palliative care from hospital to nursing home addressing the needs of elderly patients who have a...
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Palliative Care From Hospital To Nursing Home
Addressing the needs of elderly patients who have a life limiting
progressive illness with palliative care needs
Palliative Care
“ Palliative care is an approach that improves quality of life of patients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.”
WHO (2003)
Terminal Care
Terminal care is a continuum of palliative care and is used to describe the care that is offered during the period when death is imminent, and life expectancy is limited to a short number of days, hours or less.
Department of Health and Children (2001)
Levels of Palliative Care
Level 1 - Palliative care approach
Level 2 - General palliative care
Level 3 - Specialist palliative care
Levels of Palliative Care
Level One - Palliative care approach
Palliative care principles should be practiced by all health care professionals.The palliative care approach should be a core skill of every clinician at hospital and community level.
Levels of Palliative Care
Level Two – General Palliative Care
A proportion of patients and families will benefit from the expertise of health care professionals who although not engaged full time in palliative care have some additional training and experience in palliative care, perhaps to diploma level. This level of expertise should be available at hospital and community level.
Levels of Palliative Care
Level Three- Specialist Palliative Care
Specialist palliative care services are those services whose core activity is limited to the provision of palliative care. These services are involved in the care of patients with more complex and demanding needs.
Many patients with progressive and advanced disease will have their needs met comprehensively and satisfactorily without referral to specialist palliative care units or personnel.
Facts
27,479 people died in 2006 in Ireland 28% died from cancer 33% died from cardiovascular/circulatory 14% died from respiratory disease 25% died from other causes Almost 16,000 deaths were in the 75-94
age group
Irish Hospice Foundation- Palliative Care For All (2008)
Ageing Population
By 2050 the ‘over 80’ age group is projected to number almost 379 million worldwide, about 5.5 times as many as in 2000 ( 69 million persons).
In 1950, persons over 80 numbered less than 14 million. It has never been more critical to address the palliative
care needs of older people than in the context of today’s ageing populations. The proportion of people aged 65 and over is steadily on the increase in Europe.
World Population Ageing 1950-2050
A/E Survey Conducted in Connolly Hospital Feb 2007
High levels of A/E use, by patients>65 years and those in LTC.
420 attendances by patients>65 years old 56(13%) from nursing home care- (52% had 1
or more attendances in the last 4 months) 65% admitted to hospital; high hospital
mortality
P McCormack & S Kennelly (2008)
Consequences of Inappropriate Hospital Admissions
Patients at risk of dying in an inappropriate place of care, e.g. A/E
Lengthy hospital stays Poor quality of life for the patient Medication errors Poor communication of new care plans Changing care teams/ fragmentation of care Transportation delays and discomfort
Inappropriate patient transfers between nursing homes and hospitals can be very stressful for both patients and families. It can be frustrating for staff in both care settings.
Case Scenario
Grandpa Simpson 85 year old nursing home resident over 5 yrs
Background - advanced dementia, previous CVA Progressive decline over the last six months, less interest in eating and drinking, poor swallow
Admitted to an acute hospital with aspiration pneumonia, treated with iv antibiotics, improved clinically, transferred back to nursing home residence 7 days later.
Of note he had 4 admissions over the previous 8 months
Readmitted 2 weeks later following recurrent aspiration pneumonia, died in A/E
Outcome ?
Planned to Fail !
How can we improve the transition of care for the elderly patient who have a progressive life limiting illness and prevent inappropriate readmission to hospital??
A “Transitional” Problem
Poor communication between hospitals and nursing homes
Lack of advanced care planning Poor documentation re goals of care Poor communication with patient and family Lack of knowledge and skills re managing symptoms
Challenges in Providing Palliative Care To The Nursing Home Resident
Communication Prognosis Care planning Confidence in managing symptoms Support
Improving End of Life Care for Patients
Who Have a Life Limiting Illness
Aims of care should be:
To provide a mechanism to improve care given to patients at end of life
To enhance communication between different care settings
To discuss wishes for care with family and multidisciplinary team
To provide a tool to improve implementation of advanced care planning
Prognostic Criteria For Advanced Disease
Any one of 3 criteria could trigger a patient to be considered to have palliative, supportive care needs
1. Patient need or choice is for comfort care only and not for possible curative treatment.
2. Use of the ‘Surprise’ question – would you be surprised if the patient was to die in the next year? If not, then they are likely to need supportive/palliative care.
3. Patients have Clinical indicators of need for palliative care – prognostic clinical indicators of ‘advanced’ or irreversible disease – to include 1 core and 1 disease specific indicator
Gold Standards Framework Prognostic Indicator Guidance
Beaumont Hospital Discharge Guidelines For Patients Returning To Nursing Homes For Supportive -Comfort Care ( Pilot Project)
These are guidelines for the medical team based on the patients medical condition and wishes under the direction of the patient’s consultant doctor and should accompany patient when transferred.
Section A
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
Attempt Resuscitate (CPR) DO Not Attempt Resuscitation
(no CPR)
When not in cardiopulmonary arrest, follow B, C and D
Section B
MEDICAL INTERVENTIONS: Person has pulse and/ or is breathing.
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. 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 and s/c fluids. 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 cardio version as indicated. Transfer to hospital is indicated. Include intensive care.
Other instructions:_______________________________________________
Section B
This section allows discussion re level of medical intervention if the patient deteriorates.
Comfort indicates a desire for only those interventions that enhance comfort . Transfer to hospital is indicated only if comfort needs cannot be met in current location
Limited additional interventions, in addition to comfort measures e.g. s/c fluids, oral antibiotics as indicated. Transfer to hospital if indicated.
Full treatment includes all care as above with no limitation of medically indicated treatment .
Section C
ANTIBIOTICS
No Antibiotics
Oral Antibiotics
IV Antibiotics ( usually requires hospital admission, consider community intervention team if appropriate)
Other instructions:______________________________________
Section C
This section stimulates conversations about the goals of antibiotic use. Antibiotics often are life sustaining treatments. Advance care planning in the use of antibiotics can help clarify goals of care for the person and caregiver.
Many families of patients with advanced progressive illness may prefer to have antibiotics withheld and want other measures such as a antipyretics and opioids to treat symptoms of infection and maintain comfort.
Additional instructions can also be written “Antibiotics may be used only as needed for comfort” for example a urinary tract infection may cause discomfort for a dying patient. Treating the UTI with an antibiotic may serve as a comfort measure.
Section D
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- term
Other instructions:_________________________________________________
Section D
Oral fluids and nutrition must be offered if medically feasible, i.e. the patient is alert and able to swallow
Goal of care may be allowing to eat and drink for comfort versus aspiration risk
IV fluids may cause oedema, shortness of breath, and the need for frequent urination. At the end of life they can cause excess secretions
s/c fluids may be considered for a defined trial period to see if this benefits the patient. ( s/c fluids will not alleviate dry mouth)
If the patient is being tube feed this may be continued if there is no ill effects e.g. chestiness, aspiration and vomiting .
Section E
DISCUSSED WITH :
Patient /Resident Next of kinFamily memberOther ______________ (Specify)
The Basis for These Orders is:
Patient’s preferencesPatient’s best interest
Section F
ANTICIPATORY PRESCRIBING
Oral medications
1) Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort, Pyrexia
2) Diclofenac 100mg PR daily PRN for signs of pain or discomfort
3) Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea
4) Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea
Section F
Subcutaneous medications ( where patients no longer able to take oral medications )
5) Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea
6) Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness
7) Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions.
Section F
Medications
Medications rationalized where possible to reduce tablet burden and where no longer appropriate given the patient’s condition and prognosis.
Section G
Nursing and Support services ( Primary, community continuing care providers)
Liaise with hospital and community palliative care team as appropriate
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 hour
prior to transfer Appropriate transport arranged and confirmed Fully comprehensive nursing discharge letter
Case Scenario 2
Mr Burns 78 year old nursing home resident. Background: COPD, CCF, Vascular Dementia. Admitted to an acute hospital with infective
exacerbation of COPD, 48hrs in A/E prior to being admitted to ward.
Treated with iv antibiotics with little response, remained comfortable but weak, not eating or drinking, barely responsive
Referral to Palliative care re symptom management, comfort care.
Case Scenario 2
Family meeting with multidisciplinary team. Given Mr Burns current state of health, failure to improve despite active treatment and his co-morbidities family and medical team in agreement most appropriate goal of care was comfort measures. Family keen for transfer back to nursing home as it had been his home for 5 years.
Discharge guideline used in consultation with family. Mr Burns for comfort measures only, for transfer back to hospital only if comfort measures cannot be met, advice given re symptomatic management
Liaised with nursing home re goal of care, discharge guidelines. Transferred back to nursing home, died peacefully five days
later.
Example letter
RE. Mr Ryan DOB 10 0ctober 1920 Garda Retirement Home Raheny Dublin 5
29 May 2009 Dear Doctor,
Both Mr Ryan and his family have expressed a wish not to have Mr Ryan referred to the hospital for further tests or clinical management.
He should only be transferred in the event of severe pain or haemorrhage or accident requiring acute hospital treatment.
He is not for Resuscitation in the event of an acute cardiac event.
Yours sincerely
Confidence In Managing Symptoms
Multidisciplinary involvement Liaise with hospital palliative care team if
appropriate Referral to specialist community palliative
care team where available Liaising with nursing home re plan of care Use of anticipatory prescribing Liaise with GP or relevant medical officer
Confidence In Managing Symptoms
Irish Hospice Foundation in conjunction with the Palliative Care Education Task Force is preparing a training programme for Nursing Homes Ireland, the representative organisation for the private and voluntary nursing homes sector.
This training programme is seeking to establish a common multidisciplinary approach to level 1 palliative care education in Ireland for nursing home staff.
References
Department of Health and Children. Report of the National Advisory Committee on Palliative Care (2001)
McCormack P & Kennelly S (2008) Care delivery in the most appropriate setting?. Experience of Connolly Hospital Liaison Medicine for the Elderly Service. www.nhi.ie .
Palliative Care For All (2008) Integrating Palliative Care into Disease Management Frameworks. The Irish Hospice Foundation. Health Service Executive.
World Population Ageing 1950-2050, Chapter iv Population Division, DESA, United Nations
WHO
Additional information
Alvin H. Moss (2004) Respecting Patients’ Wishes at the End of Life. Physician Orders for scope of Treatment www.wvendoflife.org
Centre to Advance Palliative Care (2007) Improving Palliative Care in Nursing Homes.
Centre For End-Of-Life-Care (2006). Robert C Byrd Health Services Centre Of West Virginia University. www.wvendoflife.org
The Irish Hospice Foundation Annual Report,2008 www.goldstandardsframework.nhs.uk