Member Care at the End of Life: Fulfilling Shepherding with Palliative and Hospice Care.

Primary credential: “Adult Nigerian Missionary Kid”Involved in MMH and Member Care

Professional Credentials:Jarrett Richardson MD FAPA, ABIM, Hospice and

Palliative CareChristian Medical and Dental Associations

Member Care at the End of Life February 21, 2015

Jarrett Richardson MD

1. Defining the Issues:a. Models of Care- Life Cycle, Bio/Psycho/Social/Spiritualb. Epidemiology- Health at retirement, aging, end of life,

2. One Approach: Anne Noble –SIM ministry -needs and resources

3. Understanding The Palliative/Hospice Model/Philosophy

4. Discussion5. Resources:

Too Valuable to Lose: Exploring the Causes and Cures of Missionary Attrition edited by William D. Taylor

• Individual, Family, Team, Organization, Partnerships have life cycles

• The Unattached young Adult• The Newly Married Couple• The Family With Young Children• The Family with Adolescents• Launching Children and Moving On• The Family in Later LifeAuthor: O'Donnell, K. Helping missionaries grow: Readings in mental health and missions (pp. 148-163)

Missionary Lifecycle Shepherding• . We are committed to a holistic model of caring for missionaries, from start to

finish. To that end, we: – Partner with a network of like minded churches and pastors‐– Recruit missionaries by pastoring prospects, not persuading them– Assess candidates with wisdom and compassion– Utilize a well developed pipeline to move missionaries from short term to ‐ ‐

long term service‐– Shepherd missionaries closely through the fund raising process‐– Provide a compensation and benefits package fully adequate to support

long-term service– Ensure thorough pre field preparation and training‐– Nurture deployed missionaries with high quality member care;

– Assist in the re-entry process at the end of a term of service, and

– Employ a seasoned staff of experienced missionaries committed to training others.

Retirement• What Missionaries Ought to know about

Retirement• http://www.missionarycare.com/brochures/

br_retirement.htm

• Where will I live?• Will I have enough money?• What will I do?• Who will be my friends?• Special Considerations.

Missionary Life Cycle With a Sending Organization-JWR• “Dating” [Exploration of a call]• “Engagement” [Application process]• “Marriage” [Mutual commitment]• “Deployment” [First and subsequent “tours”]• “Re-entry” [First and subsequent home assignments]• “Single or pre-children”• “With children” [Married before and with children]• “With parents” [Sandwich generation]• “Retirement/Removal” [Planned and unplanned]• “Aging” [After retirement- may be 30 + years]• “End of Life” [Most common is not sudden

death]

Final Stage of Missionary Life Cycle

• “End of Life”– Little discussion of death and

dying in mission circles– Little research available– Little written on this stage of

missionary life– Seldom taught in missionary

courses or in courses for Churches, Mission Sending Organizations, or Missionary Preparation for..

The Facts• Life is still 100% fatal unless the Lord comes first• Modern medical care and other factors has

extended the life expectancy in the North by 10 years since 1970.

• The causes of death are shifting toward chronic and degenerative disorders rather than sudden or catastrophic causes

• Missionaries survive the “field” in better health than their USA peers, but are not protected from the “problems” of living longer

78.64 years (2011)United States of America, Life expectancy

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Aging Demographics

• Currently, 35 million Americans

65 & over

• By 2030, over 69 million

Americans 65 & over

• By 2050, almost 80 million

Americans 65 & over

• By 2050, elderly increase by

115%AAHSA WEBSITE, AGING DEMOGRAPHICS, 2003

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Aging Demographics

• Increase in aging population means increase in

chronic, progressive illnesses

• Increase healthcare costs to treat older

population with these illnesses

• Decrease in number of capable caregivers AAHSA WEBSITE, AGING DEMOGRAPHICS, 2003

Number of deaths for leading causes of death1. Heart disease: 597,6892. Cancer: 574,7433. Chronic lower respiratory diseases: 138,0804. Stroke (cerebrovascular diseases): 129,4765. Accidents (unintentional injuries): 120,8596. Alzheimer's disease: 83,4947. Diabetes: 69,0718. Nephritis, nephrotic syndrome, and nephrosis: 50,4769. Influenza and Pneumonia: 50,09710. Intentional self-harm (suicide): 38,364

Change in Number of Deaths Between 2000 and 2010

The 2013 Alzheimer's Disease Facts and Figures http://www.alz.org/documents_custom/2013_facts_figures_fact_sheet.pdf

What about Missionaries at the End of Life?

Missionaries survive the “field” in better health than their USA peers,

but are not protected from the “problems” of living longer and of

dying

What about Missionaries at the End of Life?

No information published• Anne Noble SIM Canada Retiree Member Care Administrator• Telephone interview and review of documents exchanged.

– Presented with her permission– Served in Pakistan for 18 years in Muslim outreach– Married with three children– Met her husband in Pakistan (single years ‘ experience)– 58 years old– Involved in this ministry for 13 years– Lived with chronic severe pain while undertaking this

ministry

Anne Noble SIM Canada Retiree Member Care Administrator

• “We now have 160 retired missionaries and have seen about 140 go to be with the Lord [Anne has done many, many vigils for those with no one else]”

• “The elderly need so little but they need that little so much!”

• Be shepherds of God's flock that is under your care, serving as overseers--not because you must, but because you are willing, as God wants you to be; not greedy for money, but eager to serve; I Peter 5:2 (Anne’s member care verse)

Issues Identified as Priorities:1. Preparation for those who are retiring2. Recognition of Life and Ministry 3. Communication4. Legal Matters5. Palliative Care6. Time of Death7. Power of Attorney

Palliative Care per Ann Noble :1. Dealing with spouses and family that live at great distance2. Hands on care for those who are local3. Talking through the upcoming death4. Dealing with spiritual issues [crises of faith and self worth]5. Fulfilling last of their needs and desires6. Advance directives7. Sitting and waiting…. (includes singing, prayer, holding of hands, reading, reminiscing and lots of assurance that I will not leave them)

Time of Death Needs

1. Contact the family2. Write up tribute and arrange for SIM3. Presence Writing of death benefit4. Contact other retirees5. Personal letter to family6. Memorial gifts7. Last chance with family members for contact

with SIM

Greatest Concerns/Fears about End of Life

• Don’t want to die alone• Want to preserve dignity• Don’t want unbearable dehumanizing pain• Don’t want to suffocate

• Want to be in control/ able to participate as

long as possible

• Don’t want to be a burden

• Don’t want to deplete own or others resources

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End of Life Care

Disease Oriented Care

Curative/LifeProlonging Therapy

Diagnosis Death

Symptoms Diagnosis

Treatment Cure

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End of Life Care

Disease Oriented Care

Curative/LifeProlonging Therapy

Diagnosis Death

Symptoms Diagnosis

Treatment Cure

Hospice

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End of Life Care

Curative/LifeProlonging Therapy

Diagnosis Death

Palliative Care

Hospice

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End of Life Care

Curative/LifeProlonging Therapy

Diagnosis Death

Palliative CareHospice

Bereavement

Palliative Care

“An approach that improves the quality of life of patients and their families, facing the problems associated with life-threatening illness, through the prevention and relief from suffering, by means of early identification, impeccable assessment, treatment of pain and other problems physical, psychosocial, and spiritual”.

(World Health Organization, 2002; Sepulveda, et al, 2002)

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PhysicalFunctional AbilityStrength/Fatigue

Sleep & RestNausea

AppetiteConstipation

Pain

PsychologicalAnxiety

DepressionEnjoyment/Leisure

Pain DistressHappiness

FearCognition/Attention

Quality of Life

SocialFinancial BurdenCaregiver Burden

Roles and RelationshipsAffection/Sexual Function

Appearance

SpiritualHope

SufferingMeaning of Pain

ReligiosityTranscendence

Adapted from Ferrell, et al.

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Hospice and End of Life Care

Hospice Care: Program of care that supports the patient and family through the dying process and surviving family members through bereavement. No longer curative care, only comfort care

End of Life Care: Refers to the final weeks of life when death is imminent

Shift in Goals of Care

• Curative Care• Cure of disease• Avoidance of

premature death • Maintenance or

improvement in function

• Prolongation of life

• PC/Hospice Care• Relief of suffering• Quality of life• Staying in control• A “good death” • Support for families

and loved ones

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Hierarchy of a Dying Person’s Needs

To share and come to terms with the unavoidable futureTo perceive meaning in death

To maintain respect in the face of increasing weaknessTo maintain independence

To feel like a normal person, a part of life right to the endTo preserve personal identity

To talkTo be listened to with understandingTo be loved and to share love

To be given the opportunity to voice hidden fearsTo trust those who care for themTo feel that they are being told the truthTo be secure

To obtain relieve from physical symptomsTo conserve energy

To be free from pain

Knowledge and skills to help with end-of-life care• Learn general geriatric principles• Learn end-of-life physiological

changes• Learn not to fear death and dying• Learn the meaning of symptoms

– Medically– Psychologically– Spiritually– Socially

End of Life “work”

• Confirming meaning of a life well lived• Healing from failures of a life not well lived• Forgiveness• Reconciliation• Facing mortality/immortality• Maintaining Dignity

Issues Identified as Priorities:1. Preparation for those who are retiring2. Recognition of Life and Ministry 3. Communication4. Legal Matters5. Palliative Care6. Time of Death7. Power of Attorney

Palliative Care per Ann Noble :1. Dealing with spouses and family that live at great distance2. Hands on care for those who are local3. Talking through the upcoming death4. Dealing with spiritual issues [crises of faith and self worth]5. Fulfilling last of their needs and desires6. Advance directives7. Sitting and waiting…. (includes singing, prayer, holding of hands, reading, reminiscing and lots of assurance that I will not leave them)

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Palliative CareLet us not underestimate how hard it is to listen and

to be compassionate. Compassion requires the inner disposition to go with others to the place where they are weak, vulnerable, lonely and broken. As busy, active, relevant people, we want to earn our bread by making a real contribution. This means first and foremost doing something to show that our presence makes a difference. And so we ignore our greatest gift, which is our ability to be there, to listen and to enter into solidarity with those who suffer.

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PALLIATIVE CARE

TO CURE SOMETIMES……..…....

TO RELIEVE OFTEN………..

TO COMFORT ALWAYS

Collected/Reviewed resources include:

• Anne Noble SIM Canada Retiree Member Care Administrator • End-of-life • http://www.aahpm.org/• http://www.eperc.mcw.edu/EPERC• Global Member Care – nothing on web search at all about • http://www.globalmembercare.com/• Member Care http://membercareassociates.org/• MissionaryCare.com and GO InterNational Ron and Bonnie Koteskey · 122 Lowry Lane · Wilmore ·

Kentucky · 40390 · USA http://www.missionarycare.com/index.htm• O'Donnell, K. Title: Helping missionaries grow: Readings in mental health and missions Pasadena, CA:

William Carey Library. 1988 • Palliative Care at the End of Life. Presentation 2003 by Liz Rice, RN, MSN Manager, Mayo Clinic

Hospital Scottsdale, Arizona• Re-entry http://www.missionarycare.com/dbListArticles.asp?TOPICID=84• Retirement http://www.missionarycare.com/dbListArticles.asp?TOPICID=83• Richardson Workshop on Dementia and Palliative Care