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End of Life Train the Trainer 1

Westin Wall Centre HotelDecember 9, 2010

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End of Life MOA role

Pat Porterfield, Josefa Kontogiannis

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Getting started… what is the palliative approach?

• Expanded definition of the End of Life.

• Guided by an understanding of the illness progression.

• Assists in understanding the transition of illness from cure to symptom control.

• Improves quality of life in all life-limiting illnesses.

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End of Life Module: MOA Role

Identification• Flagging• Gut feeling• Surprise Question• Things you are noticing

Care management• Planning• Registry• Tools• “Paperwork”

Assessment• Communication• Tools: ESAS,

pain diaries etc. Engaging family

Engaging community

• Huddles, pertaining to overall plan

• Patient specific huddles

• Processes• Billing

Office methodology

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Identification: Surprise question

Would you be surprised if this patient will die within the next year??? This question will be the physician’s “trigger”… how can you help?

• What are the signs to look for? What are the questions to ask yourself?

• What are the steps to take when you start answering “No” when thinking of certain patients?

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Identification - what changes do you see?..... Flagging• Changes in appearance.• Missing appointments.• Admissions to Long Term

Care or multiple hospital visits or even frequent doctors visits.

• Family members expressing concern, wanting to talk to the doctor about them.

• Changes in behaviour.• Changes in gait.• Decrease in ability to care

for themselves.• Changes in

communication.• Gut feeling.

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Registry

What is it?• A list• A database

What is it used for?• Tracking• Maintaining• Follow up

What types are there?• Paper list• Excel spreadsheet• Binder• Flagged chart

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Care management: Tools for toolkit

• Care plan template.

• EOL care MOA flow sheet.

• My Voice (Advance Care Plan).

• No CPR form.

• BC Palliative Care Benefits Program form.

• Employment Insurance Compassionate Care Benefits form.

• Notification of Expected Death in Home form.

• Death certificate.

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Assessment

Using the assessment tools:

• Palliative Performance Scale (PPS)

• ESAS: Screening for Distress

– When?

– How?

• Pain and Symptom Diary

• Seniors Assessment Tool

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Engaging family• Who are the primary contact people?

• Current contact information of all parties.

• Ensuring contact with family

– How is the family managing with caregiving?

– What can you say? What can’t you say?

• Following patient’s death, contacting family

– What family needs to do after death?

– Family members that aren’t actual patients, how are they seen or informed?

– Discuss your possible roles in making bereavement calls or cards.

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Engaging with community

• Identify resources available in the community and how to contact them

– Home and Community Care - professional team and HSW.

– Specialized palliative care services.

– Community supports: hospice societies, caregiver support services, transport, meals, etc.

• Create an information package for patients and families

– Work with community providers to develop a kit for patients …identify written materials and on-line sites.

– Where are additional resources found: local libraries, resource centers.

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Websites to obtain important forms

• BC Palliative Care Benefits Program application form

https://www.health.gov.bc.ca/exforms/pharmacare/349.pdf

• Employment Insurance Compassionate Care Benefits

http://www.servicecanada.gc.ca/eng/ei/publications/compassionate.pdf

• Notification of Expected Deathhttp://www.health.gov.bc.ca/hcc/pdf/expected_death.pdf

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Office methodology: Things to ponder…..

• When will your meetings be?

• Who fits “The Surprise Question”?

• What will your registry look like?

• Where will your toolkit be kept?

• What else can you add to your toolkit?

• What supports do you need?

• What other tools will help you?

• What’s in your community?

• What is your billing process?

• Your comfort level, how do you feel about this?

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Thanks and feedback

We would appreciate your contact information so that we can keep in touch with you and further support your implementation of this work.