Download Palliative Care From Hospital To Nursing Home

Palliative Care From Hospital
To Nursing Home
Addressing the needs of elderly
patients who have a life limiting
progressive illness with palliative care
needs
Palliative Care
“ Palliative care is an approach that improves quality of
life of patients and their families facing the problem
associated with life threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychological and spiritual.”
WHO (2003)
Terminal Care
Terminal care is a continuum of palliative care and is
used to describe the care that is offered during the
period when death is imminent, and life expectancy is
limited to a short number of days, hours or less.
Department of Health and Children (2001)
Levels of Palliative Care
 Level 1
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Palliative care approach
 Level 2
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General palliative care
 Level 3
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Specialist palliative care
Levels of Palliative Care
 Level One - Palliative care approach
Palliative care principles should be practiced by all
health care professionals.The palliative care
approach should be a core skill of every clinician at
hospital and community level.
Levels of Palliative Care
 Level Two – General Palliative Care
A proportion of patients and families will benefit from
the expertise of health care professionals who
although not engaged full time in palliative care have
some additional training and experience in palliative
care, perhaps to diploma level. This level of expertise
should be available at hospital and community level.
Levels of Palliative Care
 Level Three- Specialist Palliative Care
Specialist palliative care services are those services
whose core activity is limited to the provision of
palliative care. These services are involved in the
care of patients with more complex and demanding
needs.
 Many patients with progressive and advanced
disease will have their needs met
comprehensively and satisfactorily without
referral to specialist palliative care units or
personnel.
Facts
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27,479 people died in 2006 in Ireland
28% died from cancer
33% died from cardiovascular/circulatory
14% died from respiratory disease
25% died from other causes
Almost 16,000 deaths were in the 75-94
age group
Irish Hospice Foundation- Palliative Care For All (2008)
Ageing Population
 By 2050 the ‘over 80’ age group is projected to number
almost 379 million worldwide, about 5.5 times as many as
in 2000 ( 69 million persons).
 In 1950, persons over 80 numbered less than 14 million.
 It has never been more critical to address the palliative
care needs of older people than in the context of today’s
ageing populations. The proportion of people aged 65 and
over is steadily on the increase in Europe.
World Population Ageing 1950-2050
A/E Survey Conducted in Connolly
Hospital Feb 2007
 High levels of A/E use, by patients>65 years
and those in LTC.
 420 attendances by patients>65 years old
 56(13%) from nursing home care- (52% had
1 or more attendances in the last 4 months)
 65% admitted to hospital; high hospital
mortality
P McCormack & S Kennelly (2008)
Consequences of Inappropriate
Hospital Admissions
 Patients at risk of dying in an inappropriate place of
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care, e.g. A/E
Lengthy hospital stays
Poor quality of life for the patient
Medication errors
Poor communication of new care plans
Changing care teams/ fragmentation of care
Transportation delays and discomfort
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Inappropriate patient transfers between nursing
homes and hospitals can be very stressful for
both patients and families. It can be frustrating
for staff in both care settings.
Case Scenario
 Grandpa Simpson 85 year old nursing home resident
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over 5 yrs
Background - advanced dementia, previous CVA
Progressive decline over the last six months, less
interest in eating and drinking, poor swallow
Admitted to an acute hospital with aspiration
pneumonia, treated with iv antibiotics, improved
clinically, transferred back to nursing home residence 7
days later.
Of note he had 4 admissions over the previous 8
months
Readmitted 2 weeks later following recurrent aspiration
pneumonia, died in A/E
 Outcome ?
 Planned to Fail !
 How can we improve the transition of care for
the elderly patient who have a progressive life
limiting illness and prevent inappropriate
readmission to hospital??
A “Transitional” Problem
 Poor communication between hospitals and nursing
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homes
Lack of advanced care planning
Poor documentation re goals of care
Poor communication with patient and family
Lack of knowledge and skills re managing symptoms
Challenges in Providing Palliative
Care To The Nursing Home Resident
 Communication
 Prognosis
 Care planning
 Confidence in managing symptoms
 Support
Improving End of Life Care for Patients
Who Have a Life Limiting Illness
Aims of care should be:
 To provide a mechanism to improve care given to
patients at end of life
 To enhance communication between different care
settings
 To discuss wishes for care with family and
multidisciplinary team
 To provide a tool to improve implementation of
advanced care planning
Prognostic Criteria For Advanced Disease
Any one of 3 criteria could trigger a patient to be
considered to have palliative, supportive care needs
1.
Patient need or choice is for comfort care only and not for possible
curative treatment.
2.
Use of the ‘Surprise’ question – would you be surprised if the patient
was to die in the next year? If not, then they are likely to need
supportive/palliative care.
3.
Patients have Clinical indicators of need for palliative care – prognostic
clinical indicators of ‘advanced’ or irreversible disease – to include 1
core and 1 disease specific indicator
Gold Standards Framework Prognostic Indicator Guidance
Beaumont Hospital Discharge Guidelines For Patients
Returning To Nursing Homes For Supportive -Comfort
Care ( Pilot Project)
These are guidelines for the medical team
based on the patients medical condition and
wishes under the direction of the patient’s
consultant doctor and should accompany
patient when transferred.
Section A
CARDIOPULMONARY RESUSCITATION (CPR): Person
has no pulse and is not breathing.
 Attempt Resuscitate (CPR)
 DO Not Attempt
Resuscitation (no CPR)
When not in cardiopulmonary arrest, follow B, C and D
Section B
MEDICAL INTERVENTIONS: Person has pulse and/ or is breathing.
 Comfort measures Treat with dignity and respect
Use medication by any route, positioning, wound care and other measures to relieve
pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as
needed for comfort. Do not transfer to hospital for life –sustaining treatment.
Transfer only if comfort needs cannot be met in current location.
 Limited Additional Interventions Includes care described above. Use medical
treatment and s/c fluids. Do not use intubation, advanced airway interventions, or
mechanical ventilation.
Transfer to hospital if indicated. Avoid intensive care
 Full Treatment Includes care above. Use intubation, advanced airway interventions,
mechanical ventilation, and cardio version as indicated.
Transfer to hospital is indicated. Include intensive care.
Other instructions:_______________________________________________
Section B
 This section allows discussion re level of medical
intervention if the patient deteriorates.
 Comfort indicates a desire for only those
interventions that enhance comfort . Transfer to
hospital is indicated only if comfort needs cannot be
met in current location
 Limited additional interventions, in addition to comfort
measures e.g. s/c fluids, oral antibiotics as indicated.
Transfer to hospital if indicated.
 Full treatment includes all care as above with no
limitation of medically indicated treatment .
Section C
ANTIBIOTICS
 No Antibiotics
 Oral Antibiotics
 IV Antibiotics ( usually requires hospital admission, consider
community intervention team if appropriate)
Other instructions:______________________________________
Section C
 This section stimulates conversations about the goals of
antibiotic use. Antibiotics often are life sustaining treatments.
Advance care planning in the use of antibiotics can help clarify
goals of care for the person and caregiver.
 Many families of patients with advanced progressive illness may
prefer to have antibiotics withheld and want other measures
such as a antipyretics and opioids to treat symptoms of infection
and maintain comfort.
 Additional instructions can also be written “Antibiotics may be
used only as needed for comfort” for example a urinary tract
infection may cause discomfort for a dying patient. Treating the
UTI with an antibiotic may serve as a comfort measure.
Section D
MEDICALLY ADMINSTERED FLUIDS AND NUTRITION: Oral fluids and
nutrition must be offered if medically feasible.
 No iv fluids
 S/c fluids for a defined trial period
 s/c fluids long- term if indicated
 No feeding tube
 feeding tube for a defined trial period
 Feeding tube long- term
Other instructions:_________________________________________________
Section D
 Oral fluids and nutrition must be offered if medically
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feasible, i.e. the patient is alert and able to swallow
Goal of care may be allowing to eat and drink for
comfort versus aspiration risk
IV fluids may cause oedema, shortness of breath,
and the need for frequent urination. At the end of life
they can cause excess secretions
s/c fluids may be considered for a defined trial period
to see if this benefits the patient. ( s/c fluids will not
alleviate dry mouth)
If the patient is being tube feed this may be continued
if there is no ill effects e.g. chestiness, aspiration and
vomiting .
Section E
DISCUSSED WITH :
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Patient /Resident
 Next of kin
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Family member
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Other
______________ (Specify)
The Basis for These Orders is:
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Patient’s preferences
Patient’s best interest
Section F
ANTICIPATORY PRESCRIBING
Oral medications
1)
Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort,
Pyrexia
2)
Diclofenac 100mg PR daily PRN for signs of pain or discomfort
3)
Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea
4)
Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea
Section F
Subcutaneous medications ( where patients no longer able to take oral
medications )
5)
Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea
6)
Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness
7)
Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of
problematic upper airway secretions.
Section F
Medications
 Medications rationalized where possible to reduce tablet burden
and where no longer appropriate given the patient’s condition and
prognosis.
Section G
Nursing and Support services ( Primary, community continuing
care providers)
 Liaise with hospital and community palliative care team as
appropriate
 Liaise with community intervention team as appropriate
 Date of discharge confirmed with Patient/family and nursing home
 Confirmation that medications available in nursing home 24 hour
prior to transfer
 Appropriate transport arranged and confirmed
 Fully comprehensive nursing discharge letter
Case Scenario 2
 Mr Burns 78 year old nursing home resident.
 Background: COPD, CCF, Vascular Dementia.
 Admitted to an acute hospital with infective
exacerbation of COPD, 48hrs in A/E prior to being
admitted to ward.
 Treated with iv antibiotics with little response,
remained comfortable but weak, not eating or
drinking, barely responsive
 Referral to Palliative care re symptom management,
comfort care.
Case Scenario 2
 Family meeting with multidisciplinary team. Given Mr Burns
current state of health, failure to improve despite active
treatment and his co-morbidities family and medical team in
agreement most appropriate goal of care was comfort
measures. Family keen for transfer back to nursing home as it
had been his home for 5 years.
 Discharge guideline used in consultation with family. Mr Burns
for comfort measures only, for transfer back to hospital only if
comfort measures cannot be met, advice given re symptomatic
management
 Liaised with nursing home re goal of care, discharge guidelines.
 Transferred back to nursing home, died peacefully five days
later.
Example letter
RE. Mr Ryan DOB 10 0ctober 1920
Garda Retirement Home
Raheny
Dublin 5
29 May 2009
Dear Doctor,
Both Mr Ryan and his family have expressed a wish not to have Mr
Ryan referred to the hospital for further tests or clinical management.
He should only be transferred in the event of severe pain or
haemorrhage or accident requiring acute hospital treatment.
He is not for Resuscitation in the event of an acute cardiac event.
Yours sincerely
Confidence In Managing Symptoms
 Multidisciplinary involvement
 Liaise with hospital palliative care team if
appropriate
 Referral to specialist community palliative
care team where available
 Liaising with nursing home re plan of care
 Use of anticipatory prescribing
 Liaise with GP or relevant medical officer
Confidence In Managing Symptoms
 Irish Hospice Foundation in conjunction with
the Palliative Care Education Task Force is
preparing a training programme for Nursing
Homes Ireland, the representative
organisation for the private and voluntary
nursing homes sector.
 This training programme is seeking to
establish a common multidisciplinary
approach to level 1 palliative care education
in Ireland for nursing home staff.
References
 Department of Health and Children. Report of the
National Advisory Committee on Palliative Care
(2001)
 McCormack P & Kennelly S (2008) Care delivery in
the most appropriate setting?. Experience of
Connolly Hospital Liaison Medicine for the Elderly
Service. www.nhi.ie .
 Palliative Care For All (2008) Integrating Palliative
Care into Disease Management Frameworks. The
Irish Hospice Foundation. Health Service Executive.
 World Population Ageing 1950-2050, Chapter iv
Population Division, DESA, United Nations
 WHO
Additional information
 Alvin H. Moss (2004) Respecting Patients’ Wishes at
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the End of Life. Physician Orders for scope of
Treatment www.wvendoflife.org
Centre to Advance Palliative Care (2007) Improving
Palliative Care in Nursing Homes.
Centre For End-Of-Life-Care (2006). Robert C Byrd
Health Services Centre Of West Virginia University.
www.wvendoflife.org
The Irish Hospice Foundation Annual Report,2008
www.goldstandardsframework.nhs.uk