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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
For the slides from this presentation, visit:
www.teepasnow.com/presentations
Slides will be available for 2 weeks
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Handouts are intended for personal use only. Any copyrighted materials or
DVD content from Positive Approach, LLC (Teepa Snow) may be used for
personal educational purposes only. This material may not be copied, sold or
commercially exploited, and shall be used solely by the requesting individual.
Copyright 2017, All Rights Reserved
Teepa Snow and Positive Approach® to Care
Any redistribution or duplication, in whole or in part, is strictly prohibited, without the expressed written consent of Teepa Snow and
Positive Approach, LLC
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Caring at the
End of Life
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Terms to Know:
• Advanced Directives: you do
• Living Will: you develop
• DNR Orders: MD does based on your input
• Durable HC-POA: who will decide?
• Palliative Care: comfort care, not curing
• Hospice Care: entire system of end-of-life care
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Why is Dementia Different
as the End of the Journey
Approaches?
- It has taken a long time
- The person has changed, and changed, and
changed, and changed….
- You have lost the person, even as they remain
- You have changed over the journey
- How it was is not how it is
- What should happen/work, doesn’t always
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What are the Different Care
Approaches to Consider?
- Health Promotion
- Curative
- Restorative - Rehabilitative
- Maintenance
- Compensatory
- Palliative
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Health Promotion:
- Check-ups
- Annual vaccinations
- Lower the numbers
- Increase activity level
- Eat well and moderately
- Monitor all conditions for careful control
- Do what you should to be the best you can be!
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Curative:
- Fix what is wrong
- Test to figure out what is happening, then
do something about it
-Surgery
-Medications
-Treatment
- Full recovery of function: good as new!
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Restorative:
- Recovery of some degree of function or
ability
- Focuses on the person regaining skills
and abilities with help
-Rehab personnel
-Special equipment
-New techniques
- Not perfect, but back to a higher level of
function
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Maintenance:
- Maintaining the ‘status quo’, keepin’ on
- Not losing ground
- Depends on:
-Physical environment not changing
-Caregiver consistency
-Sustained abilities of the person
-All other things staying the same
- It’s hard work, so is what is had worth
keeping?
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Compensatory:- Providing what the person can’t do to ‘fill in
the gaps’ so that life goes on
- Supportive
-Physical environment changes
-Caregiver cueing and helping changes
-Expectations change
-Schedules and routines change to
accommodate
- End point is the same, but how we get there
changes
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Palliative:
- Comfort Care
- Top Priorities:
-Honor personal preferences and choices
-Manage Pain, Distress, Anxiety, Fear,
Discomfort
-Identify and seek to meet social, physical,
psychological, and spiritual needs
- Let go of fixing and move on to comforting
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Acute Illness vs. Dementia:You can fix it!
It gets better and goes away
It lasts only a short time
Doctors know what to do to make it better
The person goes back to how they were pre-illness
You can’t change it
It keeps getting worse no matter what you do
It lasts a long time – maybe years
Doctors can offer only help – they can’t fix it
You can’t go home again –the person is never the same
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Progression of Dementia:
- Early Loss: Habits and Routines
- Moderate Loss: Just Get it Done!
- Middle Loss: Hunting and Gathering
- Severe Loss: Constant Go or Down and Out
- Profound Loss: Stuck in Glue
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
The GEMS® Progression of
Dementia:
Sapphires: True Blue – Slower but Fine
Diamonds: Repeats and Routines, Cutting
Emeralds: Going – Time Travel – Where?
Ambers: In the Moment – Sensations
Rubies: Stop and Go – Big Movements
Pearls: Hidden in a Shell - Immobile
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Does this
Look Like?
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
‘Letting Go’
Versus ‘Giving Up’:- When is it time?
- How will you know?
- What is enough?
- Who should help decide?
- How to balance old wishes/promises and
the current realities
- How can we make it happen?
- What do we do instead?
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
So When Should You Say
‘When’?
- Cost versus benefit to the person
- What is possible versus what is probable
- Best case outcome: is it worth it?
- See the ‘big picture’ for the person
- What did they tell you before?
- Who are they and are they still able to be
that person?
- Is this about them or about you or about
someone else?
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Skills for Success:
- Meeting unmet needs with or without
words: using empathy and validation
and detective work
- Coping with and resolving distress one-
on-one
- Helping with challenging behaviors using
a problem-solving approach
- Providing coaching support and guidance
to teammates
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What if There are
No Words?
- Observe their cues to you:
-Visual
-Auditory
-Touch and movement or lack of it
-Olfactory: any unusual smells or odors
-Taste: changes in eating/drinking/preferences
- Use your other cueing systems
- Make your cues bigger and simpler
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Indications that You Are
Getting Near the End of the
Journey…
Ambers… Rubies … Pearls
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Signs that it may be time…
Repeated infections
Antibiotics seem ineffective
Refusals to eat, even favorite items
Holding food in mouth or spitting it out
Soft coughs, wet voice
Stops moving, curling up
Sleeping a lot
Lots of low grade fevers
Primitive reflexes show up
Withdrawal from those around, closing eyes
Drifting in and out
Says ‘good-bye’
Talks about ‘going home’
Asks permission to go
Albumin drops very low
Wounds won’t heal
Can’t keep weight on
Skin and bones
Moaning but not actively communicating
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Does This Mean?
- Reduce or stop monitoring if there is not
a ‘treatment’ that will be pursued
- Provide what the person wants or needs,
not what is ‘best’ for them
- Provide comfort
-Assess for and manage pain, discomfort,
or distress
- Give them permission to ‘go’
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Does This Mean?
-Don’t treat infections, but treat the discomfort
of infections
-Don’t force intake, but offer tastes and
textures
-Don’t push fluids or put in IVs, but offer fluids
(possibly thickened)
-Don’t force movement, but use touch,
massage, and controlled repositioning
-Don’t just ‘do the care’ then leave alone, but be
present
-Don’t force interaction but balance offerings of
silence with communication/contact
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Changes Near the End:
- Primitive reflexes become strong
- Flexor tone dominates
- Temperature control is broken
- ‘Skin and bones’ appearance, not hungry or thirsty
- Spends more time drowsy or ‘inside’ themselves
- Infections are common
- Startles easily, harder to calm
- Pain from stiffness, immobility, dry mouth/skin, etc.
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
The Care that Works is
Comfort Care!
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Building Skills to Help
in Late Stages
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Special Programming:
- Focuses on the spirit of the person
- Recognizes the changing needs of the person
- Provides support to meet those needs
- Provides a space where a caregiver can provide for the care of several residents in a meaningful way
-Reducing distress and discomfort
-Addressing caregiver distress over behaviors
-Reducing distress of other residents
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Is It?
- A more specific way to do what you
already do: accompany the person in
the final steps of this journey
- Mostly it is ‘being there’ for the person
who is the final stage of dementia
- Knowing the person: who is this, who has
this person been, what is important to
them, what offers them comfort, what
distresses them?
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Is It?
- Using comfort measures that help
- Providing a supportive sensory and
physical environment
- Meeting the needs of the body through
temperature, positioning, touch,
smells, taste, sight, sound, movement
- Celebrating and connecting to the spirit
within through your presence and
involvement
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Warmer room temperature
-Sunlight offered
-Warmed, lightweight blankets
-Foot and hand warmers: bean/rice socks
-Head covers
-Warm your hands before touching them
-Warm lotion and cloths for cleaning, warm
towels for drying
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Reclining chairs that are comfortable and
support the hip angle
-Shifting position smoothly and slowly to
allow circulation
-Gentle and slow rotational movements to
relax muscles that cannot relax on
their own
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Your Touch:
-Flats of fingers
-Contact over joints, first
-Still, unmoving pressure first before moving
-Slow movement
-Slow, rhythmic, circular motions
-Massage: hands, feet, temples, jaw, back, hips, shoulders
-Hand clasp: Hand-under-Hand®, sandwich their hand in between your two hands
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Their Touch:
-Be aware of grasp reflex – plan for it
-Be aware of hand-to-mouth – plan for it
-Offer various textures to hold, touch,
handle
-Offer familiar objects that can be explored
and handled, such as a stuffed
animal or doll to cuddle and nurture
- Warm objects or cloth: use a heating pad
or a nearby clothes dryer
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Taste:
-It’s not about eating for nourishment
-Connect smell and taste experience, but
smell first
-Try straws
-Try an infant spoon: small, plastic-
coated
-Mouth care: moisten lips and mouth
-Wet washcloth
-Vaseline-type moisteners
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Smells: connect us to our past
-Lavender is calming
-Citrus is arousing
-Mint is stimulating
-Other possibilities: cinnamon, incense,
bacon, cut grass, chocolate, sun-dried
cloth, etc.
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Sights:
-Your face with a smile and a nod
-Dim lights overhead
-A candle or covered lamp within visual field
-Familiar and favorite objects presented
-Pictures or symbols that offer comfort
-Nature posters, videos, or DVDs, or a
window
-Objects at a distance that move, spin, blow
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
- Sounds:
-Silence at times, with your presence
-Quiet rhythmic sounds: waves, streams, wind
-Wind chimes
-Favorite music from their youth
-Your calm, deep, gentle, still voice
-Prayers of their faith
-Readings from their faith, poetry, favorite books
-Bird songs, cat purr, your deep and slow breathing
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Some Specifics:
Movement:
-Glide rockers that offer smooth rhythmic
movement
-Trips outside: go slowly
-Trips to new location in the room
-Slow shifts, give info as you go, watch
responses
-Support at the hips and shoulders
-Draw sheets/blankets up close to the body
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
With dementia,
it’s not the destination,
it’s how you get there!
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
The content contained in this presentation is strictly for informational purposes. Therefore, if you wish to apply concepts o r ideas contained from this presentation you are
taking full responsibility for your actions. Neither the creators, nor the copyright holder shall in any event be held liable to any party for any direct, indirect, implied,
punitive, special, incidental or other consequential damages arising directly or indirectly from any use of this material, which is provided as is, and without warranties.
Any links are for information purposes only and are not warranted for content, accuracy or any other implied or explicit purpose.
This presentation is copyrighted by Positive Approach to Care and is protected under the US Copyright Act of 1976 and all other applicable international, federal, state and
local laws, with ALL rights reserved. No part of this may be copied, or changed in any format, sold, or used in any way other than what is outlined within this under any
circumstances without express permission from Positive Approach to Care.
Copyright 2017, All Rights Reserved
Teepa Snow and Positive Approach to Care
DISCLAIMER
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© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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