Caring For A Patient With Palliative Care Needs in The Nursing Home Setting

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Caring For A Patient With Palliative Care Needs
in The Nursing Home Setting

• Catherine Dunleavy
• Tara Winthrop Private Clinic

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Standard 16 HIQA 2009

• HIQA Regulations

• Standard 16

Each resident continues to receive care at the
end of his/her life which meets his/her physical,
emotional, social and spiritual needs and
respects his/her dignity and autonomy.
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Aims Objectives

• Overview of Dementia
• Case History to Demonstrate Typical Palliative
  Care in Nursing Home Setting
• HIQA and Palliative Care/ End Of Life Care.

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Dementia Palliative Care

• Dementia is a syndrome affecting 35.6 million
  people worldwide. There is deterioration in
  cognitive function (i.e. the ability to process
  thought) beyond what might be expected from
  normal ageing. It affects memory, thinking,
  orientation, comprehension, calculation, learning
  capacity, language, and judgement. Consciousness
  is not affected. (WHO 2012)

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Stage of Dementia

• Stage 1 Normal
• Stage 2 Normal aged forgetfulness
• Stage 3 Mild cognitive impairment
• Stage 4 Mild Alzheimer's disease
• Stage 5 Moderate Alzheimer's disease
• Stage 6 Moderately severe Alzheimer's disease
• Stage 6 Moderately severe Alzheimer's disease
• Stage 7 Severe Alzheimer's disease

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When Does Palliative Care Begin

• On Admission to Nursing Home

• When Resident Deteriorates

• Facilitates advanced care planning for the future
  medical and nursing needs of the resident.
• Ensures the resident receives the appropriate
  treatment in the appropriate place ant the
  appropriate time

• Change Alert requires review of care plan and
  triggers the discussion/treatment
• Following readmission from hospital
• When it is too late.

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James

• Age 76
• Advanced Lewy Body Dementia
• Depression
• Enlarged Prostate
• Long Term Catheter
• Admitted 2005 immobile and fully dependent with
  all Adls

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Murray et Al, 2005
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Acute Episode Trajectory
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When Does Palliative Care Begin ?

• May 2010 following Acute Episode Aspiration
  Pneumonia
• Nursing Home Comfort Care Plan/End Of Life
• On Admission

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End Of Life

• Patients are approaching the end of life when
  they are likely to die within the next 12 months.
  
• This includes patients whose death is imminent
  (expected within a few hours or days) and those
  with
• advanced, progressive, incurable conditions
• general frailty and co-existing conditions that
  mean they are expected to die within 12 months
• existing conditions if they are at risk of dying
  from a sudden acute crisis in their condition
• life-threatening acute conditions caused by
  sudden catastrophic events

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Name of GP/ Medical Officer with whom this plan discussed  
Name of Director of Nursing / Clinical Nurse Manager with whom this plan discussed  
Name/s of family members with whom this plan discussed     Diagnosis 
The basis for these orders is ? Patients preferences ? Patients best interest
    Section A   Check One Box Only   CARDIOPULMONARY RESUSCITATION (CPR) Person has no pulse and is not breathing.   ? Attempt Resuscitate (CPR) ? Do Not Attempt Resuscitation (no CPR)   If DNR, letter for ambulance crew When not in cardiopulmonary arrest, follow B, C and D  
    Section B   Check One Box Only MEDICAL INTERVENTIONS   ? 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. Refer to Section C re antibiotic care plan. Refer to Section D for nutrition and fluid plan. 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. Refer to Section C re antibiotic care plan. Refer to Section D for nutrition and fluid plan. 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 cardioversion as indicated. Transfer to hospital is indicated. Include intensive care. Other instructions_______________________________________________  
  Section C   Check One Box Only   ANTIBIOTICS ? No Antibiotics ? Oral Antibiotics ? IV Antibiotics ( usually requires hospital admission, consider community intervention team if appropriate) Other instructions_______________________________________________        
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    Section D   Check One Box Only in Each Column   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 (e.g. alternative hand-feeding care plan in place if appropriate)_________________________       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 (e.g. alternative hand-feeding care plan in place if appropriate)_________________________    
    Section E ANTICIPATORY PRESCRIBING Please be aware of special circumstances which might require different drugs- use clinical judgement   Oral medications   Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort pyrexia   Diclofenac 100mg PR daily PRN for signs of pain or discomfort   Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea   Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea   Subcutaneous medications ( where patients no longer able to take oral medications )   Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea   Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness   Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions.     ANTICIPATORY PRESCRIBING Please be aware of special circumstances which might require different drugs- use clinical judgement   Oral medications   Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort pyrexia   Diclofenac 100mg PR daily PRN for signs of pain or discomfort   Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea   Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea   Subcutaneous medications ( where patients no longer able to take oral medications )   Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea   Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness   Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions.    
  Medications   ? Medications rationalised where possible to reduce tablet burden and where no longer appropriate given patients condition and prognosis.   Medications   ? Medications rationalised where possible to reduce tablet burden and where no longer appropriate given patients condition and prognosis.  
    Section F Nursing and Support services ( to be organised by hospital medical nursing team where patient is being discharged from hospital or if patient being transferred from nursing home to hospital)   ? Liaise with hospital palliative care team ? 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 hours prior to transfer ? Appropriate transport arranged and confirmed, DNR letter for ambulance crew ? Fully comprehensive nursing discharge letter   Nursing and Support services ( to be organised by hospital medical nursing team where patient is being discharged from hospital or if patient being transferred from nursing home to hospital)   ? Liaise with hospital palliative care team ? 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 hours prior to transfer ? Appropriate transport arranged and confirmed, DNR letter for ambulance crew ? Fully comprehensive nursing discharge letter  
    Section G Specialist Palliative Care Input To be completed by specialist palliative care only   ? Patient seen in Hospital ? Patient for Community Palliative Care from Location __________________________________________ ? Patient not for Community Palliative care Medical Officer can contact appropriate Community Palliative Care service for advice   Specialist Palliative Care Input To be completed by specialist palliative care only   ? Patient seen in Hospital ? Patient for Community Palliative Care from Location __________________________________________ ? Patient not for Community Palliative care Medical Officer can contact appropriate Community Palliative Care service for advice  
        Date_______________________________     Review Date( 3 months)__________________   Signature ________________________________ (GP/Medical officer) Signature____________________________________ (Director of Nursing)  
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Care of James from 2010-2013

• Symptom Management
• 3 Monthly Reviews(full comprehensive assessment,
  must, pain scales, waterlow, care plan review,
  comfort care plan, manual handling, bed rail
  risk, medication reconciliation ,evaluation
• Acute episode in June 2013 change in appetite.
• RIP in November 2013

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End Of Life Care

• Skin Care
• Eye Care
• Mouthcare
• Positioning
• Hygiene Needs
• Bowel Care

Agitation    
Nausea / Vomiting Nausea / Vomiting  
Respiratory difficulties Respiratory difficulties Respiratory difficulties
Rattly respirations Rattly respirations  
Pain    
Subcutaneous cannula check Subcutaneous cannula check Subcutaneous cannula check
Subcutaneous infusion check Subcutaneous infusion check Subcutaneous infusion check
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End Of Life Care

• Psychological Support
• Explanation of procedures
• Information Updates and Time for Questioning

• Spiritual Needs Met
• End Of Life Wishes known and Discussed
• Preferences and traditions known and respected.

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The Journey Through Death and Dying Families
Experiences of the End-of-Life Care in Private
Nursing Homes

Our research suggests a strong culture of good
practice within private nursing homes, which
provide a home from home for elderly residents
and enable relatives to be with their loved one
at the end of life stage. The report further
demonstrates that, where an end-of-life care plan
is implemented in partnership with family
members, an outcome of good quality care at the
end of the residents life can be achieved.
Dr. Mel Duffy 2014
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Palliative Care For All

• Standard 2.4
• Each resident with a life-limiting condition or
  life threatening illness receives care and
  support, which maintains and enhances their
  quality of life, meets their needs and respects
  their dignity.
• 
  HIQA 2014

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HIQA

• Residents wishes
• Referrals to Palliative Care
• Staff Training
• Choice of Place of Death
• Family facilitated
• Procedures to be followed following death
• Staff and resident support
• Participation in Decision Making

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Duty of Care
The residential service has facilities in place
to support end-of-life care so that a resident is
not unnecessarily transferred to an acute setting
except for specific medical reasons, and in
accordance with their wishes.
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Take Home Message

• Dementia is a Terminal Illness
• Recognising that Palliative care should begin
  when residents enter the nursing home setting.
• Engagement is the key to successful palliative
  care for all.

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