Presentation on theme: "Palliative Care and Aging Veterans"— Presentation transcript:
1Palliative Care and Aging Veterans Maura Farrell Miller, PhD, ACHPN, GNP, PMHCNS, BCDirector, Hospice and Palliative Care ProgramVA Medical CenterWest Palm Beach, FloridaVHA ONS GEC FAC Hospice and Palliative Care
2Outline History of Palliative Care integration Early efforts thwarted by unfunded national mandatesCELC Funding FY 9-12Palliative Care Consultation Teams at each VAStaffing for Inpatient Hospice Units“Strive for 65” InitiativesOngoing Palliative Care InitiativesQuality Monitoring: Partnering with PROMISE CenterAdapting to the needs of each facilityRequest for Proposals (RFP)Expanding Palliative Care Services
3First things first A Definition Palliative Care * VA DIRECTIVES: VETERAN SWITH SERIOUS ILLNESS DO NOT HAVE TO BE TERMINAL OR HAVE TIME LIMITED PROGNOSIS.PALLIATIVE CARE PROVIDES AN ADDITIONAL LAYER OF SUPPORT TO PACT AND SPECIALISTS/VALUE ADDED* HPC PROGRAM PROVIDES FOR VETERANS’ PHYSICAL, EMOTIONAL, SPIRITUAL AND PSYCHOSOCIAL NEEDS DURING SERIOUS ILLNESS BY PROVIDING COMPASSIONATE CARE TO VETERANS AND A SUPPORT SYSTEM TO THEIR FAMILY AND LOVED ONES.
4Palliative Care End of Life Care Traditionally, Palliative Care followed failed aggressive care and was deferred until all aggressive treatments were exhausted and death seemed inevitable and imminent. It is an “extra layer of support” as some have characterized it, not coming after curative or life-prolonging therapy but concomitant with it.
5EMBRACE PALLIATIVE CARE: WE CAN EASILY BECOME OVERWHELMED BY THE UNMET NEEDS FOR OUR SERVICES.
6Palliative CareBoth a philosophy and treatment approach, sometimes a location “palliative care unit”Based on Patient-Centered CareReinforces VA “I-Care” Goals:I-Integrity, C-Commitment, A-Advocacy, R-Respect, E-ExcellenceINTEGRITY, COMMITMENT, ADVOCACY, RESPECT, EXCELLENCEPALLIATIVE CARE HONORS PREFERENCES, MAINTAINS DIGNITY, PROVIDES COMPASSION AND COMFORT
7“As a nurse, we have the opportunity to heal the heart, mind, soul and body of our patients, their families and ourselves. They may forget your name, but they will never forget how you made them feel.” - Maya Angelou
8Palliative Care in Community Living Centers Effective and sensitive communicationAligning treatment with patient and family values, goals and preferencesSupport to familiesAssessment and management of symptomsWHERE ARE OUR AGING VETERANS?MOST ARE LIVING IN THE COMMUNITY HOME OR ALF, MEDICAL FOSTER HOME, STATE VETERANS HOMES.OTHERS IN CLCPROVIDE PALLIATIVE CARE IN THE RIGHT PLACE AT THE RIGHT TIMEBeginning at the time of admissionRegardless of the patient’s prognosisProvided by CLC Team, PCCT, or both
9Why do we need Palliative Care? Early 1900s:Average life expectancy in 50sChild mortality highPeople died quickly (infections, accidents)Elderly folks were cared for (80% died at home)Intergeneration model of living children, parents, grandparents/extended family.
10Why Palliative Care continued Increased life expectancy (M=73, F-79)Greater incidence of chronic disease and “prolonged dying” seen in > 80% of elderly patientsOver 80% of older adults die in hospitals and nursing homes
11Who should be referred? End-stage chronic diseases: Pulmonary disease Heart diseaseCVA and ComaHIV/AIDSCancerRenal diseaseLiver diseaseALSAlzheimer’s disease and Related disordersREMINDER DOES NOT HAVE TO HAVE LIFE LIMITING PROGNOSIS OF 6 MONTHS OR LESS.
12Would I be surprised by this patient’s death within the next year? “The Question”Would I be surprised by this patient’s death within the next year?
13FY 2000 Inpatient Deaths by Location 3 facilities with palliative care vs. national percentages VA no longer has Intermediate MedicinePurple = palliative care location of deathMany of our aging Veterans LIVE AND DIE in Community Living CentersCELC funded palliative units were strategically placed in CLC
14Why Palliative Care is important Untreated pain and other distressing symptomsFailure to address patient and family social, emotional and spiritual needsPoor communication with familiesConflict among clinicians, patients and familiesDivergence of treatment goals from patient and family preferencesUse of therapies for which burdens seem to outweigh the benefitsMoral distress of clinicians (nurses)This list comes from a great deal of literature and experiences of VA clinicians.
15How do we achieve quality palliative care? Consider PCCT consultations for all new CLC admissions…..PCCT and IDT meet with Veteran and FamilyTimely completion of Advance DirectivesIdentify Veteran preferences for careDiscussion about EOL goalsClarify expectations patient, family, staffProvide ongoing education and supportPatient Centered Care is overarching philosophyPatient Self-Determination Act: patients have the right to be informed about their care and refuse care
16Interventions to Consider… PCCT Consultation RoundsICU Family Meetings include PCCTPalliative Care planningNursing interventions: how do nursing staff demonstrate they care?How are interventions such as providing dignity, care, compassion, and respect documented?MDS day # 14 care planning unrealistic for hospice but is ok for palliative careTS 95 = palliative care/ Coding is importantPOLST
17PALLIATIVE CARE ROUNDS InterdisciplinaryAttending Physician or NPOther disciplines, Chaplain, RN, LPN, NA, Social Worker, Pharmacist, Music Therapist, Recreation TherapistInvite family to participate with Veteran: we treat them bothVarious types of rounds: Quality of Life Rounds, PCCT Consult Rounds, Daily assessment rounds
18Palliative Care Plan Meetings InterdisciplinaryComprehensiveDiagnosis and prognosisGoals of treatmentVeteran and family needs and preferencesVeteran and family understandingMDS/RAI customized for palliative care
19Communication Challenges Communication Skills Lab for NursesDealing with Strong EmotionsDealing with ConflictCommunication Skills for Nursing Assistants“Using Key Words at Key Times”Communication skills are very important for staff who are involved in palliative care, Family Meetings and MDS/RAI care plan meetings.Dr. Silverman suggests the Disney Training Model: Communication by inculcation [repeating the same words and behaviors until they become ingrained and second nature.) All the characters who sweep the streets are knowledgeable, courteous, helpful.
20What are some of the problems you are experiencing? How to relieve suffering, especially when the Veteran is actively dying in the CLC…do we transfer him to the VA hospice unit or to community hospice?Ethical issues relating to conflicts between staff goals and the wishes of Veteran and/or familyCultural influences and Spiritual dilemmasVeterans’ unresolved past grief and lossUnresolved grief related to a previous loss may be impacting family’s coping100 PERCENT SERVICE CONNECTED VETERANSSOME ENTIRE FAMILIES BENEFIT FROM SC DISABILITY MONTHLY ALLOTMENT“Someone’s dying & I don’t know what to say”“The family just doesn’t get it…they want everything done”
21Partnering with the PROMISE Center Bereaved Family PROMISE SurveyFamily members rate care that the Veteran received from the VA in the last month of life including communication, emotional and spiritual support, pain management and personal care needsOverall, how would you rate the carethat he received in the last month of his life?Excellent GoodVery Good FairPoor
22It is easier to ride the horse in the direction it is going… Try not to get stuck in a maze…Give the right care at the right time in the right place.Palliative Care can be offered to any Veteran across the spectrum of VHA healthcare.Weave palliative care into your medical center strategic goals and plans.
23What is important to your Team and your facility? Veteran and Family satisfactionNurse satisfactionStandardizing palliative care processesMortality and length of stayRe$ource utilizationCultural TransformationOther needsRN uses BFS PROMISE questions as a guide to educate families about expectations for excellent care
24Nursing documentation… Veteran and family will be educated on the following topics:1. Norms/routines in hospice2. Expected effects of meds commonly used in hospice (opioids for pain anddyspnea), ativan (anxiety/insomnia), haldol (n/v/psychosis), atropine (deathrattle).3. Funeral, memorial, survivor benefits4. Bereavement Support5. Signs and symptoms of approaching death6. The Final Journey7. The Fallen Hero Star8. Need to update NOK/HCS contact information .9. RN to provide hospice admission packet, BFS PROMISE brochure, and f/uwith Veteran and family as needs change.Not every MEDICAL CENTER has a hospice unit but for those who do….here is a sample hospice patient/family education note.
25More to consider…Education [TMS] EPEC and ELNEC for Veterans Palliative Care Nursing Assistant Training VACO Supported Continuing Education End of Life Initiative (ELI) audioconferences Annual HFA Bereavement Teleconference NHPCO “We Honor Veterans”SHARED GOVERNANCE
26More… Quality Improvement QUIRC Bereaved Family PROMISE Survey Patient Centered Care CommitteeNursing Shared Governance Quality CouncilUnit based quality initiativesCommunity based quality initiatives (HVP)Qi EXAMPLE: For Veterans who receive home hospice care: what is the hospice agency AICD deactivation policy?SAME LEVEL OF EXCELLENT CARE FOR OUR VETERANS: “WE HONOR VETERANS’
27More…Certification Hospice and Palliative Care Nursing Certification APRN-RN-LPN-NA Evidence-Based PracticeIntegrate Palliative Care as part of your Magnet Journey toward nursing excellence!
28“Strive for 65” Interventions Palliative Care Admission PackageFoster Good ImpressionsUsing Key Words at Key TimesComfort Care Order SetDecedent Affairs as member of PCCTPatient Centered Care: Defining Excellence using PROMISEWPB VA has been participating in many of these quality interventions
29“Strive for 65” Best Practices BFS Question:Implementation Package Tool:How often were the doctors and other staff who took care of (Veteran) kind, caring, and respectful?4. Core Values and Palliative Care Principles18. Palliative Care Nursing Assistant Project: “Using Key Words at Key Times”8. Foster Good First Impressions at the VA16. Family and Veteran Care Amenities Cart9. Palliative Care Admission PackageHow much of the time were the doctors and other staff who care of (Veteran) willing to take time to listen?14. Life Legacy Video12.Comfort and Communication in the ICU15. Family Meeting TemplateHow often did the doctors and other staff provide the medication and medical treatment that you and (he/she) wanted?13. Comfort Care Order Set10. Defining Excellent Care for Each Veteran & Family7. Pain Management EducationHow often do you think his/her personal care needs such as bathing, dressing, and eating meals – were taken care of?18. Palliative Care NA Project: “Using Key Words at Key Times”How much of the time did the doctors and other staff who took care of (Veteran) provide you and (Veteran) the kind of emotional support that you and (he/she) would have liked prior to his/her death?22. Key Role of Chaplains in Hospice and Grief Education20. Details Clerk as Part of Hospice & Palliative Care Team26. Decedent Affairs Coordination21. Door Notification of Actively Dying Veterans28. Hospice ChoirWhat about after [MR./MS. LAST NAME]’s death—How much of the time did the doctors and other staff who took care of [HIM/HER] provide you the kind of emotional support you would have wanted?23. After Death Care of the Body24. Morgue Viewing25. Bereavement Follow Up27. SOLACE and Healing Group28. Annual Memorial ServiceCELC IMPLEMENTATION CENTER HAS IDENTIFIED BEST PRACTICES WHICH CORRELATE WITH EXCELLENT END OF LIFE CARE.
30What about after [MR. /MS What about after [MR./MS. LAST NAME]’s death—How much of the time did the doctors and other staff who took care of [HIM/HER] provide you the kind of emotional support you would have wanted?23. After Death Care of the Body24. Morgue Viewing25. Bereavement Follow Up27. SOLACE and Healing Group28. Annual Memorial ServiceDuring [MR./MS. LAST NAME]’s last month of life, how often did the doctors and other staff who took care of [HIM/HER] keep you or other family members informed about [HIS/HER] condition and treatment?15. Family Meeting Template18. Palliative Care NA Project: “Using Key Words at Key Times”10. Defining Excellent Care for Each Veteran & Family12.Comfort and Communication in the ICUDid anyone alert you or your family when [MR./MS. LAST NAME] was about to die?21. Door Notification of Actively Dying VeteransIn [MR./MS. LAST NAME]’s last month of life, how much of the time did the doctors and other staff who took care of [HIM/HER] provide you and [MR./MS. LAST NAME] the kind of spiritual support that you and [HE/SHE] would have liked?22. Key Role of Chaplains in Hospice and Grief EducationWould it have been helpful if the VA had provided more information about benefits for surviving spouses and dependents?26. Decedent Affairs Coordination9. Palliative Care Admission PackageWould it have been helpful if the VA had provided more information about burial and memorial benefits?
31Would it have been helpful if the VA had provided more help with [MR Would it have been helpful if the VA had provided more help with [MR./MS. LAST NAME]’s funeral arrangements?26. Decedent Affairs Coordination9. Palliative Care Admission PackageOverall, how would you rate the care that [MR./MS. LAST NAME] received in the last month of [HIS/HER] life?A. BFS Awareness/FamiliarizationB. Hospice RelatedC. Overall Program/Facility Function6. BFS Pocket Card11. Increase BFS Awareness Via Bereaved Family Survey Pamphlet18. Palliative Care NA Project: “Using Key Words at Key Times”5. Interface with Hospice17. Hospice On-Call Arrangement1. Organizational Goals2. Professional Certification in Palliative Care3. Palliative Care Committee19. Palliative Care Champions8. Foster Good First Impressions at the VA
32PCCT models expand to meet Veteran need… Palliative Care CBOC Clinics via CVTPACT-CCHT-PCCTPACT-PALLIATIVE CARE CLINICSPALLIATIVE CARE SPECIALTY CLINICS:Pulmonary/Oncology/Cardiac/Renal/NeuroPCCT is specialist team ….. PACT to provide palliative care as generalists…What can PACT do to help patients get the care they want and deserve?Veteran preferences are put into medical orders:Completion of Advance Directives, Care Preferences, Code Status orders
331. Continue palliative care in the CLC. EMERGENCY RESUSCITATION STATUS: Do Not Resuscitate (DNR): no CPR, no BCLS/ACLS, other limitations of care: PALLIATIVE CARE1. Continue palliative care in the CLC.2. no artificial hydration/nutrition to prolong life (no ng, peg, iv fluids)3. no lab work or diagnostic testing4. if I become ill, do not move my room or hospitalize me, treat me in the CLC5. oral antibiotics are ok, swallowing pills are not difficult for me6. my comfort, dignity, and quality of life are my prioritiesDIAGNOSIS: Multiple Sclerosis, weight loss, renal failure, protein-calorie malnutrition, decubitus ulcers.PROGNOSIS: Poor.The patient is capable of understanding and making an informed judgment in this matter. Diagnosis, prognosis and treatment options have been discussed with: patient. Treatment preferences as expressed by the patient are to be implemented. The patient does have an advance directive and the advance directive has been reviewed by me.Patient preferences are written as medical orders to be implemented by the interdisciplinary team.COMFORT CARE ORDER SET
34Hospice and Palliative Care Teams Yeeta Pandey, RN Hospice Nurse/Chaplain Leopard HPC Chaplain/Sandy DiScala Pharm D/Maura HPC Program DirectorJannette Sharpe-Paul, Nurse Mgr. Hospice/ Marie Robinson-Mclaughlin Chief Nurse GEC. Mental Health, Blind RehabilitationMichael Silverman, MD Chief GEC and Hospice Medical Director/ Lynnea Valpatic, LCSW Bereavement Coordinator inpatient hospice Social Worker/ Sandy Plata GEC AO/ Stephanie Dill, PCCT Social Worker and Home and Community Based hospice Program Coordinator/ Shoshanna Orellano, Music Therapist/ Bruce the dog.
35the Freedom North Lakeside Garden provides Staff Resiliency:the Freedom North Lakeside Garden providesa healing place for residents and staff to be with natureWhat are we doing to sustain OURSELVES, OUR TEAMS, AND EACH OTHER.RESILIENCY TRAININGMINDFUL MOMENTSTHE CARING CHANNELMONTHLY LUNCH AND LEARNMONTHLY MASSAGE AND HEALING TOUCHDON’T PULL STAFF AFTER DEATH !ENCOURAGE STAFF ATTENDANCE AT VETERANS’ FUNERALS/MEMORIAL SERVUCES
36It is my honor to serve Veterans and NOVA. Thank you! Questions?