Ann Wyatt-What Does Comfort Look Like in the Nursing Home Setting?


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2014 Jewish Home Lifecare Palliative Care Conference: It's Not the Place, It's the Practice

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Ann Wyatt-What Does Comfort Look Like in the Nursing Home Setting?

  1. 1. What Does Comfort Look Like in the Nursing Home Setting? Geriatric Palliative Care Conference Jewish Home Lifecare - November 12, 2013 Ann Wyatt, Coordinator, Palliative Care Project Alzheimer’s Association, NYC chapter
  2. 2. Palliative Care for Advanced Dementia: Training and Implementation in NYC • Based on the “Comfort First” ™model developed at the Beatitudes Campus in Phoenix, Arizona and their partner, Hospice of the Valley • Three NYC nursing homes; Cobble Hill; Isabella; Jewish Home, Manhattan • Three hospice programs: Calvary; MJHS; VNSNY • 30-month project (7/1/12 through 12/31/14)
  3. 3. Training • • • • • For leadership Visit to the Beatitudes Campus For unit staff, supervisors Weekly meetings on pilot units Phone consultation; webinars; on-unit consultations; other
  4. 4. Comfort First™ refers to both specific care practices and the process by which these practices are implemented It is about listening, to residents, to families, to staff at all levels, all disciplines
  5. 5. Comfort Care Practices • Pain and Distress identified and treated • What kinds of pain are there?? – – – – – – – – – – – Injuries Old injuries (i.e., old broken bones) Arthritis Backache Wounds Constipation Headache Cramps Boredom Loneliness Despair
  6. 6. Talking About Pain • Do you have pain? • Older adults describe pain as ‘discomfort’ or ‘hurting’ or ‘aching’ or ‘sore.’ • Discomfort/pain from emotional distress, constipation, cold, hunger, and fatigue.
  7. 7. Pain and Aging • Pain is reported in 25%--50% of older persons living in the community. • Pain is reported in 45%--80% of nursing home residents. • Pain is part of normal aging, but it is not normal
  8. 8. Measuring Pain Hospitals and nursing homes commonly ask us to indicate how much pain we have by asking us to rate our pain on a scale of 1 to 10, or by pointing to a chart with faces showing emotions from happy to tearful.
  9. 9. What about Pain and the Person with Dementia? • Pain DOES negatively affect cognitive function. • Increased affective pain from differently managing everyday activities related to the diseased state. • There is no evidence that dementia results in the loss of ability to feel pain. • Tolerance to acute pain possibly increases but pain threshold does not change—people with dementia sense even low levels of pain. • Absence of vital changes in people with dementia experiencing acute pain does not mean absence of pain. • Cognitive impairment may alter response to pain therapies--people with dementia may require more analgesic use.
  10. 10. What does Pain Look Like for the Person with Dementia? Don’t assume that someone cannot explain or rate their pain. Always ask them directly if they have pain or if they are sore, ache, or hurt. However, when the person can no longer verbally express their pain but they demonstrate obvious distress, explore further the cause and manifestation of their pain. Always rule out other forms of discomfort, such as a soiled brief or an acute medical condition.
  11. 11. Pain, Discomfort and Distress Over time, people with dementia become increasingly unable to distinguish what is causing them to feel uncomfortable. This means that it is always important to pay attention any time they are uncomfortable, to take discomfort seriously, and try as hard as possible to get to the root of the discomfort.
  12. 12. “Rejection of Care” It is very common for people with dementia to convey/exhibit signs of distress when care is being provided to them. In the nursing home setting, this is known as ‘rejection of care.” In reality, usually when someone with dementia is ‘rejecting’ care, they are really saying, ‘you are upsetting me’ in some way. By rejecting your effort, they are, in fact, protecting themselves, the only way they know how.
  13. 13. Rejection of Care (continued) • Sometimes people ‘reject’ care because the caregiver is going too fast, and they don’t understand what is happening, which upsets them. • Sometimes going slow, slower, slow helps. • Sometimes, showing them what you are asking them to do helps. • Sometimes rejection of care happens because the person is hurting in some way. • Sometimes they aren’t fully awake, or they are feeling a little tense, and need to start the day in a more relaxed way.
  14. 14. Rejection of Care (continued) However, rejection of care ALWAYS means the person is feeling distressed, and it sometimes means they are in physical pain. Therefore it is essential that every effort be made to find a way to provide the care that is not distressing. As you know, the first step is to simply stop, and come back later (if slowing down doesn’t help).
  15. 15. When the person can no longer report their pain…. It can be very helpful to use a valid and reliable pain behavioral assessment tool, such as the PAINAD. Document and communicate the findings, and work with your team members (RN, family members, physician) to address the behaviors as a manifestation of pain. When in doubt, assume pain is present! Sometimes, when no other reason for distress can be found, a trial dose of pain medication can be helpful.
  16. 16. PAINAD Form • Breathing: periods of hyperventilation, noisy, labored breathing • Negative vocalization: crying, loud moaning or groaning, wails or laments • Facial expression: very distressed look on face, ay squeeze eyes shut • Body language: the person holds themselves rigidly, or pulls or pushes, hits, kicks or grabs others • Consolability: the person is visibly upset, and cannot be soothed or comforted
  17. 17. What Brings Comfort? It is as important to know what brings comfort as it is to know what causes distress: Peanut butter sandwiches, chocolate, scrambled eggs, back rubs, the color pink, Frank Sinatra, a walk down the hall, holding hands, pictures of cats, listening to a Yankee game, pictures of dogs, holding a baby doll, gospel music, bible reading, sitting on a bench outside, a chocolate lollipop
  18. 18. Pain Medications • Sometimes helpful to offer pain medications sufficiently in advance of providing care so that it is not painful for the person • Do not rely on the person to tell you when they are in pain (don’t depend on PRN) • Sometimes pain meds work for awhile, then become less effective, so a change is needed
  19. 19. Other Comfort Care Practices • Sleep, Rest, Mobility and Falls Prevention addressed • Bathing and ADL made comfortable • Diets liberalized and comforting foods always available • Small group and one-on-one activities and interactions • Calm and pleasant environment (elimination of sundowning)
  20. 20. Care Planning &Behavior as Communication Using the MDS 3.0 to Improve Care • Physical behavioral symptoms directed toward others • Verbal behavioral symptoms directed toward others • Other behavioral symptoms not directed toward others • Rejection of Care
  21. 21. How do we improve care practices? by Being Good Detectives….. • We always start by asking, what is the resident trying to tell us, what might be prompting this behavior? • Examples
  22. 22. Knowing the Resident
  23. 23. What information do we have, what information do we need, what information do we collect….
  24. 24. And, who needs to know, and how do they find out?
  25. 25. MDS 3.0—Section F Preferences for Customary Routine and Activities • Who collects this information? • How soon after the person comes to live with you? • Where is the information kept? • What do you do with the information?
  26. 26. What Do We Need? • Ongoing Dementia Training • Ongoing Dementia QAPI • Dementia training and orientation for ALL staff on unit • Regular (weekly) Interdisciplinary Meetings • Care Planning that includes CNAs • Care Plans that include comfort (and trigger) details
  27. 27. Resources • Encouraging Comfort Care (available from website, in English and Spanish) • ADvancing Care, for nursing home staff. Anyone can subscribe for free online: • Care ADvocate, for family and friends of those living in nursing homes. Also available in Spanish. Subscribe for free online: