Module 1: Introduction to Palliative Nursing Care

1. Module 1: Introduction to Palliative Nursing Care

2. Veterans Affairs Motto “…to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow, and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.” President Abraham Lincoln 2nd Inaugural Address

3. Mission of the Department of Veterans Affairs Hospice and Palliative Care Program “To honor Veterans’ preferences for care at end of life.” Department of Veterans Affairs Office of Geriatrics and Extended Care http://www.va.gov

4. Demographics of Veterans • Projected • Over 5,000,000 Veterans cared for at a VA facility/year • US Veterans: 23,442,000 • Deaths of WW II Veterans/day: 900 • % of Veterans over the age of 65: 39.4% National Center for Veterans Analysis and Statistics, 2009; Casarett et al., 2008a

5. The Facts About Veteran Deaths • More than 50,000 Veterans die a month (600,000/year) • 23,000 die in VA inpatient settings/year • Veteran deaths account for almost 28% of all deaths in the US • Approximately 85% do not receive care in a VA facility • Only 4% die in a VA facility NHPCO, 2010

6. Veterans in the Community • Nearly 40% of enrolled Veterans live in rural communities • 121,000 Veterans are without shelter or healthcare, hence no access to hospice/palliative care NHPCO, 2010

7. Nurses Caring for Veterans at the End of Life Must Understand the Culture • Enrolled Veterans • Social isolation • Lack of family support • Low income • Military camaraderie • Culture of stoicism US Department of VA Affairs, VA Health Administration, 2005

8. Characteristics of VHA and Unique Characteristics of Enrolled Veterans • The largest integrated healthcare • system in the US • Multi-layered benefits system • Large elderly population • Higher percent of homelessness • than in general population • Multiple co-morbidities Back et al., 2005; Casarett et al., 2008a; Finlay et al., 2008

9. Various Experiences Can Affect a Veterans Dying • What branch of service? • Enlisted? Drafted? Rank? • Age? • Combat and/or POW experience? • PTSD (assess for social isolation, alcohol abuse, anxieties)? • Stoicism Department of Veterans Affairs, VA Health Administration & Office of Geriatrics and Extended Care, 2005

10. We Do Not Always Die the Way We Would Prefer • Care at home • Fear of pain • Financial burden • Invasive, painful treatments • Dependence on others • Role changes • Elderly caring for the sick • Boni-Saenz et al., 2005; Egan-City & Labyak, 2010

11. PALLIATIVE CARE Ideally begins at the time of diagnosis Can be used to complement treatments HOSPICE Most intense form of palliative care Less than 6 months to live Agrees to enroll in hospice Chooses not to receive aggressive care Hospice and Palliative Care NCP, 2009

12. Hospice and Palliative Care cont. • BOTH • Interdisciplinary care • Provide pain and symptom management • Physical, emotional, social and spiritual care

13. Palliative Care NCP, 2009

14. Death and Dying in America:Today • Over 4700 hospice programs in the US • Average length of stay in hospice is 69 days (median=21 days) • In 2007: 1,560,000 patients received hospice services and 41.6% of all deaths in the US were under the care of a hospice program • Patients with chronic illnesses make up the majority of hospice patients (i.e. heart disease, dementia, etc) NHPCO, 2005 & 2010a

15. Barriers to Quality Care at End of Life • Failure to acknowledge limits of medicine • Lack of training for healthcare providers • Hospice/palliative care services are misunderstood • Many rules and regulations • Denial of death Glare et al., 2003

16. History of Palliative Care in VA • 1992: Policy— “All Veterans should be provided access to a hospice program…” • 1998-2000: VA Faculty Leaders Project for Improved Care at the End of Life • 2001: Training and Program Assessment for Palliative Care (TAPC) • 2001-2003: TAPC launched the VA Hospice & Palliative Care Initiative (VAHPC) • VAHPC Launched Hospice-Veteran Partnership (HVP) NHPCO, 2010b

17. History of Palliative Care in the VA (cont.) • 2003-Present: Palliative Care Consultative Team (PCCT) and Accelerated Administration & Clinical Training (AACT) • 2009- Comprehensive End of Life Care Initiative (CELC) • PROMISE

18. Palliative Care in the VA Today • VA provides palliative care consultation services at • ALL of its medical centers • Many Community Living Centers (CLC) • And contracts with community-based hospice programs to enhance VA’s ability to meet the end-of-life services of its Veterans • Over 60% of all Veterans who die in VA facilities receive care from a palliative care team Department of Veteran Affairs, VA Public Affairs, 2008

19. Benefits of Palliative Care Consultation Teams (PCCT) in VA • Veteran’s goals of care are identified • Less likely to be admitted to ICU • Laboratory and technological tests decreased • Communication between PCCT and Veteran allow goals to be honored Penrod et al., 2006

20. Differences in Cause of Chronic Illness and Death by Wars • World War II • Korean War • Vietnam • Gulf War • Operation Enduring Freedom/Operation Iraqi Freedom

21. Eligibility for VA Hospice Benefit • Included in the Medical Benefits Package (both inpatient or home settings) • Eligible for both VA and Medicare may elect to have hospice paid for under Medicare Hospice Benefit Department of Veterans Affairs, VA Health Administration & Office of Geriatrics and Extended Care, 2005

22. Providing Hospice Services to a Veteran who Becomes an Inpatient • GENERALLY, VA provides needed inpatient hospice care at a VA facility (preferred option) • VA may utilize Community Nursing Home (CNH) contracts • VA may purchase inpatient hospice services from a community provider Department of Veterans Affairs, VA Health Administration & Office of Geriatrics and Extended Care, 2005

23. Prognostication: May Be Used to Establish Goals of Care • Performance status • ECOG and Karnofsky are poor indicators • Multiple symptoms • Biological markers • Albumin, etc. • “Would I be surprised if this Veteran died within the next 6 months?” Glare et al., 2010; Lamont & Christakis, 2007; Lynn et al., 2000

24. Two Palliative Care Frameworks for Assessing Patients • Making Promises Document: • Begin by envisioning what a better care system would look like • Quality of Life Model: • Identify physical, psychological, social, and spiritual aspects of care

25. Good Medical Treatment Never Overwhelmed by Symptoms Continuity, Coordination, & Comprehensiveness Well Prepared, No Surprises Customized Care, Reflecting Your Preferences Consideration for Patient and Family Resources Make the Best of Every Day Making PROMISES:Changing Systems of Care Lynn et al., 2000

26. QUALITY OF LIFE MODEL: Addressing Four Dimensions of Care

27. Role of the Nurse in Improving Palliative Care for All Patients • More time at the bedside than other healthcare providers • Some things cannot be “fixed” • Use of therapeutic presence • Maintain a realistic perspective • Keep Veteran’s goals first in all communication with the team

28. Maintaining Hope in the Midst of Death • Experiential processes • Spiritual processes • Relational processes • Rational thought processes Ersek & Cotter, 2010

29. Extending Palliative Care for Veterans Across Various Settings • Nurses are the constant caregivers • In-patient settings • Clinics • Community living centers • Expand the concept of healing • Become well-educated • Willing to be a “change agent”

30. Final Thoughts • Quality palliative care addresses quality of life for ALL patients • Increased nursing knowledge is essential • “Being with” • Interdisciplinary care is vital

31. Consider……. What steps do you need to take to improve palliative care at your institution so that you and other members of the team are prepared to “care for him who shall have borne the battle…?”