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Long Term Care Administration

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  1. Long Term Care Administration Thursday, March 19, 2009 Week 11 - Chapter 15 End-of-Life Issues Home and Community Care

  2. End-of-Life Issues “But in this world nothing can be said to be certain, except death and taxes.” Benjamin Franklin Home and Community Care

  3. End-of-Life Issues • There are two certainties in life – death and taxes. • Little progress has been made identifying and addressing end-of-life issues. Grand Solutions – those which address all people equally through a narrowly focused policy or single program. • Death and dying – one size does not fit all. Home and Community Care

  4. “To the well-organized mind, death is but the next great adventure.” J.K. Rowling Home and Community Care

  5. End-of-Life Issues One Size Does Not Fit All • Complex, ever changing interplay of culturally based traditions • Socially and family defined values • Individual interests and perspectives • Health care developments • Considerable number of other factors that influence on human needs and expectations Home and Community Care

  6. “As a well-spent day brings happy sleep, so life well used brings happy death.” Leondardo da Vinci Home and Community Care

  7. End-of-Life Issues Where Does Death and Dying Occur (based on death certificate data) • 71.2% of deaths occur in hospitals (1998). • 3.2% of deaths in other institutions. • 21.8% of deaths in other places. • 3.9% of deaths unknown or missing. Home and Community Care

  8. “Death ends a life, not a relationship.” Mitch Albom Home and Community Care

  9. End-of-Life Issues Hospital-Based Care • Aggressive but futile diagnostic and cure-oriented treatment in hospitals. • Public fear aggressive treatment. • Fear of hospital MDs making decisions. • Fear of life supporting treatment even when there is no hope of recovery. • Advances in medical technology. Home and Community Care

  10. “Death doesn’t really worry me that much, I’m not frightened about it… I just don’t want to be there when it happens.” Woody Allen Home and Community Care

  11. End-of-Life Issues Cardiopulmonary Resuscitation (CPR) • Under 3% of patients receive CPR who died in a hospital. • CPR provided for unexpected deaths. • Do Not Resuscitate Order (DNR) is an advance directive. Home and Community Care

  12. End-of-Life Issues “For three days after death hair and fingernails continue to grow, bit phone calls taper off.” Johnny Carson Home and Community Care

  13. End-of-Life Issues Distributive Justice – Use Scarce Resources • Scarce and expensive hospital resources for care, could be used elsewhere. • Dying people need nursing care which can be provided in home or long term care facilities which are less expensive. • Slow death trajectories, alternates to hospitals care can be more easily arranged. Home and Community Care

  14. End-of-Life Issues “I have lost friends, some by death… other through sheer inability to cross the street” Virginia Woolf Home and Community Care

  15. End-of-Life Issues California Daughter Syndrome • Some children, who have not seen their parents for months or years and thus do not realize or have not come to terms with the fact that death was inevitably near. • Children in this situation may insist on all possible treatment despite the existence of an advance directive. Home and Community Care

  16. End-of-Life Issues “I’m completely in favour of the separation of Church and State. My idea is that these two institutions screw up enough on their own, so both of them together is certain death.” George Carlin Home and Community Care

  17. End-of-Life Issues Decision Making – Can be regretted later • Withdrawing life support perceived as euthanasia – actively ending a life. • Withholding treatment perceived as letting nature takes its course. • Most family members are unaware of the care preferences of their loved ones. • Most deaths in Canada after a long life. Home and Community Care

  18. End-of-Life Issues “Sleep, those little slices of death; Oh how I loathe them.” Edgar Allan Poe Home and Community Care

  19. End-of-Life Issues Who Dies • Gradual increase in the average age at the time of death. Two main contributing factors. • Major reduction in infant mortality. • Increasing proportion of seniors who reach an advanced old age. Home and Community Care

  20. End-of-Life Issues “Animals have these advantages over man: they never hear the clock strike, they die without any idea of death, they have no theologians to instruct them, their last moments are not disturbed by unwelcome and unpleasant ceremonies, their funeral cost them nothing, and no one starts lawsuits over their wills.” Voltaire Home and Community Care

  21. End-of-Life Issues Some Statistics • 41.9% 80 years and older. • 12.3% 90 years and older. • 12% of seniors served by home care. • 5-7% of seniors reside in institutions. • 84.2 average age of death in LTCF. • 73.2 average age of death in Hospitals. Home and Community Care

  22. End-of-Life Issues “We believe that an informed citizenry will act for life and not for death.” Albert Einstein Home and Community Care

  23. End-of-Life Issues • LTCF end-of-life care more likely for widowed persons. • Married people more likely to receive short term end-of-life care in hospitals. • Average stay in a LTCF is 3-4 years. • More females than males died in LTCF and more males than females died in hospitals. Home and Community Care

  24. End-of-Life Issues “A single death is a tragedy; a million deaths is a statistic.” Joseph Stalin Home and Community Care

  25. End-of-Life Issues Why do Canadians Die? • 999 different causes of death • 36.3% Cardiovascular Disorders • 27.8% Cancer • 11.1% other causes • 10% respiratory disorders • 6.1% injuries and suicides Home and Community Care

  26. End-of-Life Issues “A nation or civilization that continues to produce soft-minded men purchases its own spiritual death on an installment plan.” Martin Luther King Jr. Home and Community Care

  27. End-of-Life Issues When Does Death and Dying Occur? • Two times as many deaths in the winter as in the summer. • Winter-time flu, colds, falls related to winter conditions. • Some people hold on to life until an important social event passes. • Little research in this area. Home and Community Care

  28. End-of-Life Issues “I wish to be cremated. One tenth of my ashes shall be given to my agent, as written in our contract.” Groucho Marx Home and Community Care

  29. End-of-Life Issues What Also Influences Death and Dying? • Long life expectation amongst Canadians. • Premature death prevented in most cases. • Gene therapy, advances in health care technology, and drug advances promise to prevent or abate illness. • Health care utilization and costs increases, lead to health care system unsustainability Home and Community Care

  30. “The valuing or sanctity of life is considered one of the prime values underlying Western society” Beauchamp and Childress Home and Community Care

  31. End-of-Life Issues Fears about Death and Dying • Painful, drawn-out process, dependency • Uncertainty of what comes next • Irreversibility or finality of death • Emotional, physical, & financial impact on loved ones Home and Community Care

  32. End-of-Life Issues “It is the unknown we fear when we look upon death and darkness, nothing more.” J.K. Rowling Home and Community Care

  33. End-of-Life Issues Societal Value of Life - Taxes pay to preserve and sustain life • Rescuers risk their life to save another. • Safe air & ground transportation. • Safe hospitals and medications. • Seatbelt laws, non smoking laws. • Hospitals funded better than LTCF Home and Community Care

  34. End-of-Life Issues “Healthy children will not fear life if their elders have integrity enough not to fear death.” Erik H. Erikson Home and Community Care

  35. End-of-Life Issues Safe Society • Most Canadians don’t think about a premature death. • Small proportion of people sign an organ donation card. • 50% have a will for estate planning. • Fewer have an advance directive. Home and Community Care

  36. End-of-Life Issues “I'd rather die while I'm living then live while I'm dead.” Jimmy Buffet Home and Community Care

  37. End-of-Life Issues • Nurses, physicians, clergy, bereavement counsellors, funeral directors have taken over the role of family members. • Palliative care is a noncurative, comfort-oriented care provided to dying persons and their families. • Palliative care = good, healthy death. • Death = tragedy, not ordinary experience. Home and Community Care

  38. End-of-Life Issues “In the stars is written the death of every man.” Geoffrey Chaucer Home and Community Care

  39. End-of-Life Issues Ageism • Death is viewed negatively in C’dn Society • Death is an event of old age. • Death of an older person is a tragedy for the family, for a younger person to die it is a tragedy for society. • Older people are often considered a burden on their family and society Home and Community Care

  40. End-of-Life Issues “It's funny the way most people love the dead. Once you are dead, you are made for life.” Jimi Hendrix Home and Community Care

  41. End-of-Life Issues Assisted Suicide and Euthanasia • Bob Latimer and Sue Rodriguez to high profile cases in Canada – not legal. • Legalized in other jurisdictions such as Holland, Oregon. • An aged society can expect to have different values and customs than a more youth-oriented one. Home and Community Care

  42. End-of-Life Issues “A beautiful death is for people who have lived like animals to die like angels.” Mother Teresa Home and Community Care

  43. End-of-Life Issues Options for End-of-Life Care • Aggressive or non aggressive care. • Choice of care setting when dying. • Choice of caregivers – formal or informal. • Assistance in ending life or not. • People differ in their preferences. Home and Community Care

  44. End-of-Life Issues "Look, I don't want to wax philosophic, but I will say that if you're alive you've got to flap your arms and legs, you've got to jump around a lot, for life is the very opposite of death, and therefore you must at very least think noisy and colourfully, or you're not alive." Mel Brooks Home and Community Care

  45. End-of-Life Issues • Dying people are physically, mentally, emotionally dependent on others. • Average end-of-life hospital stay 21 days. • Dying patients can feed, bathe and speak for themselves until near the end. • Dying in LTCF are dependent on others for months and sometime years. • Resources are limited, few options exist. Home and Community Care

  46. I answer the heroic question "Death, where is they sting?" with "It is here in my heart and mind and memories." Maya Angelou Home and Community Care

  47. End-of-Life Issues Palliative Care • Community based programs increasing. • Shrinking number of hospital beds. • Started in Canada in the mid 1970s. • Has competed unsuccessfully for hospital resources – hospitals diagnose and cure. Home and Community Care

  48. End-of-Life Issues "I am ready to meet my maker, but whether my maker is prepared for the great ordeal of meeting me is another matter." Winston Churchill Home and Community Care

  49. Preparing for the End-of-Life DNR • Most LTCF have DNR policies. • Policies have developed on transfer to a hospital, the initiation of antibiotics and other potentially life-prolonging medications. • Policies around living wills. Home and Community Care

  50. End-of-Life Issues “People say satire is dead. It's not dead. It's alive and living in the White House.” Robin Williams Home and Community Care