End of Life Care

Mrs. Rogers

• If Mrs. Rogers came back into the hospital with worsening CHF that was determined to be end-stage, what would you do? What priorities would you have?

The Whole Pie• Patient• Family• Nurse• Palliative care• Hospice care

All important pieces to the end of life pie

The Patient

• The most important slice in the care at the end of life

• The patient has the control over how they want to die

• If the patient is not at terms with the future, blocks might be put up

The Family

• The family is important to the patient and in turn an important slice of the pie

• When treating the patient for end of life care, the nurse (or physician) are also treating the family

• If the family is not at terms with what the patient has chosen, blocks may also be put up

The Nurse

• The nurse knows what is needed to comfort a patient and the family

• Trained to support all parts of a family and respect the patient’s wishes

Palliative Care

• Palliative care is the “medical specialty focused on relief of the pain and other symptoms of serious illness.”

• The purpose is to avoid and aid in the pain and distress for the patient while being able to offer the best possible quality of life for them and their families.

http://www.getpalliativecare.org/whatis

Palliative Care

• Is appropriate at any point in a serious or life-threatening illness.

• Prognosis has no bearing on palliative care being able to occur.

• One can receive palliative care at the same time as they are receiving life-saving or curing care

PHS Palliative Care

• Dr. Arlene Bobonich & Sarah Beam, CRNP are our palliative care team for PHS

• 231-8349• Rosemary Schaefer-Administrative

Assistant-Answers phone calls during day

• Not available yet at CGOH• At HH, can be a nurse-nurse consult

PHS Palliative Care-Mission

• Palliative Care is a unique program that focuses on the comprehensive management of the physical, emotional, social, & spiritual needs of patients & their families living with progressive, life-limiting illnesses, regardless of life expectancy or treatment options.

PHS Palliative Care Checklist

Hospice Care

• Usually need a diagnosis of a terminal illness with anticipated death within 6 months

• Can be hospital or home based

• Does incorporate palliative care into hospice care

• No longer seeking curative treatment

Patient-Family Decision Making

• Family Conference Form

• Level of Intensity• Turning off ICD• Cultural issues

Family Conference Form

• Developed to use with any family meeting discussing a patient’s condition, care, etc.

• Can be used by case management, physician, nursing, etc.

• Helps to determine proper hospital course & care

Level of Intensity (LOI)

• Determines what “heroic” or “life-saving” interventions are warranted

• Can be determined by the patient, POA, or family when patient is unable to make their own decisions

• Can also be determined by the physician when no other avenues are available

• Level I-IV• Level II-IV (considered DNR)

DNR Armband

• Don’t forget, we now have a purple DNR armband for patients

• This means the patient is not a LOI I

• If you notice a purple DNR armband on your patient, go to the chart and look at the LOI sheet for specifics on what LOI the patient is and what is or not to be done

Turning off the ICD

• The decision to turn off the ICD is one of great discussion

• Should be patient driven• Turning off the ICD does not turn off

the Pacing function– The patient will not immediately die when

the ICD is turned off– This just means, they won’t get shocked for

fatal rhythms (VT/VFib)– The patient can live for some time after the

ICD is turned off as long as not fatal rhythms occur

Cultural Issues

• The patient’s culture can play a role in deciding how to treat the patient at the end of life

Mrs. Roger’s Culture

• Mrs. Rogers is Hispanic– Large family– Close knit

• Her entire family must be included in health promotion and health teaching to increase compliance with health prescriptions and interactions

Mrs. Roger’s Culture

• Mrs. Rogers will be expressive of her pain • Prayers and lighting candles are traditional healing

practices • Her culture believes it is insensitive to tell a person

the he/she is dying, as it inspires a sense of hopelessness and hastens the process

The Use of Touch

• The use of touch with palliative care and hospice patients has been in debate for some time

• There are few studies large enough to prove a point

• It has been shown to decrease pain, anxiety, and nausea among other unpleasant side effects with cancer patients

The Use of Touch cont’d.

• Could the use of touch help CHF patients?

• Outcomes anticipated – Improved patient outcomes:

Reduced pain & anxiety– Process improvement: Added

dimension to PHS Palliative Care Program

– Reduced cost: Potential to reduce LOS

Our Case Study

• CHF clinic• Palliative care at home• Eventually could be transferred to

Hospice care• Attempt to keep her at home as

long as possible without readmissions

• If she is readmitted, get her home as soon as possible with available resources

Resources at PHS for Stressful Situations

• Crisis Intervention team-Team of staff members to assist in debriefing after a stressful situation

• Dr. Corey Rigberg-available to help debrief

• Employee Assistance Program-counseling

• Pastoral Care-Pastors available to talk to afterwards