When People Are Dying: Palliative Care

1. When People Are Dying: Palliative Care Originally by: Pamela Parrish, RN, CHPN Clinical Consultant School of Nursing, University of Pennsylvania Diane Stillman, MSN, RN, CS School of Nursing, University of Pennsylvania Neville Strumpf, PhD, RN, C, FAAN Edith Clemmer Steinbright Professor in Gerontology Director, Center for Gerontologic Nursing Science and Hartford Center of Geriatric Nursing Excellence Rewritten in 2012 by: Rebecca Trotta, PhD, RN Hospital of the University of Pennsylvania

2. Introduction • The U.S. population is rapidly aging • Many people who live in a long-term care setting will die there • The long-term care setting is an excellent one for palliative care

3. Objectives • Understand the principles of palliative care • Understand importance of establishing goals of care • Describe common physical and psychological symptoms at end-of-life and ways to address them using a palliative care approach • Describe ways to recognize the final hours and how best to support resident, family and staff, including spiritual and cultural considerations

4. What is Palliative Care? • WHO definition • Different from traditional care • Different from hospice • A philosophy of care….

5. Who Benefits from Palliative Care? • Residents • Family • Staff

6. Who Provides Palliative Care? • A team approach is best • Anyone involved in the resident’s care can provide some aspect of palliative care

7. Who Provides Palliative Care? • Nurse • Nursing Assistant • Physician • Social Worker • Dietitian • Chaplain • Physical/Occupational Therapist • Recreation Therapist

8. Developing a Palliative Plan of Care • Agreed to by all members of interdisciplinary team • Propelled by nursing • Addresses the following: • Goals of Care • Physical Symptoms • Psychological Symptoms • Spiritual Needs • Family Needs and Concerns • Liberalized Restrictions

9. Goals of Care • Hold family meeting with interdisciplinary care team • Clarify that palliative care does not mean withdrawing care • Focus on what will be done, not what will be removed • Complete advance directives • Know various types • Understand that family may be overwhelmed • Frame plan to meet goals of care • Revisit plan frequently with team, including family

10. Symptoms at End-of-Life • Pain • Common, complex • Respiratory Symptoms • Shortness of breath, coughing, wheezing • Gastrointestinal Symptoms • Nausea, constipation • Psychological Symptoms • Depression, delirium, anxiety

11. Interventions • Around the clock vs. PRN medications, especially for pain • Oxygen, nebulizers, diuretics, antitussive w. codeine, prednisone • Anti-nausea medications, gentle bowel stimulants • Anti-depressants, anxiolytics • Non-pharmacological therapies

12. Addressing Spiritual Needs • Don’t wait until the last minute! • Offer religious music and/or icons • Arrange visit from religious leader • Facilitate rituals • Assist with funeral arrangements

13. Cultural Considerations • Everyone has one or more cultures • Race, ethnicity, religion, lifestyle contribute to culture • Culture • Is manifested through values, customs, behaviors & beliefs • Affects decision-making and views re: death and dying and palliative care

14. Preserving Personhood and Dignity • Cleanliness and odor control • Bathing and grooming • Face, hands, and feet • Mouth care, nail care • Clothing and bedding • Promote home-like environment • Pictures, bedding, personal items

15. Final Hours • Common symptoms are distressing • Pain, noisy breathing • Attend to symptoms and hygiene • Limit/withhold food and fluid intake • Maintain personhood • Talk to resident

16. Supporting the Family • Address questions • Provide information • Give suggestions on how to support resident • Offer comforting items • Chairs, tissues, drinks • Offer interdisciplinary support • Social work, chaplain

17. Can You Now… • Understand the principles of palliative care • Understand importance of establishing goals of care • Describe common physical and psychological symptoms at end-of-life and ways to address them using a palliative care approach • Describe ways to recognize the final hours and how best to support resident, family and staff, including spiritual and cultural considerations