1

Palliative CareAdvance Care PlanningA Collaborative Approach

Sheldon Lewin MSW,MBA

Palliative CareAdvance Care PlanningA Collaborative Approach

Sheldon Lewin MSW,MBA

2

Program GoalsProgram GoalsCalifornia Hospital Medical Center Objectives: Reduce the suffering and increase the comfort of our patients through

symptom control and restoration of functional capacity. Participate in the CHW palliative care initiative. Plan for future medical care in the event a patient is unable to make their

own decisions. Remain sensitive to personal, cultural and religious values and beliefs.

5 components of ACP per CHW:1. Patient options for treatment2. Chances of survival or prognosis3. Options for pain/other symptoms of disease4. Patient/family’s decision about treatment5. Spiritual needs assessment

3

Medical Therapy ChoicesMedical Therapy Choices

Traditional MedicineCure illnessProlong life

Palliative CareImprove quality of life

– Pain management– Symptom management– Emotional support– Advance Care Planning– Does not exclude

traditional therapy

4

People Care AboutPeople Care About

Participation in medical decision-making The impacts of their illness on their family Physical, emotional, spiritual, support and care Living well: Quality of life, planning for the future Dying well: Dying peacefully, without extreme

discomfort, without suffering, without prolonged dependence

5

Definition- Palliative Care:Definition- Palliative Care:The art and science of relieving pain, suffering and symptoms associated with a serious illness without effecting a cure

Comprehensive management of physical, social, spiritual and existential needs of patients, in particular those with incurable, progressive illnesses

Does not mean stopping active medical treatments

Does not take the place of Hospice

Affirmation of life

Regards dying as a natural process

6

Palliative Care ComponentsPalliative Care Components

Pain Management Symptom Management Emotional Support Advance Care Planning Provide assistance with:

In-hospital support

Transitions to Home, SNF or Hospice, Home Health

7

Palliative Care Intake ScreenPalliative Care Intake Screen I. General Information MSW/ RN COMPLETE Date_________________ Time____________________ Medical Record #_______________________________ Patient ID #____________________________________ Admit Date____________________________________ Referral Source________________________________ MD Palliative Care Order Yes No Advance Directive: Type_______________Yes No On Chart Yes No Code Status- Circle all that apply Do not resuscitate Do not Hospitalize (SNF, subacute) Comfort Measures (Supportive Care) Hospice (Referral) Full Code Limited DNR Admitting Diagnosis______________________________________ Religion/Clergy_________________Race_____________________ Next of Kin Name______________________ Relationship________________ Phone #________________ Work#____________________

II. *** Are we addressing the 5 components of Advance Care Planning? Patient Options for Treatment Chances of Survival or Prognosis Options for pain/other symptoms of disease Patient decision about treatment Spiritual care assessment

Palliative Care/Advance Care Planning “COMPASSIONATE CARE TEAM”

INTAKE SCREEN ONLY (Do Not Place in Medical Record)

V. Check current and or recommended services Social Services MSW COMPLETE Emotional Support Advance Care Planning Advance Directive Information & Education Family conference Case Management Hospice Facility ___________________________

***Home Care Hospice–Palliative Care Services Name ______________Contact_____________________ Insurance______________Tele #____________________ Nursing Home SNF with Hospice Services Residential Housing with Hospice Services Long-Term Care Facilities Durable Medical Equipment Patient & Family Education Family Conference Chaplain Services Spiritual Needs Assessment & Support Grief & Bereavement Family Conference VI. Summary: (Comments) MD approved/declined PC Consult

MSW/ RN COMPLETE

IV. Check current and or recommended services RN COMPLETE

***Pain Management Pain Rating________ Symptom Management – Circle all that apply

Respiratory Dyspnea Cough

GI Anorexia Constipation Diarrhea Nausea / Vomiting Terminal Dehydration

Neuro/Psych Fatigue Depression/Anxiety Delirium/Agitation/Confusion

Patient & Family Education Family Conference

III. Does the patient meet the following criteria? Diagnostic Criteria RN COMPLETE Patients with cancer Patients with AIDS Patients over 50 years with ESRD, on dialysis with diabetes Patients over 50 years with end stage lung disease/COPD Patients with acute or chronic respiratory failure Patients with cardiac condition Patients over 65 with CAD with bypass and CHF Patients over 65 with ICB Patients over 65 with cirrhosis Patients over 65 with dementia with PEG/NG aspiration PNA

ADDRESSOGRAPH

8

Palliative Care & theSocial Worker’s Role

1. Assess Psychosocial Needs of patient and family. Provide Psychosocial Support.

2. Advanced Care Planning: Discuss and or educate on end of life or (i.e. Advance Directives, funeral arrangements, home support, burial, delineate family representative). Facilitate resolution or open topic discussion.

3. Coordinate and assemble PC Team for **ACP Meetings.4. Document ACP progress note.

**Advanced Care Planning

9

Assess Psychosocial Needs &

Provide Support

10

Assess Psychosocial NeedsAssess Psychosocial Needs

Emotional, psychological, spiritual Anger, anxiety Depression Guilt Family conflicts What is important to the patient’s life? What more does the patient want to accomplish? What does the patient fear?

11

Psychosocial SupportPsychosocial Support

Participation in medical decision-making The impacts of illness on family/respite for family Physical, emotional, spiritual, support and care Documents in order (Power of Attorney [POA], living wills,

wills, guardian for children, Substitute Decision Maker). If in hospital encourage family to bring in favorite photo and

other personal items for bedside. Living well: Quality of life, planning for the future Dying well: Dying peacefully, without extreme discomfort,

without suffering, without prolonged dependence

12

Advanced Care PlanningFacilitate ACP Meeting

13

Advance Care Planning: Issues or Conflicts

Advance Care Planning: Issues or Conflicts

No Advance Health Care Directive Confusion or Conflicts in Goals of Care Caregivers Experiencing Burden of Care

14

Advance Care Planning: Values & Beliefs

Advance Care Planning: Values & Beliefs

What gives meaning to life?

What does quality of life mean to you?

What are your priorities?

If level of disability are you willing to accept and for how long?

Who can make decisions for you if you cannot?

15

Advance Care Planning: Advance Directives

Advance Care Planning: Advance Directives

Who can speak for me if I cannot speak for myself?

What medical treatments do I want if I am near death?

16

Coordinate and assemble Palliative Care Team with family members.

Advance Care Planning: Family Conference

Advance Care Planning: Family Conference

17

ADVANCE DIRECTIVESADVANCE DIRECTIVES

18

Advance DirectivesAdvance Directives

“The Patient’s Self Determination Act” (PSDA, 1990)

Patients have a right to: make medical decisions regarding their treatment appoint an agent to speak on their behalf when incapacitated determine, or refuse, their medical treatment and care.

Upon admission, we are required to ask if the patient has an Advance Directive and if it is available.

19

Advance DirectivesAdvance Directives

If you are an adult, (at least 18 years of age, and have the capacity to make health care decisions), you have the right to make your wishes known about the extent of treatment you would desire if you became unable to communicate those wishes. This communication is called an advance directive.

20

Advance DirectivesAdvance Directives

Who do I want to speak for me? Have I told my ‘surrogate’ decision-maker what I

value, what I do and do not want??? Is there anyone I do NOT want to speak for me?

21

Advance DirectivesAdvance Directives

Two Commonly Used Advance Directives Are A health care directive (living will), in which you

communicate orally or in writing the specific treatment desired if you later cannot communicate these wishes.

A durable power of attorney for health care, in which you designate another person to make decisions about your health care if you become unable to do so.

22

Advance DirectivesAdvance Directives

People assume their family will know what medical treatments they would or would not want

Responsibility of Surrogate Decision Maker is to respond from the Patient’s Perspective:

What would Mom have wanted if she could speak for herself?

If the physician is uncertain about the patient’s desires, the default position is usually to treat.

23

CHMC-Advance Directives Process CHMC-Advance Directives Process

Access Care staff provides the patient an Advance Directive form and packet of information including copy of “Your Right to Make Decisions about Medical

Treatment” and asks if patient has a completed Advance Directive

Access care staff checks appropriate box in Condition of

Admission (COA) and Treatment (Part 1)

form

End

Patient is admitted to hospital

Does patient have an Advance Directive?

NoYes

Copy available?

No

Access care staff sends copy to nursing unit

Yes

1. Patient wishes additional information

2. Patient is unable to receive information regarding Advance Directive

1. ACCESS CAREPatient admitted to hospital

24

CHMC-Advance Directives Process CHMC-Advance Directives Process

Nurse reviews the Condition of Admission (COA) & Completes Interdisciplinary Intial Assessment

(Checks and signs Advance Directive section)

Social Worker will verify and reassess for Advance Directives as required:

Verification of Advance Directive (For patients stating they have AD at admission)1. CHECK patient’s medical record to see if there is an ADVANCE DIRECTIVE:2. If ADVANCE DIRECTIVE is not in medical record, you must do the following:3. REMIND patient and or CONTACT family/guardian to bring in document. DOCUMENT 2-3 attempts in medical record to locate ADVANCE DIRECTIVE

Reassessment of Advance Directive (For patients who might not have been asked at admissions or were non responsive due to the following (i.e. trauma, intubation)

1. ASK patient if they have an ADVANCE DIRECTIVE2. YES- make certain AD is in the medical record. Follow-up with patient/family3. NO- provide information/education on AD (Green Brochure)

Document all interventions on referral form and in medical record

Nurse

Social Worker

2. NURSING/SOCIAL SERVICES

Patient admitted to roomNurseNurse

25

Advance Directives Patient Information & Education

Advance Directives Patient Information & Education

Sobre InstruccionesMedicas Anticipadas

Available in Spanish & English

Contact Social Services at x5560 or via AS400

26

Palliative Care & the Nurse’s Role

1. Patient Advocacy and Referrals to PC Team2. Patient Symptom and Pain Assessment and

Management. (Patient Satisfaction with Pain Management )

3. Patient & Family EducationEducate patients on the pain scale Prepare patients to deal with pain at home

4. Document interventions

27

Advocacy & Referrals

28

Who Can Benefit? Who Can Benefit?

29

Who Can Benefit?

30

Who Can Benefit?

31

Who Can Benefit?

32

Who Can Benefit?

33

Patient & Family EducationPatient & Family Education

34

Patient EducationPatient Education

Upon admission every patient needs to be informed of their right to pain management, how pain is assessed and what pain management is available. Part of this education is talking with the patient about their “pain goal”.

Education of patients begins with an assessment of their cultural and belief system barriers. These are addressed in the patient education assessment.

In addition to the pain management orientation, further education related to pain management is given as appropriate and documented on the patient education record.

35

Palliative Care & the Chaplain’s Role

1. Assess patient’s spiritual needs2. Provides grief and bereavement support3. Document interventions4. Attend family conference

36

Assess Patient’s Spiritual Needs

37

Spiritual Needs Assessment& SupportSpiritual Needs Assessment& Support

Available for spiritual support and guidance.  Work closely with community clergy through visits

and supportive care, when requested by the patient. 

Recognizes the tremendous importance and value in caring for the spiritual needs of the patients and

caregivers.

38

Grief & Bereavement Support

Grief & Bereavement Support

39

Grief & BereavementGrief & Bereavement

Provides special support in dealing with grief and anticipated death.

Anticipatory grieving and support in bereavement

Assistance with psychosocial and spiritual issues related to life closure

Acknowledge feelings: Although the death has been anticipated the family may experience a myriad of feelings including guilt, relief or shock.

40

Palliative Care & the Case Manager’s Role

1. Assess patient’s discharge needs2. Coordinate and document referrals to hospice or home health, DME3. Patient Satisfaction. Preparing patients to deal with pain at home. 4. Attend family conference

41

Discharge Planning & Home Health/

Hospice Care Referrals

Discharge Planning & Home Health/

Hospice Care Referrals

42

Referrals to Home HealthHospice, LTC, SNF, etcReferrals to Home HealthHospice, LTC, SNF, etc

Coordinate and document referrals to hospice or home health, DME

Maintain working relationship with external providers of palliative/hospice care:

Outpatient Consultant Palliative Care Hospice Facility Home Care Hospice–Palliative Care Services Nursing Home or Skilled Nursing Facility with Hospice Services Residential Housing with Hospice Services Long-Term Care Facilities

43

Palliative Care & the Physician’s Role

1. Discuss and document patient’s options for

treatment2. Discuss and document options for pain and symptom management3. Ensures consensus is reached among physicians4. Certifies that the patient needs the services provided and agrees/signs plan of care5. Attend family conference