1. EDUCATING NURSING STUDENTS AND COMMUNITY ABOUT END OF LIFE CONVERSATIONS

2. EDUCATION  Our Patients Depend on OUR Knowledge about End of Life Care

3. WE WILL NOT LIVE FOREVER

4. RELATIONSHIPS

5. EOL Nursing Competencies 1. Recognize dynamic changes in population demographics, health care economics, and service delivery that necessitate improved professional preparation for end-of-life care. (AACN, 2001)

6. . 2. Promote the provision of comfort care to the dying as an active, desirable, and important skill, and an integral component of nursing care.

7. 3. Communicate effectively and compassionately with the patient, family, and health care team members about end-of-life issues.

8. 4. Recognize one's own attitudes, feelings, values, and expectations about death, and the individual, cultural, and spiritual diversity existing in these beliefs and customs.

9. 5. Demonstrate respect for the patient's views and wishes during end- of- life care.

10. 6. Collaborate with interdisciplinary team members while implementing the nursing role in end-of-life care.

11. 7. Use scientifically based standardized tools to assess symptoms (e.g., pain, dyspnea, gastrointestinal symptoms, anorexia/cachexia, asthenia, anxiety, delirium, depression, and communication barriers) experienced by patients at the end of life.

12. 8. Use data from symptom assessment to plan and intervene in symptom management using state-of-the-art traditional and complementary approaches.

13. 9. Evaluate the impact of traditional, complementary, and technological therapies on patient- centered outcomes.

14. 10. Assess and treat multiple dimensions, including spiritual- psychosocial and physical needs to improve quality at the end of life.

15. 11. Assist the patient, family, colleagues, and one's self to cope with suffering, grief, loss, and bereavement in end-of-life care.

16. 12. Apply legal and ethical principles in the analysis of complex issues in end-of- life care, recognizing the influence of personal values, professional codes, and patient preferences.

17. 13. Identify barriers and facilitators to patients' and caregivers' effective use of resources.

18. 14. Demonstrate skill at implementing a plan for improved end-of-life care within a dynamic and complex health care delivery system.

19. 15. Apply knowledge gained from palliative care research to end-of- life education and care.

20. END OF LIFE REVIEW

21. 1. Designate a surrogate decision maker 2. Stimulate end-of life discussions between patients, families and caregivers, 3.To document what outcome scenarios are acceptable to the patient. (Gordy& Klein, 2011) Advance Directive

22. Living Will A written document Voluntarily executed by an individual. Directing the withholding or withdrawal of life-sustaining procedures Usually when individual is in a terminal condition, coma, or persistent vegetative state.

23. 5 WISHES WHO WILL MAKE DECISIONS WHEN I CAN’T WHAT MEDICAL TREATMENT I WANT OR DON’T WANT

24. 5 Wishes How comfortable I want to be How I want people to treat me What I want my loved ones to know

25. Introduced in 1997 Distributed with support from a grant by The Robert Wood Johnson Foundation. Addresses Needs: Medical, personal, emotional, and spiritual.

26. GEORGIA POLST FORM  Five Sections Cardiopulmonary Resuscitation Medical Interventions Antibiotics Artificially Administered Nutrition Reason For Orders And Signatures

27. POLST Medical order completed by a health care provider Mechanism to communicate patient preferences for end-of-life treatment Designed to travel with patient from one care setting to another

35. The Go Wish Game Developed by the Coda Alliance Values assessment tool Help people and their loved ones decide what is important to them at the end of life.

36. Why Does The Game Work? Educational- New Concepts/Ideas Great for Visual, auditory and Kinesthetic learners.

37. Flexible –Complete in many places Simple not threatening Open ended Wild card Familiar comforting format

38. Easy to read Basic format Young to Old is appropriate Introspection

39. NATIONAL INITIATIVE Conversation Ready National Health Care Community February 13, 2014

40. OPPORTUNITIES FOR HAVING THE CONVERSATION Senior Centers Nursing AD, BSN, APN Classes Community Outreach Events Church/Temple/Synagogue gathering and services

41. END OF-LIFE PRINCIPLES End-Of-Life Care Is About: Compassion at the bedside Providing comfort Honoring patients’ preferences

42. GOLD STANDARD Discussing and following a patient’s preferences for end-of- life care is as routine as asking about and responding to a patient’s allergies to medicines

43. HEALTH CARE AGENT Responsibilities: To follow the patient’s known preferences To honor the patient’s Advance Directive and POLST To act in the best interest of the patient

44. Responsibilities: To follow the patient’s known preferences To honor the patient’s Advance Directive and POLST without regard to personal views If unable to honor preferences, facilitate the transfer of patient’s care When necessary, Clinical Ethics Departments can be utilized as a resource in the hospital systems. Healthcare Team

45. Honor all patients wishes Encourage all patients to have an Advance Care Plan Utilize POLST when patient condition applies Apply reasonable medical judgment Getting It Right

46. When, in the judgment of the physician, one of “three conditions” are met: Patient is in a Terminal Condition Patient is in a permanent state of unconsciousness Medical judgment that CPR would be futile Honoring End of Life Documents

47. ADVANCE CARE PLANNING Discussion Decision Documentati on

48. Engage with our patients and families to understand what matters most to them at the end of life Steward this information as reliably as we do allergy information

49. NURSING CURRICULUM EOL Health Assessment Pharmacology Psychiatric-Mental Health

50. Nursing Management Courses Interprofessional Collaboration for EOL Care Ethical Legal

51. Cultural Issues Content Nursing Research Hospital, Nursing Home/Home Care/Assisted Living

52. EOL COSTS OF CARE: WHERE IS THE MONEY GOING Health Care Costs Highest in the World Outcomes No Better ( Goodman, Skinner, Bronner, Fisher,2009)

53. Barriers to Effective Palliative End of Life Care Minority Populations Rural settings Patients with FFS insurance Langton et.al., 2014)

54. Regardless of the Outcome Resource utilization increased sharply As death approached Particularly in the last 3 months of life. (Langton, et al, 2014)

55. In nearly half of the patients that die in US hospitals, the last three days of their life is spent in an ICU.

56. More than 25% of health care cost is spent in the last year of life. (Curtis, Engelberg, Bensink & Ramsey, 2012)

57. Australian Trial Hospitalized patients over 80 years old 100% May Opt Out of ICU Care (Detering, Hancock, Reade, Silvester, 2010)

58. Patients Die in the ICU 60–80% do so after life-sustaining therapy is held. (Abrahm, 2011)

59. Education of Nursing Students Involves  Interprofessional Effort of Engagement in Many Ethical Opportunities. LET’S TAKE OUR EOL TEACHING RESPONSIBILITY SERIOUSLY

61. References Abrahm JL. Advances in Palliative Care Medicine and End-of-Life Care. Annu Rev Med. 2011;62:187–9. AACN: Peaceful Death: Recommended Competencies and Curricular Guidelines forEnd-of-Life Nursing Care: Amercian Association of Colleges of Nursing Publications, Washington, D.C.: 2001: p, 1-5, Retrieved from: http://www.aacn.nche.eduhttp://www.aacn.nche.edu Curtis, J. R., Engelberg, R. A., Bensink, M. R., Ramsey, S. D. (2012) End-of-Life care in the intensive care unit: Can we simultaneously increase quality and reduce costs? American Journal of Respiratory and Critical Care Medicine, 186, 587-592

62. Langton, Blanch, Drew, Haas, Ingham & Pearson (2014) Retrospective studies of end-of-life resource utilization and cost in cancer care using health administration data: A systematic review. Palliative Medicine, 28, 1167-1196. O’Mahony, S., Mchenry, J., Blank, A. E, Snow, D., Eti Karakas, D., Santoro, G.,…Kvetan, V. (2010). Preliminary report of the integration of a palliative care team into an intensive care unit. Palliative Med 24, 143-165. Neuberg, G. W. (2009). The cost of end of life care. A new efficiency measure falls sort of AHA/ACC standards, Circulation: Cardiovascular Quality Outcomes, 2, 127-133.