1. 1 Philosophy of End-of-Life Care Adapted from:The 2004 PERT Program Pain & Palliative Care Research Department Swedish Medical Center, Seattle, Washington Geriatric Aide Curriculum NC Division of Health Service Regulation Module 21

2. 2 Participant Goals for Palliative Care Modules Information and tools to increase knowledge, skills and confidenceInformation and tools to increase knowledge, skills and confidence A variety of practical resourcesA variety of practical resources Information and tools to provide end of life expertise at workInformation and tools to provide end of life expertise at work A sense of professional accomplishmentA sense of professional accomplishment A sense of satisfactionA sense of satisfaction A connection to the larger end of life care communityA connection to the larger end of life care community

3. 3 Palliative Care Module Topics Module 21: Philosophy of end of life care Module 22: Goals of end of life care Module 23: Communication at the end of life Module 24: Cultural dimensions Module 25: Ethical issues at the end of life Module 26: Symptom management Module 27: Spiritual considerations

4. 4 Palliative Care Module Topics Module 28: Care at the time of dying Module 29: Grief and bereavement Module 30: Hospice care Module 31: Self-care for the nurse aide

5. 5 1. Discuss the concepts of “dying well” and a “good death.” 2. Discuss specific fears about dying to address with self, resident and family. 3. Describe the history of health care and dying. 4. Describe the philosophies of palliative, hospice, and long-term care. Philosophy of End of Life Care Objectives

6. 6 5. Describe the relationship among curative, palliative and hospice care. 6. Recognize patterns (paths) of dying. 7. Identify opportunities and challenges, including pain and symptom management, to providing end of life care in nursing homes. Philosophy of End of Life Care Objectives

7. 7 yesterday is history tomorrow is a mystery… today is a gift ~~ eleanore roosevelt

8. 8 A natural part of lifeA natural part of life Opportunity for growthOpportunity for growth Profoundly personal experienceProfoundly personal experience By excluding death from our life we cannot live a full life, and by admitting death into our life we enlarge and enrich it. ~~Etty Hillesum, AuschwitzBy excluding death from our life we cannot live a full life, and by admitting death into our life we enlarge and enrich it. ~~Etty Hillesum, Auschwitz Dying Well

9. 9 GoalsGoals  Be free of physical and emotional pain  Be at peace Needs of resident & family addressedNeeds of resident & family addressed  Physical  Emotional  Spiritual A Good Death

10. 10 Fears About Our Death Or A Loved One’s Death Discomfort or painDiscomfort or pain Being aloneBeing alone Losing controlLosing control Losing our loved one and life without that personLosing our loved one and life without that person The unknownThe unknown Life will have been meaninglessLife will have been meaningless Thomas Leicht, 1978 To Comfort Always: The Hospice Alternative to the Care of Terminal Illness; August 1978 Address to the Institute on Hospices

11. 11 History of Health Care’s Approaches to Dying  Focus on disease and treatment = Death as defeat  Death in hospitals, institutions  Limits of medical technology  Health care system incentives  Hospice movement

12. 12 History of Health Care’s Approaches to Dying (continued)  SUPPORT findings  Education and training for health care professionals  Palliative Care as emerging specialty

13. 13 The Goal of Palliative (End of Life) Care Achieve the best possible quality of life through relief of suffering, control of symptoms, and restoration of functional capacity while remaining sensitive to personal, cultural, and religious values, beliefs, and practices.

14. 14 Hallmarks of Palliative Care Openness and honestyOpenness and honesty Comfort care needsComfort care needs Resident- and family- identified goalsResident- and family- identified goals Teamwork and effective communicationTeamwork and effective communication

15. 15 Palliative Care Curative Focus: Disease-specific Treatments Palliative Focus: Comfort/Supportive Treatments Hospice Care Bereavement Support Palliative Care

16. 16 Time Functional Status Sudden Death Predictable Decline (cancer) Hospice Chronic Longstanding Chronic Varying Paths of Dying Connor SR, New Initiatives Transforming Hospice Care. The Hospice Journal, 1999. 14 (3/4); p.193-203

17. 17 Opportunities: The facility as home The facility as home Long-term relationships with many residents Long-term relationships with many residents Staff expertise caring for older adults Staff expertise caring for older adults Dying in the Skilled Nursing Facility Setting Opportunities/Challenges

18. 18 Challenges:  Cultural views on aging  Decision-making/Dementia  Family issues  Institutional routines  Conflicting goals Dying in the Skilled Nursing Facility Setting Opportunities/Challenges

19. 19 Pain & Symptom Management  High prevalence of persistent pain  Management of pain in the cognitively impaired  Sensitivity of older adults to medication side effects  Multiple medications Dying in the Skilled Nursing Facility Setting Opportunities/Challenges

20. 20 Can We Let Go and Live Life Out of Grace, or Must We Hold On Out of Fear? Giving up implies a struggle – Letting go implies a partnership. Giving up dreads the future – Letting go looks forward. Giving up lives out of fear – Letting go lives out of grace & trust.

21. 21 Can We Let Go and Live Life Out of Grace, or Must We Hold On Out of Fear? (continued) Giving up is a defeat – Letting go is a victory. Giving up is unwillingly yielding control to forces beyond myself – Letting go is choosing to yield to forces beyond myself. Giving up believes that God is to be feared – Letting go trusts in God to care for me.

22. 22 “I know for certain that we never lose the people we love [care for], even to death. They continue to participate in every act, thought and decision we make. Their love [and life] leaves an indelible imprint in our memories. We find comfort in knowing that our lives have been enriched by having shared their love.” ~~Leo F. Buscaglia

23. 23 The End