1. Palliative Care in the Nursing Home

2. Objectives Develop an awareness of how a palliative care environment can be created. Recognize the need for changes in existing facility policies and procedures to promote the goals of palliative care. Become familiar with quality improvement tools that support excellence in palliative care.

3. Creating a Palliative Care Environment Quality of Care – “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care” F309 Long Term Care Regulations and Guidance to Surveyors

4. Creating a Palliative Care Environment Quality of Care, continued “Highest practicable level” is defined as the highest level of functioning and well- being possible, limited only by the individual’s presenting functional status and potential for improvement or reduced rate of functional decline. Highest practicable is determined through the comprehensive assessment by thoroughly addressing the needs of the individual.”

5. Quality of Life “A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each residents’ quality of life.” F240 Long Term Care Regulations and Guidance to Surveyors

6. Quality of Life “The intention of this requirement is to specify the responsibilities toward creating and sustaining an environment that humanizes and individualizes each resident.”

7. The facility’s leadership must embrace the palliative care philosophy and incorporate the goals of care within the daily practices and operating philosophy of the facility.

8. Recognize the differences in Goals of Care Rehabilitative Goals Maintenance Goals Preventive Goals Palliative Goals

9. Evaluate Current Practices Assess staff perceptions of resident’s needs and care goals through: –Staff Meetings –Surveys –Assessment tools Review job descriptions/role identification

10. Evaluate Current Practices, continued Assess physical plant –Private areas –Noise levels –Phone availability –Provision of food and beverages between meals Review orientation and education regarding end of life care for all staff. Review policies/procedures to evaluate how they reflect/integrate palliative care goals in delivery of care.

11. CMS suggests surveyors review the following related to end of life care: Policies and procedures for providing end of life care Palliative care protocols for pain management Palliative care protocols for treatment of distressing symptoms Care directives to maintain the resident’s dignity Care directives to assisting the family/significant other in the loss

12. Policies and procedures for review and revision MDS/RAI and Goals of Care in Care Planning Advance Directives Palliative Care Decision Making/ Care Planning Pain Management

13. Policies and Procedures continued Nutrition and hydration Spiritual and Psychosocial Interventions Hospice Collaboration Imminent Death Interventions

14. MDS/RAI and Goals of Care Planning Review existing policies for development of MDS and Care Plan Review policy for significant change assessment, need for ongoing assessment and revisions to plan of care as condition declines

15. Advance Directives Documentation of individual with decision making authority and when authority becomes effective Assurance of compliance with advance directives Documentation for residents without decision making ability CPR policies

16. Palliative Care Decision Making/Care Planning Refusals of Care Use of skilled therapies or restorative services Treatment of wounds Use of restraints, bed rails, catheters, equipment, specialty mattresses Prevention and intervention for falls Role of attending physician and Medical Director

17. Pain Management Staff education regarding pain Ongoing assessment of pain Timeframe for providing pain medications Availability of stock pain and emergency medications Use of prn medication

18. Pain Management continued Resident/family education regarding pain Documentation of pain effectiveness and follow-up Monthly drug regime reviews Utilization of pharmacy consultant Use of non-pharmacological approaches

19. Nutrition and Hydration Appropriate goals related to diet and weight loss Provision of pleasure feedings, availability of food when desired Education to staff and family regarding nutrition goals Symptom management and tube feedings Dehydration issues

20. Spiritual and Psychosocial Availability of spiritual support for patient/ family Communication with significant others and family Staff education regarding communication

21. Hospice Collaboration Contracts Process for referrals and determination of Hospice appropriateness Procedures for admission/discharge Documentation Care Plan Hospitalizations and emergency care

22. Hospice collaboration continued Medical records management Use of therapies Respite Care Acute inpatient care Business office procedures

23. Imminent Death Staff education Communication and support to family Recognition and accommodation of family needs Time of death procedure

24. Quality Assurance Monitoring Tools MDS Quality Indicator Review Medical Record Pain Management Audit Hospice Collaboration Tool Checklist Review Following an Expected Death

25. Communication, leadership and accountability are key. All of these factors in combination can result in positive resident outcomes