Palliative Care Advance Care Planning A Collaborative Approach


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Palliative Care Advance Care Planning A Collaborative Approach

  1. 1. Palliative Care Advance Care Planning A Collaborative Approach Sheldon Lewin MSW,MBA
  2. 2. Program Goals <ul><li>California Hospital Medical Center Objectives: </li></ul><ul><li>Reduce the suffering and increase the comfort of our patients through symptom control and restoration of functional capacity. </li></ul><ul><li>Participate in the CHW palliative care initiative. </li></ul><ul><li>Plan for future medical care in the event a patient is unable to make their own decisions. </li></ul><ul><li>Remain sensitive to personal, cultural and religious values and beliefs. </li></ul><ul><li>5 components of ACP per CHW: </li></ul><ul><ul><li>Patient options for treatment </li></ul></ul><ul><ul><li>Chances of survival or prognosis </li></ul></ul><ul><ul><li>Options for pain/other symptoms of disease </li></ul></ul><ul><ul><li>Patient/family’s decision about treatment </li></ul></ul><ul><ul><li>Spiritual needs assessment </li></ul></ul>
  3. 3. Medical Therapy Choices <ul><li>Traditional Medicine </li></ul><ul><ul><li>Cure illness </li></ul></ul><ul><ul><li>Prolong life </li></ul></ul><ul><li>Palliative Care </li></ul><ul><ul><li>Improve quality of life </li></ul></ul><ul><ul><ul><li>Pain management </li></ul></ul></ul><ul><ul><ul><li>Symptom management </li></ul></ul></ul><ul><ul><ul><li>Emotional support </li></ul></ul></ul><ul><ul><ul><li>Advance Care Planning </li></ul></ul></ul><ul><ul><ul><li>Does not exclude traditional therapy </li></ul></ul></ul>
  4. 4. People Care About <ul><li>Participation in medical decision-making </li></ul><ul><li>The impacts of their illness on their family </li></ul><ul><li>Physical, emotional, spiritual, support and care </li></ul><ul><li>Living well: Quality of life, planning for the future </li></ul><ul><li>Dying well: Dying peacefully, without extreme discomfort, without suffering, without prolonged dependence </li></ul>
  5. 5. Definition- Palliative Care: <ul><ul><li>The art and science of relieving pain, suffering and symptoms associated with a serious illness without effecting a cure </li></ul></ul><ul><ul><li>Comprehensive management of physical, social, spiritual and existential needs of patients, in particular those with incurable, progressive illnesses </li></ul></ul><ul><ul><li>Does not mean stopping active medical treatments </li></ul></ul><ul><ul><li>Does not take the place of Hospice </li></ul></ul><ul><ul><li>Affirmation of life </li></ul></ul><ul><ul><li>Regards dying as a natural process </li></ul></ul>
  6. 6. Palliative Care Components <ul><li>Pain Management </li></ul><ul><li>Symptom Management </li></ul><ul><li>Emotional Support </li></ul><ul><li>Advance Care Planning </li></ul><ul><li>Provide assistance with: </li></ul><ul><ul><li>In-hospital support </li></ul></ul><ul><ul><li>Transitions to Home, SNF or Hospice, Home Health </li></ul></ul>
  7. 7. Palliative Care Intake Screen
  8. 8. <ul><li>Palliative Care & the </li></ul><ul><li>Social Worker’s Role </li></ul><ul><li>Assess Psychosocial Needs of patient and family. Provide Psychosocial Support . </li></ul><ul><li>Advanced Care Planning: Discuss and or educate on end of life or (i.e. Advance Directives , funeral arrangements, home support, burial, delineate family representative). Facilitate resolution or open topic discussion. </li></ul><ul><li>Coordinate and assemble PC Team for ** ACP Meetings. </li></ul><ul><li>Document ACP progress note. </li></ul><ul><li>**Advanced Care Planning </li></ul>
  9. 9. Assess Psychosocial Needs & Provide Support
  10. 10. Assess Psychosocial Needs <ul><li>Emotional, psychological, spiritual </li></ul><ul><li>Anger, anxiety </li></ul><ul><li>Depression </li></ul><ul><li>Guilt </li></ul><ul><li>Family conflicts </li></ul><ul><li>What is important to the patient’s life? </li></ul><ul><li>What more does the patient want to accomplish? </li></ul><ul><li>What does the patient fear? </li></ul>
  11. 11. Psychosocial Support <ul><li>Participation in medical decision-making </li></ul><ul><li>The impacts of illness on family/respite for family </li></ul><ul><li>Physical, emotional, spiritual, support and care </li></ul><ul><li>Documents in order (Power of Attorney [POA], living wills, wills, guardian for children, Substitute Decision Maker). </li></ul><ul><li>If in hospital encourage family to bring in favorite photo and other personal items for bedside. </li></ul><ul><li>Living well: Quality of life, planning for the future </li></ul><ul><li>Dying well: Dying peacefully, without extreme discomfort, without suffering, without prolonged dependence </li></ul>
  12. 12. Advanced Care Planning Facilitate ACP Meeting
  13. 13. Advance Care Planning: Issues or Conflicts <ul><li>No Advance Health Care Directive </li></ul><ul><li>Confusion or Conflicts in Goals of Care </li></ul><ul><li>Caregivers Experiencing Burden of Care </li></ul>
  14. 14. Advance Care Planning: Values & Beliefs <ul><ul><li>What gives meaning to life? </li></ul></ul><ul><ul><li>What does quality of life mean to you? </li></ul></ul><ul><ul><li>What are your priorities? </li></ul></ul><ul><ul><li>If level of disability are you willing to accept and for how long? </li></ul></ul><ul><ul><li>Who can make decisions for you if you cannot? </li></ul></ul>
  15. 15. Advance Care Planning: Advance Directives <ul><li>Who can speak for me if I cannot speak for myself? </li></ul><ul><li>What medical treatments do I want if I am near death? </li></ul>
  16. 16. Advance Care Planning: Family Conference <ul><li>Coordinate and assemble Palliative Care Team with family members. </li></ul>
  18. 18. Advance Directives <ul><li>“ The Patient’s Self Determination Act” (PSDA, 1990) </li></ul><ul><li>Patients have a right to: </li></ul><ul><ul><li>make medical decisions regarding their treatment </li></ul></ul><ul><ul><li>appoint an agent to speak on their behalf when incapacitated </li></ul></ul><ul><ul><li>determine, or refuse, their medical treatment and care. </li></ul></ul><ul><li>Upon admission, we are required to ask if the patient has an Advance Directive and if it is available. </li></ul>
  19. 19. Advance Directives <ul><li>If you are an adult, (at least 18 years of age, and have the capacity to make health care decisions), you have the right to make your wishes known about the extent of treatment you would desire if you became unable to communicate those wishes. This communication is called an advance directive. </li></ul>
  20. 20. Advance Directives <ul><li>Who do I want to speak for me? </li></ul><ul><li>Have I told my ‘surrogate’ decision-maker what I value, what I do and do not want??? </li></ul><ul><li>Is there anyone I do NOT want to speak for me? </li></ul>
  21. 21. Advance Directives <ul><li>Two Commonly Used Advance Directives Are </li></ul><ul><li>A health care directive (living will), in which you communicate orally or in writing the specific treatment desired if you later cannot communicate these wishes. </li></ul><ul><li>A durable power of attorney for health care , in which you designate another person to make decisions about your health care if you become unable to do so. </li></ul>
  22. 22. Advance Directives <ul><li>People assume their family will know what medical treatments they would or would not want </li></ul><ul><li>Responsibility of Surrogate Decision Maker is to respond from the Patient’s Perspective: </li></ul><ul><ul><li>What would Mom have wanted if she could speak for herself? </li></ul></ul><ul><li>If the physician is uncertain about the patient’s desires, the default position is usually to treat. </li></ul>
  23. 23. CHMC-Advance Directives Process 1. ACCESS CARE Patient admitted to hospital Access Care staff provides the patient an Advance Directive form and packet of information including copy of “Your Right to Make Decisions about Medical Treatment” and asks if patient has a completed Advance Directive Access care staff checks appropriate box in Condition of Admission (COA) and Treatment (Part 1) form End Patient is admitted to hospital Does patient have an Advance Directive ? No Yes Copy available? No Access care staff sends copy to nursing unit Yes 1. Patient wishes additional information 2. Patient is unable to receive information regarding Advance Directive
  24. 24. CHMC-Advance Directives Process 2. NURSING/SOCIAL SERVICES Patient admitted to room Nurse Nurse Nurse reviews the Condition of Admission (COA) & Completes Interdisciplinary Intial Assessment (Checks and signs Advance Directive section) <ul><li>Social Worker will verify and reassess for Advance Directives as required: </li></ul><ul><li>Verification of Advance Directive (For patients stating they have AD at admission) </li></ul><ul><li>CHECK patient’s medical record to see if there is an ADVANCE DIRECTIVE: </li></ul><ul><li>If ADVANCE DIRECTIVE is not in medical record, you must do the following: </li></ul><ul><li>REMIND patient and or CONTACT family/guardian to bring in document. </li></ul><ul><li>DOCUMENT 2-3 attempts in medical record to locate ADVANCE DIRECTIVE </li></ul><ul><li>Reassessment of Advance Directive (For patients who might not have been asked at admissions or were non responsive due to the following (i.e. trauma, intubation) </li></ul><ul><li>ASK patient if they have an ADVANCE DIRECTIVE </li></ul><ul><li>YES- make certain AD is in the medical record. Follow-up with patient/family </li></ul><ul><li>NO - provide information/education on AD (Green Brochure) </li></ul><ul><li>Document all interventions on referral form and in medical record </li></ul>Nurse Social Worker
  25. 25. Advance Directives Patient Information & Education Sobre Instrucciones Medicas Anticipadas Available in Spanish & English Contact Social Services at x5560 or via AS400
  26. 26. <ul><li>Palliative Care & </li></ul><ul><li>the Nurse’s Role </li></ul><ul><li>Patient Advocacy and Referrals to PC Team </li></ul><ul><li>Patient Symptom and Pain Assessment and Management . ( Patient Satisfaction with Pain Management ) </li></ul><ul><li>Patient & Family Education </li></ul><ul><ul><li>Educate patients on the pain scale </li></ul></ul><ul><ul><li>Prepare patients to deal with pain at home </li></ul></ul><ul><li>Document interventions </li></ul>
  27. 27. Advocacy & Referrals
  28. 28. Who Can Benefit?
  29. 29. Who Can Benefit?
  30. 30. Who Can Benefit?
  31. 31. Who Can Benefit?
  32. 32. Who Can Benefit?
  33. 33. Patient & Family Education
  34. 34. Patient Education <ul><li>Upon admission every patient needs to be informed of their right to pain management, how pain is assessed and what pain management is available. Part of this education is talking with the patient about their “pain goal”. </li></ul><ul><li>Education of patients begins with an assessment of their cultural and belief system barriers. These are addressed in the patient education assessment. </li></ul><ul><li>In addition to the pain management orientation, further education related to pain management is given as appropriate and documented on the patient education record. </li></ul>
  35. 35. Palliative Care & the Chaplain’s Role 1 . Assess patient’s spiritual needs 2. Provides grief and bereavement support 3. Document interventions 4. Attend family conference
  36. 36. <ul><li>Assess Patient’s </li></ul><ul><li>Spiritual Needs </li></ul>
  37. 37. Spiritual Needs Assessment& Support <ul><li>Available for spiritual support and guidance.  </li></ul><ul><li>Work closely with community clergy through visits and supportive care, when requested by the patient.  </li></ul><ul><li>Recognizes the tremendous importance and value in caring for the spiritual needs of the patients and caregivers . </li></ul>
  38. 38. Grief & Bereavement Support
  39. 39. Grief & Bereavement <ul><li>Provides special support in dealing with grief and anticipated death. </li></ul><ul><li>Anticipatory grieving and support in bereavement </li></ul><ul><li>Assistance with psychosocial and spiritual issues related to life closure </li></ul><ul><li>Acknowledge feelings: Although the death has been anticipated the family may experience a myriad of feelings including guilt, relief or shock. </li></ul>
  40. 40. Palliative Care & the Case Manager’s Role 1. Assess patient’s discharge needs 2 . Coordinate and document referrals to hospice or home health, DME 3. Patient Satisfaction. Preparing patients to deal with pain at home. 4. Attend family conference
  41. 41. Discharge Planning & Home Health/ Hospice Care Referrals
  42. 42. Referrals to Home Health Hospice, LTC, SNF, etc <ul><li>Coordinate and document referrals to hospice or home health, DME </li></ul><ul><li>Maintain working relationship with external providers of palliative/hospice care: </li></ul><ul><li>Outpatient Consultant Palliative Care </li></ul><ul><li>Hospice Facility </li></ul><ul><li>Home Care Hospice–Palliative Care Services </li></ul><ul><li>Nursing Home or Skilled Nursing Facility with Hospice Services </li></ul><ul><li>Residential Housing with Hospice Services </li></ul><ul><li>Long-Term Care Facilities </li></ul>
  43. 43. Palliative Care & the Physician’s Role 1. Discuss and document patient’s options for treatment 2. Discuss and document options for pain and symptom management 3. Ensures consensus is reached among physicians 4 . Certifies that the patient needs the services provided and agrees/signs plan of care 5 . Attend family conference