responsive should be able to participate in their own treatment as much as possible Nonverbal cues Grimacing Moaning Restlessness Elevated blood pressure and/or heart rate Subtle cues interpreted by family

16 Symptom 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.

17 Symptom Management & The Family
The dying patient’s family is often viewed as a third leg of a triad much like in pediatrics Patients and family members often have different stresses and are at different stages of grieving – leading to additional stresses and issues within the family Denial Bargaining Anger Depression Acceptance Anticipatory Grief Since 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.

18 Death & Family Dynamics
(Dys) Functional Family Roles ITWBBTCI - YAGFTH Previous family issues, “old baggage”, that were never resolved or dealt with Marital issues Abuse issues Parent-child issues Estranged relationships ITWBBTCI-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-Wives A 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.

19 Education Patients and Family Members usually have little or no health care training Disease Process Disease Trajectory Treatment Options Treatment Goals Resources & Support for Patient and Family Patients and their families should be educated on all aspects of their disease and care. What are some resources for the patient and family?

20 Spiritual Aspects Spiritual Distress by the patient may actually exacerbate physical symptoms Some cultures had specific rituals or beliefs dealing with death and dying such as Last Rights or bathing after death We 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 death We 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.

21 Hospital Resources Clinical Support Case Management Social Work
Nursing Physician Pharmacy Case Management Social Work Pastoral Care Ethics Committee

22 The Legal Forms Advanced Directive (AD)
Living Will for Health Care Health Care Proxy Durable Power of Attorney for Healthcare (DPOA) Do Not Resuscitate (DNR) Certificate of Physician

23 Postmortem Care Is 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 discoloration Cultural 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.

24 Postmortem Care Standard precautions are followed.
The body is placed in proper alignment before rigor mortis occurs Position 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

25 Postmortem Care Cleans 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.

26 Postmortem Care After 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.

27 Postmortem Care Postmortem Care for patient’s going to the Medical Examiner Do 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 admission Injuries/death the result of violence (ie gang, domestic, robbery, etc) Death result of an automobile accident

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