Palliative Care & End of Life

1. Palliative Care& End of Life Integris health

2. 100 Years Ago

3. The Last 100 Years“Industrialization & Modern Medicine”

4. In 1900, the average life span was 47.5 years Leading Causes of Death Pneumonia Tuberculosis Diarrhea & Enteritis Heart Disease Stroke Liver Disease Injuries Cancer Senility Diptheria In 2000, the average life span was 76.5 years Leading Causes of Death Heart Disease Cancer Stroke Chronic Lung Disease Pneumonia Accidents Diabetes Suicide Kidney Disease Chronic Liver Disease The Last 100 Years

6. End of Life Statistics • In 1997, most Americans died in one of three settings: Hospitals 53% Nursing Homes 24% Home 23% • Most people surveyed preferred to die at home and pain free however, • 77% died in institutions • 50% died in pain (SUPPORT I) • The number of people over 85 will double to 9 million by the year 2030 (CDC) • Forty percent of all DNR’s are signed within 48 hours of death

7. Mission Statement • At INTEGRIS Health, our Palliative Care Service Mission is: • To improve the quality of life of the people and community we serve. We believe this mission extends to all stages of life. Accordingly, we believe in palliative care as a process to meet the needs of persons with chronic, life-limiting illnesses. Palliative care assists with pain and symptom relief; with education and support for patients and their family; and with transitions in care as the illness progresses.

8. What Is Palliative Care? • Palliative Care is: • Quality medical care for those with a life-limiting or life-threatening illness • Pursuing the goals as defined by the patient • Guiding patients/families as care transitions from curative therapy to disease & symptom management • Addressing the patient’s needs in context of their own social system • Prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems

9. Why Palliative Care? • Palliative Care is an option for anyone with: • A life-limiting illness that includes the cascade of physical, emotional, psychosocial and spiritual needs • A need to relieve suffering • Feelings of isolation • Feelings of being less than a person (the disease has become their primary focus in life) • A need for aggressive symptom management • A need to maximize their quality of life

10. Who Provides Palliative Care? • A multidisciplinary team of palliative care professionals – MD, RN, MSW, Chaplain in collaboration with the primary physician, nurses, healing touch therapists, pharmacist, dietician and all staff who provide care to this patient and family • The Palliative Care Team provides consult services to in-patients with complex palliative care needs identified through the palliative care screening process • Every care provider has responsibility to address the palliative care needs of our patients

11. What Services Are Provided? • Pain and symptom management • Coordination of health care services • Disease process information • Community resource information • Spiritual support • Assistance with communication and decision-making • Setting care goals that expand throughout the progression of illness

12. Palliative care is: Expert care of pain and symptoms throughout illness Communication and support for decision making Attention to practical support and continuity across settings Care that patients want at the same time as efforts to cure or prolong life Palliative is not: “giving up” on the patient What we do when there is nothing more we can do In place of curative or life-prolonging care The same as hospice What It Is and Is Not

13. Palliative Care Available while patient still receiving life prolonging or life saving therapies Begins much earlier in disease trajectory Disease treating professionals continue consulting services Hospice Care Those in hospice always receive palliative care, but hospice focuses on a person’s final months of life Team oriented approach to enhance comfort and improve quality of life with such therapies as symptom management, emotional, spiritual and bereavement support for the patient and families Palliative Care Vs. Hospice

14. Symptom Management • Pain • Nausea • Vomiting • Shortness of Breath • Lack of appetite • Anxiety • Depression • Fatigue • Drowsiness

15. Alert vs. Nonresponsive • Patients who are alert or responsive should be able to participate in their own treatment as much as possible • Nonverbal cues • Grimacing • Moaning • Restlessness • Elevated blood pressure and/or heart rate • Subtle cues interpreted by family

16. Symptom Management • Expect the presence of multiple symptoms • All symptoms can have their severity measured with a simple scale of 1 – 10. • Symptom severity is best scored by the patient. If the patient is unable, the family or nurse may be ask to provide a score. • Measuring and recording symptom severity over time allows interventions to be adjusted and maximizes comfort and quality of life. • The goal of symptom management is to control symptoms, promote meaningful interactions between patients and significant others and facilitate peaceful deaths.

17. Symptom Management & The Family • The dying patient’s family is often viewed as a third leg of a triad much like in pediatrics • Patients and family members often have different stresses and are at different stages of grieving – leading to additional stresses and issues within the family • Denial • Bargaining • Anger • Depression • Acceptance • Anticipatory Grief

18. Death & Family Dynamics • (Dys) Functional Family Roles • ITWBBTCI - YAGFTH • Previous family issues, “old baggage”, that were never resolved or dealt with • Marital issues • Abuse issues • Parent-child issues • Estranged relationships

19. Education • Patients and Family Members usually have little or no health care training • Disease Process • Disease Trajectory • Treatment Options • Treatment Goals • Resources & Support for Patient and Family

20. Spiritual Aspects • Spiritual Distress by the patient may actually exacerbate physical symptoms • Some cultures had specific rituals or beliefs dealing with death and dying such as Last Rights or bathing after death

21. Hospital Resources • Clinical Support • Nursing • Physician • Pharmacy • Case Management • Social Work • Pastoral Care • Ethics Committee

22. The Legal Forms • Advanced Directive (AD) • Living Will for Health Care • Health Care Proxy • Durable Power of Attorney for Healthcare (DPOA) • Do Not Resuscitate (DNR) • Certificate of Physician

23. Postmortem Care • Is the care provided to the patients body after their death. • Postmortem care is necessary to keep the body in proper alignment and prevent skin damage and discoloration • Cultural and religious beliefs often dictate how the body is to cared for after death and by whom. • In some cultures the family members help to clean and prepare the body.

24. Postmortem Care • Standard precautions are followed. • The body is placed in proper alignment before rigor mortis occurs • Position the body: • Place the patient in center of bed with a pillow under the head. • Close the eyes. Put a moistened cotton ball on each eyelid if the eyes do not stay closed. • Replace the patient’s dentures

25. Postmortem Care • Cleans the body. Often times the patient will loose control of bowl and bladder. • Place a clean gown, sheets and blanket. • Remove any trash or clutter from the room. Put bed in lowest position with all four side rails down. Move chairs around bed and have a box of tissue within reach. • Allow the patients family enter the room.

26. Postmortem Care • After the patients family leaves the funeral home will be notified. • If there is not a bed crunch the patient may stay in the room until the funeral home can come and pick the patient up. • If there is a need for the room or if the funeral home will not be able to come for several hours the patient may have to go to the morgue. • If you have to take the patient to the morgue: • Call security and ask them to meet you at the morgue. • Transport the body to the morgue. Security will have to unlock the door and then relock after you place the body in the morgue.

27. Postmortem Care • Postmortem Care for patient’s going to the Medical Examiner • Do everything that you would normally do except: • Do not remove any tubes (foley, NG, Vent, etc) or IV/lines. • These will go with the patient to the ME’s office. • Patients who might go to the ME’s Office: • Patient’s who die within 24 hours of admission • Injuries/death the result of violence (ie gang, domestic, robbery, etc) • Death result of an automobile accident