conf_present_002.ppt

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  • conf_present_002.ppt

    1. 1. An Innovative Educational Program toAn Innovative Educational Program to Encourage Nurses to Be More Family-Encourage Nurses to Be More Family- Centered in End-of-Life CareCentered in End-of-Life Care Connie Dahlin RN APNConnie Dahlin RN APN Adele Keeley RNAdele Keeley RN Ed Coakley RNEd Coakley RN Massachusetts General HospitalMassachusetts General Hospital Boston, MABoston, MA
    2. 2. Massachusetts General Hospital • 900 Beds (122 ICU beds) • Level I Trauma
    3. 3. MGH MICU (18 beds) • Closed ICU with ~ 60 FTE nurses • 2 ICU teams: Intensivist, fellow, HOs, students • Medical with trauma, surgical boarders • Unit-based social worker, case manager, RT, chaplain
    4. 4. BackgroundBackground • Critical care nurses attend to large numbers of dyingCritical care nurses attend to large numbers of dying patientspatients • An estimated 20% of intensive care patients in the U.S.An estimated 20% of intensive care patients in the U.S. die while hospitalized in a critical care unit.die while hospitalized in a critical care unit. • Life and death decisions have to be made quicklyLife and death decisions have to be made quickly • Many of the patients are unconsciousMany of the patients are unconscious • Discussion with patients about limitation of treatmentDiscussion with patients about limitation of treatment occurs relatively infrequentlyoccurs relatively infrequently • Do-not-resuscitate decisions are left until late in theDo-not-resuscitate decisions are left until late in the illness, just days before deathillness, just days before death • More common for patient’s families to be the decisionMore common for patient’s families to be the decision makersmakers
    5. 5. BackgroundBackground • Majority of deaths involve theMajority of deaths involve the withholding or withdrawal of multiplewithholding or withdrawal of multiple life-sustaining therapieslife-sustaining therapies • Decision making and communicationDecision making and communication about these end-of-life decisions areabout these end-of-life decisions are difficultdifficult • Understanding ICU culture is criticalUnderstanding ICU culture is critical
    6. 6. BackgroundBackground • Meta-analysis of studies of needs of ICUMeta-analysis of studies of needs of ICU family membersfamily members • 8/10 family needs related to8/10 family needs related to communication with clinicianscommunication with clinicians • Desire moreDesire more listeninglistening • Needs primarily addressed by nursesNeeds primarily addressed by nurses • Deficits in end-of-life communication skillsDeficits in end-of-life communication skills shared by nurses and physiciansshared by nurses and physicians Hickey, Heart Lung 1990; Maguire, Eur J Cancer 1996
    7. 7. BackgroundBackground • Study of outpatent MD/family meetings:Study of outpatent MD/family meetings: • MDs rarely explored patient goalsMDs rarely explored patient goals and valuesand values • Avoided discussing uncertaintyAvoided discussing uncertainty • Failed to explore reasons for choicesFailed to explore reasons for choices • Failed to discuss quality of life afterFailed to discuss quality of life after treatmenttreatment Tusky, Ann Int Med 1995
    8. 8. BackgroundBackground • Study of inpatient MD/family meetings:Study of inpatient MD/family meetings: • MDs spend 75% of time talkingMDs spend 75% of time talking • Missed important opportunities forMissed important opportunities for patients/families to discuss personalpatients/families to discuss personal values important goals of Rxvalues important goals of Rx • Majority felt they did a good jobMajority felt they did a good job Tulsky, J Gen Int Med 1995
    9. 9. RWJF Study BackgroundRWJF Study Background 1.1. Improve ICU care at end of lifeImprove ICU care at end of life 2.2. Co-PIs: Nurse and MDCo-PIs: Nurse and MD 3.3. Four sites funded. Variety of settingsFour sites funded. Variety of settings (trauma, community, city hospital, +/-(trauma, community, city hospital, +/- palliative care service, open/closedpalliative care service, open/closed units)units) 4.4. Shared home grown interventionsShared home grown interventions 5.5. For all ICU patients; not just aboutFor all ICU patients; not just about deathsdeaths
    10. 10. September2003 January2004 October2004 January2005 September2005 December2005 June2006 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Preparation Baseline Data Phase Pilot Intervention Phase Evaluate/Communicate 4` MethodsMethods and Timelineand Timeline
    11. 11. Adele Keeley Nurse DirectorAdele Keeley Nurse Director
    12. 12. Mission StatementMission Statement Based on theBased on the 5th International ConsensusInternational Consensus Conference in Critical Care: Brussels, Belgium,Conference in Critical Care: Brussels, Belgium, April 2003April 2003 • Patient and familyPatient and family are Members of the MICUare Members of the MICU TeamTeam.. • Measure success byMeasure success by patient and familypatient and family outcomesoutcomes • The attending physician is ultimately responsibleThe attending physician is ultimately responsible for the patient’s medical care in the ICUfor the patient’s medical care in the ICU Intensive Care Med. 2004
    13. 13. Mission StatementMission Statement • Both living and dying in the ICU involvesBoth living and dying in the ICU involves focusing from the very beginning onfocusing from the very beginning on comfort as well as cure. We believe thatcomfort as well as cure. We believe that palliative care must begin from thepalliative care must begin from the moment the patient and family enter ourmoment the patient and family enter our unit. Providing the best possible patient-unit. Providing the best possible patient- andand family-centered care, whether it isfamily-centered care, whether it is aimed at a “great save” or a “good death,”aimed at a “great save” or a “good death,” is our mission.is our mission.
    14. 14. Mission StatementMission Statement • The multidisciplinaryThe multidisciplinary processprocess ofof developing the statement and thedeveloping the statement and the subsequentsubsequent buy inbuy in by all the stakeby all the stake holders were important first stepsholders were important first steps
    15. 15. Family Meeting InterventionFamily Meeting Intervention • Family meetingsFamily meetings taught as a proceduretaught as a procedure • Critical Care Grand RoundsCritical Care Grand Rounds • Monthly House Officer teaching sessionsMonthly House Officer teaching sessions • Intensivist supervision and teachingIntensivist supervision and teaching • 3x5 card3x5 card • ““Guide to ICU Family Meetings”Guide to ICU Family Meetings” • ““Talking with ICU Families”Talking with ICU Families” • Nurse Champions encouraged and taughtNurse Champions encouraged and taught good meeting techniquegood meeting technique
    16. 16. • Preparation (pre-meeting) involving the full teamPreparation (pre-meeting) involving the full team • Listen and “align”–Listen and “align”– who is our patient?who is our patient? • Elicit understanding & concerns, informationElicit understanding & concerns, information preferences,preferences, then educatethen educate • Elicit patient values & goals in order to ascertainElicit patient values & goals in order to ascertain “substituted judgment”“substituted judgment” • Recommendations, not a menu for the familyRecommendations, not a menu for the family • The difficulty of prognosticationThe difficulty of prognostication • Communicate, document, reflectCommunicate, document, reflect Family Meeting TipsFamily Meeting Tips
    17. 17. Open VisitationOpen Visitation • Families welcome 24x7:Families welcome 24x7: • Initial resistance from staffInitial resistance from staff • Subsequent enthusiasm: emphasisSubsequent enthusiasm: emphasis on the patienton the patient andand family as thefamily as the focus of carefocus of care • Family involvement in bedside careFamily involvement in bedside care • Catalyst for family involvement inCatalyst for family involvement in roundsrounds
    18. 18. Palliative Care ChampionsPalliative Care Champions • 25 MICU nurses25 MICU nurses • End of Life Nursing EducationEnd of Life Nursing Education Consortium (ELNEC) trainingConsortium (ELNEC) training • Coaching and mentoring in being aCoaching and mentoring in being a change agentchange agent • Quality improvement projectsQuality improvement projects • Go-To PeopleGo-To People
    19. 19. ELNECELNEC • http://www.aacn.nche.edu/elnec/currihttp://www.aacn.nche.edu/elnec/curri culum.htmculum.htm
    20. 20. ELNEC CurriculumELNEC Curriculum • Nursing Care at the End of Life:Nursing Care at the End of Life: Overview of death and dying in America, principles and goals of hospice andOverview of death and dying in America, principles and goals of hospice and palliative care, dimensions of and barriers to quality care at EOL, concepts of suffering and healing, role of thepalliative care, dimensions of and barriers to quality care at EOL, concepts of suffering and healing, role of the nurse in EOL care.nurse in EOL care. • Pain Management:Pain Management: Definitions of pain, current status of and barriers to pain relief, components of painDefinitions of pain, current status of and barriers to pain relief, components of pain assessment, specific pharmacological, and non-pharmacological therapies including concerns for specialassessment, specific pharmacological, and non-pharmacological therapies including concerns for special populations.populations. • Symptom Management:Symptom Management: Detailed overview of symptoms commonly experienced at the EOL, and for each, theDetailed overview of symptoms commonly experienced at the EOL, and for each, the cause, impact on quality of life, assessment, and pharmacological/non-pharmacological management.cause, impact on quality of life, assessment, and pharmacological/non-pharmacological management. • Ethical/Legal Issues:Ethical/Legal Issues: Recognizing and responding to ethical dilemmas in EOL care including issues of comfort,Recognizing and responding to ethical dilemmas in EOL care including issues of comfort, consent, prolonging life, withholding treatment; euthanasia, and allocation of resources; and legal issues includingconsent, prolonging life, withholding treatment; euthanasia, and allocation of resources; and legal issues including advance care planning, advance directives, and decision making at EOL.advance care planning, advance directives, and decision making at EOL. • Cultural Considerations in EOL Care:Cultural Considerations in EOL Care: Multiple aspects of culture and belief systems, components of culturalMultiple aspects of culture and belief systems, components of cultural assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement.assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement. • Communication:Communication: Essentials of communication at EOL, attentive listening, barriers to communication, breakingEssentials of communication at EOL, attentive listening, barriers to communication, breaking bad news, and interdisciplinary collaboration.bad news, and interdisciplinary collaboration. • Grief, Loss, Bereavement:Grief, Loss, Bereavement: Stages and types of grief, grief assessment and intervention, and the nurse'sStages and types of grief, grief assessment and intervention, and the nurse's experience with loss/grief and need for support.experience with loss/grief and need for support. • Achieving Quality Care at the End of Life:Achieving Quality Care at the End of Life: Challenge for nursing in EOL care, availability and cost of EOL care,Challenge for nursing in EOL care, availability and cost of EOL care, the nurses' role in improving care systems, opportunities for growth at EOL, concepts of peaceful or "good death",the nurses' role in improving care systems, opportunities for growth at EOL, concepts of peaceful or "good death", "dying well", and dignity."dying well", and dignity. • Preparation and Care for the Time of Death:Preparation and Care for the Time of Death: Nursing care at the time of death including physical,Nursing care at the time of death including physical, psychological, and spiritual care of the patient, support of family members, the death vigil, recognizing death, andpsychological, and spiritual care of the patient, support of family members, the death vigil, recognizing death, and care after deathcare after death
    21. 21. Nursing Care at the End ofNursing Care at the End of LifeLife
    22. 22. Pain ManagementPain Management
    23. 23. Symptom Management:Symptom Management: • DeleriumDelerium
    24. 24. Ethical/Legal Issues:Ethical/Legal Issues: • Barbara HoweBarbara Howe Boston Globe, March 12, 2005 Hospital, family agree to withdraw life support
    25. 25. Cultural Considerations inCultural Considerations in EOL CareEOL Care
    26. 26. CommunicationCommunication • Clinical TimeClinical Time
    27. 27. Grief, Loss, Bereavement:Grief, Loss, Bereavement:
    28. 28. Achieving Quality Care atAchieving Quality Care at the End of Lifethe End of Life • Susan SontagSusan Sontag
    29. 29. Preparation and Care at thePreparation and Care at the Time of Death in an ICUTime of Death in an ICU Unexpected experience for manyUnexpected experience for many
    30. 30. Heard from the Champions…Heard from the Champions… ““more collaborative”more collaborative” ““more cognizant”more cognizant” ““more proactive”more proactive” ““less mystery”less mystery” ““able to articulate in a professionalable to articulate in a professional way”way” ““confident to bring up the question…”confident to bring up the question…”
    31. 31. Ethics RoundsEthics Rounds • Twice a monthTwice a month • RNs, MDs, SW, Chaplain, EthicsRNs, MDs, SW, Chaplain, Ethics Fellow, and Ethicist (Alex Cist)Fellow, and Ethicist (Alex Cist) • MICU RN Director frequently attendsMICU RN Director frequently attends • Case discussionCase discussion • Review of DeathsReview of Deaths • Encouraged by RN ChampionsEncouraged by RN Champions
    32. 32. MICU Nurse Perceptions onMICU Nurse Perceptions on the Quality of Deathsthe Quality of Deaths Nursing QODDNursing QODD Baseline vs.Baseline vs. InterventionIntervention General quality of deathGeneral quality of death ↑ ↑ ↑↑ ↑ ↑ Family relationshipFamily relationship ↑↑ Physician communicationPhysician communication ↓↓ Job satisfactionJob satisfaction ↑ ↑ ↑↑ ↑ ↑
    33. 33. Results: All MICU AdmitsResults: All MICU Admits BaselineBaseline InterventionIntervention ICU admissions (#)ICU admissions (#) 748748 735735 ICU MortalityICU Mortality 21.4%21.4% 17.1%17.1% Case Mix Index (by DRG)Case Mix Index (by DRG) 5.185.18 5.435.43 MICU/Hospital LOS (days)MICU/Hospital LOS (days) 5.7/19.75.7/19.7 5.5/18.55.5/18.5 MICU/Hospital LOSMICU/Hospital LOS (non-survivors)(non-survivors) 8.3/158.3/15 7.6/147.6/14 Mean Cost/patientMean Cost/patient $55,477$55,477 $57,958$57,958
    34. 34. Family PerceptionsFamily Perceptions Heyland FamilyHeyland Family Satisfaction QuestionnaireSatisfaction Questionnaire Baseline vs.Baseline vs. InterventionIntervention ICU experienceICU experience ↑ ↑↑ ↑ Informational needsInformational needs ↑ ↑↑ ↑ DecisionsDecisions +/-+/- Family QODDFamily QODD +/-+/-
    35. 35. What worked for usWhat worked for us 1.1. Open visiting policyOpen visiting policy 2.2. Teaching and encouraging familyTeaching and encouraging family meetings with nurses uniformlymeetings with nurses uniformly present for collaboration with MDspresent for collaboration with MDs 3.3. Educating nurses in palliative careEducating nurses in palliative care knowledge and supporting their role.knowledge and supporting their role. MGH plans to extend the interventionMGH plans to extend the intervention to other ICUsto other ICUs
    36. 36. 4.4. Ethics and multi-disciplinary roundsEthics and multi-disciplinary rounds and improved psychosocial/ spiritualand improved psychosocial/ spiritual attention toattention to selectedselected families infamilies in collaboration with palliative carecollaboration with palliative care 5.5. Family orientation materialsFamily orientation materials 6.6. ““Get to Know Me” poster - a techniqueGet to Know Me” poster - a technique that helps “humanize” the patient andthat helps “humanize” the patient and promote an alliance with the familypromote an alliance with the family What worked for usWhat worked for us
    37. 37. Lessons Learned ILessons Learned I 1.1. Need to get on the same pageNeed to get on the same page (Mission Statement). Process more(Mission Statement). Process more important than the productimportant than the product 2.2. Staff education (ELNEC) and supportStaff education (ELNEC) and support has a big payoffhas a big payoff 3.3. Teaching family meeting skills wasTeaching family meeting skills was very well received by HOs andvery well received by HOs and Fellows.Fellows.
    38. 38. Thank youThank you

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