Palliative CarePalliative Care& End of Life& End of Life

Integris healthIntegris health

100 Years Ago100 Years Ago

The Last 100 YearsThe Last 100 Years“Industrialization & Modern “Industrialization & Modern

Medicine”Medicine”19001900 20002000

Life ExpectancyLife Expectancy 47.5 yrs.47.5 yrs. 76.5 yrs.76.5 yrs.

Causes of DeathCauses of Death Primarily InfectiousPrimarily Infectious Primarily Chronic Primarily Chronic IllnessesIllnesses

Disease Disease TrajectoryTrajectory

ShortShort ExtendedExtended

Medical FocusMedical Focus ComfortComfort CureCure

CaregiversCaregivers FamilyFamily Health Care ProvidersHealth Care Providers

Site of DeathSite of Death HomeHome Hospitals & Nursing Hospitals & Nursing HomesHomes

Death RateDeath Rate 1720 per 100,0001720 per 100,000 860 per 100,000860 per 100,000

The Last 100 YearsThe Last 100 Years In 1900, the average life In 1900, the average life

span was 47.5 yearsspan was 47.5 years Leading Causes of DeathLeading Causes of Death

PneumoniaPneumonia TuberculosisTuberculosis Diarrhea & EnteritisDiarrhea & Enteritis Heart DiseaseHeart Disease StrokeStroke Liver DiseaseLiver Disease InjuriesInjuries CancerCancer SenilitySenility DiptheriaDiptheria

In 2000, the average life In 2000, the average life span was 76.5 yearsspan was 76.5 years

Leading Causes of Leading Causes of DeathDeath Heart DiseaseHeart Disease CancerCancer StrokeStroke Chronic Lung DiseaseChronic Lung Disease PneumoniaPneumonia AccidentsAccidents DiabetesDiabetes SuicideSuicide Kidney DiseaseKidney Disease Chronic Liver DiseaseChronic Liver Disease

End of Life StatisticsEnd of Life Statistics

In 1997, most Americans died in one of three settings:In 1997, most Americans died in one of three settings:Hospitals 53%Hospitals 53% Nursing Homes 24% Home 23%Nursing Homes 24% Home 23%

Most people surveyed preferred to die at home and Most people surveyed preferred to die at home and pain free however, pain free however,

77% died in institutions77% died in institutions 50% died in pain (SUPPORT I)50% died in pain (SUPPORT I)

The number of people over 85 will double to 9 million The number of people over 85 will double to 9 million by the year 2030 (CDC)by the year 2030 (CDC)

Forty percent of all DNR’s are signed within 48 hours of Forty percent of all DNR’s are signed within 48 hours of deathdeath

Mission StatementMission Statement

At INTEGRIS Health, our Palliative Care At INTEGRIS Health, our Palliative Care Service Mission is: Service Mission is: To improve the quality of life of the people and To improve the quality of life of the people and

community we serve. We believe this mission community we serve. We believe this mission extends to all stages of life. Accordingly, we extends to all stages of life. Accordingly, we believe in palliative care as a process to meet believe in palliative care as a process to meet the needs of persons with chronic, life-limiting the needs of persons with chronic, life-limiting illnesses. Palliative care assists with pain and illnesses. Palliative care assists with pain and symptom relief; with education and support for symptom relief; with education and support for patients and their family; and with transitions in patients and their family; and with transitions in care as the illness progresses.care as the illness progresses.

What Is Palliative Care?What Is Palliative Care?

Palliative Care is:Palliative Care is: Quality medical care for those with a life-limiting or Quality medical care for those with a life-limiting or

life-threatening illnesslife-threatening illness Pursuing the goals as defined by the patientPursuing the goals as defined by the patient Guiding patients/families as care transitions from Guiding patients/families as care transitions from

curative therapy to disease & symptom curative therapy to disease & symptom managementmanagement

Addressing the patient’s needs in context of their Addressing the patient’s needs in context of their own social systemown social system

Prevention, assessment and treatment of pain and Prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problemsother physical, psychosocial and spiritual problems

Why Palliative Care?Why Palliative Care?

Palliative Care is an option for anyone with:Palliative Care is an option for anyone with: A life-limiting illness that includes the cascade of A life-limiting illness that includes the cascade of

physical, emotional, psychosocial and spiritual physical, emotional, psychosocial and spiritual needsneeds

A need to relieve sufferingA need to relieve suffering Feelings of isolationFeelings of isolation Feelings of being less than a person (the disease Feelings of being less than a person (the disease

has become their primary focus in life)has become their primary focus in life) A need for aggressive symptom managementA need for aggressive symptom management A need to maximize their quality of lifeA need to maximize their quality of life

Who Provides Palliative Who Provides Palliative Care?Care?

A multidisciplinary team of palliative care A multidisciplinary team of palliative care professionals – MD, RN, MSW, Chaplain in professionals – MD, RN, MSW, Chaplain in collaboration with the primary physician, nurses, collaboration with the primary physician, nurses, healing touch therapists, pharmacist, dietician and healing touch therapists, pharmacist, dietician and all staff who provide care to this patient and familyall staff who provide care to this patient and family

The Palliative Care Team provides consult The Palliative Care Team provides consult services to in-patients with complex palliative care services to in-patients with complex palliative care needs identified through the palliative care needs identified through the palliative care screening processscreening process

Every care provider has responsibility to address Every care provider has responsibility to address the palliative care needs of our patientsthe palliative care needs of our patients

What Services Are What Services Are Provided?Provided?

Pain and symptom managementPain and symptom management Coordination of health care servicesCoordination of health care services Disease process informationDisease process information Community resource informationCommunity resource information Spiritual supportSpiritual support Assistance with communication and decision-Assistance with communication and decision-

makingmaking Setting care goals that expand throughout the Setting care goals that expand throughout the

progression of illnessprogression of illness

What It Is and Is NotWhat It Is and Is Not

Palliative care isPalliative care is:: Expert care of pain and Expert care of pain and

symptoms throughout symptoms throughout illnessillness

Communication and Communication and support for decision support for decision makingmaking

Attention to practical Attention to practical support and continuity support and continuity across settingsacross settings

Care that patients want at Care that patients want at the same time as efforts to the same time as efforts to cure or prolong lifecure or prolong life

Palliative is not:Palliative is not:

““giving up” on the patientgiving up” on the patient

What we do when there is What we do when there is nothing more we can donothing more we can do

In place of curative or life-In place of curative or life-

prolonging careprolonging care

The same as hospiceThe same as hospice

Palliative Care Vs. Palliative Care Vs. HospiceHospice

Palliative CarePalliative Care Available while patient still Available while patient still

recreceiving life prolonging or life eiving life prolonging or life saving therapiessaving therapies

Begins much earlier in Begins much earlier in disease trajectorydisease trajectory

Disease treating Disease treating professionals continue professionals continue consulting servicesconsulting services

Hospice CareHospice Care Those in hospice always Those in hospice always

receive palliative care, but receive palliative care, but hospice focuses on a hospice focuses on a person’s final months of lifeperson’s final months of life

Team oriented approach to Team oriented approach to enhance comfort and improve enhance comfort and improve quality of life with such quality of life with such therapies as symptom therapies as symptom management, emotional, management, emotional, spiritual and bereavement spiritual and bereavement support for the patient and support for the patient and familiesfamilies

Symptom ManagementSymptom Management

PainPain NauseaNausea VomitingVomiting Shortness of BreathShortness of Breath Lack of appetiteLack of appetite AnxietyAnxiety DepressionDepression FatigueFatigue DrowsinessDrowsiness

Alert vs. NonresponsiveAlert vs. Nonresponsive

Patients who are alert or responsive Patients who are alert or responsive should be able to participate in their should be able to participate in their own treatment as much as possibleown treatment as much as possible

Nonverbal cuesNonverbal cues GrimacingGrimacing MoaningMoaning RestlessnessRestlessness Elevated blood pressure and/or heart rateElevated blood pressure and/or heart rate Subtle cues interpreted by family Subtle cues interpreted by family

Symptom ManagementSymptom Management Expect the presence of multiple symptomsExpect the presence of multiple symptoms All symptoms can have their severity measured with All symptoms can have their severity measured with

a simple scale of 1 – 10.a simple scale of 1 – 10. Symptom severity is best scored by the patient. If Symptom severity is best scored by the patient. If

the patient is unable, the family or nurse may be ask the patient is unable, the family or nurse may be ask to provide a score.to provide a score.

Measuring and recording symptom severity over time Measuring and recording symptom severity over time allows interventions to be adjusted and maximizes allows interventions to be adjusted and maximizes comfort and quality of life.comfort and quality of life.

The goal of symptom management is to The goal of symptom management is to control symptoms, promote meaningful control symptoms, promote meaningful interactions between patients and interactions between patients and significant others and facilitate peaceful significant others and facilitate peaceful deaths.deaths.

Symptom Management Symptom Management & The Family& The Family

The dying patient’s family is often viewed as a The dying patient’s family is often viewed as a third leg of a triad much like in pediatricsthird leg of a triad much like in pediatrics

Patients and family members often have Patients and family members often have different stresses and are at different stages different stresses and are at different stages of grieving – leading to additional stresses of grieving – leading to additional stresses and issues within the familyand issues within the family DenialDenial BargainingBargaining AngerAnger DepressionDepression AcceptanceAcceptance

Anticipatory GriefAnticipatory Grief

Death & Family DynamicsDeath & Family Dynamics

(Dys) Functional Family Roles(Dys) Functional Family Roles ITWBBTCI - YAGFTHITWBBTCI - YAGFTH

Previous family issues, “old baggage”, Previous family issues, “old baggage”, that were never resolved or dealt withthat were never resolved or dealt with Marital issuesMarital issues Abuse issuesAbuse issues Parent-child issuesParent-child issues Estranged relationshipsEstranged relationships

EducationEducation

Patients and Family Members usually have Patients and Family Members usually have little or no health care traininglittle or no health care training Disease ProcessDisease Process Disease TrajectoryDisease Trajectory Treatment OptionsTreatment Options Treatment GoalsTreatment Goals

Resources & Support for Patient and FamilyResources & Support for Patient and Family

Spiritual AspectsSpiritual Aspects

Spiritual Distress by Spiritual Distress by the patient may the patient may actually exacerbate actually exacerbate physical symptomsphysical symptoms

Some cultures had Some cultures had specific rituals or specific rituals or beliefs dealing with beliefs dealing with death and dying such death and dying such as Last Rights or as Last Rights or bathing after deathbathing after death

Hospital ResourcesHospital Resources

Clinical SupportClinical Support NursingNursing PhysicianPhysician PharmacyPharmacy

Case ManagementCase Management Social WorkSocial Work Pastoral CarePastoral Care Ethics CommitteeEthics Committee

The Legal FormsThe Legal Forms

Advanced Directive (AD)Advanced Directive (AD) Living Will for Health CareLiving Will for Health Care Health Care ProxyHealth Care Proxy

Durable Power of Attorney for Healthcare Durable Power of Attorney for Healthcare (DPOA)(DPOA)

Do Not Resuscitate (DNR)Do Not Resuscitate (DNR) Certificate of PhysicianCertificate of Physician

Postmortem CarePostmortem Care Is the care provided to the patients body Is the care provided to the patients body

after their death.after their death. Postmortem care is necessary to keep Postmortem care is necessary to keep

the body in proper alignment and prevent the body in proper alignment and prevent skin damage and discolorationskin damage and discoloration

Cultural and religious beliefs often dictate Cultural and religious beliefs often dictate how the body is to cared for after death how the body is to cared for after death and by whom. and by whom. In some cultures the family members help to In some cultures the family members help to

clean and prepare the body. clean and prepare the body.

Postmortem CarePostmortem Care

Standard precautions are followed. Standard precautions are followed. The body is placed in proper alignment before The body is placed in proper alignment before

rigor mortis occursrigor mortis occurs Position the body:Position the body:

Place the patient in center of bed with a pillow under Place the patient in center of bed with a pillow under the head. the head.

Close the eyes. Put a moistened cotton ball on each Close the eyes. Put a moistened cotton ball on each eyelid if the eyes do not stay closed.eyelid if the eyes do not stay closed.

Replace the patient’s denturesReplace the patient’s dentures

Postmortem CarePostmortem Care

Cleans the body. Often times the patient will Cleans the body. Often times the patient will loose control of bowl and bladder. loose control of bowl and bladder.

Place a clean gown, sheets and blanket.Place a clean gown, sheets and blanket. Remove any trash or clutter from the room. Put Remove any trash or clutter from the room. Put

bed in lowest position with all four side rails bed in lowest position with all four side rails down. Move chairs around bed and have a box down. Move chairs around bed and have a box of tissue within reach.of tissue within reach.

Allow the patients family enter the room. Allow the patients family enter the room.

Postmortem CarePostmortem Care

After the patients family leaves the funeral home will be After the patients family leaves the funeral home will be notified.notified.

If there is not a bed crunch the patient may stay in the If there is not a bed crunch the patient may stay in the room until the funeral home can come and pick the room until the funeral home can come and pick the patient up.patient up.

If there is a need for the room or if the funeral home will If there is a need for the room or if the funeral home will not be able to come for several hours the patient may not be able to come for several hours the patient may have to go to the morgue.have to go to the morgue.

If you have to take the patient to the morgue:If you have to take the patient to the morgue: Call security and ask them to meet you at the morgue.Call security and ask them to meet you at the morgue. Transport the body to the morgue. Security will have to unlock Transport the body to the morgue. Security will have to unlock

the door and then relock after you place the body in the the door and then relock after you place the body in the morgue.morgue.

Postmortem CarePostmortem Care

Postmortem Care for patient’s going to the Postmortem Care for patient’s going to the Medical ExaminerMedical Examiner Do everything that you would normally do except:Do everything that you would normally do except:

Do not remove any tubes (foley, NG, Vent, etc) or IV/lines.Do not remove any tubes (foley, NG, Vent, etc) or IV/lines. These will go with the patient to the ME’s office. These will go with the patient to the ME’s office.

Patients who might go to the ME’s Office:Patients who might go to the ME’s Office: Patient’s who die within 24 hours of admissionPatient’s who die within 24 hours of admission Injuries/death the result of violence (ie gang, domestic, Injuries/death the result of violence (ie gang, domestic,

robbery, etc)robbery, etc) Death result of an automobile accidentDeath result of an automobile accident