Workshop presentation on Irish Hospice Foundation Dementia guidance document 1 "Facilitating Discussions on Future and end of life care with a person with dementia"
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Facilitating Discussions on Future and End of Life Care With People who have Dementia
1. FACILITATING DISCUSSIONS ON FUTURE
AND END-OF-LIFE CARE WITH PEOPLE
WHO HAVE DEMENTIA
Deirdre Shanagher, Cecelia Hayden, Carmel Collins,
Sarah Cronin, Jean Barber, Anne Quinn, Lasarina Maguire, Marie
Lynch, Dr Suzanne Timmons
Palliative Care Needs of People With Dementia: Building Capacity
Mullingar, November, 2015
6. Context:
• People with dementia have unique care needs
• Long illness trajectory
• May be complicated with responsive behaviours and
communication difficulties
(Bayer, 2006 & Tilly et al,
2008)
• Staff should be knowledgeable, confident and competent
(Bayer, 2006 & VanDerSteen et al,
2013)
7. I’m not ready to
die yet…
Please don’t
send me
away to die
I’m not afraid to die.
But I don’t want to be
in pain
Am I
dying?
9. Case Study 1:
• Tom, who has dementia has been in your care for the past
six months and has become increasingly frail. He is
currently unable to walk and has a very poor appetite
which has caused him to lose a noticeable amount of
weight in recent months. His wife has become anxious
about her husbands deteriorating health. His wife, who is
distressed approaches you asking “could my husband die
from not eating enough?”. As a healthcare worker you
know that Toms wife is heavily involved in his care but you
aren’t sure what she knows about her husbands diagnosis
and care plan.
10. Case Study 2:
• Two years ago, Kathleen was diagnosed with dementia.
Over the last year, she has needed a lot more help with
most personal and domestic activities. One day Kathleen
became quite tearful when speaking to you and said “I am
so frightened of having to move from here and the
thoughts of being cared for and dying in a strange place”.
11. Case Study 3:
• Michael is a 43-year-old man who has Down Syndrome and a mild
Intellectual Disability. He had until lately travelled either by bus or train to
attend matches as he is a passionate supporter of his local and county
GAA teams. Michael attends a day service where staff have observed
that he was “not himself” and that he was not engaging with either them
or his colleagues. He has appeared to be withdrawn at times. He has
also become more reliant on others and less likely to initiate activities.
Michael recognises that he is struggling more now, his coping skills are
diminishing, and he is finding it increasingly difficult to make sense of the
world around him. There is evidence of reduced emotional control,
irritability and loss of self direction. He is less tolerant of his peers, and
with decline in social behaviours becoming more evident, he has begun
shouting at others, for no obvious reason. Michael attended the memory
clinic. A full physical work-up was carried out to out rule pseudo dementia
and to inform differential diagnosis. He had a full cognitive work up and
following comprehensive interviews with key people in his life a
consensus diagnosis agreed that he met ICD-10 criteria for Alzheimer’s
type dementia. It was agreed that Michael is presenting with a very
compressed decline and that the level of support that he will require in
the future will be significant.
13. 8 Tips for Effective Communication
1. Adopt a person centred approach to
communication
2. Connect with the person
3. Consider the communication environment
4. Be aware of your own communication style and
approach
5. Use active listening
6. Use simple language
7. Focus on one question at a time
8. Clarify Information and check understanding
20. Going Forward…….
• What one thing can you do differently within your
practice or organisation with regard to
discussions on future and end of life with a
person with dementia?
21. List of Guidance Documents Being
Developed:
1. Facilitating discussions on future and end-of-life care with a person with
dementia
2. Advance care planning and advance healthcare directives
3. Loss & Grief
4. Hydration and Nutrition
5. Pain assessment & management
6. Ethical decision making
7. Medication
23. Acknowledgements
Thank you and
Questions
For more information:
Deirdre Shanagher
Deirdre.shanagher@hospicefoundation.ie
People with dementia and carers who have
contributed and advised IHF
IHF Changing Minds Team
Project and Expert Advisory and Governance
Groups
Atlantic Philanthropies
Editor's Notes
Sticky notes on the table – write down one question you have about having discussions with people who have dementia.
We’ll try to answer these – if we don’t get a chance we can send feedback when circulating todays evaluation responses.
I think we all know at this stage that the number of people living with dementia is rising continuously as people are living longer with more chronic illnesses to include dementia.
The chart on the screen indicates that by 2046 within Ireland alone the number of people with dementia will have increased by over 170%! Doubling in the next ten years and trebling in the next 30 years.
From a policy point of view, the need for a palliative approach in the care of people with illnesses other than cancer has been recognised in Ireland since 2001 with many reports to include the PCFA report in 2008 and more recently the National Dementia Strategy in 2014 particularly emphasising the need for a palliative care approach for people with dementia
We know that Dementia is a terminal illness.
We know that people dying with dementia are a vulnerable group who have unique needs.
The nature of dementia is that it is progressive.
The literature indicates that palliative care principles should be introduced early in the illness so that the PWD can engage meaningfully in discussions about their future and end of life care.
To do this staff need to be knowledgeable, confident and competent to support people with addressing issues and inviting them to make decisions about their future care needs
However, there is a void of practice guidelines to support healthcare staff to do this.
Link to resources- I.E Think Ahead form might be useful
Prior to engaging with a person with an Intellectual Disability and using the AFIRM response, it is important to acknowledge that the person may find it hard to express how they are feeling. Consequently, it is important that staff who know the person very well, and who understand the person’s usual methods of communication are involved when a diagnosis is being explored – particularly where the person involved does not use words to communicate.
So before outlining specific guidance for facilitating discussions with people with dementia the expert advisory group agreed that it was necessary to set out some fundamental knowledge applicable to caring for people with dementia. The key considerations were identified in the literature review and the idea of these considerations is that they should be applied as foundation steps by ALL healthcare staff supporting people with dementia.
So the 5 areas to inform good practice are:
1 to recognise that communication with a person with dementia is ALWAYS possible
2 Develop knowledge about the progression of dementia and key triggers for end of life discussions. Such as time of diagnosis or deterioration in a persons condition.
3 Plan future care to optimise comfort
4 Promote personhood throughout the persons journey
And 5 Record future wishes when they are expressed.
So we came up with these 8 tips for effective communication.
Adopt a person centred approach. So find out how best to support a person to understand information, use aids, talking mats, sign language, be creative & open, observe behaviours and build a collaborative picture
Connect with the person. Prioritise this and don’t get focused on exchanging information and facts. Use life story work as a means of developing relationships and focus on the feelings BEHIND words.
Consider the communication environment such as lighting, noise, seating and resources such as aids required (picture boards or talking mats)
Be aware of your own communication style. So approach to the front, make eye contact, get to the same level as the person, introduce yourself, call them by their name, explain what you’re there for, speak slowly and clearly using a calm tone of voice
Use active listening techniques such as conversational cues like “hmm” “I see” or “really”, don’t rush to fill silences and give the person extra time to process information,
Use simple language and the persons name, focus on one topic at a time, avoid jargon, use aids and different words
Focus on one question at a time so reframe open ended questions to closed questions focusing on 1 idea at a time
Clarify information and check understanding so ask questions and repeat back information
So to focus on one of those techniques the guidance documents recommends use of Stirlings AFIRM approach
Acknowledge the persons concerns and fears
Find out what is known
Address immediate concerns
Respond to other questions
Meet again or with senior staff to address concerns
To indicate how this is used we’ll look at a case study from a healthcare assistants perspective….
Using the AFIRM approach here are some possible responses that can be used.
The final product is a full document and a 2 page factsheet that was designed to be accessible by healthcare staff so it can be hung on clinic room walls as a prompt.
That’s just some of the contents to this first guidance document.
Other guidance documents are being prepared on the following areas and are relevant when caring for a person with dementia.
I’d like to acknowledge these people and will now take some questions if there are any.