Palliative Care From Hospital To Nursing Home

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Palliative Care From Hospital To Nursing Home

• Addressing the needs of elderly patients who have
  a life limiting progressive illness with
  palliative care needs

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Palliative Care

• Palliative care is an approach that improves
  quality of life of patients and their families
  facing the problem associated with life
  threatening illness, through the prevention and
  relief of suffering by means of early
  identification and impeccable assessment and
  treatment of pain and other problems, physical,
  psychological and spiritual.
• WHO (2003)

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Terminal Care

• Terminal care is a continuum of palliative
  care and is used to describe the care that is
  offered during the period when death is imminent,
  and life expectancy is limited to a short number
  of days, hours or less.
• Department
  of Health and Children (2001)

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Levels of Palliative Care

• Level 1 - Palliative care approach
• Level 2 - General palliative care
• Level 3 - Specialist palliative care

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Levels of Palliative Care

• Level One - Palliative care approach
• Palliative care principles should be
  practiced by all health care professionals.The
  palliative care approach should be a core skill
  of every clinician at hospital and community
  level.

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Levels of Palliative Care

• Level Two General Palliative Care
• A proportion of patients and families will
  benefit from the expertise of health care
  professionals who although not engaged full time
  in palliative care have some additional training
  and experience in palliative care, perhaps to
  diploma level. This level of expertise should be
  available at hospital and community level.

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Levels of Palliative Care

• Level Three- Specialist Palliative Care
• Specialist palliative care services are those
  services whose core activity is limited to the
  provision of palliative care. These services are
  involved in the care of patients with more
  complex and demanding needs.

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• Many patients with progressive and advanced
  disease will have their needs met comprehensively
  and satisfactorily without referral to specialist
  palliative care units or personnel.

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Facts

• 27,479 people died in 2006 in Ireland
• 28 died from cancer
• 33 died from cardiovascular/circulatory
• 14 died from respiratory disease
• 25 died from other causes
• Almost 16,000 deaths were in the 75-94 age group
• Irish Hospice Foundation-
  Palliative Care For All (2008)

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Ageing Population

• By 2050 the over 80 age group is projected to
  number almost 379 million worldwide, about 5.5
  times as many as in 2000 ( 69 million persons).
• In 1950, persons over 80 numbered less than 14
  million.
• It has never been more critical to address the
  palliative care needs of older people than in the
  context of todays ageing populations. The
  proportion of people aged 65 and over is steadily
  on the increase in Europe.
• World Population Ageing 1950-2050

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A/E Survey Conducted in Connolly Hospital Feb 2007

• High levels of A/E use, by patientsgt65 years and
  those in LTC.
• 420 attendances by patientsgt65 years old
• 56(13) from nursing home care- (52 had 1 or
  more attendances in the last 4 months)
• 65 admitted to hospital high hospital mortality
  
• P McCormack S Kennelly
  (2008)

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Consequences of Inappropriate Hospital Admissions

• Patients at risk of dying in an inappropriate
  place of care, e.g. A/E
• Lengthy hospital stays
• Poor quality of life for the patient
• Medication errors
• Poor communication of new care plans
• Changing care teams/ fragmentation of care
• Transportation delays and discomfort

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• Inappropriate patient transfers between nursing
  homes and hospitals can be very stressful for
  both patients and families. It can be frustrating
  for staff in both care settings.

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Case Scenario

• Grandpa Simpson 85 year old nursing home resident
  over 5 yrs
• Background - advanced dementia, previous CVA
  Progressive decline over the last six months,
  less interest in eating and drinking, poor
  swallow
• Admitted to an acute hospital with aspiration
  pneumonia, treated with iv antibiotics, improved
  clinically, transferred back to nursing home
  residence 7 days later.
• Of note he had 4 admissions over the previous 8
  months
• Readmitted 2 weeks later following recurrent
  aspiration pneumonia, died in A/E

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• Outcome ?
• Planned to Fail !

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• How can we improve the transition of care for the
  elderly patient who have a progressive life
  limiting illness and prevent inappropriate
  readmission to hospital??

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A Transitional Problem

• Poor communication between hospitals and nursing
  homes
• Lack of advanced care planning
• Poor documentation re goals of care
• Poor communication with patient and family
• Lack of knowledge and skills re managing symptoms
  
• 
  

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Challenges in Providing Palliative Care To
The Nursing Home Resident

• Communication
• Prognosis
• Care planning
• Confidence in managing symptoms
• Support

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Improving End of Life Care for Patients Who Have
a Life Limiting Illness

• Aims of care should be
• To provide a mechanism to improve care given to
  patients at end of life
• To enhance communication between different care
  settings
• To discuss wishes for care with family and
  multidisciplinary team
• To provide a tool to improve implementation of
  advanced care planning

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Prognostic Criteria For Advanced Disease

• Any one of 3 criteria could trigger a
  patient to be considered to have palliative,
  supportive care needs
• Patient need or choice is for comfort care only
  and not for possible curative treatment.
• Use of the Surprise question would you be
  surprised if the patient was to die in the next
  year? If not, then they are likely to need
  supportive/palliative care.
• Patients have Clinical indicators of need for
  palliative care prognostic clinical indicators
  of advanced or irreversible disease to
  include 1 core and 1 disease specific indicator
• Gold Standards Framework Prognostic
  Indicator Guidance

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Beaumont Hospital Discharge Guidelines For
Patients Returning To Nursing Homes For
Supportive -Comfort Care ( Pilot Project)

• These are guidelines for the medical team based
  on the patients medical condition and wishes
  under the direction of the patients consultant
  doctor and should accompany patient when
  transferred.

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Section A

• CARDIOPULMONARY RESUSCITATION (CPR) Person has
  no pulse and is not breathing.
• ? Attempt Resuscitate (CPR) ? DO
  Not Attempt Resuscitation (no CPR)
• When not in cardiopulmonary arrest, follow B, C
  and D

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Section B

• MEDICAL INTERVENTIONS Person has pulse and/ or
  is breathing.
• ? Comfort measures Treat with dignity and
  respect
• Use medication by any route, positioning,
  wound care and other measures to relieve pain and
  suffering. Use oxygen, suction and manual
  treatment of airway obstruction as needed for
  comfort. Do not transfer to hospital for life
  sustaining treatment. Transfer only if comfort
  needs cannot be met in current location.
• ? Limited Additional Interventions Includes
  care described above. Use medical treatment and
  s/c fluids. Do not use intubation, advanced
  airway interventions, or mechanical ventilation.
• Transfer to hospital if indicated. Avoid
  intensive care
• ? Full Treatment Includes care above. Use
  intubation, advanced airway interventions,
  mechanical ventilation, and cardio version as
  indicated.
• Transfer to hospital is indicated. Include
  intensive care.
• Other instructions_______________________________
  ________________

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Section B

• This section allows discussion re level of
  medical intervention if the patient deteriorates.
• Comfort indicates a desire for only those
  interventions that enhance comfort . Transfer to
  hospital is indicated only if comfort needs
  cannot be met in current location
• Limited additional interventions, in addition to
  comfort measures e.g. s/c fluids, oral
  antibiotics as indicated. Transfer to hospital if
  indicated.
• Full treatment includes all care as above with no
  limitation of medically indicated treatment .

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Section C

• ANTIBIOTICS
• ? No Antibiotics
• ? Oral Antibiotics
• ? IV Antibiotics ( usually requires hospital
  admission, consider community intervention team
  if appropriate)
• Other instructions__________________________
  ____________

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Section C

• This section stimulates conversations about the
  goals of antibiotic use. Antibiotics often are
  life sustaining treatments. Advance care planning
  in the use of antibiotics can help clarify goals
  of care for the person and caregiver.
• Many families of patients with advanced
  progressive illness may prefer to have
  antibiotics withheld and want other measures such
  as a antipyretics and opioids to treat symptoms
  of infection and maintain comfort.
• Additional instructions can also be written
  Antibiotics may be used only as needed for
  comfort for example a urinary tract infection
  may cause discomfort for a dying patient.
  Treating the UTI with an antibiotic may serve as
  a comfort measure.

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Section D

• MEDICALLY ADMINSTERED FLUIDS AND NUTRITION Oral
  fluids and nutrition must be offered if medically
  feasible.
• ? No iv fluids
  ? No feeding tube
• ? S/c fluids for a defined trial period ?
  feeding tube for a defined trial period
• ? s/c fluids long- term if indicated ?
  Feeding tube long- term
• Other instructions_______________________________
  __________________

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Section D

• Oral fluids and nutrition must be offered if
  medically feasible, i.e. the patient is alert and
  able to swallow
• Goal of care may be allowing to eat and drink for
  comfort versus aspiration risk
• IV fluids may cause oedema, shortness of breath,
  and the need for frequent urination. At the end
  of life they can cause excess secretions
• s/c fluids may be considered for a defined trial
  period to see if this benefits the patient. ( s/c
  fluids will not alleviate dry mouth)
• If the patient is being tube feed this may be
  continued if there is no ill effects e.g.
  chestiness, aspiration and vomiting .

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Section E

• DISCUSSED WITH
• ?? Patient /Resident
• ???? Next of kin
• ?? Family member
• ?? Other
• ______________ (Specify)
• The Basis for These Orders is
• ?? Patients preferences
• ?? Patients best interest

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Section F

• ANTICIPATORY PRESCRIBING
• Oral medications
• 1) Paracetamol 1g 6 hourly P0/PR PRN for signs
  of pain, discomfort, Pyrexia
• 2) Diclofenac 100mg PR daily PRN for signs
  of pain or discomfort
• 3) Alprazolam 0.125mg PO 4 hourly PRN for signs
  of anxiety, dyspnoea
• 4) Oramorph 2mg PO 4 hourly PRN for signs of
  pain, dyspnoea

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Section F

• Subcutaneous medications ( where patients no
  longer able to take oral medications )
• 5) Morphine sulphate 2.5mg s/c 4 hourly PRN for
  signs of pain, dyspnoea
• 6) Midazolam 2.5mg s/c 4 hourly PRN for signs of
  agitation, restlessness
• 7) Hyoscine Butylbromide 20mg s/c 4 hourly PRN
  for signs of problematic upper airway
  secretions.

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Section F

• Medications
• ? Medications rationalized where possible to
  reduce tablet burden and where no longer
  appropriate given the patients condition and
  prognosis.

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Section G

• Nursing and Support services ( Primary,
  community continuing care providers)
• ? Liaise with hospital and community palliative
  care team as appropriate
• ? Liaise with community intervention team as
  appropriate
• ? Date of discharge confirmed with
  Patient/family and nursing home
• ? Confirmation that medications available in
  nursing home 24 hour prior to transfer
• ? Appropriate transport arranged and confirmed
• ? Fully comprehensive nursing discharge letter

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Case Scenario 2

• Mr Burns 78 year old nursing home resident.
• Background COPD, CCF, Vascular Dementia.
• Admitted to an acute hospital with infective
  exacerbation of COPD, 48hrs in A/E prior to being
  admitted to ward.
• Treated with iv antibiotics with little response,
  remained comfortable but weak, not eating or
  drinking, barely responsive
• Referral to Palliative care re symptom
  management, comfort care.

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Case Scenario 2

• Family meeting with multidisciplinary team. Given
  Mr Burns current state of health, failure to
  improve despite active treatment and his
  co-morbidities family and medical team in
  agreement most appropriate goal of care was
  comfort measures. Family keen for transfer back
  to nursing home as it had been his home for 5
  years.
• Discharge guideline used in consultation with
  family. Mr Burns for comfort measures only, for
  transfer back to hospital only if comfort
  measures cannot be met, advice given re
  symptomatic management
• Liaised with nursing home re goal of care,
  discharge guidelines.
• Transferred back to nursing home, died peacefully
  five days later.

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Example letter

• RE. Mr Ryan DOB 10 0ctober 1920
• Garda Retirement Home
• Raheny
• Dublin 5
• 29 May 2009
• Dear Doctor,
• Both Mr Ryan and his family have expressed a
  wish not to have Mr Ryan referred to the hospital
  for further tests or clinical management.
• He should only be transferred in the event
  of severe pain or haemorrhage or accident
  requiring acute hospital treatment.
• He is not for Resuscitation in the event of
  an acute cardiac event.
• Yours sincerely

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Confidence In Managing Symptoms

• Multidisciplinary involvement
• Liaise with hospital palliative care team if
  appropriate
• Referral to specialist community palliative care
  team where available
• Liaising with nursing home re plan of care
• Use of anticipatory prescribing
• Liaise with GP or relevant medical officer

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Confidence In Managing Symptoms

• Irish Hospice Foundation in conjunction with the
  Palliative Care Education Task Force is preparing
  a training programme for Nursing Homes Ireland,
  the representative organisation for the private
  and voluntary nursing homes sector.
• This training programme is seeking to establish a
  common multidisciplinary approach to level 1
  palliative care education in Ireland for nursing
  home staff.

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References

• Department of Health and Children. Report of the
  National Advisory Committee on Palliative Care
  (2001)
• McCormack P Kennelly S (2008) Care delivery in
  the most appropriate setting?. Experience of
  Connolly Hospital Liaison Medicine for the
  Elderly Service. www.nhi.ie .
• Palliative Care For All (2008) Integrating
  Palliative Care into Disease Management
  Frameworks. The Irish Hospice Foundation. Health
  Service Executive.
• World Population Ageing 1950-2050, Chapter iv
  Population Division, DESA, United Nations
• WHO

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Additional information

• Alvin H. Moss (2004) Respecting Patients Wishes
  at the End of Life. Physician Orders for scope of
  Treatment www.wvendoflife.org
• Centre to Advance Palliative Care (2007)
  Improving Palliative Care in Nursing Homes.
• Centre For End-Of-Life-Care (2006). Robert C Byrd
  Health Services Centre Of West Virginia
  University. www.wvendoflife.org
• The Irish Hospice Foundation Annual Report,2008
• www.goldstandardsframework.nhs.uk