1 / 73

Transforming End-of-Life Care in Skilled Nursing Facilities

CARE Recommendations Compassion & Respect toward the End of Life Steps and Tools to Redefine Healing and Hope in Nursing Homes. Transforming End-of-Life Care in Skilled Nursing Facilities. CARE Recommendations: Steps and Tools to Redefine Healing and Hope in Nursing Homes.

calida
Download Presentation

Transforming End-of-Life Care in Skilled Nursing Facilities

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CARE RecommendationsCompassion & Respect toward the End of LifeSteps and Tools to Redefine Healing and Hope in Nursing Homes Transforming End-of-Life Care in Skilled Nursing Facilities CARE Recommendations: Steps and Tools to Redefine Healing and Hope in Nursing Homes Aging Services May 2010

  2. Michael GuntherMaher, MD, FACP Medical Director, Hospice Kaiser-Permanente Sacramento / Roseville Bonnie Darwin Executive Director California Culture Change Coalition Aging Services May 2010

  3. Bucket List Exchange Find 1-2 persons you don’t already know Exchange names, facilities, time in this profession Share 1 thing you hope to do before you die, and why you want to do it Aging Services May 2010

  4. When it’s my turn…. Aging Services May 2010

  5. Sudden death, unexpected cause < 10%, MI, accident, etc Health Status Death Time Aging Services May 2010

  6. Steady decline, short terminal phase Aging Services May 2010

  7. Slow decline, periodic crises, sudden death Aging Services May 2010

  8. Dementia/Frailty Trajectory High Function Low Death Time Quite variable - up to 6-8 years Onset could be deficits in ADL, speech, ambulation Source: Joanne Lynne Aging Services May 2010

  9. Aging Services May 2010

  10. Dying in America 10% will die suddenly from accidents, cardiac arrest and other abrupt life-ending events 70% will die of protracted chronic illness Cancer Heart disease, lung disease Organ system failure: kidneys, liver, etc. 20% will die of progressive neurologic failure Alzheimer’s and other dementias Stroke Aging Services May 2010

  11. Where do we die? Source: Center for Gerontology and Health Care Research at Brown Medical School, Brown University. Atlas of Dying. Joan Teno, MD www.chcr.brown.edu/dying/castats.htm Aging Services May 2010 11

  12. EoL in Nursing Homes 61% of those >85 yo who are severely impaired live in NH 22% of all deaths in 2003 occurred in nursing homes 42% of NH patients were hospitalized during last month of life 67% of patients with dementia die in NH 272 days: national average LOS in NH Source: J Pall Med. 2010: Vol 13, No 2; 111-115 Aging Services May 2010 12

  13. ECHO (Extreme Care, Humane Options)Nursing Facility Recommendations 2000 ECHO LTC Task Force: health care professionals, LTC associations, state agencies and consumers “…to facilitate institutional processes, enhance provider competence and strengthen organizational relationships to improve…advance care planning…(and) palliative care services” Aging Services May 2010 13

  14. ECHO Nursing Facility Recommendations 2000 Palliative Care shares priority with restorative and supportive care Discussions about EoL care are routine Residents participate in care planning Aging Services May 2010 14

  15. ECHO Nursing Facility Recommendations 2000: How? Strategies to accomplish each outcome were articulated Tools offered in appendix Statewide dissemination process Aging Services May 2010 15

  16. How has NH quality of care evolved in 10 years? Increasing focus on the post-acute role Greater presence of medical staff Regular focus on care processes NCQI credentialing Relationships with Health Systems Prevalence of contracts for post-acute services Presence of medical and care-coordination staff Aging Services May 2010

  17. How has NH EoL care evolved in 10 years? Preferred Intensity of Treatment (PIT) forms have become standard EoL training of many NH staff ELNEC Respecting Choices curriculum Informal dissemination Increased focus on pain management Aging Services May 2010

  18. Some things have not changed in 10 years… Ever more patients will die in SNFs • Fresh from acute care, complex & dazed • Long term residents • Some admitted expressly to die there Most have complex needs for comfort • Pain and other symptoms are common • Unrecognized spiritual needs • Complex social dynamics Aging Services May 2010 18 18

  19. Not Pain… Source: The Gerontologist. 2006: Vol 46, No 3; 325-333 45-83% of NH residents have under-treated pain 26% of residents in daily pain from cancer receive no analgesics Despite increased focus, there is little evidence that this is improving Aging Services May 2010 19

  20. Not Concerns about NH Care . . . CMS OSCAR Survey data 2005 38%: quality of care 30%: dignity not respected Aging Services May 2010 20

  21. A real human being… Mrs. C is 83, caucasian Long history of heart failure, diabetes, glaucoma Widowed 4 years ago, depressed off/on since then; lives alone; a son nearby checks on her, dtr lives in Oregon Hospitalized with UTI, delirium, exacerbated heart failure Aging Services May 2010 21

  22. A real human being… Admitted to SNF for PT, IV abx Full code, no POLST done in hospital On admission son indicates “do everything”, PIT completed accordingly Aging Services May 2010 22

  23. A real human being… During first 5 days at your SNF: Poor appetite Refuses PT & OT twice Complains of pain “all over” On day 6 she becomes confused, is coughing and hypoxic Aging Services May 2010 23

  24. A real human being… She is sent 911 to the hospital Admitted for 5 days with probable aspiration pneumonia Returns to SNF with NG tube Orders include IV abx, PT DNR Aging Services May 2010 24

  25. A real human being… Physician’s assessment Probable underlying dementia High risk for future infection Poor motivation to participate in care Aging Services May 2010 25

  26. A real human being…in your SNF What strengths does your SNF bring to these problems? Where is your SNF deficient or ineffective? How hopeful are you that things could improve? How committed are you that things will improve Aging Services May 2010 26

  27. SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments “…Changes in care at the end of life are not going to happen with marginal adjustments in the way we organize services. It takes a much more sustained effort on many fronts to refocus priorities for the care of the critically ill. Changes in social norms, professional values, and social priorities all need to be part of the solution.” Joanne Lynne, PI for SUPPORT Aging Services May 2010 27 27

  28. Barriers to Quality EoL Care:Conflicted Care Plans “Don’t ask, don’t tell” re dx & prognosis “There’s always hope” despite likely outcomes Many find it difficult to forego remedial care even in the face of misery and futility Hospital personnel often don’t understand what works in the NH environment Result: care plans fail to address the likelihood of decline and the priority of comfort Aging Services May 2010 28

  29. Barriers to Quality EoL Care:Unsteady Medical Presence Patients and families still rely on doctors to give prognosis and advice Most NH staff are reluctant to give guidance unless supported by the physician NH MDs/NPs/PAs are typically over-worked and over-regulated Result: they may not be available to guide sick and frightened patients/families at EoL Aging Services May 2010 29

  30. Barriers to Quality EoL Care:Uncommitted Symptom Management “This is what the doctor ordered” “It’s not time for your next dose” Concerns about drug dependency Ignorance Indifference Poorly-evolved metrics Result: poor symptom management, lack of trust by patients and families Aging Services May 2010 30

  31. Barriers to Quality EoL Care:Cultural Forces in NH Universal cultural forces • Pervasive expectation to provide remedial care • Limited expertise in EoL care • Regulatory and licensing issues • Financial issues Peculiar / local cultural forces • Ethnic biases / preferences of staff • Patient characteristics • Partnering health plans and providers • Work environment psychology Aging Services May 2010 31 31

  32. Creating the New Paradigm for EoL Care in Nursing Homes The current health care system is perfectly poised to maintain the status quo of EoL care in nursing homes. Aging Services May 2010 32

  33. Creating the New Paradigm:Health Systems & HC Providers Move resources together with patients EoL care is the dominant need in NH Give equal priority to palliative care as well as remedial care Innovate the clinician’s role Teach, family meetings, group visits, POLST completion Aging Services May 2010 33

  34. Creating the New Paradigm:NH Nursing staff Own responsibility for pain and symptom management Initiate conversations “How is it going” Benefits of palliative care plans (even though they should have happened earlier) Re-create the NH as a place where a “good death” can be realized Aging Services May 2010 34

  35. Creating the New Paradigm:Regulatory and Legal Milieu Some regulations work against quality EoL care weight loss, failure to thrive “highest practical level of function” may also be a spiritual or psycho-social domain, not just physical Trends in “elder abuse” lawsuits promote defensiveness and a “life at all costs” approach to all NH care Aging Services May 2010

  36. We did the best we could with what we knew, and when we knew better, we did better. Maya Angelou Aging Services May 2010

  37. CARE (Compassion and Respect Towards the EoL) Recommendations: 2010 ECHO LTC Task Force reconvened 12/2008 to ask: Is the state of EoL care in NH where it needs to be? What have the ECHO LTC recommendations accomplished? Is there merit is creating updated or new recommendations, and what would be goal of doing this? Aging Services May 2010 37

  38. CARE (Compassion and Respect Towards the EoL) Recommendations: 2010 Task Force convened in 2009 CHCF provided sponsorship CCCC directed process Similar composition as ECHO LTC Task Force, some returning members Recommendations assembled during 2009 and finalized early 2010 Aging Services May 2010

  39. CARE Recommendations:Vetting Process: CCCC Partners American Association of Retired Persons (AARP) Alzheimer’s Association California Advocates for Nursing Home Reform (CANHR) Laguna Honda Hospital San Diego Hospice California Department of Veterans Affairs Woodland Healthcare Santa Clara Valley Medical Center Sutter Auburn Faith Hospital Evercare On Lok Lifeways Motion Picture & TV Fund Archstone Foundation American Medical Directors Association Aging Services May 2010

  40. CARE (Compassion and Respect Towards the EoL) Recommendations: 2010 Assumptions Science of EoL care is advanced Effective communication tools exist Legal, regulatory and financial barriers to good EoL care are largely (if incompletely) resolved Aging Services May 2010

  41. CARE (Compassion and Respect Towards the EoL) Recommendations: 2010 Approach: Build upon existing foundations Original ECHO recommendations Current NH policies & best practices Emphasize empowerment of NH-based personnel State of the Art tools, eg POLST Multi-pronged vetting and dissemination processes Aging Services May 2010

  42. CARE (Compassion and Respect Towards the EoL)Recommendations: 2010 Designed to be used by NH Staff Tips for caring for the physical, emotional, psych-social and spiritual needs Establishes processes and rituals that acknowledge the sacredness of the human spirit Creates a culture of identifying and honoring the individuals needs and preferences Aging Services May 2010

  43. CARE (Compassion and Respect Towards the EoL) Recommendations: 2010 Step 1: Advance Care Planning • Emphasizes role of NH in owning ACP • POLST • Grounded in “Person Centered” • Establishing a sense of trust through • Giving realistic information • Encouraging expression of wishes • Policies to solicit, document, and honor expressed wishes Aging Services May 2010 43

  44. CARE (Compassion and Respect Towards the EoL) Recommendations: 2010 Step 2: Common EoL Care Issues • When to perform EoL care planning • Pain and symptom management • Reducing unwanted hospitalization through • Consistent assignment of personnel • Helping families to understand and cope • Effective communication through out Aging Services May 2010

  45. Trust: the Magic ingredient Trust = Goodwill x Time* Disappointment Goodwill = Other-centeredness x Competence Competence = Expectations x Results *the only thing you don’t have control over Aging Services May 2010 45

  46. Trust: Demonstrate Competence Exceed expectations by initiating conversations about Goals Who will be accountable for this? What skills do these people need for talking with patients, families, docs? Get results Document completion: POLST, DPA Assure that patients / families get informed about prognosis, alternatives Aggressive pain & symptom relief Aging Services May 2010 46

  47. Trust: Demonstrate Other-Centeredness Be curious What’s their story? What do they know? What do they hope for? Be their partners when it comes to achieving the patient’s goals It’s your job to provide good care It’s your privilege to share life together with other human beings Aging Services May 2010 47

  48. Trust: Minimize Disappointments Take responsibility for addressing mistakes and poor results, even if it isn’t your fault Be honest about the challenges you all face in addressing complex needs Invite collaboration and accountability Physicians, NPs, pharmacists, MSWs, chaplains, ombudsman, etc. Families Aging Services May 2010 48

  49. Competent Conversations:Make them normative Assign and empower a clinical expert Expect them to happen By when? By whom? How? Expect appropriate documentation Narrative in clinician notes POLST Expect collaboration Aging Services May 2010 49

  50. Competent Conversations:Care Plans vs. Goals Goals belong to human beings, and describe what they hope for This is always contextual Care plans are created by professionals to address and respect the patient’s goals The prevalent mistake is to think that, if we have a care plan, we have enough. Aging Services May 2010 50

More Related