Mary Ersek-Nursing Home-Based Palliative Care: Empowering Nurses as IDT Team Leaders
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Mary Ersek-Nursing Home-Based Palliative Care: Empowering Nurses as IDT Team Leaders



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

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



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Mary Ersek-Nursing Home-Based Palliative Care: Empowering Nurses as IDT Team Leaders Mary Ersek-Nursing Home-Based Palliative Care: Empowering Nurses as IDT Team Leaders Presentation Transcript

  • Jewish Home Lifecare 11th Annual Geriatric Palliative Care Conference, November 12, 2013 Mary Ersek, PhD, RN, FAAN Philadelphia VAMC University of Pennsylvania School of Nursing
  • Describe the growing need for integrating palliative care into nursing homes. Describe the role of nursing in palliative care. Describe strategies to prepare nursing staff for delivering palliative care and in leading palliative care practices.
  • Between 1.5–1.8 million people live in US nursing homes (NHs) Kaye et al, Health Affairs, 2010 By 2050, more than 3 million people are expected to spend time in a NH Kaye et al, 2010 28% of persons ≥ 65 years died in a NH in 2007 CDC NCHS, 2010 Nearly 70% of persons with advanced dementia die in a NH Mitchell et al, JAGS, 2005
  • Over half are totally dependent or need extensive assistance with bathing, dressing, toileting, and transferring 67% of nursing home residents are female 64.8% have moderate to severe cognitive impairment 78.9% are non-Hispanic White 15.3% reported moderate to severe pain (last 5 days) 35.6% incontinent of bowel and/or bladder 25.5% received antipsychotic medication (last 7 days) Average length of stay ≈ 2 years Nursing Home Data Compendium, 2012 Edition
  • Nursing Assistants Licensed nursing staff (RNs and LPNs) Medication and Treatment nurses Unit manager Care manager MDS Coordinator Staff educator Quality Improvement Director Assistant Director of Nursing Director of Nursing/Clinical Services Nurse Practitioners
  • Identifying and documenting goals of care Facilitating completion of advance directives Assessing and managing symptoms Facilitating life closure Offer grief and bereavement support Decreasing burdensome transitions Maximizing human dignity
  • 1. Hospice 2. External palliative care teams 3. Internal palliative care teams/units
  • Education Knowledge Attitudes Policies: development and implementation Teams Role modeling Quality improvement – monitoring progress
  • License nursing staff, certified nursing assistants, activities director, etc. Self-assessment Supervisor assessment Knowledge assessment
  • Internal Teams Principles of palliative care Hospice 101 Pain and symptom management Communication with residents and families Goals of care/Advance directives/POLST Ethical issues Cultural and spiritual issues Loss, grief and bereavement Care for imminently dying Quality improvement External Teams (including hospice) Nursing home history Nursing home culture Work teams and organization Staff as family Central role of CNAs Family involvement Nursing home regulations Nursing home trends Dementia care Geriatrics Respect for NH work and staff
  • EOL/Palliative Educational Resource Center (EPERC), Advancing Excellence, Geriatric Pain, Prepare for Your Care,
  • “No complaints of pain” “That’s the way she always is…” “Of course she’s in pain…she’s 92, what do you expect?”
  • Policies and procedures: Symptom assessment & management Policies and procedures: Advanced directives, assessing capacity Policies and procedures: Management of acute conditions
  • Demonstrates knowledge of pain assessment techniques Re-evaluates pain following pain medications and nondrug pain intervention Advocates for residents experiencing pain Role models best practices for pain assessment Consistently observes and reports to the nurse residents’ reports of pain and/or pain-related behaviors Solicits all team members’ evaluations of residents’ pain.
  • Quality improvement team Training team Pain management team Goals of care team Transitions team
  • Ask about a residents’ comfort level Report a resident’s concerns to the nurse Advocate for a resident Communicate respectfully Keep families informed
  • RN/LPN Nurse practitioner Nursing assistants DON/Admin RESIDENTS Physician Non-nursing staff Family
  • Structure Process Outcome
  • Structure: Policies - symptom assessment & management, advance directives Protocols for managing acute conditions to avoid hospitalizations Process: Documentation of pain management plan and f/u Documentation of AD Outcomes: Resident symptoms (chart/MDS) Care matches preferences Bereaved Family Perceptions of Care at EOL Hospitalizations, ER visits Staff satisfaction, staff turnover
  • MDS: Symptoms: Pain, dyspnea; Depressive symptoms (PHQ-9) Feeding tubes Hospice Quality indicators Percent of Residents who Self-Report Moderate to Severe Pain (Short and Long Stay) Percent of Residents Who Have Depressive Symptoms (Long Stay) F-tag 309 – Pain and End-of-life Care