1. End of Life Care

2. Mrs. Rogers If Mrs. Rogers came back into the hospital with worsening CHF that was determined to be end-stage, what would you do? What priorities would you have?

3. The Whole Pie Patient Family Nurse Palliative care Hospice care All important pieces to the end of life pie

4. The Patient The most important slice in the care at the end of life The patient has the control over how they want to die If the patient is not at terms with the future, blocks might be put up

5. The Family The family is important to the patient and in turn an important slice of the pie When treating the patient for end of life care, the nurse (or physician) are also treating the family If the family is not at terms with what the patient has chosen, blocks may also be put up

6. The Nurse The nurse knows what is needed to comfort a patient and the family Trained to support all parts of a family and respect the patient’s wishes

7. Palliative Care Palliative care is the “medical specialty focused on relief of the pain and other symptoms of serious illness.” The purpose is to avoid and aid in the pain and distress for the patient while being able to offer the best possible quality of life for them and their families. http://www.getpalliativecare.org/whatis

8. Palliative Care Is appropriate at any point in a serious or life-threatening illness. Prognosis has no bearing on palliative care being able to occur. One can receive palliative care at the same time as they are receiving life-saving or curing care

9. PHS Palliative Care Dr. Arlene Bobonich & Sarah Beam, CRNP are our palliative care team for PHS 231-8349 Rosemary Schaefer-Administrative Assistant-Answers phone calls during day Not available yet at CGOH At HH, can be a nurse-nurse consult

10. PHS Palliative Care-Mission Palliative Care is a unique program that focuses on the comprehensive management of the physical, emotional, social, & spiritual needs of patients & their families living with progressive, life-limiting illnesses, regardless of life expectancy or treatment options.

11. PHS Palliative Care Checklist

12. Hospice Care Usually need a diagnosis of a terminal illness with anticipated death within 6 months Can be hospital or home based Does incorporate palliative care into hospice care No longer seeking curative treatment

13. Patient-Family Decision Making Family Conference Form Level of Intensity Turning off ICD Cultural issues

14. Family Conference Form Developed to use with any family meeting discussing a patient’s condition, care, etc. Can be used by case management, physician, nursing, etc. Helps to determine proper hospital course & care

16. Level of Intensity (LOI) Determines what “heroic” or “life- saving” interventions are warranted Can be determined by the patient, POA, or family when patient is unable to make their own decisions Can also be determined by the physician when no other avenues are available Level I-IV Level II-IV (considered DNR)

18. DNR Armband Don’t forget, we now have a purple DNR armband for patients This means the patient is not a LOI I If you notice a purple DNR armband on your patient, go to the chart and look at the LOI sheet for specifics on what LOI the patient is and what is or not to be done

19. Turning off the ICD The decision to turn off the ICD is one of great discussion Should be patient driven Turning off the ICD does not turn off the Pacing function –The patient will not immediately die when the ICD is turned off –This just means, they won’t get shocked for fatal rhythms (VT/VFib) –The patient can live for some time after the ICD is turned off as long as not fatal rhythms occur

20. Cultural Issues The patient’s culture can play a role in deciding how to treat the patient at the end of life

21. Mrs. Roger’s Culture Mrs. Rogers is Hispanic –Large family –Close knit Her entire family must be included in health promotion and health teaching to increase compliance with health prescriptions and interactions

22. Mrs. Roger’s Culture Mrs. Rogers will be expressive of her pain Prayers and lighting candles are traditional healing practices Her culture believes it is insensitive to tell a person the he/she is dying, as it inspires a sense of hopelessness and hastens the process

23. The Use of Touch The use of touch with palliative care and hospice patients has been in debate for some time There are few studies large enough to prove a point It has been shown to decrease pain, anxiety, and nausea among other unpleasant side effects with cancer patients

24. The Use of Touch cont’d. Could the use of touch help CHF patients? Outcomes anticipated –Improved patient outcomes: Reduced pain & anxiety –Process improvement: Added dimension to PHS Palliative Care Program –Reduced cost: Potential to reduce LOS

25. Our Case Study CHF clinic Palliative care at home Eventually could be transferred to Hospice care Attempt to keep her at home as long as possible without readmissions If she is readmitted, get her home as soon as possible with available resources

26. Resources at PHS for Stressful Situations Crisis Intervention team-Team of staff members to assist in debriefing after a stressful situation Dr. Corey Rigberg-available to help debrief Employee Assistance Program- counseling Pastoral Care-Pastors available to talk to afterwards