Presentation is loading. Please wait.

Presentation is loading. Please wait.

An Innovative Educational Program to Encourage Nurses to Be More Family- Centered in End-of-Life Care Connie Dahlin RN APN Adele Keeley RN Ed Coakley RN.

Similar presentations


Presentation on theme: "An Innovative Educational Program to Encourage Nurses to Be More Family- Centered in End-of-Life Care Connie Dahlin RN APN Adele Keeley RN Ed Coakley RN."— Presentation transcript:

1 An Innovative Educational Program to Encourage Nurses to Be More Family- Centered in End-of-Life Care Connie Dahlin RN APN Adele Keeley RN Ed Coakley RN Massachusetts General Hospital Boston, MA

2 Massachusetts General Hospital 900 Beds (122 ICU beds) Level I Trauma

3 MGH MICU (18 beds) Closed ICU with ~ 60 FTE nurses 2 ICU teams: Intensivist, fellow, HOs, students Medical with trauma, surgical boarders Unit-based social worker, case manager, RT, chaplain

4

5 Background Critical care nurses attend to large numbers of dying patientsCritical care nurses attend to large numbers of dying patients An estimated 20% of intensive care patients in the U.S. die while hospitalized in a critical care unit.An estimated 20% of intensive care patients in the U.S. die while hospitalized in a critical care unit. Life and death decisions have to be made quicklyLife and death decisions have to be made quickly Many of the patients are unconsciousMany of the patients are unconscious Discussion with patients about limitation of treatment occurs relatively infrequentlyDiscussion with patients about limitation of treatment occurs relatively infrequently Do-not-resuscitate decisions are left until late in the illness, just days before deathDo-not-resuscitate decisions are left until late in the illness, just days before death More common for patient’s families to be the decision makersMore common for patient’s families to be the decision makers

6 Background Majority of deaths involve the withholding or withdrawal of multiple life-sustaining therapiesMajority of deaths involve the withholding or withdrawal of multiple life-sustaining therapies Decision making and communication about these end-of-life decisions are difficultDecision making and communication about these end-of-life decisions are difficult Understanding ICU culture is criticalUnderstanding ICU culture is critical

7 Background Meta-analysis of studies of needs of ICU family membersMeta-analysis of studies of needs of ICU family members 8/10 family needs related to communication with clinicians8/10 family needs related to communication with clinicians Desire more listeningDesire more listening Needs primarily addressed by nursesNeeds primarily addressed by nurses Deficits in end-of-life communication skills shared by nurses and physiciansDeficits in end-of-life communication skills shared by nurses and physicians Hickey, Heart Lung 1990; Maguire, Eur J Cancer 1996

8 Background Study of outpatent MD/family meetings:Study of outpatent MD/family meetings: MDs rarely explored patient goals and valuesMDs rarely explored patient goals and values Avoided discussing uncertaintyAvoided discussing uncertainty Failed to explore reasons for choicesFailed to explore reasons for choices Failed to discuss quality of life after treatmentFailed to discuss quality of life after treatment Tusky, Ann Int Med 1995

9 Background Study of inpatient MD/family meetings:Study of inpatient MD/family meetings: MDs spend 75% of time talkingMDs spend 75% of time talking Missed important opportunities for patients/families to discuss personal values important goals of RxMissed important opportunities for patients/families to discuss personal values important goals of Rx Majority felt they did a good jobMajority felt they did a good job Tulsky, J Gen Int Med 1995

10 RWJF Study Background 1.Improve ICU care at end of life 2.Co-PIs: Nurse and MD 3.Four sites funded. Variety of settings (trauma, community, city hospital, +/- palliative care service, open/closed units) 4.Shared home grown interventions 5.For all ICU patients; not just about deaths

11 Methods and Timeline

12 Adele Keeley Nurse Director

13 Mission Statement Based on the International Consensus Based on the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003 Patient and family are Members of the MICU Team.Patient and family are Members of the MICU Team. Measure success by patient and family outcomesMeasure success by patient and family outcomes The attending physician is ultimately responsible for the patient’s medical care in the ICUThe attending physician is ultimately responsible for the patient’s medical care in the ICU Intensive Care Med. 2004

14 Mission Statement Both living and dying in the ICU involves focusing from the very beginning on comfort as well as cure. We believe that palliative care must begin from the moment the patient and family enter our unit. Providing the best possible patient- and family-centered care, whether it is aimed at a “great save” or a “good death,” is our mission.Both living and dying in the ICU involves focusing from the very beginning on comfort as well as cure. We believe that palliative care must begin from the moment the patient and family enter our unit. Providing the best possible patient- and family-centered care, whether it is aimed at a “great save” or a “good death,” is our mission.

15 Mission Statement The multidisciplinary process of developing the statement and the subsequent buy in by all the stake holders were important first stepsThe multidisciplinary process of developing the statement and the subsequent buy in by all the stake holders were important first steps

16 Family Meeting Intervention Family meetings taught as a procedureFamily meetings taught as a procedure Critical Care Grand RoundsCritical Care Grand Rounds Monthly House Officer teaching sessionsMonthly House Officer teaching sessions Intensivist supervision and teachingIntensivist supervision and teaching 3x5 card3x5 card “Guide to ICU Family Meetings”“Guide to ICU Family Meetings” “Talking with ICU Families”“Talking with ICU Families” Nurse Champions encouraged and taught good meeting techniqueNurse Champions encouraged and taught good meeting technique

17 Preparation (pre-meeting) involving the full teamPreparation (pre-meeting) involving the full team Listen and “align”– who is our patient?Listen and “align”– who is our patient? Elicit understanding & concerns, information preferences, then educateElicit understanding & concerns, information preferences, then educate Elicit patient values & goals in order to ascertain “substituted judgment”Elicit patient values & goals in order to ascertain “substituted judgment” Recommendations, not a menu for the familyRecommendations, not a menu for the family The difficulty of prognosticationThe difficulty of prognostication Communicate, document, reflectCommunicate, document, reflect Family Meeting Tips

18

19

20

21

22 Open Visitation Families welcome 24x7:Families welcome 24x7: Initial resistance from staffInitial resistance from staff Subsequent enthusiasm: emphasis on the patient and family as the focus of careSubsequent enthusiasm: emphasis on the patient and family as the focus of care Family involvement in bedside careFamily involvement in bedside care Catalyst for family involvement in roundsCatalyst for family involvement in rounds

23 Palliative Care Champions 25 MICU nurses25 MICU nurses End of Life Nursing Education Consortium (ELNEC) trainingEnd of Life Nursing Education Consortium (ELNEC) training Coaching and mentoring in being a change agentCoaching and mentoring in being a change agent Quality improvement projectsQuality improvement projects Go-To PeopleGo-To People

24 ELNEC culum.htmhttp://www.aacn.nche.edu/elnec/curri culum.htm

25 ELNEC Curriculum Nursing Care at the End of Life: Overview of death and dying in America, principles and goals of hospice and palliative care, dimensions of and barriers to quality care at EOL, concepts of suffering and healing, role of the nurse in EOL care.Nursing Care at the End of Life: Overview of death and dying in America, principles and goals of hospice and palliative care, dimensions of and barriers to quality care at EOL, concepts of suffering and healing, role of the nurse in EOL care. Pain Management: Definitions of pain, current status of and barriers to pain relief, components of pain assessment, specific pharmacological, and non-pharmacological therapies including concerns for special populations.Pain Management: Definitions of pain, current status of and barriers to pain relief, components of pain assessment, specific pharmacological, and non-pharmacological therapies including concerns for special populations. Symptom Management: Detailed overview of symptoms commonly experienced at the EOL, and for each, the cause, impact on quality of life, assessment, and pharmacological/non-pharmacological management.Symptom Management: Detailed overview of symptoms commonly experienced at the EOL, and for each, the cause, impact on quality of life, assessment, and pharmacological/non-pharmacological management. Ethical/Legal Issues: Recognizing and responding to ethical dilemmas in EOL care including issues of comfort, consent, prolonging life, withholding treatment; euthanasia, and allocation of resources; and legal issues including advance care planning, advance directives, and decision making at EOL.Ethical/Legal Issues: Recognizing and responding to ethical dilemmas in EOL care including issues of comfort, consent, prolonging life, withholding treatment; euthanasia, and allocation of resources; and legal issues including advance care planning, advance directives, and decision making at EOL. Cultural Considerations in EOL Care: Multiple aspects of culture and belief systems, components of cultural assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement.Cultural Considerations in EOL Care: Multiple aspects of culture and belief systems, components of cultural assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement. Communication: Essentials of communication at EOL, attentive listening, barriers to communication, breaking bad news, and interdisciplinary collaboration.Communication: Essentials of communication at EOL, attentive listening, barriers to communication, breaking bad news, and interdisciplinary collaboration. Grief, Loss, Bereavement: Stages and types of grief, grief assessment and intervention, and the nurse's experience with loss/grief and need for support.Grief, Loss, Bereavement: Stages and types of grief, grief assessment and intervention, and the nurse's experience with loss/grief and need for support. Achieving Quality Care at the End of Life: Challenge for nursing in EOL care, availability and cost of EOL care, the nurses' role in improving care systems, opportunities for growth at EOL, concepts of peaceful or "good death", "dying well", and dignity.Achieving Quality Care at the End of Life: Challenge for nursing in EOL care, availability and cost of EOL care, the nurses' role in improving care systems, opportunities for growth at EOL, concepts of peaceful or "good death", "dying well", and dignity. Preparation and Care for the Time of Death: Nursing care at the time of death including physical, psychological, and spiritual care of the patient, support of family members, the death vigil, recognizing death, and care after deathPreparation and Care for the Time of Death: Nursing care at the time of death including physical, psychological, and spiritual care of the patient, support of family members, the death vigil, recognizing death, and care after death

26 Nursing Care at the End of Life

27 Pain Management

28 Symptom Management: DeleriumDelerium

29 Ethical/Legal Issues: Barbara HoweBarbara Howe Boston Globe, March 12, 2005 Hospital, family agree to withdraw life support

30 Cultural Considerations in EOL Care

31 Communication Clinical TimeClinical Time

32 Grief, Loss, Bereavement:

33 Achieving Quality Care at the End of Life Susan SontagSusan Sontag

34 Preparation and Care at the Time of Death in an ICU Unexpected experience for many

35 Heard from the Champions… “more collaborative” “more cognizant” “more proactive” “less mystery” “able to articulate in a professional way” “confident to bring up the question…”

36 Ethics Rounds Twice a monthTwice a month RNs, MDs, SW, Chaplain, Ethics Fellow, and Ethicist (Alex Cist)RNs, MDs, SW, Chaplain, Ethics Fellow, and Ethicist (Alex Cist) MICU RN Director frequently attendsMICU RN Director frequently attends Case discussionCase discussion Review of DeathsReview of Deaths Encouraged by RN ChampionsEncouraged by RN Champions

37 MICU Nurse Perceptions on the Quality of Deaths Nursing QODD Baseline vs. Intervention General quality of death ↑ ↑ ↑ Family relationship ↑ Physician communication ↓ Job satisfaction ↑ ↑ ↑

38 Results: All MICU Admits BaselineIntervention ICU admissions (#) ICU Mortality 21.4% 17.1% 17.1% Case Mix Index (by DRG) MICU/Hospital LOS (days) 5.7/ /18.5 MICU/Hospital LOS (non-survivors) 8.3/157.6/14 Mean Cost/patient $55,477$57,958

39 Family Perceptions Heyland Family Satisfaction Questionnaire Baseline vs. Intervention ICU experience ↑ ↑ Informational needs ↑ ↑ Decisions+/- Family QODD +/-

40 What worked for us What worked for us 1.Open visiting policy 2.Teaching and encouraging family meetings with nurses uniformly present for collaboration with MDs 3.Educating nurses in palliative care knowledge and supporting their role. MGH plans to extend the intervention to other ICUs

41 4.Ethics and multi-disciplinary rounds and improved psychosocial/ spiritual attention to selected families in collaboration with palliative care 5.Family orientation materials 6.“Get to Know Me” poster - a technique that helps “humanize” the patient and promote an alliance with the family What worked for us

42 Lessons Learned I 1.Need to get on the same page (Mission Statement). Process more important than the product 2.Staff education (ELNEC) and support has a big payoff 3.Teaching family meeting skills was very well received by HOs and Fellows.

43 Thank you


Download ppt "An Innovative Educational Program to Encourage Nurses to Be More Family- Centered in End-of-Life Care Connie Dahlin RN APN Adele Keeley RN Ed Coakley RN."

Similar presentations


Ads by Google