Nursing Facility and Hospice Collaborative Training

1. Nursing Facility and Hospice Collaborative Training Presented by Care Initiatives Hospice, Hospice of Central Iowa, Iowa Health Hospice, Iowa Hospice, Mercy Hospice and Wesley Community Hospice

2. What your residents can expect from the hospice program: • Hospice neither hastens death or prolongs life. • Your resident’s comfort is of utmost importance. Hospice will focus on pain and symptom management in an attempt to maintain comfort. • Your resident will be given quality care and services by the hospice staff. • Your resident, his/her family and you will be treated with dignity and respect. • Your resident has the right to self-determination. In the event he/she is unable to express this, the person with the decision making capacity has that right.

3. What your residents can expect from the hospice program: • Your resident will be accepted unconditionally. • Your resident will be given a statement of his/her rights as a hospice patient. • Hospice will provide support & care for your resident’s emotional & spiritual needs. • Hospice respects each person’s cultural differences.

4. What you can expect from the Hospice program: • Hospice is responsible for managing your resident’s hospice services and any care related to the terminal diagnosis. • Hospice will work as a team to provide the needed care and services to your resident. You can expect: Coordination of hospice care with facility staff. Communication with your medical director, your resident’s attending physician and any other physician involved in the care of the resident. Ongoing documentation of all hospice service.

5. Hospice will provide the following information to you: • The most recent hospice plan of care specific to each resident. • The hospice election form and any advance directives specific to each resident. • The physician certification and recertification of the terminal illness. • Names and contact information for hospice staff involved in the resident’s care.

6. Hospice will provide the following information to you: • Instructions on how to access the hospice’s 24 hour care system. • Medication information specific to each resident. • Orders from the hospice physician and attending physician.

7. What hospice expects from you: • Meet the personal care and nursing needs of your residents (our hospice patients). • Promptly notify hospice of a change in your hospice resident’s condition. • Immediately notify hospice of the death of a hospice resident. • Ensure hospice orientation to new facility staff.

8. Pain and symptom management ~ your resident’s comfort Pain and symptom management are treated with very specific interventions in hospice care. These include: medication and non medication methods such as massage, pet therapy, music therapy, and healing touch. We make every effort to treat the whole person and consider spiritual, emotional and psychosocial interventions to help control symptoms.

9. Pain management: • Medication is given around the clock. This maintains the steady level of medicine and provides quality pain control. • Medication is given in the amount needed to control the pain to the resident’s satisfaction. • Medications are administered in ways comfortable to the resident. Hospice will consider using sublingual or rectal routes before subcutaneous, intramuscular or IV.

10. Pain management: Non-pharmacologic interventions such as massage, healing touch, music, pet therapy and guided imagery may be used to help maintain pain control.

11. Other comfort concerns: • Bowel programs are started for residents receiving certain pain meds. • Other difficult symptoms to manage can include: • Nausea and vomiting • Breathlessness • Anxiety and restlessness • Delirium and dementia

12. Other comfort concerns: • Hospice staff receives specific education and additional in-services to understand and learn how to minimize and control these and other symptoms. • Hospice staff are alert to facility regulations, in particular those regarding the use of psychotropic meds that could lead to sedation and its possible use as a restraint.

13. Some Principles of Death & Dying • Location: consider your resident’s desired location of death. • Presence of others: The hospice philosophy encourages the participation & presence of family & significant others during the dying process, and will work with you and the facility staff to accommodate additional visitors.

14. Some Principles of Death & Dying • Environment: It is important that the environment surrounding a person at death provides a sense of peace and comfort not only for your resident but for family and caregivers as well. • Comfort: Hospice staff are available to provide assistance with comfort management as well as emotional and spiritual support for the resident, family and caregivers (which includes facility staff).

15. Some Principles of Death & Dying • Individualized: All of us die differently; for each one us death and dying is a unique experience. Many people die in the way that they lived and will not experience a significant change in their personality or lifestyle just because they are at the end of life.

16. Coolness: Hands, arms, feet and legs may become increasingly cool to the touch. Color of the skin may change. This is because normal circulation is decreasing and being reserved for the body’s vital organs. Sleeping: Your resident may spend an increasing amount of time sleeping and appear to be non-communicative and unresponsive. Speak to them as you normally would, even though there may be no response. Signs and Symptoms of Impending Death:

17. Disorientation: Your resident may seem confused about time, place and identity of family and friends. Identify yourself by name before you speak. Speak softly, truthfully and clearly. • Incontinence: Your resident may lose control of bowel and bladder as muscles begin to relax. • Congestion: Noisy, gurgling sounds may occur. These sounds can be concerning for family and friends. Gently turn your resident’s head to the side to allow gravity to drain the secretions.

18. Intake decreases: Your resident may want little or no food or liquid. This means his/her body is conserving energy for other functions and getting ready for the end phase. Do not force food or drink. Glycerin swabs may be used to keep the mouth moist.

19. Urine decreases due to decreased intake & decreased circulation. Change in breathing pattern: Breathing may change pace which alternates with periods of no breathing. Decreased socialization: Your resident may only want to be with a very few or even just one person. Withdraw: Your resident may seem unresponsive, withdrawn or in a comatose state. He/she is beginning to “let go”. Continue to speak to him/her as they can still hear you. Restlessness: Your resident may perform repetitive & restless tasks like picking at his/her clothes or linens. This is due to decreased oxygen in the brain.

20. Sensory experiences: Your resident may speak or claim to have spoken to those who have already died, or see or have seen places not visible to you. Affirm the experiences. These are normal and common.

21. Giving permission: Your resident may need permission to die or “let go” without feeling guilty or feeling they are letting someone down. Encourage family and friend to give this permission. • Saying goodbye: Help your resident’s family say goodbye and take time to say goodbye yourself. It is the final gift of love, for it achieves closure & makes the final release possible. Tears are normal.

22. Bereavement services: Bereavement services are available to your resident’s family, to other facility residents and to facility staff. Contact the hospice program for specific information regarding bereavement services.

23. For further questions regarding this hospice education or any questions regarding hospice care, please contact any of the following providers: Care Initiatives Hospice, Hospice of Central Iowa, Iowa Health Hospice, Iowa Hospice, Mercy Hospice and Wesley Community Hospice