Caring For A Patient With Palliative Care Needs in The Nursing Home Setting

1. Caring For A Patient With Palliative Care Needs in The Nursing Home Setting Catherine Dunleavy Tara Winthrop Private Clinic

2. Standard 16 HIQA 2009 HIQA Regulations Standard 16 Each resident continues to receive care at the end of his/her life which meets his/her physical, emotional, social and spiritual needs and respects his/her dignity and autonomy.

3. Aims & Objectives • Overview of Dementia • Case History to Demonstrate Typical Palliative Care in Nursing Home Setting • HIQA and Palliative Care/ End Of Life Care.

4. Dementia & Palliative Care • Dementia is a syndrome affecting 35.6 million people worldwide. There is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing. It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected. (WHO 2012)

5. Stage of Dementia • Stage 1: Normal • Stage 2: Normal aged forgetfulness • Stage 3: Mild cognitive impairment • Stage 4: Mild Alzheimer's disease • Stage 5: Moderate Alzheimer's disease • Stage 6: Moderately severe Alzheimer's disease • Stage 6: Moderately severe Alzheimer's disease • Stage 7: Severe Alzheimer's disease

6. When Does Palliative Care Begin On Admission to Nursing Home When Resident Deteriorates Change Alert requires review of care plan and triggers the discussion/treatment Following readmission from hospital When it is too late. • Facilitates advanced care planning for the future medical and nursing needs of the resident. • Ensures the resident receives the appropriate treatment in the appropriate place ant the appropriate time

7. James • Age 76 • Advanced Lewy Body Dementia • Depression • Enlarged Prostate • Long Term Catheter • Admitted 2005 immobile and fully dependent with all Adls

8. Murray et Al, 2005

9. Acute Episode Trajectory

10. When Does Palliative Care Begin ? May 2010 following Acute Episode Aspiration Pneumonia Nursing Home Comfort Care Plan/End Of Life On Admission

11. End Of Life Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months. • This includes patients whose death is imminent (expected within a few hours or days) and those with: • advanced, progressive, incurable conditions • general frailty and co-existing conditions that mean they are expected to die within 12 months • existing conditions if they are at risk of dying from a sudden acute crisis in their condition • life-threatening acute conditions caused by sudden catastrophic events

15. Care of James from 2010-2013 • Symptom Management • 3 Monthly Reviews(full comprehensive assessment, must, pain scales, waterlow, care plan review, comfort care plan, manual handling, bed rail risk, medication reconciliation ,evaluation • Acute episode in June 2013 change in appetite. • RIP in November 2013

16. End Of Life Care • Skin Care • Eye Care • Mouthcare • Positioning • Hygiene Needs • Bowel Care

17. End Of Life Care • Psychological Support • Explanation of procedures • Information Updates and Time for Questioning • Spiritual Needs Met • End Of Life Wishes known and Discussed • Preferences and traditions known and respected.

18. The Journey Through Death and Dying: Families’ Experiences of the End-of-Life Care in Private Nursing Homes “Our research suggests a strong culture of good practice within private nursing homes, which provide a ‘home from home’ for elderly residents and enable relatives to be with their loved one at the end of life stage. The report further demonstrates that, where an end-of-life care plan is implemented in partnership with family members, an outcome of good quality care at the end of the resident’s life can be achieved.” Dr. Mel Duffy 2014

19. Palliative Care For All • Standard 2.4 • Each resident with a life-limiting condition or life threatening illness receives care and support, which maintains and enhances their quality of life, meets their needs and respects their dignity. HIQA 2014

20. HIQA • Residents wishes • Referrals to Palliative Care • Staff Training • Choice of Place of Death • Family facilitated • Procedures to be followed following death • Staff and resident support • Participation in Decision Making

21. Duty of Care The residential service has facilities in place to support end-of-life care so that a resident is not unnecessarily transferred to an acute setting except for specific medical reasons, and in accordance with their wishes.

22. Take Home Message • Dementia is a Terminal Illness • Recognising that Palliative care should begin when residents enter the nursing home setting. • Engagement is the key to successful palliative care for all.