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6 STEPS WORKSHOP 2. Pam Williams Clinical Nurse Educator End of Life Care May 2011. Objectives of the session. Recognise the importance of holistic care planning An awareness of assessing residents mental capacity
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6 STEPSWORKSHOP 2 Pam Williams Clinical Nurse Educator End of Life Care May 2011
Objectives of the session • Recognise the importance of holistic care planning • An awareness of assessing residents mental capacity • Produce an action plan to implement a system to support advance care planning
Quality Markers/Policy Workshop 1- Families & carers are involved in end of life decisions to the extent that they and the residents wish Workshop 2- There is a mechanism in place to discuss, record and communicate (where appropriate) the wishes and preferences of those approaching end of life. The residents needs for end of life care are assessed and reviewed on an on-going basis.
WHAT IS A HOLISTIC ASSESSMENT • Definition of ‘holistic’ An holistic assessment is one which not only looks at the physical aspects of a person, but looks also at the psychological, social and spiritual aspects
Holistic assessment; • Is a continuous process & leads to; • More effective treatment of symptoms • More patient-centred (patient’s priority) • Improves communication between MDT • Improves evaluation of treatments • Reassures resident’s family • Improves the resident’s quality of life
THE WHOLE PERSON? • PHYSICAL • PSYCHOLOGICAL • SPIRITUAL • SOCIAL
TOTAL PAIN Emotional & Psychological Physical ‘TOTAL PAIN’ Social Personal & Spiritual
Case study • Margaret is a 66 year old lady who has recently been admitted to your care home following a stroke. • The stroke has left Margaret with a severe left sided weakness for which she did initially receive physiotherapy but there was no significant improvement. • Currently Margaret is nursed in bed or her chair and the hoist is used for transfer. • Margaret is only able to tolerate a pureed diet with thickened fluids and continues under the care of the Speech and Language Therapist. • Margaret requires a high level of care with all activities of daily living and this appears to frustrate Margaret. • Time is allowed to encourage Margaret to express herself as the stroke has made it difficult for her to verbally communicate. • Margaret is a widow with three children and seven grandchildren. • Before the stroke Margaret had been very involved in supporting her two daughters and one son with childcare when possible. • Margaret is a Christian and has always enjoyed attending church with her two friends. She frequently volunteered in the church and regularly baked with her grandchildren to raise funds for the church. • Margaret has been very emotional since the stroke and frequently cries when care staff attend to her.
Margarets holistic assessment • Physical • Emotional/Psychological • Personal/Spiritual • Social
HELP WITH ASSESSMENTS • WHAT QUESTIONS SHOULD YOU ASK?
Ask…. • Nature – what is it like • Location – where do you get it • Severity – what is it like at its worst • Frequency – how often do you get this • Duration – how long does it last • Triggers – does anything bring it on/ make it worse • Alleviating factors – does anything relieve it • Assessment tools useful e.g. body charts, symptom diaries.
Physiological Changes Change in Temperature Change of Respiratory Rate Change in Blood Pressure Change in Pulse Rate
And…………… Observation
What other information would help? • History of pain reaction (life story) • Individual personal knowledge of patient • Disease context • Process of elimination • Validation by assess- treat – re assess • Repeat observations by multiple observers • Concept of probability
Don’t forget medication • Regular review of medication • Some tips; • Residents with dementia may require lower doses of medication • Residents with kidney or liver failure may respond differently to medication • Are all your residents medications necessary & appropriate? • When were they last reviewed? • Are they in the correct format i.e. syrup • Residents on a lot of medication may be more likely to take what is important if some of the less important drugs are discontinued
OVERLAPPING SYMPTOMS OUTCOME FOR RESIDENT; IMPROVED QUALITY OF LIFE
OTHER THINGS TO CONSIDER • PREFERRED NAME • PREFERRED LANGUAGE written & spoken • CAPACITY • ANYTHING WHICH MAY IMPAIR ASSESSMENT- hearing aid, speech, memory
ASSESSING CAPACITY- 4 TESTS • Can the client understand the information? • Can they retain the information? • Can they use or weigh up the information? • Can they communicate their decision?
A REMINDER OF THE 5 PRINCIPLES OF THE MCA • A person must be assumed to have capacity unless established otherwise • All practicable steps must be taken to allow an individual to make their own decisions • A person is able to make an unwise decision • Anything done under this act for a person who lacks capacity, must be done in their best interests • Decisions made should be as unrestrictive as possible
Tools • Which assessment tools might you use in Margaret’s case?
Assessment Tools Pain Distress Skin Breakdown=waterlow Oral Assessment HOPE- spiritual assessment
Have a go! • Abbey pain tool • Doloplus pain scale
Pain tool scenario • Pat has osteoarthritis and dementia • She cannot communicate pain verbally • She grimaces and cries out when her joints are moved and tries to prevent you touching them. This makes her flushed and warm. • She sometimes has disturbed sleep • She is not off her food • she is prescribed cocodamol as required but not regular
Pat & the Abbey pain tool • Pat scores 9 on the Abbey Pain scale- moderate pain. • On reviewing her MARS sheet she has prn cocodamol prescribed but is never offered it as she doesn’t ask for it. • You decide to give it regularly i.e. 3 times a day for the next 3 days and then review the score. You also continue to observe for any other causes of pain but decide that she exhibits the signs when her arthritic joints are being moved. • On repeating 3 days later she scores 5. • You continue with this but ask the GP to review pain relief for arthritis • You also brief the staff on the pain in Pats joints so that they treat her with care. • You set a review date to see if her score improves following any new treatment.
SPIRITUALITY & RELIGION HOW DO WE OFFER SPIRITUAL & RELIGIOUS SUPPORT TO PALLIATIVE & DYING RESIDENTS?
THE LIVERPOOL CARE PATHWAY PART 1, ASKS THAT ‘RELIGIOUS & SPIRITUAL NEEDS ARE ASSESSED.’ What is religion? What is spirituality? Is there a difference?
HOW MIGHT YOU ASSESS THE NEED FOR SPIRITUAL CARE? Is the patient agitated despite all physical needs being met? Are they afraid of falling asleep in case they don’t wake up? Are they asking questions you can’t answer?- ‘why me?’ ‘where is God? Why is he letting this happen to me?
HOPE-A SPIRITUAL ASSESSMENT H What are the persons sources of HOPEwhat are their sources of strength, meaning, and connection For example: “ What have been your sources of strength and support in life’s ups and downs?” “What do you hold onto in difficult times?” “What keeps you going?”
hOpe O Is the person or has the person been involved in Organised Religion For example “For some people their religious beliefs are a source of comfort and strengths, is that true for you?” “What beliefs are important to you?” “Do you have a connection with a church or faith group?
hoPe P What are their Personal spiritual Practices? For example “What do you like to do that lifts your spirits?” – Pray, meditate, listen to music, walk, garden, commune with nature, be with your loved ones?
hopE E What are the Effects on medical/nursing/social care? For example “Is there anything I (or someone) can do to help you find resources that help you?” “Would you find it helpful to speak to a Chaplain/faith or spiritual leader? “Do you have any spiritual or religious needs we should know of in providing care for you?” (dietary restriction, use of blood products)
WHAT CAN YOU DO TO HELP? It doesn’t have to be complicated-it’s the small things that matter Using the patients name Sitting down to listen Keep talking even if they are not conscious Privacy to be with family/friends Maintaining dignity-keeping them and their room clean & tidy Be sensitive to requests-no matter how strange- it may be their last request Ask about faith & offer a minister if appropriate Care for family/friends
Depression Depressed mood/pessimism Anhedonia-Loss of interest/apathy Poor concentration/memory/Slowed thinking Fatigue/weight loss Insomnia (early morning waking) Worthlessness/feeling a burden/Excessive guilt Helplessness/Hopelessness Suicidal ideation Symptoms present>2 weeks
Deliruium Disturbance of consciousness (reduced clarity of environmental awareness) with impaired ability to focus or shift attention. Changes in cognition (memory impairment, disorientation, language disturbances, perceptual disturbances. Disturbance evolves over a short period of time (hours/days) and fluctuates during the day. Evidence of a general medical condition judged to be related to the disturbance.
What can you do? • Being present: offering empathy, understanding, clarification of stressors, physical touch • Physical symptoms such as pain, nausea, fatigue are managed • Medication: antidepressants etc • Complementary therapies ; Relaxation, therapeutic massage
How are you going to record the plan of care? • Assessment outcome- current needs & projected needs • How will the needs be met? • How will this be measured? • How will it be shared? • How will it be recorded?
PATIENT NAME; NHS NUMBER; DOB ; DATE; CARE PLAN; The patient is approaching end of life;
End of life care Register • Change of Colour Alert Form • Name of Resident………………………………….Date………………… • Details of Change of Condition e.g. Pain, Mobility, Continence, breathing, skin condition/deterioration, breathing. • ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………… • Have the following measures been put in place? • Aircell mattress…………………………. • Dietician/S.A.L.T informed………………….. • Macmillan nurse informed…………………… • G.P. informed………………………………… • Family informed……………………………… • Care plans amended………………………….. • Funding team informed………………………. • General Manager informed…………………... • Kitchen staff informed……………………….. • L.C.P. if relevant…………………………………… • District nurses informed……………………… • All staff informed………………………………….. • OOH staff informed……………………………….. • Oral care products prescribed……………………… • If any other problems identified enter here……………………………………………………………………….………………………………………………………………………………………………………………………………………………………… • Signature of person completing form …………………………………
PUTTING THE PIECES OF THE JIGSAW TOGETHER • IDENTIFIYING DETERIORATION • HOLISTIC ASSESSMENT • SIGNPOSTING • DISCUSSIONS & DOCUMENTING WISHES • PLAN OF CARE (equipment, dnar, drugs) • RECORDING,SHARING & EVALUATING
How do we review our plans? • How do we maintain the circle of; • Assess, plan, implement, evaluate, • Time? • Place? • Staff involvement? • Other members of the MDT?
DNAR- THE PRINCIPLES • There is no need for DNAR to be discussed if it is not likely to happen • Where no explicit decision has been made in advance there should be an initial presumption in favour of CPR • Where CPR would not be successful it should not be initiated • The decision of a patient with capacity to refuse CPR should be respected • DNAR does not override clinical judgement in the event of a reversible cause • DNAR applies only to CPR and not to any other treatments • ACP & DNAR discussions are an important part of good clinical care for appropriate patients
YOUR ROLE IN THE RESUSCITATION ISSUE • To provide information to patients • To encourage dialogue • To uphold the autonomy of the patient • To encourage patients to make their own decisions • To promote the value of consent • To undertake education in the topic of DNAR orders to best support their patients
The legalities • No adult can make a decision about CPR for another adult • DNAR decisions relating to patients without capacity should be made by the most senior healthcare professional in charge of their care i.e. GP • Where CPR is clearly inappropriate, i.e. a patient in the end stage of terminal disease, but no DNAR exists, healthcare workers should be supported by their senior colleagues and employers.
