Hospice Care for C.N.A.s Prepared by Ellen Williams, CAHPN for Capitol Community College

1. Hospice Care for C.N.A.sPrepared by Ellen Williams, CAHPNforCapitol Community College

2. Objectives At the end of the course learner will be able to: Discuss hospice philosophy and care Discuss importance of communication and IDT in hospice care State the role of C.N.A. in pain control State the role of C.N.A. in dyspnea Discuss nearing death awareness State the role of the C.N.A. at time of death Discuss the importance of self care 2

3. Dying Well Deeply personal experience Natural part of life Growth opportunity 3

4. Dying Well Manage needs of patient and family Physical Emotional Spiritual Goals Symptoms well controlled Be at peace 4

5. Fears That Arise When Thinking of Own or Family Death Being alone Having discomfort Loosing control Loosing loved ones/ life without him/her Life had no meaning Unknown 5

6. History of Healthcare in Dying No treatment--death at home Focus on treatment of disease--death is failure Death in hospitals, institution Medical technology has limits Hospice movement Education and training 6

7. Hospice Care and Philosophy 7

8. Goals in Hospice Quality of life Symptom control Openness and honesty in dealing with dying process Support for patient and family Focus on patient and family goals Peaceful death Allow natural death 8

9. Overview of Hospice Philosophy Interdisciplinary team Pt and family as unit of care Across many settings Pt and family as unit of care Quality of life Aggressive symptom control Cancer Non cancer illness Let nature take its course 9

10. Hospice Interdisciplinary Team Nursing CNA’s Counseling Social work Spiritual Bereavement Dietary Volunteers Medical director 10

11. Symptom Control Pain Difficulty breathing Cough Respiratory congestion Nausea and vomiting Nutrition and hydration Anxiety Delirium 11

12. Hospice Medicare Benefit Available for anyone who has Medicare A Covers hospice services Covers medicine and equipment related to terminal condition Levels of care Routine Inpatient Continuous care Respite 12

13. Cancer People who are not responding to treatment People who choose not to have treatment People who are not candidates for treatment 13

14. Non-Cancer Illnesses 14

15. Non-Cancer Illnesses for which Hospice may be Appropriate Acute Cerecute Cerebrovascular Accident (CVA) – Commonly referred to as a ‘stroke’ when patient has severe deficits. Autoimmune Deficiency Syndrome (AIDS) – Caused by a virus, which attacks the body’s immune system and leaves the patient susceptible to many life-threatening diseases including bacterial infections and cancers. Amyotrophic Lateral Sclerosis (ALS) – This is also called Lou Gehrig’s disease. Cause unknown, but the disease is characterized by an advancing degeneration of portions of the nervous system, causing weakness and progressive loss of function. Alzheimer’s Dementia – Caused by degeneration of the brain cells. The disease is progressive, with the rate of progression varying widely among individuals. In the final stages the patient frequently discontinues eating and drinking. 15

16. Non-Cancer Illnesses ...(continued) Cardiac Disease – This group includes many diseases of the heart that may be life threatening, such as congestive heart failure and cardiomyopathy. Fluids may accumulate in the tissues, generating swelling (edema) or in the lungs producing congestion and difficulty breathing. Chronic Obstructive Pulmonary Disease (COPD) – This includes several diseases on the lungs, characterized by obstruction of the tiny air passages or air sacs in the lungs. Breathing becomes difficult and patients frequently require oxygen. Debility Syndrome – or Failure To Thrive. Patients without one specific diagnosis that is considered terminal, but with multiple diagnoses contributing to a general system failure. Kidney Disease – Kidneys are not functioning correctly. Patient chooses to stop dialysis or not start. 16

17. Non-Cancer Illnesses ...(continued) Liver Disease – Diseases may include cirrhosis, hepatitis or vascular disorders of the liver. Patients with end stage liver disease may become confused then lapse into a coma due to accumulations of toxins in the blood. Cirrhosis is caused by many different things, not necessarily alcohol. Multiple Sclerosis - Multiple Sclerosis is a progressive disease in which nerve fibers of the brain and spinal cord lose their myelin cover. Parkinson’s Disease - a slowly progressive neurological disorder characterized by resting tremor, shuffling gait, stooped posture, rolling motions of the fingers, drooling and muscle weakness, sometimes with emotional instability. 17

18. Dementia Dependent with dressing Dependent with bathing Unable to ambulate independently Incontinent of bowel and bladder Unable to speak more than six words meaningfully 18

19. Dementia At least one of the following medical complications: Aspiration pneumonia Recurrent fever despite antibiotic treatment Upper respiratory infection Urinary tract infection Weight loss of 10 % in six months or less 19

20. Goals of Care To provide care that matches the resident’s and family’s goals and values To guide everyday clinical decisions and actions To make sure we use healthcare resources wisely 20

21. C.N.A. Roles Listening to residents and families and helping them to identify and express their goals, values, and wishes Communicating goals, values, and wishes to other team members Encouraging residents and families to discuss their goals and wishes with other hospice interdisciplinary team members (e.g, MD, spiritual care counselor, social worker, nurse) 21

22. Goals of Medical Therapies Care Control Comfort/palliation 22

23. Decisions at the End of Life Should I continue with treatments aimed at curing my disease or condition? or Should the focus of my medical care be on keeping me comfortable? 23

24. Decisions at the End of Life If my condition gets worse or I develop a medical problem: Do I want to be transferred to a hospital? or Do I want to be cared for at the nursing home or my home or my child’s? 24

25. Decisions at the End of Life If I can no longer make decisions for myself, who should make the decisions for me? What decisions do I need to make to get my affairs in order? 25

26. Decisions at the End of Life If I needed machines and other medical treatments to stay alive: Would I want to receive those therapies? or Do I want nature to take its course? 26

27. Treatment Options Decision makers need to understand risks/benefits and probable outcomes of therapy: CPR/mechanical ventilation Kidney dialysis Diagnostic tests Hospitalization Antibiotics Blood transfusions Tube feeding/intravenous fluids Pain management and comfort care 27

28. Exploring Values and Beliefs Who should speak for me? What makes my life worth living? What are personal and spiritual beliefs that influence decisions? Hope for recovery? 28

29. Advance care planning, informed consent, and medical decision making are Processes 29

30. Ideally, identifying goals of care occurs before a major change in resident status or a medical crisis 30

31. Ideally, the Resident is Ableto Make Decisions Understands the information given Thinks clearly about treatment options Can communicatedecisions 31

32. Residents Who Might Not be Able to Make Decisions Those with advanced dementia Who have had strokes that decrease their ability to understand or to speak Who are in a coma Who have a serious mental disease 32

33. Don’t Assume a Resident is Unable to Make Good Decisions Because: They are strange or odd They don’t speak your language They are not well educated They are physically handicapped They are deaf They disagree with their family or the health care team 33

34. Advance Directives Are written instructions (directives) to a health care provider before (advance) the need for medical treatment Ensure that your wishes are followed in the event that a future accident or illness makes it impossible for you to communicate your wishes In an AD, you can refuse or consent to future treatment 34

35. Types of Advance Directives Living will (health care directive) Durable power of attorney for health care (health care proxy) No code/do not resuscitate (DNR) Anatomical gifts - tissue/organ/body donation Do not hospitalize (DNH) 35

36. Purposes of Advance Directives To help a person maintain autonomy after he or she can no longer make decisions; helps ensure that person’s wishes are honored Provides guidance to family and caregivers about type and goals of care Can decrease family and caregiver distress about decision making Can decrease conflict around EOL decision making 36

37. Who Can Make Decisions if the Resident isn’t Capable? (List is in order of priority) Appointed guardian DPOA - HC Patient's spouse Adult (18+ years) children Patient’s parents Adult brothers and sisters If none of the above, guardian may be appointed RCW 7.70.065 37

38. Communication in Hospice Staff Patient Family 38

39. Basic Principles of Communication One cannot not communicate Communication is a two way activity Much communication is nonverbal Actions and words are perceived by the receiver based on own personal experiences Listening is one of the most important parts of EOL communication 39

40. Communicating with Staff Hospice IDT important in exploring all aspects Need to update one another with patient and family issues Each patient has individual needs Update nurse as you find new information or needs Update individual care plans 40

41. Co-Workers Update them on new concerns with patient or family or care needs Report how the day is going There may be emotional upheavings Report what has helped 41

42. How to Address Your Patients Ask what they want to be called Find if they have a nickname they want used Many folks find “honey” and “sweetie” insulting 42

43. Cultural Influences One’s rules for communication (is touching OK?) How emotions are expressed One’s view of illness and death How the family makes decisions and who the sick person wants to speak for him or her 43

44. Life Experiences People often die how they have lived People who have not trusted much most likely still will not trust People who have been demanding will probably continue to be demanding People who have been fairly happy will probably still be somewhat pleasant 44

45. Some Challenges in Communication in Hospice Society's denial of death -- how openly families will talk about approaching death Patient and family’s fears and emotions Dementia and severe illnesses where patients are not able to talk about their wishes 45

46. Caregiver Challenges Not sure of what to say Not having “the answers” Fear of showing own emotions Fear of making a mistake which might upset the family or patient One’s own fear of dying Having trouble with patient or family reactions 46

47. Family Emotions Fear Guilt Hopelessness Helplessness Anger Sadness Relief Ambivalence Acceptance 47

48. Tips on How to Respond Remove yourself from the situation Ask yourself : what am I feeling? Anger? Fear? How are you showing these feelings? Are they affecting your care? Talk with other team members Make a plan to deal with the conflict with the team Use “I” statements: ”I feel uncomfortable when you raise your voice” 48

49. When Communicating With Someone Who Is Upset Stay calm Do not raise your voice Treat them with respect Do not argue or touch the person Answer questions or if you do not know, find someone who can Let the person vent but do not let them abuse you Remember anger is normal part of grieving process 49

50. Concepts in EOL Communication Being present is most important Use active listening Allow the patient and family let you know what is important to them Encourage life review Listen to all tell their story 50