| Date post: | 20-May-2015 |
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Mary Ersek, PhD, RN, FAAN Philadelphia VAMC
University of Pennsylvania School of Nursing [email protected]
Jewish Home Lifecare 11th Annual Geriatric Palliative Care Conference, November 12, 2013
Describe the growing need for integrating palliative care into nursing homes.
Describe the role of nursing in palliative care.
Describe strategies to prepare nursing staff for delivering palliative care and in leading palliative care practices.
Between 1.5–1.8 million people live in US nursing homes (NHs) Kaye et al, Health Affairs, 2010
By 2050, more than 3 million people are expected to spend time in a NH Kaye et al, 2010
28% of persons ≥ 65 years died in a NH in 2007 CDC NCHS, 2010
Nearly 70% of persons with advanced dementia die in a NH Mitchell et al, JAGS, 2005
Over half are totally dependent or need extensive assistance with bathing, dressing, toileting, and transferring
67% of nursing home residents are female
64.8% have moderate to severe cognitive impairment
78.9% are non-Hispanic White
15.3% reported moderate to severe pain (last 5 days)
35.6% incontinent of bowel and/or bladder
25.5% received antipsychotic medication (last 7 days)
Average length of stay ≈ 2 years
Nursing Home Data Compendium, 2012 Edition
Nursing Assistants
Licensed nursing staff (RNs and LPNs)
Medication and Treatment nurses
Unit manager
Care manager
MDS Coordinator
Staff educator
Quality Improvement Director
Assistant Director of Nursing
Director of Nursing/Clinical Services
Nurse Practitioners
Identifying and documenting goals of care
Facilitating completion of advance directives
Assessing and managing symptoms
Facilitating life closure
Offer grief and bereavement support
Decreasing burdensome transitions
Maximizing human dignity
1. Hospice
2. External palliative care teams
3. Internal palliative care teams/units
Education Knowledge
Attitudes
Policies: development and implementation
Teams
Role modeling
Quality improvement – monitoring progress
License nursing staff, certified nursing assistants, activities director, etc.
Self-assessment
Supervisor assessment
Knowledge assessment
Internal Teams
Principles of palliative care
Hospice 101
Pain and symptom management
Communication with residents and families
Goals of care/Advance directives/POLST
Ethical issues
Cultural and spiritual issues
Loss, grief and bereavement
Care for imminently dying
Quality improvement
External Teams (including hospice)
Nursing home history
Nursing home culture Work teams and organization
Staff as family
Central role of CNAs
Family involvement
Nursing home regulations
Nursing home trends
Dementia care
Geriatrics
Respect for NH work and staff
EOL/Palliative Educational Resource Center (EPERC), www.eperc.mcw.edu/EPERC
Advancing Excellence, www.nhqualitycampaign.org
Geriatric Pain, www.geriatricpain.org
Prepare for Your Care, www.prepareforyourcare.org
“No complaints of pain”
“That’s the way she always is…”
“Of course she’s in pain…she’s 92, what do you expect?”
Policies and procedures: Symptom assessment & management
Policies and procedures: Advanced directives, assessing capacity
Policies and procedures: Management of acute conditions
Demonstrates knowledge of pain assessment techniques Re-evaluates pain following pain medications and nondrug pain intervention Advocates for residents experiencing pain Role models best practices for pain assessment Consistently observes and reports to the nurse residents’ reports of pain and/or pain-related behaviors Solicits all team members’ evaluations of residents’ pain.
Quality improvement team
Training team
Pain management team
Goals of care team
Transitions team
Ask about a residents’ comfort level
Report a resident’s concerns to the nurse
Advocate for a resident
Communicate respectfully
Keep families informed
RN/LPN
DON/Admin
Physician
Nurse practitioner
Nursing assistants
Family
Non-nursing staff
RESIDENTS
Structure
Process
Outcome
Structure: Policies - symptom assessment & management, advance directives
Protocols for managing acute conditions to avoid hospitalizations
Process: Documentation of pain management plan and f/u
Documentation of AD
Outcomes: Resident symptoms (chart/MDS)
Care matches preferences
Bereaved Family Perceptions of Care at EOL
Hospitalizations, ER visits
Staff satisfaction, staff turnover
MDS:
Symptoms: Pain, dyspnea; Depressive symptoms (PHQ-9)
Feeding tubes
Hospice
Quality indicators
Percent of Residents who Self-Report Moderate to Severe Pain (Short and Long Stay)
Percent of Residents Who Have Depressive Symptoms (Long Stay)
F-tag 309 – Pain and End-of-life Care
