Nursing Needs for Older Person
Nursing Needs for Older Person Palliative and End-of-Life Care
Joshua Jaime P. Nario RNNurse EducatorNursing Education Research
and Development Makati Medical CenterCoordinated palliative care
matched to patient needs improves quality of care for vulnerable
patients with serious illness and reduces costly use of hospitals
and emergency departments.
1ObjectivesAt the end of the 30-minute session, participants
must be able to:Review key concepts in Palliative and End-of-Life
Care Learn issues in older adult palliative care and hospiceDiscuss
the different needs of older patient in palliative care and final
hour
Review of ConceptsNursing Needs for Older Person Palliative and
End-of-Life Care I told the doctor that I never wanted to go back
to the hospital again. Its torture you have no control and cant do
anything for your self. And you get weaker and sicker. Every time
I'm in the hospital it feels like Ill never get out--- 88 year old
man with mild dementia Palliative CareAn approach that improves the
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 identificationimpeccable
assessment treatment of pain and other physical , psychosocial and
spiritual problems WHO, 2005 QUESTION: If you need palliative care,
does that mean youre dying?Receiving palliative care DOES NOT
necessarily mean youre dying.
supports you and those who love you by maximizing your comfortIt
also helps you set goals for the future that lead to a meaningful,
enjoyable life while you get treatment for your illness.
Palliative Care is not just for the end of life
Specialized medical care for those facing an advanced illness
Specialized multidisciplinary team provides an extra layer of
support Can be provided along with curative treatment
Main Goal: To provide relief from the symptoms, pain, and stress
of a serious illness To improve quality of life for both the
patient and the family
6Curative TreatmentPalliative CareHospiceCurrent Practice of
Hospice and Palliative CareELNEC Core Curriculumhe differences
between hospice and palliative care.Hospice care and palliative
care are very similar when it comes to the most important issue for
dying people: care. Most people have heard of hospice care and have
a general idea of what services hospice provides. What they dont
know or what may become confusing is that hospice provides
palliative care, and that palliative care is both a method of
administering comfort care and increasingly, an administered system
of palliative care offered most prevalently by hospitals. As an
adjunct or supplement to some of the more traditional care options,
both hospice and palliative care protocols call for patients to
receive a combined approach where medications, day-to-day care,
equipment, bereavement counseling, and symptom treatment are
administered through a single program. Where palliative care
programs and hospice care programs differ greatly is in the care
location, timing, payment, and eligibility for services.Place
Hospice
Hospice programs far outnumber palliative care programs.
Generally, once enrolled through a referral from the primary care
physician, a patients hospice care program, which is overseen by a
team of hospice professionals, is administered in the home. Hospice
often relies upon the family caregiver, as well as a visiting
hospice nurse. While hospice can provide round-the-clock care in a
nursing home, a specially equipped hospice facility, or, on
occasion, in a hospital, this is not the norm.Palliative Care
Palliative care teams are made up of doctors, nurses, and other
professional medical caregivers, often at the facility where a
patient will first receive treatment. These individuals will
administer or oversee most of the ongoing comfort-care patients
receive. While palliative care can be administered in the home, it
is most common to receive palliative care in an institution such as
a hospital, extended care facility, or nursing home that is
associated with a palliative care team.Timing
Hospice
You must generally be considered to be terminal or within six
months of death to be eligible for most hospice programs or to
receive hospice benefits from your insurance.Palliative Care
There are no time restrictions. Palliative care can be received
by patients at any time, at any stage of illness whether it be
terminal or not.Payment
Hospice
Before considering hospice, it is important to check on policy
limits for payment. While hospice can be considered an
all-inclusive treatment in terms of payment (hospice programs cover
almost all expenses) insurance coverage for hospice can vary. Some
hospice programs offer subsidized care for the economically
disadvantaged, or for patients not covered under their own
insurance. Many hospice programs are covered under
Medicare.Palliative Care
Since this service will generally be administered through your
hospital or regular medical provider, it is likely that it is
covered by your regular medical insurance. It is important to note,
however, that each item will be billed separately, just as they are
with regular hospital and doctor visits. If you receive outpatient
palliative care, prescriptions will be billed separately and are
only covered as provided by your regular insurance. In-patient care
however, often does cover prescription charges. For more details,
check with your insurance company, doctor, or hospital
administration.Treatment
Hospice
Most programs concentrate on comfort rather than aggressive
disease abatement. By electing to forego extensive life-prolonging
treatment, hospice patients can concentrate on getting the most out
of the time they have left, without some of the negative
side-effects that life prolonging treatments can have. Most hospice
patients can achieve a level of comfort that allows them to
concentrate on the emotional and practical issues of
dying.Palliative Care
Since there are no time limits on when you can receive
palliative care, it acts to fill the gap for patients who want and
need comfort at any stage of any disease, whether terminal or
chronic. In a palliative care program, there is no expectation that
life-prolonging therapies will be avoided.It is important to note,
however, that there will be exceptions to the general precepts
outlined. There are some hospice programs that will provide
life-prolonging treatments, and there are some palliative care
programs that concentrate mostly on end-of-life care. Consult your
physician or care-administrator for the best service for
you.Reprinted from Hospice vs. Palliative Care, by Ann
Villet-Lagomarsino. Educational Broadcasting Corporation/Public
Affairs Television, Inc. Reprinted with permission.
7Disease-Modifying TreatmentHospice CareBereavement
SupportContinuum of CarePalliative CareTerminal Phase of
IllnessDeathNational Quality Forum, 2006ELNEC Core Curriculumhe
differences between hospice and palliative care.Hospice care and
palliative care are very similar when it comes to the most
important issue for dying people: care. Most people have heard of
hospice care and have a general idea of what services hospice
provides. What they dont know or what may become confusing is that
hospice provides palliative care, and that palliative care is both
a method of administering comfort care and increasingly, an
administered system of palliative care offered most prevalently by
hospitals. As an adjunct or supplement to some of the more
traditional care options, both hospice and palliative care
protocols call for patients to receive a combined approach where
medications, day-to-day care, equipment, bereavement counseling,
and symptom treatment are administered through a single program.
Where palliative care programs and hospice care programs differ
greatly is in the care location, timing, payment, and eligibility
for services.Place
Hospice
Hospice programs far outnumber palliative care programs.
Generally, once enrolled through a referral from the primary care
physician, a patients hospice care program, which is overseen by a
team of hospice professionals, is administered in the home. Hospice
often relies upon the family caregiver, as well as a visiting
hospice nurse. While hospice can provide round-the-clock care in a
nursing home, a specially equipped hospice facility, or, on
occasion, in a hospital, this is not the norm.Palliative Care
Palliative care teams are made up of doctors, nurses, and other
professional medical caregivers, often at the facility where a
patient will first receive treatment. These individuals will
administer or oversee most of the ongoing comfort-care patients
receive. While palliative care can be administered in the home, it
is most common to receive palliative care in an institution such as
a hospital, extended care facility, or nursing home that is
associated with a palliative care team.Timing
Hospice
You must generally be considered to be terminal or within six
months of death to be eligible for most hospice programs or to
receive hospice benefits from your insurance.Palliative Care
There are no time restrictions. Palliative care can be received
by patients at any time, at any stage of illness whether it be
terminal or not.Payment
Hospice
Before considering hospice, it is important to check on policy
limits for payment. While hospice can be considered an
all-inclusive treatment in terms of payment (hospice programs cover
almost all expenses) insurance coverage for hospice can vary. Some
hospice programs offer subsidized care for the economically
disadvantaged, or for patients not covered under their own
insurance. Many hospice programs are covered under
Medicare.Palliative Care
Since this service will generally be administered through your
hospital or regular medical provider, it is likely that it is
covered by your regular medical insurance. It is important to note,
however, that each item will be billed separately, just as they are
with regular hospital and doctor visits. If you receive outpatient
palliative care, prescriptions will be billed separately and are
only covered as provided by your regular insurance. In-patient care
however, often does cover prescription charges. For more details,
check with your insurance company, doctor, or hospital
administration.Treatment
Hospice
Most programs concentrate on comfort rather than aggressive
disease abatement. By electing to forego extensive life-prolonging
treatment, hospice patients can concentrate on getting the most out
of the time they have left, without some of the negative
side-effects that life prolonging treatments can have. Most hospice
patients can achieve a level of comfort that allows them to
concentrate on the emotional and practical issues of
dying.Palliative Care
Since there are no time limits on when you can receive
palliative care, it acts to fill the gap for patients who want and
need comfort at any stage of any disease, whether terminal or
chronic. In a palliative care program, there is no expectation that
life-prolonging therapies will be avoided.It is important to note,
however, that there will be exceptions to the general precepts
outlined. There are some hospice programs that will provide
life-prolonging treatments, and there are some palliative care
programs that concentrate mostly on end-of-life care. Consult your
physician or care-administrator for the best service for
you.Reprinted from Hospice vs. Palliative Care, by Ann
Villet-Lagomarsino. Educational Broadcasting Corporation/Public
Affairs Television, Inc. Reprinted with permission.
8Geriatric Palliative Care Approach to care for the chronically
ill and frail elderlyFocus on Quality of lifeSupport for functional
independence Centrality of the patients values and experiences in
determining the goal of medical care - Morrison & Miere,
2003Benefits of Palliative care to older AdultImprove caregiver
well beingIncrease patient , family and health care provider
satisfactionTreatment of distressing symptoms by interdisciplinary
team translate to reduce medical complications and hospital
utilizationExpertise on symptom managementExpertise in the conduct
of conversation with families and patients
Background in Older AdultNursing Needs for Older Person
Palliative and End-of-Life Care Palliative and EOL CareBackground:
PALLIATIVE CAREInternational World Health OrganizationPalliative
care, while still a relatively new component to modern healthcare,
is increasingly recognized as an essential part of all healthcare
systems.
Palliative BackgroundCOPYRIGHT 2014 by Worldwide Palliative Care
Alliance, All Rights Reserved.The World Health Organization has
granted Worldwide Palliative Care Alliance permission for the
reproductionof Chapter 2, entitled How many people at the end of
life are in need of palliative care worldwide? WHO retainscopyright
of Chapter 2 and grants permission for use in this publication.
World Health Organization 2014Background: PALLIATIVE CAREIsolated
palliative care provision. characterized by:the development of
palliative care activism that is patchy in scope and not well
supported; sourcing of funding that is often heavily donor
dependent;limited availability of morphine; and a small number of
hospice-palliative care services that are often home-based in
nature and relatively limited to the size of the population.
Palliative BackgroundBackground: PALLIATIVE CARENational The
Palliative and Hospice Care Act of 2013House Bill Act 49 during the
15 Congress, no further action was taken due to time
constraintsHighlight the following section:Services and Site of
CareCompassionate Care Leave BenefitsMandatory Palliative Care and
Hospice ServicesAccreditationEducation and Training Health care
ProfessionalContinuing ResearchDesignation of National Palliative
and Hospice Care Council of the Philippines
Palliative Background
14PROCLAMATION 1110 by GMA1st week of October of each year as
National Hospice and Palliative Care WeekPROCLAMATION 936 by
GMANational hospice and palliative care council of the Philippines
( HOSPICE PHILIPPINES) as one of the major conduits of the
department of heath in the distribution of morphine
Palliative BackgroundBackground: PALLIATIVE CAREJoint Commission
International requirementStandard ACC.2.1 Patient needs for
preventive, palliative, curative, and rehabilitative services are
prioritized based on the patients condition at the time of
admission as an inpatient to the hospital.Standard COP.7 The
hospital addresses end-of-life care. Standard COP.7.1 Care of the
dying patient optimizes his or her comfort and dignity.
Palliative Background
Background: EOLDying patients frequently do not receive basic
nursing care or assistance with eating and drinking (Rogers,
2003)Alternatively staff may focus on meeting physical needs at the
expense of psychological and spiritual careComorbidity and drug
reactions make symptom control more difficult
Patient over 80 referred for palliative care consultation have
fewer interventions for pain, nausea , anxiety and other
symptomsPerson 65 and over often have under-treated pain and other
symptomsOlder persons are higher risk for developing multiple
chronic , life threatening diseases
17Background: EOLOlder people are less likely to receive
appropriate pain control than their younger counterparts. Older
people are less likely to receive hospice careIn care homes end of
life care may be impeded by inadequate staff training, poor symptom
control and lack of psychological and emotional support
This is especially for patients with dementia.They are less
likely to take opioids for pain due to cultural beliefs.
It is essential to understand the patient and families
conditions We can start with identifying their level/ types of
dying awareness
18Types of Dying AwarenessTypes of awareness of dyingClosed
awareness- the patient is unaware of impending death while the
staff and/or family engage in tactics to avoid disclosure
Suspicion awareness- suspects his prognosis but the family and
staff do not confirm, tactics to avoid the subject.Mutual
pretense-all parties are aware of the dying but agree to act as if
the person is going to live. Tact and silence dominate the
environment. when pt is crying the Nurse change the topic
Open Awareness- occurs when both staff/family and patient
acknowledge dying-opportunity to bring closure-sorry, goodbye, Im
sorry
Markers for Initiation of Palliative and EOL Care in
GeriatricsNursing Needs for Older Person Palliative and End-of-Life
Care 3 classifications1. Disease Specific MarkersSymptomatic
CHFDementiaStrokeCancerRecurrent InfectionsDegenerative joint
Disease causing functional impairment and chronic pain2. Non
Disease Specific Indicators patient/ family and/or
caregiversFrailty : extreme vulnerability to morbidity and
mortality due to progressive decline in function and physiological
reserve . Frequently falls , disability, susceptibility to acute
illness and reduced ability to recover are examples of frailty
Functional Dependence : Dependence to others to perform
activities of daily living ( see function topic)
Cognitive Impairment: Changes in memory , attention, thinking,
language, praxis and executive function ( see dementia)
Family Support Needs: emotional support, information and
educational support unique to each patient/ family / or
caregivers
253. Core End-Stage Indicators Indicating terminal phase of
chronic Illness are:Physical declineWeight lossMultiple co
morbidities
3. Core End-Stage Indicators Indicating terminal phase of
chronic Illness are:Serum albumin of < 2.5 g/dLDependence on
assistance with most activities of daily livingKarnofsky
Performance Score of less than 50%
General Needs of Older Person in Palliative ManagementNursing
Needs for Older Person Palliative and End-of-Life Care
Subjective Depends on preference, culture and beliefNeeds of
Older Person in Palliative CareContinuity and coordination of care
that responds to episodic and long term chronic illnesses and
transitioning between levels of care
Needs of Older Person in Palliative CareManagement of chronic
IllnessesAssistance in navigating a complex medical system
Maintaining functional independence
Needs of Older Person in Palliative CareDecision making
regarding care and treatment decisions Pain and symptoms
control
Needs of Older Person in Palliative CareDetermining risk versus
benefits of treatmentHome support for family and care givers
Community Resource information and access assistance.
Needs of Older Person in the FINAL Hours (End-of-Life
Nursing)Nursing Needs for Older Person Palliative and End-of-Life
Care TRAJECTORIES on DYINGTRAJECTORIES on DYING
Field and Cassel, 1997
Field and Cassel, 1997
Field and Cassel, 1997Roads to DEATH
Two Roads to DeathNORMALTHE USUAL ROADTHE DIFFICULT
ROADSleepySemicomatoseLethargicComatoseSeizuresMyoclonic
JerksMumbling
DeliriumHallucinationsTremulousConfusedRestlessDEADObtundedFerris
et al., 20031. The Nurse, Dying and DeathNurses provide support to
:StaffPatientsFamiliesInterpersonal competenceBearing
witnessInterdisciplinary care
Presence + Healing + Ethnic Nurse-Patient Relationship392. Dying
is an Individualized Personal ExperienceThere is no typical
deathPatient preferencesNurses advocate for choicesSetting of
deathSupportELNEC Core Curriculum3. Older Adult needs Open, Honest
CommunicationConvey caring, sensitivity, compassionProvide
information in simple termsPatient awareness of dyingMaintain
presenceELNEC Core Curriculum4. Psychological and Emotional
ConsiderationsFear of dying processFear of abandonmentFear of
unknownNearing death awarenessWithdrawal Berry & Griffie,
2010ELNEC Core Curriculum5. Cultural ConsiderationsDeath
ritesRituals
Lipson & Dibble, 2005
What can each of you do? Recognize patients who may benefit from
palliative care Start interdisciplinary discussion about palliative
and end-of-life care Ask about symptoms, physical and emotional
(holistic approach)Talk with patient and family about concept of
palliative/supportive care Know the available palliative care
resources in your institutions
Any Question ?Final ThoughtsQuality palliative care addresses
quality-of-life concernsIncreased HCP knowledge is essentialBeing
with one care needs of older patientImportance of interdisciplinary
approach to careNurses play a big role in addressing the needs and
supporting dying patient and their significant others.
Nursing Needs for Older Person Palliative and End-of-Life Care
Joshua Jaime P. Nario RNNurse EducatorNursing Education Research
and Development Makati Medical CenterTHANK YOU VERY
MUCH!Coordinated palliative care matched to patient needs improves
quality of care for vulnerable patients with serious illness and
reduces costly use of hospitals and emergency departments.
48ReferencesEdmonds P., Rogers A. If only someone had told me. A
review of patients dying in hospital. Clin Med 2003 3,
149-152.Global Atlas of Palliative Care program , 2015Department of
Health , Philippines, 2015ELNEC, Core Curriculum Pincombe J., Brown
M., Thorne D., Ballantyne A., McCutcheon, Care of Dying Patients in
the Acute Hospital. Prog Palliative Care 2000, 8, 71-7.Ellershaw
J., Foster A., Murphy D., Shea T. and Overhill S.: Developing an
integrated care pathway for the dying patient. Eur J Pall Care,
1997, 4 (6) 203-207Burns E. 2012. Palliative and End of Life Care
for Older People. British Geriatrics Society
