Transcript Caring For A Patient With Palliative Care Needs in The

Caring For A Patient With Palliative
Care Needs in The Nursing Home
Setting
Catherine Dunleavy
Tara Winthrop Private Clinic
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.
Aims & Objectives
• Overview of Dementia
• Case History to Demonstrate Typical Palliative
Care in Nursing Home Setting
• HIQA and Palliative Care/ End Of Life Care.
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)
Stage of Dementia
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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
When Does Palliative Care Begin
On Admission to Nursing Home
When Resident Deteriorates
• 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
• Change Alert requires
review of care plan and
triggers the
discussion/treatment
• Following readmission from
hospital
• When it is too late.
James
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Age 76
Advanced Lewy Body Dementia
Depression
Enlarged Prostate
Long Term Catheter
Admitted 2005 immobile and fully
dependent with all Adls
Murray et Al, 2005
Acute Episode Trajectory
When Does Palliative Care Begin ?
• May 2010 following Acute Episode Aspiration
Pneumonia
• Nursing Home Comfort Care Plan/End Of Life
• On Admission
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
Name of GP/ Medical Officer with whom this
plan discussed
Name of Director of Nursing / Clinical Nurse
Manager with whom this plan discussed
Name/s of family members with whom this
plan discussed
 Patient’s preferences
 Patient’s best interest
The basis for these orders is:
Section
A
Check
One Box
Only
Diagnosis:
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
 Attempt Resuscitate (CPR)
 Do Not Attempt Resuscitation (no CPR)
If DNR, letter for ambulance crew
When not in cardiopulmonary arrest, follow B, C and D
MEDICAL INTERVENTIONS:
Section
B
Check
One Box
Only
 Comfort measures Treat with dignity and respect
Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use
oxygen, suction and manual treatment of airway obstruction as needed for comfort. Refer to Section C re
antibiotic care plan. Refer to Section D for nutrition and fluid plan. Do not transfer to hospital for life –sustaining
treatment. Transfer only if comfort needs cannot be met in current location.
 Limited Additional Interventions Includes care described above. Use medical treatment. Refer to Section C re
antibiotic care plan. Refer to Section D for nutrition and fluid plan. Do not use intubation, advanced airway
interventions, or mechanical ventilation.
Transfer to hospital if indicated. Avoid intensive care
 Full Treatment Includes care above. Use intubation, advanced airway interventions, mechanical ventilation, and
cardioversion as indicated.
Transfer to hospital is indicated. Include intensive care.
Other instructions:_______________________________________________
Section
C
Check
One Box
Only
ANTIBIOTICS
 No Antibiotics
 Oral Antibiotics
 IV Antibiotics ( usually requires hospital admission, consider community intervention team if appropriate)
Other instructions:_______________________________________________
Section
D
MEDICALLY ADMINSTERED FLUIDS AND NUTRITION: Oral fluids and nutrition must be offered if medically feasible.
Check One Box Only in Each Column
 No iv fluids
 No feeding tube
 S/c fluids for a defined trial period
 feeding tube for a defined trial period
 s/c fluids long- term if indicated
 Feeding tube long- term
Other instructions (e.g. alternative hand-feeding care plan in place if appropriate):_________________________
Section
E
ANTICIPATORY PRESCRIBING: Please be aware of special circumstances which might require different drugs- use
clinical judgement
Oral medications
1)
Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort & pyrexia
1)
Diclofenac 100mg PR daily PRN for signs of pain or discomfort
1)
Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea
1)
Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea
Subcutaneous medications ( where patients no longer able to take oral medications )
1)
Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea
1)
Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness
1)
Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions.
Medications
 Medications rationalised where possible to reduce tablet burden and where no longer appropriate given
patient’s condition and prognosis.
Section
F
Nursing and Support services ( to be organised by hospital medical + nursing team where patient is being
discharged from hospital or if patient being transferred from nursing home to hospital)
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Section G
Liaise with hospital palliative care team
Liaise with community intervention team as appropriate
Date of discharge confirmed with Patient/family and nursing home
Confirmation that medications available in nursing home 24 hours prior to transfer
Appropriate transport arranged and confirmed, DNR letter for ambulance crew
Fully comprehensive nursing discharge letter
Specialist Palliative Care Input
To be completed by specialist palliative care only
 Patient seen in Hospital
 Patient for Community Palliative Care from Location __________________________________________
 Patient not for Community Palliative care; Medical Officer can contact appropriate Community Palliative
Care service for advice
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
End Of Life Care
Agitation
Nausea /
Vomiting
Respiratory difficulties
Rattly
respirations
Pain
Subcutaneous cannula
check
Subcutaneous infusion
check
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Skin Care
Eye Care
Mouthcare
Positioning
Hygiene Needs
Bowel Care
End Of Life Care
• Psychological Support
• Spiritual Needs Met
• Explanation of
procedures
• End Of Life Wishes
known and Discussed
• Information Updates
and Time for
Questioning
• Preferences and
traditions known and
respected.
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
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
HIQA
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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
Duty of Care
The residential service has
facilities in place to support endof-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.
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.