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

Setting

Catherine DunleavyTara Winthrop Private Clinic

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.

Standard 16 HIQA 2009

HIQA Regulations Standard 16

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

• 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

• 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

When Resident Deteriorates

• Change Alert requires review of care plan and triggers the discussion/treatment

• Following readmission from hospital

• When it is too late.

James

• 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

Diagnosis:

The basis for these orders is: Patient’s preferences Patient’s best interest

Section A Check One Box Only

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 crewWhen not in cardiopulmonary arrest, follow B, C and D

Section B Check One Box Only

MEDICAL INTERVENTIONS: 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 Check One Box Only in Each Column

MEDICALLY ADMINSTERED FLUIDS AND NUTRITION: Oral fluids and nutrition must be offered if medically feasible. 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- termOther 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) 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

Section G

Specialist Palliative Care InputTo 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

Date:_______________________________ Review Date( 3 months):__________________

Signature: ________________________________(GP/Medical officer)Signature:____________________________________(Director of Nursing)

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 difficultiesRattly respirations

Pain

Subcutaneous cannula checkSubcutaneous infusion check

• Skin Care • Eye Care• Mouthcare• Positioning• Hygiene Needs• Bowel Care

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.

“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

The Journey Through Death and Dying: Families’ Experiences of the End-of-Life Care in Private Nursing Homes

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

• 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

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.

Duty of Care

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.