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Palliative Care and Aging Veterans

Palliative Care and Aging Veterans. Maura Farrell Miller, PhD, ACHPN, GNP, PMHCNS, BC Director, Hospice and Palliative Care Program VA Medical Center West Palm Beach, Florida VHA ONS GEC FAC Hospice and Palliative Care. Outline. History of Palliative Care integration

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Palliative Care and Aging Veterans

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  1. Palliative Care and Aging Veterans Maura Farrell Miller, PhD, ACHPN, GNP, PMHCNS, BC Director, Hospice and Palliative Care Program VA Medical Center West Palm Beach, Florida VHA ONS GEC FAC Hospice and Palliative Care

  2. Outline • History of Palliative Care integration • Early efforts thwarted by unfunded national mandates • CELC Funding FY 9-12 • Palliative Care Consultation Teams at each VA • Staffing for Inpatient Hospice Units • “Strive for 65” Initiatives • Ongoing Palliative Care Initiatives • Quality Monitoring: Partnering with PROMISE Center • Adapting to the needs of each facility • Request for Proposals (RFP) • Expanding Palliative Care Services

  3. First things first A Definition Palliative Care

  4. Palliative Care End of Life Care

  5. Palliative Care • Both a philosophy and treatment approach, sometimes a location “palliative care unit” • Based on Patient-Centered Care • Reinforces VA “I-Care” Goals: • I-Integrity, C-Commitment, A-Advocacy, R-Respect, E-Excellence

  6. “As a nurse, we have the opportunity to heal the heart, mind, soul and body of our patients, their families and ourselves. They may forget your name, but they will never forget how you made them feel.” - Maya Angelou

  7. Palliative Care in Community Living Centers • Effective and sensitive communication • Aligning treatment with patient and family values, goals and preferences • Support to families • Assessment and management of symptoms • Beginning at the time of admission • Regardless of the patient’s prognosis • Provided by CLC Team, PCCT, or both

  8. Why do we need Palliative Care? Early 1900s: • Average life expectancy in 50s • Child mortality high • People died quickly (infections, accidents) • Elderly folks were cared for (80% died at home)

  9. Why Palliative Care continued In 2014…. • Increased life expectancy (M=73, F-79) • Greater incidence of chronic disease and “prolonged dying” seen in > 80% of elderly patients • Over 80% of older adults die in hospitals and nursing homes

  10. Who should be referred? • End-stage chronic diseases: • Pulmonary disease • Heart disease • CVA and Coma • HIV/AIDS • Cancer • Renal disease • Liver disease • ALS • Alzheimer’s disease and Related disorders

  11. “The Question” • Would I be surprised by this patient’s death within the next year?

  12. FY 2000 Inpatient Deaths by Location3 facilities with palliative care vs. national percentages

  13. Why Palliative Care is important • Untreated pain and other distressing symptoms • Failure to address patient and family social, emotional and spiritual needs • Poor communication with families • Conflict among clinicians, patients and families • Divergence of treatment goals from patient and family preferences • Use of therapies for which burdens seem to outweigh the benefits • Moral distress of clinicians (nurses)

  14. How do we achieve quality palliative care? • Consider PCCT consultations for all new CLC admissions….. • PCCT and IDT meet with Veteran and Family • Timely completion of Advance Directives • Identify Veteran preferences for care • Discussion about EOL goals • Clarify expectations patient, family, staff • Provide ongoing education and support

  15. Interventions to Consider… • PCCT Consultation Rounds • ICU Family Meetings include PCCT • Palliative Care planning • Nursing interventions: how do nursing staff demonstrate they care? • How are interventions such as providing dignity, care, compassion, and respect documented?

  16. PALLIATIVE CARE ROUNDS • Interdisciplinary • Attending Physician or NP • Other disciplines, Chaplain, RN, LPN, NA, Social Worker, Pharmacist, Music Therapist, Recreation Therapist • Invite family to participate with Veteran: we treat them both

  17. Palliative Care Plan Meetings • Interdisciplinary • Comprehensive • Diagnosis and prognosis • Goals of treatment • Veteran and family needs and preferences • Veteran and family understanding • MDS/RAI customized for palliative care

  18. Communication Challenges • Communication Skills Lab for Nurses • Dealing with Strong Emotions • Dealing with Conflict • Communication Skills for Nursing Assistants • “Using Key Words at Key Times”

  19. What are some of the problems you are experiencing? • How to relieve suffering, especially when the Veteran is actively dying in the CLC…do we transfer him to the VA hospice unit or to community hospice? • Ethical issues relating to conflicts between staff goals and the wishes of Veteran and/or family • Cultural influencesand Spiritual dilemmas • Veterans’ unresolved past grief and loss • Unresolved grief related to a previous loss may be impacting family’s coping • “Someone’s dying & I don’t know what to say” • “The family just doesn’t get it…they want everything done”

  20. Partnering with the PROMISE Center Bereaved Family PROMISE Survey Family members rate care that the Veteran received from the VA in the last month of lifeincluding communication, emotional and spiritual support, pain management and personal care needs Overall, how would you rate the care that he received in the last month of his life? Excellent Good Very Good Fair Poor

  21. It is easier to ride the horse in the direction it is going…

  22. What is important to your Team and your facility? • Veteran and Family satisfaction • Nurse satisfaction • Standardizing palliative care processes • Mortality and length of stay • Re$ourceutilization • Cultural Transformation • Other needs

  23. Nursing documentation… • Veteran and family will be educated on the following topics: • 1. Norms/routines in hospice • 2. Expected effects of meds commonly used in hospice (opioids for pain and • dyspnea), ativan (anxiety/insomnia), haldol (n/v/psychosis), atropine (death • rattle). • 3. Funeral, memorial, survivor benefits • 4. Bereavement Support • 5. Signs and symptoms of approaching death • 6. The Final Journey • 7. The Fallen Hero Star • 8. Need to update NOK/HCS contact information . • 9. RN to provide hospice admission packet, BFS PROMISE brochure, and f/u • with Veteran and family as needs change.

  24. More to consider… Education [TMS] EPEC and ELNEC for Veterans Palliative Care Nursing Assistant Training VACO Supported Continuing Education End of Life Initiative (ELI) audioconferences Annual HFA Bereavement Teleconference NHPCO “We Honor Veterans”

  25. More… Quality Improvement QUIRC Bereaved Family PROMISE Survey Patient Centered Care Committee Nursing Shared Governance Quality Council Unit based quality initiatives Community based quality initiatives (HVP)

  26. More… Certification Hospice and Palliative Care Nursing Certification APRN-RN-LPN-NA Evidence-Based Practice Integrate Palliative Care as part of your Magnet Journey toward nursing excellence!

  27. “Strive for 65” Interventions • Palliative Care Admission Package • Foster Good Impressions • Using Key Words at Key Times • Comfort Care Order Set • Decedent Affairs as member of PCCT • Patient Centered Care: Defining Excellence using PROMISE

  28. “Strive for 65” Best Practices

  29. PCCT models expand to meet Veteran need… • Palliative Care CBOC Clinics via CVT • PACT-CCHT-PCCT • PACT-PALLIATIVE CARE CLINICS • PALLIATIVE CARE SPECIALTY CLINICS: Pulmonary/Oncology/Cardiac/Renal/Neuro

  30. EMERGENCY RESUSCITATION STATUS: Do Not Resuscitate (DNR): no CPR, no BCLS/ACLS, other limitations of care: PALLIATIVE CARE 1. Continue palliative care in the CLC. 2. no artificial hydration/nutrition to prolong life (no ng, peg, iv fluids) 3. no lab work or diagnostic testing 4. if I become ill, do not move my room or hospitalize me, treat me in the CLC 5. oral antibiotics are ok, swallowing pills are not difficult for me 6. my comfort, dignity, and quality of life are my priorities DIAGNOSIS: Multiple Sclerosis, weight loss, renal failure, protein-calorie malnutrition, decubitus ulcers. PROGNOSIS: Poor. The patient is capable of understanding and making an informed judgment in this matter. Diagnosis, prognosis and treatment options have been discussed with: patient. Treatment preferences as expressed by the patient are to be implemented. The patient does have an advance directive and the advance directive has been reviewed by me.

  31. Hospice and Palliative Care Teams

  32. Staff Resiliency: the Freedom North Lakeside Garden provides a healing place for residents and staff to be with nature

  33. It is my honor to serve Veterans and NOVA. Thank you!Questions?

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