Palliative Care From Hospital To Nursing Home Addressing the needs of elderly patients who have a life limiting progressive illness with palliative care needs

Palliative Care “ Palliative care is an approach that improves quality of life of patients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.” WHO (2003)

Terminal Care T erminal care is a continuum of palliative care and is used to describe the care that is offered during the period when death is imminent, and life expectancy is limited to a short number of days, hours or less. Department of Health and Children (2001)

Levels of Palliative Care  Level 1 - Palliative care approach  Level 2-General palliative care  Level 3-Specialist palliative care

Levels of Palliative Care Level One - Palliative care approach Palliative care principles should be practiced by all health care professionals.The palliative care approach should be a core skill of every clinician at hospital and community level.

Levels of Palliative Care Level Two – General Palliative Care A proportion of patients and families will benefit from the expertise of health care professionals who although not engaged full time in palliative care have some additional training and experience in palliative care, perhaps to diploma level. This level of expertise should be available at hospital and community level.

Levels of Palliative Care Level Three- Specialist Palliative Care Specialist palliative care services are those services whose core activity is limited to the provision of palliative care. These services are involved in the care of patients with more complex and demanding needs.

Many patients with progressive and advanced disease will have their needs met comprehensively and satisfactorily without referral to specialist palliative care units or personnel.

Facts 27,479 people died in 2006 in Ireland 28% died from cancer 33% died from cardiovascular/circulatory 14% died from respiratory disease 25% died from other causes Almost 16,000 deaths were in the age group Irish Hospice Foundation- Palliative Care For All (2008)

Ageing Population By 2050 the ‘over 80’ age group is projected to number almost 379 million worldwide, about 5.5 times as many as in 2000 ( 69 million persons). In 1950, persons over 80 numbered less than 14 million. It has never been more critical to address the palliative care needs of older people than in the context of today’s ageing populations. The proportion of people aged 65 and over is steadily on the increase in Europe. World Population Ageing

A/E Survey Conducted in Connolly Hospital Feb 2007 High levels of A/E use, by patients>65 years and those in LTC. 420 attendances by patients>65 years old 56(13%) from nursing home care- (52% had 1 or more attendances in the last 4 months) 65% admitted to hospital; high hospital mortality P McCormack & S Kennelly (2008)

Consequences of Inappropriate Hospital Admissions Patients at risk of dying in an inappropriate place of care, e.g. A/E Lengthy hospital stays Poor quality of life for the patient Medication errors Poor communication of new care plans Changing care teams/ fragmentation of care Transportation delays and discomfort

Inappropriate patient transfers between nursing homes and hospitals can be very stressful for both patients and families. It can be frustrating for staff in both care settings.

Case Scenario Grandpa Simpson 85 year old nursing home resident over 5 yrs Background - advanced dementia, previous CVA Progressive decline over the last six months, less interest in eating and drinking, poor swallow Admitted to an acute hospital with aspiration pneumonia, treated with iv antibiotics, improved clinically, transferred back to nursing home residence 7 days later. Of note he had 4 admissions over the previous 8 months Readmitted 2 weeks later following recurrent aspiration pneumonia, died in A/E

Outcome ? Planned to Fail !

How can we improve the transition of care for the elderly patient who have a progressive life limiting illness and prevent inappropriate readmission to hospital??

A “Transitional” Problem Poor communication between hospitals and nursing homes Lack of advanced care planning Poor documentation re goals of care Poor communication with patient and family Lack of knowledge and skills re managing symptoms

Challenges in Providing Palliative Care To The Nursing Home Resident Communication Prognosis Care planning Confidence in managing symptoms Support

Improving End of Life Care for Patients Who Have a Life Limiting Illness Aims of care should be: To provide a mechanism to improve care given to patients at end of life To enhance communication between different care settings To discuss wishes for care with family and multidisciplinary team To provide a tool to improve implementation of advanced care planning

Prognostic Criteria For Advanced Disease Any one of 3 criteria could trigger a patient to be considered to have palliative, supportive care needs 1. Patient need or choice is for comfort care only and not for possible curative treatment. 2. Use of the ‘Surprise’ question – would you be surprised if the patient was to die in the next year? If not, then they are likely to need supportive/palliative care. 3. Patients have Clinical indicators of need for palliative care – prognostic clinical indicators of ‘advanced’ or irreversible disease – to include 1 core and 1 disease specific indicator Gold Standards Framework Prognostic Indicator Guidance

Beaumont Hospital Discharge Guidelines For Patients Returning To Nursing Homes For Supportive - Comfort Care ( Pilot Project) These are guidelines for the medical team based on the patients medical condition and wishes under the direction of the patient’s consultant doctor and should accompany patient when transferred.

Section A CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.  Attempt Resuscitate (CPR)  DO Not Attempt Resuscitation (no CPR) When not in cardiopulmonary arrest, follow B, C and D

Section B MEDICAL INTERVENTIONS: Person has pulse and/ or is breathing.  Comfort measures Treat with dignity and respect Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life –sustaining treatment. Transfer only if comfort needs cannot be met in current location.  Limited Additional Interventions Includes care described above. Use medical treatment and s/c fluids. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care  Full Treatment Includes care above. Use intubation, advanced airway interventions, mechanical ventilation, and cardio version as indicated. Transfer to hospital is indicated. Include intensive care. Other instructions:_______________________________________________

Section B This section allows discussion re level of medical intervention if the patient deteriorates. Comfort indicates a desire for only those interventions that enhance comfort. Transfer to hospital is indicated only if comfort needs cannot be met in current location Limited additional interventions, in addition to comfort measures e.g. s/c fluids, oral antibiotics as indicated. Transfer to hospital if indicated. Full treatment includes all care as above with no limitation of medically indicated treatment.

Section C ANTIBIOTICS  No Antibiotics  Oral Antibiotics  IV Antibiotics ( usually requires hospital admission, consider community intervention team if appropriate) Other instructions:______________________________________

Section C This section stimulates conversations about the goals of antibiotic use. Antibiotics often are life sustaining treatments. Advance care planning in the use of antibiotics can help clarify goals of care for the person and caregiver. Many families of patients with advanced progressive illness may prefer to have antibiotics withheld and want other measures such as a antipyretics and opioids to treat symptoms of infection and maintain comfort. Additional instructions can also be written “Antibiotics may be used only as needed for comfort” for example a urinary tract infection may cause discomfort for a dying patient. Treating the UTI with an antibiotic may serve as a comfort measure.

Section D MEDICALLY ADMINSTERED FLUIDS AND NUTRITION : Oral fluids and nutrition must be offered if medically feasible.  No iv fluids  No feeding tube  S/c fluids for a defined trial period  feeding tube for a defined trial period  s/c fluids long- term if indicated  Feeding tube long- term Other instructions:_________________________________________________

Section D Oral fluids and nutrition must be offered if medically feasible, i.e. the patient is alert and able to swallow Goal of care may be allowing to eat and drink for comfort versus aspiration risk IV fluids may cause oedema, shortness of breath, and the need for frequent urination. At the end of life they can cause excess secretions s/c fluids may be considered for a defined trial period to see if this benefits the patient. ( s/c fluids will not alleviate dry mouth) If the patient is being tube feed this may be continued if there is no ill effects e.g. chestiness, aspiration and vomiting.

Section E DISCUSSED WITH :  Patient /Resident  Next of kin  Family member  Other ______________ (Specify) The Basis for These Orders is:  Patient’s preferences  Patient’s best interest

Section F ANTICIPATORY PRESCRIBING Oral medications 1)Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort, Pyrexia 2) Diclofenac 100mg PR daily PRN for signs of pain or discomfort 3)Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea 4)Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea

Section F Subcutaneous medications ( where patients no longer able to take oral medications ) 5)Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea 6)Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness 7)Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions.

Section F Medications  Medications rationalized where possible to reduce tablet burden and where no longer appropriate given the patient’s condition and prognosis.

Section G Nursing and Support services ( Primary, community continuing care providers)  Liaise with hospital and community palliative care team as appropriate  Liaise with community intervention team as appropriate  Date of discharge confirmed with Patient/family and nursing home  Confirmation that medications available in nursing home 24 hour prior to transfer  Appropriate transport arranged and confirmed  Fully comprehensive nursing discharge letter

Case Scenario 2 Mr Burns 78 year old nursing home resident. Background: COPD, CCF, Vascular Dementia. Admitted to an acute hospital with infective exacerbation of COPD, 48hrs in A/E prior to being admitted to ward. Treated with iv antibiotics with little response, remained comfortable but weak, not eating or drinking, barely responsive Referral to Palliative care re symptom management, comfort care.

Case Scenario 2 Family meeting with multidisciplinary team. Given Mr Burns current state of health, failure to improve despite active treatment and his co-morbidities family and medical team in agreement most appropriate goal of care was comfort measures. Family keen for transfer back to nursing home as it had been his home for 5 years. Discharge guideline used in consultation with family. Mr Burns for comfort measures only, for transfer back to hospital only if comfort measures cannot be met, advice given re symptomatic management Liaised with nursing home re goal of care, discharge guidelines. Transferred back to nursing home, died peacefully five days later.

Example letter RE. Mr Ryan DOB 10 0ctober 1920 Garda Retirement Home Raheny Dublin 5 29 May 2009 Dear Doctor, Both Mr Ryan and his family have expressed a wish not to have Mr Ryan referred to the hospital for further tests or clinical management. He should only be transferred in the event of severe pain or haemorrhage or accident requiring acute hospital treatment. He is not for Resuscitation in the event of an acute cardiac event. Yours sincerely

Confidence In Managing Symptoms Multidisciplinary involvement Liaise with hospital palliative care team if appropriate Referral to specialist community palliative care team where available Liaising with nursing home re plan of care Use of anticipatory prescribing Liaise with GP or relevant medical officer

Confidence In Managing Symptoms Irish Hospice Foundation in conjunction with the Palliative Care Education Task Force is preparing a training programme for Nursing Homes Ireland, the representative organisation for the private and voluntary nursing homes sector. This training programme is seeking to establish a common multidisciplinary approach to level 1 palliative care education in Ireland for nursing home staff.

References Department of Health and Children. Report of the National Advisory Committee on Palliative Care (2001) McCormack P & Kennelly S (2008) Care delivery in the most appropriate setting?. Experience of Connolly Hospital Liaison Medicine for the Elderly Service. Palliative Care For All (2008) Integrating Palliative Care into Disease Management Frameworks. The Irish Hospice Foundation. Health Service Executive. World Population Ageing , Chapter iv Population Division, DESA, United Nations WHO

Additional information Alvin H. Moss (2004) Respecting Patients’ Wishes at the End of Life. Physician Orders for scope of Treatment Centre to Advance Palliative Care (2007) Improving Palliative Care in Nursing Homes. Centre For End-Of-Life-Care (2006). Robert C Byrd Health Services Centre Of West Virginia University. The Irish Hospice Foundation Annual Report,2008