Assignment 1 Poster Presentation Analyze a Palliative Service or Program in Your Community Lisa Bailey ID 1431907 October 10, 2012 Grant MacEwan UniversityNurs 483 Conceptualizing Hospice and Palliative Care Instructor: Gail Couch
Lacombe, Alberta Canada Population: 11, 710Located in central Alberta
Palliative Care Services Located in Lacombe 75 beds Long Term Care Hospital and Care (43 of which are Centre. private rooms) Home Care Serves City of Care is provided Lacombe and in client’s home. County of Lacombe.Lacombe Hospital Care is provided and Care Centre in the hospital. 2 palliative care suites. Information for this project was obtained through interviewing senior Registered Nurses that work in the above settings.
Disciplines providing care and their responsibilities Long Term Care❖ Family Physician: Assesses resident at least one time per week, orders and/or discontinues medications and treatments, communicates with family.❖ Nursing: (Registered Nurses (RN), Licensed Practical Nurses and (LPN), Health Care Aides (HCA): All work as a team, it is important to note that their responsibilities are very similar in this setting.
Disciplines providing care and their responsibilities Long Term Care(continued)❖ RNs: Primary responsibilities are medication administration and communicating with the family and physician. Assists with dressing changes, personal care, transferring and repositioning of residents if needed.❖ LPNs: Medication administration, dressing changes, personal care, transferring and repositioning of residents and assists with feeding residents.❖ HCAs: Provide personal care, transferring and repositioning of residents and assists with feeding residents.
Disciplines providing care and their responsibilities Long Term Care (continued)❖ Dietary: Assesses residents swallowing and recommends appropriate diet.❖ Occupational Therapy: Assesses residents mobility and provide equipment for special needs regarding wheelchairs,beds, cushions, walking aids and special eating utensils. Please note, RN that was interviewed stated that “physiotherapists do not see palliative patients very often in this setting”.❖ Pharmacy: Assesses residents and their medications. Makes recommendations for medication changes as needed.
Disciplines providing care and their responsibilities Long Term Care (continued)❖ Volunteers: Provide respite for families and spend time with the residents that do not have family members present. Volunteers often sit, visit, play games, and read to residents. I see volunteers as a vital and valuable part of the team. I have seen LTC volunteers providing the extra special care that the residents deserve. Mellow (2007) explained that“Volunteers feel the importance of their contribution lies in doing tasks that nurses do not have time to do, such as listening to stories patients tell...”(p. 464). Mellow, M. (2007). Hospital Volunteers and Carework. The Canadian Review of Sociology and Anthropology, 44(4), 451-467.
Palliative Care in Lacombe Strengths LTC •Pharmacy and their input. •Calm environment. Weaknesses •Staﬀ have developed a relationship with residents and •Cafeteria has limited hours (1100h -1300h). their families. •No family rooms. •Death is expected in LTC (residents are admitted knowing they will most likely die there) •Environment is not conducive Brock & Foley and Teno, Bird & Mor (as cited in Ersek for caring for families. & Wilson, 2003) found that “recent estimates suggest that by 2040, 40% of deaths will occur in NHs” (p. 45). •Team works very well together. •Access to Lacombe Palliative Care Society. •Access to Palliative Care Resource Nurse.Ersek, M., & Wilson, S. (2003). The challenges and opportunities in providing end-of-life care in nursing homes. Journal of Pa!iative Medicine, 6(1), 45-57.
Palliative care challenges in❖ Lacombe LTC Diﬃcult to provide care and maintain privacy and dignity in semi-private and multiple bed rooms.❖ Family dynamics and diﬀerent opinions about palliative care.❖ Residents with out do not resuscitate (DNR) orders and advance directives.❖ Some lack of specialty palliative care education and training with staﬀ.It is evident that the The Canadian Hospice Palliative CareAssociation (2012) also sees education as an issue in LTC theystated “Providing care at end-of life has become vital to LTCpractice, however, palliative care has not been incorporatedinto the culture and self-perceived roles of LTC. Further,homes are not equipped with some of the specializedknowledge and skills and dedicated resources to providepalliative care” (para. 1). Canadian Hospice Palliative Care Association (2012). End-of-life care in long term care. Ottawa, ON : Author. Retrieved October 6, 2012 from http://www.chpca.net/projects-and-advocacy/eol-care-in-ltc.aspxwww.chpca.net
Ways to manage palliative care challenges in Lacombe LTC ❖ Always pull curtains, move palliative resident to private room if possible, take roommate(s) out of room if possible. Be aware that others are around and can hear you. ❖ It is important to remember that all LTC facilities are diﬀerent and this dictates how the palliative patient is cared for. ❖ Be respectful and take into consideration all of the family member’s opinions (even if they have not been to visit the resident). This not a time to judge, take this opportunity to listen, to show empathy and to teach.
Ways to manage palliative care challenges in Lacombe LTC (continued) ✴Engage in conversation about advance care planning and goals of care upon admission with resident and their family. This is essential as many LTC residents have chronic or life threatening illnesses. Paulus (2008) made a good point when she said “...advance care planning and establishing goals of care are essential because they enhance the control patients have over their care and assure autonomy if the patient is unable to communicate their wishes or make decisions at later stages of illness” (Establishing goals of care section, para. 3). Having DNR orders prior to admission to a palliative care program is controversial and at times an ethical dilemma. I believe that residents and families need more education in this area, they need to be reassured that it does not mean that the resident will not get any care or not be well looked after. They also need to be informed what CPR and post CPR can be like. Gordon’s studies (as cited in Gordon, 2006) supported this idea when he talked about CPR in the frail elderly by stating “Families should be told by physicians and other health care providers about limited beneﬁts to be gained from CPR” (p. 2).Gordon, M. (2006) . Ethical and clinical issues in cardiopulmonary resuscitation (CPR) in the frail elderly with dementia: A Jewish perspective. Journal of Ethics in Mental Health, 1(1), 1-4.Paulos, S. (2008). Pa!iative care: An ethical obligation. Retrieved from Santa Clara University, Markkula Center for applied ethics website: http://www.scu.edu/ethics/practicing/focusareas/medical/palliative.html
Ways to manage palliative care challenges in Lacombe LTC (continued) ✴ Encourage and inspire staﬀ to obtain more knowledge and skills in palliative care. ✴ Provide education opportunities for all staﬀ. ★ Ersek, Grant & Krayhill (2005) found that educating nursing staﬀ in end-of-life care in nursing homes improved patient outcomes (p. 557). Ersek, M., Grant, M., & Kraybill, B. (2005). Enhancing end-of-life care in nursing homes: Palliative care educational resource team (PERT) program. Journal of Pa!iative Medicine, 8(3), 556-566)
Palliative Home CareThe Canadian Hospice Palliative Care Association (2006) states in The Pan-Canadian gold standard for palliative home care that: Canadians who chose to spend their ﬁnal days at home typically receive a signiﬁant amount of their care from family caregivers supported by members of the interdisciplinary health care team (e.g., personal support workers, nurses, physician, pharmacists, volunteers, depending on their hospice palliative care needs. (p. 8) Canadian Hospice Palliative Association. (2006). The Pan-Canadian gold standard for pa!iative home care. Ottawa, ON: Author. Retrieved on October 8, 2012, from http:// www.cdnhomecare.ca/media.php?mid=2394
Registered Nurse: Licensed Practical Nurse:•Client assessment. •Personal care.•Responsible for symptom management. •Dressing changes.•Medication administration. •Psychosocial support to client and family.•Infusion pump changes and adjustments. •Patient assessment, report assessment•Development of nursing care plans. to registered nurse.•Psychosocial support to client and family. Disciplines providing care and their responsibilities Home Care Mental Health Counsellor: Health Care Aide: •Assessment of client and family. •Personal care. •Counselling. •Respite care. •Bereavement counselling after death. •Psychosocial support to client and family.
Volunteer: •Respite care. •Psychosocial support to client and family. •Variety of responsibilities depending on what the patient and family need (make meals, sit with client, visit with client, play games with client, read to client). Disciplines providing care and•Swallowing assessments. Dietician: their responsibilities•Gives family tips for providing highestprotein and calorie diet withsmallest volume. Home Care (continued)Bruera (1997) studied nutrition and palliative care andrecognized that “Nutritional counselling should be basedon eating high calorie meals of small portions that arepleasant for the patient” (p. 1222). Occupational Therapist and Physiotherapist: •Assessment of client’s mobility and transfers. •Client and family teaching regarding safe transfers and repositioning in bed. •Supply equipment (walker, air mattresses, roho cushions etc.). Bruera, E. (1997). ABC of palliative care: Anorexia, cachexia and nutrition. British Medical Journal, 315(7117), 1219-1222.
Palliative Home Care in Lacombe Strengths:• Staﬀ is highly dedicated and educated with a high sense of professionalism.• Most clients are able to stay at home. This is becoming very common and desirable for many. It is evident that in the last ten years there has been a shift from palliative care being institutional based to home based ( Peters & Sellick, 2006, p. 531). There are many reasons for this, Hudson (2003) found the “beneﬁts of palliative care at home include a sense of normality, choice, and comfort” (p. S36).• Access to Lacombe Palliative Care Society.• Access to Palliative Care Resource Nurse. Hudson, P. (2003). Home-based support for palliative care families: Challenges and recommendations. Medical Journal of Australia, 179(6), S35-S37. Peters, L., & Sellick, K. (2006). Quality of life of cancer patients receiving inpatient and home-based palliative care. Journal of Advanced Nursing, 53(5), 524-533.
Palliative Home Care in Lacombe (continued) Weaknesses:• Lack of Alberta Health Services funds to provide more personal care, resources, and respite care.• Decreased staﬀ on evenings and nights (RN on call) LPNs and HCAs available at times.
Challenges in Palliative Home Care in Lacombe Some palliative care issues and emergencies can makeAt times client’s care needs it diﬃcult for the clientexceed the funds available and family to be at home for (e.g., hemorrhage, spinal palliative home care. cord compression, drug toxicity, and seizures).
Ways to manage challenges of Palliative Home Care in Lacombe Seek out volunteers, friends, family, churches and social organizations to help supply resources to keep patientat home (provide care, equipment, and funds). Utilize Lacombe Palliative Care Society. Provide education to families about palliative issues and emergencies. Provide psychosocial support. Ensure staﬀ is available for emergencies. Contact and consult Palliative Care Resource Nurse if needed. If needed, allow client and family to say that they do not feel comfortable being at home anymore (they needto know that this is ok). Stenekes and Streeter (2011) acknowledged that “Families often experience mixedemotions about death at home, especially when: the person is unconscious and no longer able to respond tofamily members; they realize that they many not be comfortable living in the home after a death” (p. 5). Stenekes, S., & Streeter, L. (2011). Considerations for a home death. Canadian Virtual Hospice, 1-5. Retrieved October 8, 2012, from http:// www.virtualhospice.ca/Html2PdfHandler.ashx?vlink=en_US-Main%20Site%20Navigation-Home-Topics-Topics-Decisions-Considerations%20for %20a%20Home%20Death
Disciplines providing care and their responsibilities Hospital Palliative Care Nursing (Team): RN: Assessments, medication administration, personal care, psychosocialsupport to patient and family, patient and family Family Physician: teaching. Daily rounds. Dietician: LPN: Assessments, medication Rotation of on call in ER. Assessment of patient. Nutritional assessments. Dietary suggestions- changes in texture, administration, personal care, psychosocial Medication and treatment orders. catered diets. support to patient and family. Discussion and meetings with patients and families.HCA: Personal care, psychosocial support to patient and family. Occupational Therapist (OT) and Physiotherapist (PT): (Often work together) Pharmacist: PT: Depends on what stage of disease patient is in. Assessment related to mobility. Speech Pathologist: Assessments related to medications. Suggestions related to positioning and mobility. Swallowing assessments. Medication suggestions. Suggestions for eating and swallowing. Medication teaching to patients and families. OT: Assessments related to ADL’s and mobility. Suggestions for positioning and mobility. Supplies special chairs, cushions and utensils. Families and staﬀ provide care and volunteers are not used as much in this setting.
Hospital palliative care in Lacombe Strengths:Two private rooms and familysuites.Rooms equipped withkitchenettes.Rooms have access to courtyard.Some permanent staﬀ (workpalliative care only), continuity ofcare.Well educated senior staﬀ (investin continuing education).
Hospital palliative care in Lacombe Weaknesses: High staﬀ turn over in the last 3-4 years (new staﬀ have not been as focused on and dedicated to palliative care). This can be very diﬃcult on staﬀ. Investments in new staﬀ training and support can help with retention. The results from Ablett and Jones’s (2007) study suggested “implications for staﬀ training and support in that the factors that promote resilience, particularly hardiness and a strong sense of coherence, could be developed through staﬀ training packages” (p. 739). No dedicated palliative physician of their own (rely on family physicians and palliative physician consults from Red Deer (30 km) and Rimbey (48.5 km). Ablett, J., & Jones, R. (2007). Resilience and well-being in palliative care staﬀ: A qualitative study of hospice nurses’ experience of work. Psychooncology, 16(8), 733-740.
❖ Care is in hospital whichPalliative care has a variety of patients on same unit.challenges in ❖ High acuity at times, decreased time available Lacombe for palliative patients. Hospital ❖ Lack of funds from Alberta Health Services for palliative care services.
❖ Be aware and sensitive of the diﬀerentHow to manage patients and families on the unit. ❖ Create a relaxed and calm environment aspalliative care possible.challenges in ❖ Contact government and AHS oﬃcials, make them aware of the need for more funds allocated toLacombe palliative care services. ❖ Utilize local social organizations,Hospital volunteers and churches to help with funding and resource issues. ❖Utilize Lacombe Palliative Care Society.
It is important to highlight two exceptional resources that all three settings have in common.
Lacombe Palliative Care Society Mandate: To provide support and education to end-of -life care. Funds for staﬀ continuing education. Hosts annual dinner and speaker every year during National Hospice Palliative Care Week Hosts other educational events. Keep palliative suites stocked (coﬀee, teas etc.). Renovate palliative rooms and suites when needed. Supply palliative volunteers. “Volunteers often augment and enhance the range of EOL care services provided to terminally ill individuals and their families” (Wilson et.al., 2005, p. 244). Supply needed equipment for patients. Will cover costs of medication if needed for palliative patients.Wilson, D., Justice, C., Thomas, R., Sheps, S., MacAdam, M., & Brown, M. (2005). End-of- life care volunteers: A systematic review of the literature. Health Services Management Research 18(4), 244-257.
Access to Palliative Care Resource Nurse: Provides consultation Provides recommendations Provides support to patients, families and staﬀ.
Important to note I think it is vital to share an unexpected outcome of the assignment.None of the three palliative care staﬀ that I interviewed talked about a chaplain,member of clergy or minister being a part of the interdisciplinary team.I found this very interesting because at my place of work they are an essential part ofthe team. They provide meaningful religious and spiritual counselling to manypatients and their families. I concur with a research study that found the importanceof clergy to palliative care. It is an older study but still signiﬁcant. In the 1990’s,Flannelly, Weaver, Smith, & Oppenheimer (2003) found that chaplain andcommunity-based clergy were discussed and mentioned more frequently in threepalliative care journals than any other profession (p. 267). “The fact that clergy andchaplains were mentioned most often in program descriptions gives some indicationof their integral role among hospice staﬀ ” (Flannelly et al., 2003, p. 267).I think it is very interesting that all three nurses either forgot (which I believe to bethe case) about this discipline or that they are not utilized in these settings. This will require further research. Flannelly, K., Weaver, A., Smith, W., & Oppenheimer, J. (2003). A systematic review on chaplains and community-based clergy in three palliative care journals: 1990-1999. American Journal of Hospice and Pa!iative Care, 20(4), 263-268.
Conclusion In conclusion, I discovered that Lacombe oﬀers a wide variety of exceptional palliative care services. Each setting is unique in the way it delivers palliativecare. It is interesting how they all refer to the “patient” diﬀerently. Depending on the setting, you be looking after a resident, a client or a patient. To gain a full understanding of the palliative care services available, it is crucial to also understand the similarities between the settings. They all aim to provide excellent, holistic palliative care, to promote comfort and prevent suﬀering in the dying. The Canadian Hospice Palliative CareAssociation (2012) state “All Canadians have the right to die with dignity, free of pain, surrounded by their loved ones, in the setting of their choice” (p. 12). Canadian Hospice Palliative Care Association. (2012). Fact sheet: Hospice pa!iative care in Canada. Ottawa, ON: Author.
ReferencesAblett, J., & Jones, R. (2007). Resilience and well-being in palliative care staff: A qualitative study of hospice nurses’ experience of work. Psychooncology, 16(8) 733-740.Bruera, E. (1997). ABC of palliative care: Anorexia, cachexia, and nutrition. British Medical Journal, 315(7117), 1219-1222.Canadian Hospice Palliative Care Association. (2006). The Pan-Canadian gold standard for palliative home care. Ottawa, ON: Author. Retrieved on October 8, 2012, from http://www.cdnhomecare.ca/media.php?mid=2394Canadian Hospice Palliative Care Association. (2012). Fact sheet: Hospice palliative care in Canada. Ottawa, ON: Author.Canadian Hospice Palliative Care Association. (2012). End-of-life-care in long term care. Ottawa, ON: Author. Retrieved on October 6, 2012, from http://www.chpca.net/projects-and-advocacy/eol-care-in-ltc.aspxErsek, M., Grant, M., & Miller, B. (2005). Enhancing end-of-life care in nursing homes: Palliative care educational resource team (PERT) program. Journal of Palliative Medicine, 8(3), 556-566.Ersek, M., & Wilson, S. (2003). The challenges and opportunities in providing end-of-life care in nursing homes. Journal of Palliative Medicine, 6(1), 45-57.Flannelly, K., Weaver, A., Smith, W., & Oppenheimer, J. (2003). A systematic review on chaplains and community-based clergy in three palliative care journals: 1990-1999. American Journal of Hospice and Palliative Medicine, 20(4), 263-268.
ReferencesGordon, M. (2006). Ethical and clinical issues in cardiopulmonary resuscitation (CPR) in the frail elderly with dementia: A Jewish perspective. Journal of Ethics in Mental Health 1(1), 1-4.Hudson, P. (2003). Home-based support for palliative care families: Challenges and recommendations. Medical Journal of Australia, 179(6), S35-S37.Mellow, M. (2007). Hospital volunteers and carework. The Canadian Review of Sociology and Anthropology, 44(4), 451-467.Paulus, S. (2008). Palliative care: An ethical obligation. Retrieved October 6, 2012, from Santa Clara University, Markkula Canter for applied ethics website http://www.scu.edu/ethics/practicing/focusareas/medical/palliative.htmlPeters, L., & Sellick, K. (2006). Quality of life of cancer patients receiving inpatient and home-based palliative care. Journal of Advanced Nursing, 53(5), 524-533.Stenekes, S., & Streeter, L. (2011). Considerations for a home death. Canadian Virtual Hospice, 1-5. Retrieved on October 8, 2012, from http://www.virtualhospice.ca/en_US/Main+Site+Navigation/Home/Topics/Topics/Decisions/Considerations+for+a+Home +Death.aspxWilson, D., Justice, C., Thomas, R., Sheps, S., MacAdam, M., & Brown, M. (2005). End-of- life care volunteers: A systematic review of literature. Health Services Management Research 18(4), 244-257.