day 2. any reflections from the last day? any hopes for today?
TRANSCRIPT
5 PRIORITIES OF CARE
Day 2
WELCOME BACK Any reflections from the last day? Any hopes for today?
RECOGNISE PRIORITY 1
The possibility that a • person may die within the next few days
or hours is recognised • and communicated clearly, • decisions made and actions taken in
accordance with the person’s needs and wishes,
• and these are regularly reviewed and decisions revised accordingly.
Always consider reversible causes, e.g. infection, dehydration, hypercalcaemia, etc.
EXPANDED When a person’s condition deteriorates unexpectedly, and it is
thought they may die soon, i.e. within a few hours or very few days, they must be assessed by a doctor who is competent to judge whether the change is potentially reversible or the person is likely to die. If the doctor judges that the change in condition is potentially reversible, prompt action must be taken to attempt this, provided that is in accordance with the person’s wishes or in their best interests if it is established that they lack capacity to make the decision about treatment at that time. If the doctor judges that the person is likely to be dying, taking into account the views of others caring for the person, this must be clearly and sensitively explained to the person in a way that is appropriate to their circumstances (if conscious and they have not indicated that they would not wish to know), and their family and others identified as important to them. The person’s views and preferences must be taken into account, and those important to them must be involved in decisions in accordance with the person’s wishes. A plan of care must be developed, documented, and the person must be regularly reviewed to check that the plan of care remains appropriate and to respond to changes in the person’s condition, needs and preferences.
ACTIVITYIn groups discuss your statement(s)
What are the possible complications, issues that may arise or impact you in your role?
Will this help you in your role?
HOW DO WE KNOW IF SOMEONE IS DYING?
3 TRIGGERS THAT SUGGEST THAT PATIENTS ARE NEARING THE END OF LIFE ARE:
1. The Surprise Question: ‘Would you be
surprised if this patient were to die in the next
few months, weeks, days’?
2 General indicators of decline - deterioration,
increasing need or choice for no further active
care.
3. Specific clinical indicators related to certain
conditions.
THE END OF LIFE CARE STRATEGY (2008) RECOMMENDS ASKING:
“Would I be surprised if the person in front of me were to die in the next six months or year?”
This is an intuitive question taking into consideration the stage and progression of the patient's disease, co-morbidities, frailty, age, social and other factors.
RECOGNISING THE ONSET OF DYING PHASE
Rapid progression of disease or co-morbid condition
Greatly reduced mobility Increased frailty Accumulated complications of
treatments, e.g. dialysis Infections becoming less responsive to
treatment
AVERAGE 20 DEATHS PER GP PER YEAR APPROX PROPORTIONS
“Dying is very complex. People are likely to die
in old age after a prolonged decline beset by multiple
conditions”
Leadbetter & Garber, 2010
IS THE PATIENT LIKELY TO BE AWARE OF THIS?”
Given the physical changes experienced
Opportunity to tell you how they feel things are going.
It may be that the patient has thought they are nearing the dying phase.
They may be ready to have confirmation of this, and to discuss their end of life issues and concerns.
On the other hand, it is important to be sensitive to patients who might not be ready to discuss this.
SIGNS OF APPROACHING DEATH
Last few daysYour thoughts…….
HEAD AND FACE Patient will be more fatigued, tired,
sleepy even semi-conscious Patient will have difficulty in
concentrating on activities and conversations
Patient may appear gaunt with sunken eyes, no sparkle and pale in colour
Patient may experience a dry and sore mouth with the risk of oral thrush and ulcers developing
Patient may experience visual changes.
NECK AND CHEST Patient’s fluid and food intake will
decrease or cease Swallowing difficulties will be apparent
and alternative routes for medication need to be sought
Patients breathing pattern may change and be more laboured.
Respiration with mandibular movement may be observed as patient is very close to death
Patient may experience bubbly secretions at the back of the throat
CENTRAL BODY Patient is normally bed bound at this
stage. Movement in the bed needs to be gentle as the patients joints can be very stiff, sore and painful.
Skin is very dry and fragile. More likely to bruise. The patient is at a huge risk of pressure sores developing.
With the disease progressing to this stage and the patient unlikely to have received adequate nutrition for a while they could look cachexic, especially around collar bone and ribs.
LOWER BODY Patient may experience urinary
retention or urinary and faecal incontinence as unable to mobilise or maintain control over bodily functions.
A catheter maybe assessed as appropriate if not pads can be used but this could increase risk to pressure areas i.e. sacrum.
EXTREMITIESPatients are at risk of developing multi system failure. Both cardiac and renal failure can present themselves through:Oedematous legsCyanosed/blue fingers and toesCold arms and legsBruising
COMMUNICATION Withdrawn patient
Picking up on cues Open questions Educated guesses (tentative) Acknowledging/reflecting/paraphrasing as
you go Checking what they know already Clarifying/Exploring anything you don’t
100% understand Use of appropriate silences to allow for
reflection Summarising at the end of the
conversation
Facilitative skills: Key Communication Skills
AFTER TEA BREAK IN AFTERNOON
WHAT IS THE GOAL OF GOOD COMMUNICATION?
• To build positive relationships• To ensure needs are accurately identified and
responded to• To allow for the feeling of being supported and
listened to • To ensure understanding of choices• To learn what has been understood and what further
information is needed or wanted• To deliver new information helpfully, sensitively and
at the right pace• To provide space to talk about whatever they want to
in order that the conversation may allow them to organise their thoughts and feelings in helpful ways…
• To enable planning of present and future care in a timely manner
EXERCISE: Get into pairs Both people in each pair should have a go
at the following: Person 1 should spend 5 minutes talking to
person 2 about a recent challenging experience at work
Person 2 will be given a card and must do what it states on the card
After 5 minutes reverse roles
FEEDBACK What did you notice?
How did you feel being the talker?
How did you feel being the ‘unresponsive listener’?
So: what ratio of importance do you think these ‘ingredients’ of communication hold:
• Content of Speech• Vocal Characteristics (e.g. tone)• Non-verbal Communication
IF COMMUNICATION WAS A CAKE….. Words Non verbal Tone and pitch
How big would the piece be…..
Content of Speech7%
Vocal Charac-teristics
(e.g. tone)38%Non-
verbal Com-
munica-tion55%
Impact of the different elements of communication
BARRIERS TO COMMUNICATION In groups list the barriers you find in
your work that effect yours or others communication skills
BEHAVIOURS THAT ‘BLOCK’ EFFECTIVE COMMUNICATION
• Being defensive• Overuse of practical
questions• Changing topic or
redirecting the conversation
• Lecturing (‘telling people what to do’)
• Collusion/hesitation to introduce topics
• Inappropriate information
• Closed questions• Multiple questions• Leading questions• Passing the buck• Jollying along• Chit chat
30
CONSEQUENCES OF POOR COMMUNICATION
A significant potential for increased psychological distress for the service user and for their family
Poor adherence to advice/guidance Reduced quality of life Dissatisfaction with services Complaints and litigation Potential burnout in health and social care
professionals
WHAT ARE OUR WORRIES? When someone has just died…….
DEFINITIONS Bereavement: describes the loss that
people experience when someone close to them dies.
Grief: describes the emotions that people go through as a result of the loss of someone close to them
Mourning: describes the period of time when people are grieving.
However,
Most people want to feel that others are supportive and care That they know what to expect Where they can get help if needed
Grief is a difficult time but most people manage with their own support from family,
friends and local organisations.
NICE (2004) IDENTIFIES THREE LEVELS TO SUPPORT BEREAVED PEOPLE.
1) Those who have sufficient resilience and support to
manage their grief but may lack understanding about grief.
Offer information (largest group)
2) May need a formal opportunity to reflect on their loss as
well as information. Offered by non specialist professionals,
volunteer groups and community groups.
3) Will need more specialised help. Provided by trained
bereavement counsellors, and psychotherapy services.
(minority)
LOSS
Lets spend some time thinking about what we can lose?
Grieving is a personal and highly individual experience.
How you grieve depends on many factors; personality and coping style, life experience,
faith, and the nature of the loss.
1: We only grieve deaths.
2: Only family members grieve.
3: Grief is an emotional reaction.
4: Individuals should leave grieving at home.
5: We slowly and predictably recover from grief.
6: Grieving means letting go of the person who
died.
7: Grief finally ends.
8: Grievers are best left alone.
COMMON MYTHS
• Myth 1: We only grieve deaths.Reality: We grieve all losses.
• Myth 2: Only family members grieve.Reality: All who are attached grieve.
• Myth 3: Grief is an emotional reaction.Reality: Grief is manifested in many ways.
• Myth 4: Individuals should leave grieving at home.Reality: We cannot control where we grieve.
• Myth 5: We slowly and predictably recover from grief.
Reality: Grief is an uneven process, a roller coaster with no
timeline.
• Myth 6: Grieving means letting go of the person who died.
Reality: We never fully detach from those who have died.
• Myth 7: Grief finally ends.
Reality: Over time most people learn to live with loss.
• Myth 8: Grievers are best left alone.
Reality: Grievers need opportunities to share their
memories and grief, and to receive support.
What emotions do you think people will experience?
ONCE THE PERSON HAS DIED numbness inability to accept the situation shock and pain relief anger and resentment guilt sadness feelings of isolation a feeling of lack of purpose.
Life function
SHOCK
PROTESTDISORGANISATION
REORGANISATION
GRIEF WHEEL
DEATH
Dual Process Model of Coping with Loss
Loss -oriented Restoration-oriented
Grief work
Intrusion of grief
Breaking bonds and ties
Denial/avoidance of restoration changes
Attending to life changes
Doing new things
Distraction from grief
Denial/avoidance of grief to life changes
New roles, Identities, relationships
Everyday Life Changes
TEN WAYS TO HELP THE BEREAVED
1. By being there
2. By listening in an accepting and non-judgemental way
3. By showing that you are listening and that you understand something of that they are going through
4. By encouraging them to talk about the deceased
5. By tolerating silences
6. By being familiar with your own feelings about loss and grief
7. By offering reassurance
8. By not taking anger personally
9. By recognising that your feelings may reflect how they feel
10. By accepting that you cannot make them feel better
People will forget what you said,
people will forget what you did,
but people will never forget how
you made them feel Maya Angelou