22nd Annual Manitoba Provincial Hospice & Palliative Care Conference

September 26, 27, 2013Winnipeg, Manitoba

Is There a Role for the Registered Psychiatric Nurse on the Palliative Care

Team?

Faculty/Presenter Disclosure

Speaker:

Debra Dusome R.N., B.A. (Hons.), Ex.A.T., M.A.

Relationships with commercial interests:Other:

Debra is an Assistant Professor in the Faculty of Health Studies at Brandon University and

teaches in the Bachelor of Science in Psychiatric Nursing Program

Disclosure of Commercial SupportThis presentation has received no

financial support

This presentation has received no in-kind support

Potential for conflict(s) of interest:

Brandon University does seek placement opportunities for their B.Sc.P.N. students

Mitigating Potential BiasAlthough I may visit potential clinical

placement sites to assess whether sites can meet student learning objectives, I do not personally arrange and negotiate student placements

Student placements are arranged through the Brandon University Clinical Co-ordinators: Betty Wedgewood and Jacqueline Pentney

All placements are negotiated using HSPnet and employers always have the right to accept or decline requests

Learning Objectives:1. Participants will learn about the Brandon

University Psychiatric Nursing Curriculum2. Participants will learn about the skill set of

Registered Psychiatric Nurses3. Discussion of needs of individuals with

Serious Mental Illness in the Palliative Care Setting

4. Mental Status Examination – Assessing for Depression and Suicide Risk in the Palliative Care Setting

5. Intervention strategies to manage depression and suicidal thoughts

6. Open dialogue about preparing students for Palliative and Hospice Care work

7. Respond to questions from participants

Curriculum – Year OnePre-Psychiatric Nursing Year

Health Promotion: Developmental Transitions Throughout the Lifespan

Fundamentals of Psychiatric Nursing Practice I

Introduction to Interpersonal CommunicationIntro PsychologyIntro SociologyThe Sociology of Medical SystemsHuman Anatomy and PhysiologyIntroduction to Statistics/Data

Analysis/Fundamentals of Psychological Research/Social Research Methods

Curriculum – Year TwoFundamentals of Psychiatric Nursing

Practice II (Lab)Principles of Health Assessment (Lab)PsychopharmacologyFundamentals of Psychiatric Nursing

Practice III (Lab)Integrated Practicum I (3 weeks)Principles of Individual Counselling (Lab)Medical Nursing for Psychiatric Nurses

(Clinical 1 day/wk for the Winter Term)PsychopathologyIntegrated Practicum II (3 weeks)

Curriculum – Year ThreePsychiatric Nursing for Elderly PersonsIntroduction to Palliative CareCommunity Health (Field Work)Therapeutic Groups (Lab)Acute Mental Health Challenges IFamily Counselling (Lab)Developmental Challenges (Field Work)AddictionsInterpersonal AbuseIntegrated Practicum III (6 weeks)

Curriculum – Year Four

Psychiatric Nursing with Children and Adolescents

Psychiatric Rehabilitation and Recovery (Field

Work)

Philosophical Perspectives for Practice

Introduction to Health Research Methods

Leadership in Professional Practice

Contemporary Perspectives on Professional

Health Issues

Integrative Clinical Practicum (8 weeks)

Skill Sets

Infection Control (includes hand hygiene, personal protection gear, universal/routine precautions & practices)

Vital Signs Oxygen Therapy Airway Management (includes

inserting airways, suctioning, mouth care, tracheostomy care and tracheostomy suctioning)

Mobility and Safety Hygiene Elimination (includes specimen

collection, urinary and bowel care, ostomy care, cathether insertion, care and removal)

Nutrition (includes assisted feeding with dysphagia, tube feeding and medication administration via jejunostomy or gastrostomy tubes)

BU, BScPN Fundamental Psychiatric Nursing Skills Portfolio (2012)

Intravenous Therapy (includes calculation of flow rates, maintenance and care of peripheral I.V’s gravity fed and via pump, regulating I.V. flow, discontinuing peripheral I.V.’s, changing solutions and tubing and discontinuing peripheral I.V.’s)

Wound Care (includes sterile technique, dry dressings and packing, wound irrigation, assessment, prevention and treatment of pressure ulcers, suture and staple removal, and hydrocolloid dressings)

Documentation Medication Administration (all

routes, cannot give I.V. medications as students)

Health Assessment (includes full systems assessment including mental status exam and the mini-mental status exam to assess cognitive functioning)

Blood Sugar Monitoring Post Mortem Care

Introduction to Palliative Care CourseCourse DescriptionThis course is a 1.5 CH course that meets 1.5 hours per

week for 12 weeks with a group presentation requirement. Students in this course will gain knowledge of the principles of palliative care for persons with life threatening and life-ending illnesses. Emphasis is placed on understanding within a familial context from the perspective of an interdisciplinary team. Students have the opportunity to explore their own beliefs and values about living and dying and to examine how their own experiences contribute to their professional practice role in palliative care.

Course TextZerwekh, J.V. (2006). Nursing care at the end of life: palliative care for patients and families. Philadelphia, PA:F.A. Davis.

The Hospice Family Care-giving Model

Zerwekh, (2006)

Course Topics

The Context of Palliative Care

Historical Evolution of Palliative Care

Sustaining Yourself as a Nurse

Palliation in Severe and Persistent Mental Illness

Children Facing Death

Cultural Humility in Palliative Care

Communication in Palliative Care

Legal and Ethical Issues in Palliative Care

Symptom Management (Pain)

Management of Physical Non-Pain Symptoms

Strengthening the Family

Spiritual CareThe Final HoursPersonal Reflections

and Learnings Regarding the Role of the Psychiatric Nurse in Palliative/Hospice Care

W.R.H.A. Tool Kit Re: Staff Mix

Identifying Potential Areas of Practice for RPN’s

“At a 2009 meeting of the W.R.H.A. Nursing Leadership Council, discussions regarding the appropriate utilization of R.P.N.’s within the health care system in Winnipeg resulted in the agreement that other patient populations would benefit from the addition of a RPN to the health care team.”

Tool Kit for the Introduction of Registered Psychiatric Nurses in Non-Identified Mental Health Settings – Introduction and Background, Feb. 2011.

Staff MixDecisions as to the appropriate staff mix for a

particular unit, program or service and the potential benefit of introducing a RPN role are complex and need to consider a number of factors including:

Needs of the patient population (for example, prevalence of mental health issues, complex family dynamics, need for psychosocial interventions and therapies. etc.)

Scope of practice of the LPN, RN and RPNScope of practice of other health care providers on the

current health care teamEnvironmental factors (for example, practice supports,

consultation resources, and the stability/predictability of the environment) (CLPNM, CRNM, & CRPNM, 2010; College of Nurses of Ontario, 2009) Tool Kit Feb. 2011.

Populations that are Underserved in Palliative Care

People with Serious and Persistent Mental Illness

People with Intellectual Disability

People experiencing Dementia

People with Significant Substance Abuse and

Dependence

Individuals who are Homeless

People who are IncarceratedBaker (2005), Woods et al. (2008), Goldenberg et al. (2000), Foti,

(2003), Webber (2012), Cross et al. (2012), McGraft & Jarrett (2007), Ellison (2008), Albisson & Strang (2003),Aminoff & Adunsky (2005), Diwan et al. (2004), DRC (2006), McCarron & McCallion (2007), Robinson et al. (2005), Davis & Bucknell, (2011), Hughes, (2001).

Barriers to Access to Palliative CareCare provider concern that they do not have the

theoretical and practical skill sets to work with these populations of individuals with specialized needs

Issues related to competency re: consent for treatment, making informed decisions and designating substitute decision makers

Communication issues i.e., individuals who are non-verbal or who possess limited speech, individuals who experience ongoing delusional thinking and hallucinations who are difficult to engage in conversation related to illness and/or issues of trust

Behavioural issues: concerns that patients may be aggressive, elopement risks, non-compliance with treatment and odd behavioural presentations

Reciprocal StigmaMcCasland (2007), Cross et al. (2012), Foti (2003), Baker (2005),

Woods et al. (2008), Goldenberg et al. (2000), McGrath & Jarrett (2007)

Stigma During End-of-life Care“Individuals with a terminal illness in psychiatric facilities

can have multiple stigmatized social identities as they are not only considered mentally ill, but are often imprisoned, aged, and have other illnesses or disabilities apart from the fact that they are also dying. The impact of multiple stigmatising social identities may affect not only the institutionalized individual with a mental illness seeking end-of-life care but also the service providers who care for them.”

The Park Centre for Mental Health StudyFor many staff had become family – reluctance to move

patients to unfamiliar settingsPalliative Care Consultation – desire for more on-site

supportReciprocal stigmaMcGraft, P. & Jarrett, V. (2007). The Problem of Stigma during End-of-life

Care at a Psychiatric Institution. International Journal of Psychosocial Rehabilitation. 11 (2), 19-30.

Palliative Care and the Seriously Mentally Ill

SchizophreniaBipolar DisorderMajor DepressionDementiaSchizoaffective Disorder

Significant Substance Abuse/Dependence

Personality Disorders/Complex PTSDAnorexia NervosaCo-Occurring Disorders

The Prevalence of Medical Illness in People with Mental Illness

People with mental illness have high mortality and morbidity rates associated with high suicide rates, accident rates and the incidence of alcohol and drug problems

This population also has high rates of unrecognized medical disorders and consequent neglect of physical problems

Late diagnosis and early death is considered to be a normal statistic for people with SPMI

Hahm & Segal (2005), McCasland (2007), Foti (2003),Ellison (2008), Davie (2006), McGrath et al, (2004), Goldenberg et al. (2000), Woods et al., (2008)

Needs of Individuals with Serious Mental Illness in the Palliative Care Setting

Engaged treatment relationship with people they know and trust as much as possible

Earlier identification of medical illnesses and treatment Cross-training of palliative care and mental health care

providers Involvement as much as possible in end-of-life decisions

with use of both psychiatric advance directives and end-of-life medical care advance directives

Education, care, support, assistance, and bereavement counselling by providers who value collaboration, advocacy and research

Access to compassionate end-of life care in a variety of settings (ideally involving client choice)

Woods et al. (2008), Baker, (2005),Goldenberg et al. (2000), Tate & Longo (2005), Foti (2003), Webber (2012)

Serious Mental Illness and the Capacity to Make Decisions Regarding End-of-Life Care

“Do It Your Way” : A Demonstration Project on End-of-Life Care for Persons with Serious Mental Illness – Foti, M. E. (2003)

End of Life Care for People with Mental Illness – Inner City Health Associates, Toronto, Mission Hospice Program, Ottawa Inner City Health, Florida, U.S.A. “Just-Do-It” approach – Webber, T. (2012)

Service Delivery Settings for Individuals with Serious and Persistent Mental IllnessHospice/Palliative Care UnitsLong Term Care Units in Psychiatric InstitutionsLong Term Care Units In Nursing Home, PCH Settings Psychiatric Rehabilitation Group HomesOwn Homes with Intensive Psychiatric Support &

Palliative Home Care SupportHome of Family Members or Significant OthersCombination Medical/Psychiatric UnitsOn the Street (Shelter and Mobile Services)**Majority of research does not support palliative care

delivery on acute psychiatric unitsBaker (2005), Davie (2006), Foti (2003),Goldenberg et al. (2000),

Hughes (2001), McCasland (2007), Woods et al. (2008), Webber (2012)

Recommended Reading

Bartok, Mira, (2011). The Memory Palace. Free Press, Simon & Schuster, Inc., New York: N.Y.

Depression Experienced by Individuals Receiving Palliative CareDepression is common in hospice and palliative care

settings with prevalence ranges of 1% - 42% and 0% - 58% in patients with cancer, a rate 4x’s that of the general population, other studies have rates of 25% - 50%

Under recognition leads to under treatment and unwanted outcomes

Depression can interfere with an individual’s capacity to understand his/her situation, make decisions, interact with caregivers and to reach final goals

Those with depression have increased illness severity and pain and depression increases the risk of suicide

Irwin et al. (2008), McCabe et al. (2012)

Mental Status Assessment General Description Attention Span: digit repetition

forward and backward Orientation: time, place,

person Memory: good, fair, poor Fund of Knowledge: good, fair,

poor Judgment: good, fair, poor Insight: good, fair, poor Thought Processes: including

conceptual ability, organization, speed/flow, content, delusional ideations, preoccupations, affect, and mood

Perceptual Disturbances: including hallucinations; auditory, visual, gustatory, olfactory, tactile and command, illusions, déjà vu, depersonalization, and derealization

Motor Activity Disturbances: agitation, catatonia, tremors, mannerisms, retardation, stereotypy

Coping/Stress Tolerance: identification of current stressors and coping skills and strategies

Aggression Potential: high, moderate, or low

Suicide/Lethality: high moderate or low

Summary of Mental StatusMini-Mental Status Examination: Assess cognitive functioning

Assessing for Depression and Suicide Risk in Palliative Care

Explore DSM-IV-TR criteria for depression i.e. at least 2 weeks depressed mood or loss of interest and at least four additional symptoms of depression; changes in appetite or weight, sleep, and psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty thinking and concentrating or making decisions, recurrent thoughts of death or suicidal ideation, plans or attempts to commit suicide. The symptoms must be different from person’s pre-morbid state and must persist for most of the day, every day for at least two weeks.

In Palliative Care recognize that somatic symptoms are less reliable as they often overlap with symptoms related to terminal illness

Use of instruments to measure levels of depression

Suicide Risk and Lethality Assessment Are there current thoughts of suicide? How often do these

thoughts occur? Assess for feelings of hopelessness, helplessness, worthlessness and guilt. Does the individual feel they are a burden to others?

Does the individual have a plan? How detailed is the plan? Has the person made plans to avoid discovery?

Is the individual seeking death or a relief from suffering? Does the individual have the means to complete the plan? How lethal is the methodology i.e. use of guns, hanging, jumping,

CO2 poisoning, drug overdose, cutting, deliberate car accident ? Does the individual have a past history of suicide attempts and/or

history of previous depression? What happened related to past attempts? Does the individual have access to drugs and/or alcohol and are they regularly under the influence of these substances?

Has a significant other successfully completed suicide? Is there anything that prevents individual from acting on thoughts

i.e. doesn’t want to hurt loved ones, religious beliefs, stigma associated with suicide, loss of insurance for family?

Suicide Risk and Lethality Assessment (cont.)

Is there estrangement or family conflict? Does the individual fear abandonment by significant others or

care-givers due to increased level of dependence and care required?

Is the individual experiencing pain and/or other illness symptomatology that is untenable and/or frightening i.e. nausea, failing cognition, air hunger, terminal restlessness, loss of bowel and bladder control, ability to swallow? Does the individual feel their life no longer has dignity? How does the individual imagine his last days or hours? Are these perceptions accurate?

Is the person experiencing a loss of a sense of self? Is the individual frightened of dying and the letting go of control?

Do they fear retribution for past sins or transgressions? Is the person angry and if so what is the anger related to? Is there

the potential for aggressive behaviours towards self and others? LISTEN, LISTEN, LISTEN

Intervention Strategies to Manage Depression and Suicidal Thoughts

Identify if individual is at significant risk of harming self or others and inform treatment team so that additional support and observation can be given in addition to developing safety plans for individual and others – referral for psychiatric consultation

Does assessment indicate underlying depression that may respond to treatment – if yes – referral for psychiatric consultation

If individual has detailed plan and means – remove means if possible

Address suffering – Ask individual what they think might help and assist with suggested interventions

Work on affirming life affirming beliefs and valuesAddress family estrangement and conflict if possible and

individual is supportive of this intervention

Intervention Strategies to Manage Depression and Suicidal Thoughts (cont.)Address fears of abandonment and feelings about loss of

control and increased dependencyAllow as much room for autonomy and choice in making

end of life decisions – act as an advocate for the individual with the treatment team and significant others

Provide options i.e. referral to spiritual care, Dignity Therapy, involvement in preparatory bereavement groups, an opportunity to express self through the arts, ongoing 1:1 engagement or counselling to facilitate expression of feelings and to let individual know they are not alone, visits from Artists in Healthcare, palliative care volunteers, opportunities for sharing life review with others

Provide positive outlets for the expression of angry feelings

Assist and support in the saying goodbye process

Intervention Strategies to Manage Depression and Suicidal Thoughts (cont.)Talk about fears of dying for clarification of

what individual concerns areProvide education re: what will be experienced

in the last weeks, days and hours and indicate what comfort measures can be provided

If medication is ordered, administer as ordered and provide psycho-education re: expected effects, possible side effects and monitor individual response to treatment and maintain ongoing 1:1 engagement – treat individual as collaborative partner in care

Distinguishing Depression from Preparatory GriefDepression Preparatory Grief

Appetite & weight changes, fatigue, low energy, sleep disturbances & sexual dysfunction

Persistent flat affect Negative self-image Anhedonia Hopelessness, tearfulness Prolonged social withdrawal Ongoing persistent agitation Active desire for early

death, suicidal ideation and plans

Decreased ability to concentrate and make decisions

Appetite & weight changes, fatigue, low energy, sleep disturbances & sexual dysfunction

Mourning the multiple losses associated with dying

Intense grieving that comes in waves, temporary social withdrawal

Grieving individuals usually maintain a normal sense of self-esteem

Still experience pleasure in connecting with others and look forward to special events

Maintain a sense of hope Desire for continuing social

interactionPeriyakoii & Hallenbeck (2002), Axtell, (2008), Noorani & Montagnini (2007)

Intervention Strategies to Manage Anxiety in the Palliative Care Setting Spend 1:1 time with individual to explore anxiety i.e. fears,

specific triggers, past history of anxiety, previous treatment interventions – which ones worked

Explore previous coping strategies for managing anxiety and support individual to use effective interventions

Teach self-soothing , grounding strategies, mindfulness-based stress reduction techniques, relaxation therapy, meditation, use of music, lullabyes, singing

Address specific fears and concerns similar to interventions on previous slides i.e. are they specifically related to the dying process?

Assess whether anxiety is related to loved ones left behind re: emotional, financial security etc. these may be very valid fears – assist to plan for care of loved ones – referral to social worker on team

Possible psychiatric consultation and medication assistance – administer and monitor effectiveness of medication – provide education to individual about medication – act as a collaborative partner in care

Ideological Interface of Palliative Care and Psychiatric/Mental Health Care

McGrath, P. & Holewa, H. (2004) Person-centered practiceRelationship-based connectednessBelief in compassionate, holistic careRespect for autonomy and choiceQuality of Life issuesFamily as the unit of careNeed for democratic multidisciplinary

team work – flat structureNeed of special personality attributes for

staff

Similarities Between Psychiatric Nursing and Palliative Care Nursing

Cutcliffe, J. R. et al. (2001)

Psychiatric NursingPalliative Care

Nursing Holistic, biopsychosocial

and spiritual approach Recovery oriented focusing

on best QOL i.e. finding a meaningful life path in spite of chronic illness – focus on care VS cure

Focus on psychosocial, emotional needs

Primacy of the nurse/client relationship and therapeutic use of self

Support individual autonomy and decision making

Holistic, biopsychosocial and spiritual approach

Active total care of patients whose disease is not responsive to curative treatment

Focus on symptom control and management enabling best QOL and meaningful experience until death

Focus on psychosocial, emotional needs

Relationship is one of the essential tenets of care

Support individual autonomy and decision making

Similarities Between Psychiatric Nursing and Palliative Care Nursing (cont.)

Cutcliffe, J. R. et al. (2001)

Psychiatric NursingPalliative Care

Nursing Connecting with individuals

who are distressed and suffering

Focus on ‘being with’ rather than ‘doing for’

Primacy of providing non-physical psychosocial support

True ‘presence’ with individual and family required

Use of intuitive knowing Focus on the

phenomenological understanding of the person and their world

Collaborative relationship in which care is negotiated

Connecting with individuals who are distressed and suffering

Focus on ‘being with’ rather than ‘doing for’

Primacy of providing both physical and non-physical psychosocial support

True ‘presence’ with individual and family required

Use of intuitive knowing Focus on the

phenomenological understanding of the person and their world

Collaborative relationship in which care is negotiated

Dignity Therapy and Recovery

Narrative

Psychiatric Nursing Skills Sets Related to Palliative Care

StrengthsAreas for Further

DevelopmentCommunication and

counselling skills for individuals, families and groups

Specialist knowledge re: mental illness, developmental challenges, addictions, forensic nursing, addictions, interpersonal abuse and psychosocial rehabilitation and recovery

Increased knowledge re: pain management and pharmacological interventions in palliative care

Increased knowledge re: life-threatening and life–ending illnesses

Dialogue

Questions ???

ReferencesA Reference Sheet Handout will be available to all participants.