Amanda Pate Project Proposal for Care Bag

Cancer Treatment Centers of America
Amanda Pate, BSN, RN
Proposal for Care Bag
We understand death for the first time when
he puts his hand upon one whom we love.
— Madame deStael (1766-1817)

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I. SUMMARY ................................................................................................................4
II. BACKGROUND ..........................................................................................................5
III. OTHER EVIDENCE/STORIES.......................................................................................6
IV. ITEMS POSSIBLY PLACED IN THE BAG......................................................................8
V. NEEDS/PROBLEMS ....................................................................................................9
VI. GOALS/OBJECTIVES ..................................................................................................9
VII. PROCEDURES/SCOPE OF WORK...............................................................................10
Other risk factors/predictors of short-mediumterm death............................................................11
Evidence of frailty: 2 or more of these:....................................................................................12
VIII. TIMETABLE.............................................................................................................15
IX. BUDGET ..................................................................................................................15
X. KEY PERSONNEL.....................................................................................................16
XI. EVALUATION..........................................................................................................16
XII. ENDORSEMENTS .....................................................................................................17
XIII. NEXT STEPS ............................................................................................................17
XIV. APPENDIX ...............................................................................................................18

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I. Summary
I am currently pursuing my Master's degree in nursing and of course this requires
research and lots of it. While looking for some evidence based information on a separate
subject I ran across an article that states families at times need a transition item to help
with the adjustment of losing a loved one. A blanket was used in the experiment and the
families seemed to better cope with the loss verses those who did not receive a
transitional item. So this made me think, why do we not have something like that here?
We give the care that never quits! It shouldn't quit because the patient has passed.....
This program will begin on the inpatient unit and once the patient is approved to
be in the program we will give the patient and their family a "care bag" which is a canvas
bag with a blanket inside and a few other items such as lotions, information on grief,
information on counseling, tissues, notepad and pen, and a card which we will remove
before giving to the family and have all staff on the floor sign. We will send the card after
the patient's passing to his or her address and address it "to the family of" the patient. The
lotion will be for the family to rub the patient as he or she is passing so that the
helplessness that is many times felt may be lessened and possibly the patient will feel
more relaxed. The pad and pen is for anything that needs to be written down and may be
forgotten due to the stress of having just lost a loved one. Finally the blanket is something
that the family is able to cover the patient with and then take with them as a transition
item after the patient's passing.
 The patient must be actively dying and meet the criteria set forth later in this
proposal.
 Evidence shows that a transitional item helps family members transition into a life
without their loved one.
 Most of the items will be donated.
 Bags will be donated by CTCA with our name on it.
 Our chaplains will be asked to provide information on grief.

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 Our care managers led by Roxanne Mcintyre, mind and body team and spiritual
team will be asked to provide information on local counseling to include in the bag for
the family.
 Our discharge planners will also be included due to a need for referral to hospice.
 Our pastoral care team led by Chip Gordon will be asked to provide spiritual
guidance for our patient and their family.
 Growth, led by Nina Dobbs, will also be included for the marketing and public
relations aspect of the program.
II. Background
As we know our goal is cure and we provide hope to our patients and their
families but unfortunately at times we try with everything we have but there are other
plans for that patient and they must leave their families to "go home". I would like to
begin a program here for those patient's families to help them with the transition of life
without their loved one. Here a little background of how the idea was born and more
information on the program:
I have personally had this experience when my father passed away this past May
from lung CA. I mentioned this idea to him and he loved it. When he was told he had
lung cancer and decided to receive chemo I went to the store and bought him a blanket,
some comfortable clothing, snacks, juices, etc. and placed it all along with his kindle in a
cloth bag I had at my home. We called this his chemo bag. I always took him to his
chemo appointments and would ask every time if he wanted his blanket to cover up and
every time he would say "nope, they will give me one." He never would use that darn
blanket!
On the day of his death, as always my mother asked what she could fix him to eat
and he said nothing. She asked him if he wanted anything and he said "yes, bring me my
blanket". Of course she had no idea what he meant because he never used it, until he said
it was in his "chemo bag". She retrieved it for him and he covered up with it all that day.
When I arrived at my mother's and father's house after my husband came to my work tell

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me my father had passed away and I saw that blanket lying next to him and knew that he
did that for me. I cherish that blanket and it has helped me greatly to deal with his death a
little better. I wrap it tightly around me when I start to really miss him. It is as if he is
hugging me tightly.
III. Other Evidence/Stories
I recently had a patient that I believed his wife would benefit from this. I stopped
on my way to work and purchased a blanket from our gift shop. Unfortunately when I
arrived he was already gone and she had already left the building. I found her address and
mailed her the blanket. She sent me a message a few weeks later and told me that she
wanted many times to say thank you but had been unable to because of sadness. She told
me that the blanket helped her tremendously and that day was actually their wedding
anniversary. She said when she wrapped it around her it was as if he was giving her a
huge hug which made her feel closer to him. Of course it is not about the blanket so much
as it is about the need for a human connection.
There are so many uplifting stories to tell concerning this type of program: “One
of our volunteers comes in every Wednesday at 1 p.m.; she visited with an elderly
woman, her son and daughter. The woman seemed alert, but very ill. After talking with
the family, the volunteer decided she’d appreciate having a prayer shawl from the cart
and read the accompanying note: ‘This shawl was crafted with prayers for your healing
body, mind and spirit. As you wear this shawl, may you feel the divine warm embrace.’
The woman, even though frail, reached for the shawl and quickly wrapped it tightly
around her. One week later, the volunteer returned. This time the woman was very quiet
and uncommunicative. She learned from the family that she hadn’t taken the shawl off.”
She passed away the following day and the family knew how much the shawl meant to
her so in turn it meant so much to them.
“Consider the case of Tom Stephens, a man in his 50s who suffered a rupture of
an aneurysm of the aorta. By the time he arrived at the hospital, Mr. Stephens had nearly
bled to death. Although the physicians and nurses involved in his care did everything
right, including replacing lost blood and repairing the tear in his aorta, he suffered severe

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brain damage. For almost two weeks, he lingered in a coma, suffering respiratory failure
and other medical complications.”
During this time his family had great hope that he would recover. Sadly he was
not going to recover so the family decided to focus on his comfort until the end of his life
verses trying to prolong his life. This was found in a new kind of cart that is being
implemented at a number of hospitals across the country: the comfort cart. (Gunderman,
2012) Unlike the crash cart, it does not contain a cardiac defibrillator, endotracheal tubes,
or powerful medications such as epinephrine and dopamine. Instead it contains much
lower-tech but nonetheless powerful items, including music, scriptures in various faith
traditions, and a variety of homemade “love” blankets. For the patient’s family, it also
includes information on grief, the dying process, and lists of area support groups, funeral
homes, and community assistance programs for burial. Finally, it contains a plaster kit for
making a cast of the dying patient’s hand.
Mr. Stephens’ boys both got to pick out a blanket. Each of his sons could keep his
dad warm while he was dying and also help to inject some warmth into the otherwise
cold and impersonal process of dying in the hospital. After their father was gone, they
could take it home with them, keeping it in their room, or perhaps even using it on their
own bed. (Caring, 2015) Such blankets help to create a sense of community around dying
patients and their families. . The blanket becomes what psychologists and anthropologists
sometimes refer to as a “transitional object,” providing something to cling to throughout
the dying process, the funeral, and after. They help to create a caring atmosphere that
lives on in memory long after the patient is gone.

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IV. Items possibly placed in the bag
 Information on grief
 Information on counseling
 Condolence card (To be taken out and mailed at a later time)
 “In Memory of” label to be included in the condolence card for the blanket
 Tissues
 Music and nature sounds CDs
 Guided imagery and relaxation tapes
 Soft blankets
 Crossword and Sudoku puzzles
 Lavender-scented eye packs
 Prayer shawls and beads
 Books
 Battery-operated candles
 Combs/Brushes
 Soothing creams and lotions
 Hope Stones
 Spiral notebooks for journaling

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V. Needs/Problems
Our patients receive wonderful care while here with us at Cancer Treatment
Centers of America and we offer the care that never quits. However, if the patient is not
able to beat the cancer they are fighting our care should not stop there. This is where the
care bag can help. As the patient is actively passing we are supporting the patient and the
family with this program. After the patient passes we are supporting the family by
helping with grief counseling and reminding them we still care by sending the
condolence card that will be included with the care package.
 CTCA can show our families that our care truly never quits.
 This program is in the infant stage and may have rough ends to smooth out.
 We can show our community we care also by informing the local newspapers
through growth.
 The leaders of each department will need to be committed to working on this
project in order to make this program a success. Leaders such as Chip
Gordon, Lakeisha Henderson, Kim Dunn, Roxanne McIntyre, and Nina
Dobbs, along with all other leaders of the departments here at CTCA.
VI. Goals/Objectives
 Provide grief counseling for our patient’s families.
 Working with upper management in order to smooth out any issues that may
arise.
 Ensure condolence cards are signed by all staff possible, in memory of label
included and sent out to the family of.
 Inform our local newspapers of this new program.
 Show our patients and their families that our care really never quits.
 Increase patient/family satisfaction.

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VII. Procedures/Scope of Work
 The program will begin with collection of all required items to prepare the bags
which is currently underway. A team has been put into place to help the beginning
management of the program and will continue to manage with the future growth
of the program.
 The nurses will be taught to use a calculator for identifying how close death
possibly is. The program for the calculator will be discussed further on in this
proposal.
 The primary nurses will be taught to request the bag once it is imminent that the
patient is going to pass.
 The charge nurse or house supervisor will issue the bag for the family removing
the condolence card before it is given to the family.
 Some of the physical signs that a person is about to pass are:
 Shortness of breath
 Depression
 Anxiety
 Tiredness and sleepiness
 Mental confusion
 Constipation or incontinence
 Nausea
 Refusal to eat or drink
According to research that was published in the British Medical Journal there are
twenty-nine items that can determine when a patient is close to death. The name of this
list is Critera for Screening and Triaging to Appropriate aLternative care, or CriSTAL for
short. The proposed components that make up the 'The Critera for Screening and

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Triaging to Appropriate aLternative care, or CriSTAL to identify end-of-life status before
hospital admission are listed below. (Cardona-Morrell, 2015)
 Age ≥65 AND admitted via emergency this hospitalization (associated with 25%
mortality within 1 year)
 Decreased LOC: Glasgow Coma Score change >2 or AVPU=P or U
 Systolic blood pressure <90 mm Hg
 Respiratory rate <5 or >30
 Hypoglycemia: BGL
 Repeat or prolonged seizures
 Low urinary output (<15 mL/h or <0.5 mL/kg/h)
 OR MEW (modified early warning) or SEWS score >
 Pulse rate <40 or >140
 Need for oxygen therapy or known oxygen saturation <90%
Other risk factors/predictors of short-medium term death
Personal history of active disease (at least one of):
 Advanced malignancy
 Chronic kidney disease
 Chronic heart failure,
 Chronic obstructive pulmonary disease
 New cerebrovascular disease
 Myocardial infarction
 Moderate/severe liver disease
 Evidence of cognitive impairment (eg, long-term mental disorders, dementia,
behavioral alterations or disability from stroke)
 Length of stay before this RRT call (>5 days predicts 1-year mortality)
 Previous hospitalization in past year10
 Repeat ICU admission at this or previous hospitalization (associated with a
fourfold increase in mortality)

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Evidence of frailty: 2 or more of these:
 Unintentional or unexplained weight loss (10 lbs in past year)
 Self-reported exhaustion (felt that everything was an effort or felt could not get
going at least 3 days in the past week)
 Weakness (low grip strength for writing or handling small objects, difficulty or
inability to lift heavy objects ≥4.5 kg)
 Slow walking speed (walks 4.5 m in >7 s)
 Inability for physical activity or new inability to stand
 Nursing home resident/in supported accommodation
 Proteinuria on a spot urine sample: positive marker for chronic kidney disease &
predictor of mortality: >30 mg albumin/g creatinine
 Abnormal ECG (Atrial fibrillation, tachycardia, any other abnormal rhythm or ≥5
ectopics/min, Changes to Q or ST waves.
Each of these symptoms, taken alone, is not a sign that someone is dying.
But, for someone with a serious illness or declining health, these might suggest that that
person is nearing the end of life. In addition, closer to death, the hands, arms, feet, or legs
may be cool to the touch. Some parts of the body may become darker or blue-colored.
Breathing and heart rates may slow. Some people hear a death rattle. (NIA, 2014)
Hospital mortality may be calculated using the following equation:
logit=−7.7631+0.0737∗Score+0.9971∗ln(Score+1)Mortality=elogit1+elogit
In order to make things easier, we will use the Simplified Acute Physiology Score
(SAPS II) Calculator that is based on seventeen factors to determine a score for the
possibility of demise. This platform was developed by Le Gall, Lemeshow, Saulnier in
1993 thus making this program the most current evidence based over the previous
mortality score APACHE II.
SAPS II was designed to measure the severity of disease for patients admitted
to Intensive care units aged 15 or more. We will be using SAPS II throughout the
inpatient units. Twenty four hours after admission, the measurement has been completed
and resulted in an integer point score between 0 and 163 and a predicted mortality

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between 0% and 100%. No new score can be calculated during the stay. If a patient is
discharged from the hospital and readmitted, a new SAPS II score can then be calculated.
The point score is calculated from 12 routine physiological measurements during
the first 24 hours, information about previous health status and some information
obtained at admission.
The parameters are:
 Age
 Heart Rate
 Systolic Blood Pressure
 Temperature
 Glasgow Coma Scale
 Mechanical Ventilation or CPAP
 PaO2
 FiO2
 Urine Output
 Blood Urea Nitrogen
 Sodium
 Potassium
 Bicarbonate
 Bilirubin
 White Blood Cell
 Chronic diseases
 Type of admission
In contrast to APACHE II, the resulting value is much better at comparing patients
with different diseases. The calculation method results in a predicted mortality, which is
pure statistics. The nurses will be taught to use this online calculator to receive the
patients’ “score”. Then use the included scale to determine if the patient is currently
eligible for the program.

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Mortality
SAPS
II
Score
10% 29 pts
25% 40 pts
50% 52 pts
75% 64 pts
90% 77 pts
(http://clincalc.com/icumortality/SAPSII.aspx)

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VIII. Timetable
Description ofWork Start and End Dates
Phase One
Collection of items for the care
bag
06/01/15-06/15/15
Phase Two
Training of staff/Assembly of
bags
06/16/15-06/23/15
Phase Three
Finality of planning and
beginning of project
06/24/15
IX. Budget
Description ofWork Anticipated Costs
Phase One
Collections of items for the care
bag. (Approximate)
$600.00
Phase Two
Training of staff/Assembly of
bags
$0.00
Phase Three
Finality of planning and
beginnings of project
$0.00
Total $ 600.00

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X. Key Personnel
XI. Evaluation
The program will start with a small group of stakeholders managing then
hopefully grow into a multitude of small groups with many mangers. Each
current member of the beginning group will be responsible for different tasks
such as inventory, collection of items/money, and assembly of the bags. The
primary nurse will determine with other interdisciplinary team members if the
patient is actively dying. The charge nurse or house will be responsible for
determining if the patient is currently eligible for the program.
The program can be evaluated by the satisfaction survey that is normally
sent out. The increase in patient satisfaction score should reflect how well the
program is performing and if it should be continued. Also, the nurses and others
involved in the program will be polled to see if the team members are satisfied
with the way the program is running as well.
Amanda Pate,
BSN, RN
Kimberly
Crum, BSN,
RN
Angelisse
Martinez, RN
Tonya
Wisenbaker,
RN

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XII. Endorsements
Amanda Pate 238 Hannah Court, Greenville, Ga. 30222
Tonya Wisenbaker 600 Celebrate Life Highway, Newnan, Ga. 30265
Kimberly Crum 600 Celebrate Life Highway, Newnan, Ga. 30265
Angelisse Martinez 600 Celebrate Life Highway, Newnan, Ga. 30265
Shelia Martin 34562 Main Highway, Douglasville, Ga. 30134
Patty Calhoun P.O. Box 246 Luthersville, Ga. 30251
Mrs. Ritchie~ Address Private
XIII. Next Steps
 Receiving approval of this project.
 Inpatient staff will collect more blankets for the program.
 Pate will receive pricing for canvas bags with CTCA printed on them from
growth.
 Information needs to be sent to every stakeholder to spread awareness of the
program and promote donations via the growth department.
 Reaching out to the financial department for the financial management side
of the project.

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XIV. Appendix
End-of-life care is the term used to describe the support and medical care given
during the time surrounding death. Such care does not happen just in the moments before
breathing finally stops and a heart ceases to beat. An oncology patient is often living, and
dying, with one or more chronic illnesses and needs a lot of care for days, weeks, and
sometimes even months. Comfort care is an essential part of medical care at the end of
life. It is care that helps or soothes a person who is dying. The goal is to prevent or
relieve suffering as much as possible while respecting the dying person’s wishes.
Generally speaking, people who are dying need care in four areas—physical comfort,
mental and emotional needs, spiritual issues, and practical tasks. (NIA, 2014)
A patient may be uncomfortable due to many reasons such as pain, breathing
problems, skin irritation, digestive problems, temperature sensitivity, and fatigue. Pain,
digestive and breathing problems are normally handled medically. Skin irritation,
temperature sensitivity and fatigue can be treated with this program using the lotion and
blanket given to the family. Mental and emotional needs can also be met with this
program due to the human connection that we create when implementing the care bag
program. The family rubbing lotion on the patient to help relax will also help with this
need. Spiritual issues will be handled by our pastoral team. Finally, practical tasks will
also be fulfilled due to the patient knowing that the family will be taken care of after he
or she is gone by offering the family information on grief and counseling.
Death is a fact of life and death is a life stressor. With the loss of someone close to
you, you are also going through a normal life crisis. You too, need a period of
adjustment. How do you deal with the powerful emotions that threaten to overwhelm
you? It is likely that you have no guide to follow during that painful period after the death
of a loved one. You have no preparation for your new role as mourner. In our society there
is no formalized way to sever the relationship you have maintained with the
deceased. What are you to do with the emotional investment of a lifetime? The body may
be buried, but the emotions of those who lost the deceased continue to survive. This is

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where the blanket may be able to help with the transition of life without the deceased.
(McCullough, 2009)
It is not the blanket, of course, that is transitional. The blanket represents the
family members transition from a state of being merged with the deceased loved one to a
state of being in relation to the deceased as something outside and separate. The feeling
of loss of contact with the loved one is diminished due to having the last object the
patient touched while here and alive. This continues the contact physiologically and helps
the family members cope more effectively.
Words of compassion and acts of kindness are more healing that all of the
medicine in the world. We at Cancer Treatment Centers of America have the opportunity
to help these family members get through their crisis and life stressor and prove that our
care never ever quits.

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References
Cardona-Morrell M, et al. BMJ Supportive & Palliative Care 2015;0:1–13.
doi:10.1136/bmjspcare-2014-000770 1
Caring Connections. (2015). Retrieved January 9, 2015, from http://www.caringinfo.org
Crowther, B. (2015). Dad’s spirit warms us in our comfort blankets. Retrieved January 9,
2015, from http://www.theguardian.com/lifeandstyle/2015/jan/24/dads-spirit-
warms-us-in-our-comfort-blankets
Engals-Smith, J. (2013). Transition Blanket. Retrieved January 15, 2015, from
https://www.shamanportal.org/article_details.php?id=825
Gunderman, R., & Nelson, P. (2012). Exchanging a Blanket for a Code Blue. Retrieved
January 7, 2015, from
http://www.theatlantic.com/health/archive/2013/08/exchanging-a-blanket-for-a-
code-blue/279125/
Hospital based comfort carts lifts spirits, unites a community in caring. (2012). Pain
Community News, 8-9.
Jean-Roger Le Gall, MD; Stanley Lemeshow, PhD; Fabienne Saulnier, MD. (1993). A
New Simplified Acute Physiology Score (SAPS II) Based on a European/North
American Multicenter Study. JAMA. 1993;270:2957-2963
McCullough, C. (2009). A Child's Use of Transitional Objects in Art Therapy to (1st ed.,
Vol. 26, pp. 19-25). Mahopac, NY: Journal of the American Art Therapy
Association.
National Institute on Aging. (2014). End of life: Helping with comfort care. Retrieved
January 6, 2015, from
http://www.nia.nih.gov/sites/default/files/end_of_life_helping_with_comfort_care
_0.pdf

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Sympathy Throws. (2015). Retrieved January 10, 2015, from http://www.keepsakes-
etc.com/sympathygift.html
Temes, R. (2002). Living with an Empty Chair. Philip A. Pecorino.
Winnicott, D. (n.d.). 1. In Transitional objects and transitional phenomena (2nd ed., Vol.
34, pp. 1-18). London, England: Tavistock Publications.

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