End of Life Care Pathways

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End of Life Care Pathways

• David Abriel MD, MCFP, ABHM Cert.
• Physician, South Shore Health
• Palliative Care Program
• April 2009
• NSHPCA

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End of Life Care Pathways

• (Check to see if anyone came
• its Friday
  afternoon)
• Lets Communicate!

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End of Life Care Pathways

• Whos Who?
• ME

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End of Life Care Pathways

• Whos Who?
• YOU

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End of Life Care Pathways

• Talk about End of Life Care and problems
• Introduce Care Pathways
• Walk through the LCP
• Review some opportunities as we see them
• Questions and..
• SOMETHING ELSE?

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Case 2George

• 84y/o m, Rockfield, mets abd ca
• Cachexic, Anorexic, SOB, Too Tired
• Mary 86, family nearby, cant travel
• Keep home as long as possible

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GeorgeChallenges.

• Mary frail, intact
• Geography 45m-2hrs hosp
• GP 3/7 in town, no after hours / ER only
• VON/personal care on good days, PC Nurse 1/7,
  PCmd usually away on course
• pt. min po intake, mild pain, SOBOE but on the
  coach
• Low dose po opiod , laxative

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HELP

• END OF LIFE CARE

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HELP

• PT Dying ?
• No orders
• No Doctor
• No Meds
• Not enough MEDS
• In Pain or Not
• Start Morphine gt Death
• Dont want to KILL PT

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HELP

• Personal care
• Spiritual care
• Caregiver stress, respite
• Financial
• CATS ASStrophies
• Charting/Record/Audit/QA
• Accreditation

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CHPCA Norms of PracticeA Model to Guide

• ..\Palliative care\AModeltoGuideHospicePallia
  tiveCare2002-URLUpdate-August2005.pdf
  complete.pdf
• http//www.cpsonline.info/content/resources/chpcap
  dffiles/complete.pdf

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• CHPCA Norms of Practice

CHPCA Norms of Practice
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• What do you have?
• How are you different?
• where do you start?
• What do you need?
• ????

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UK- Gold Standard Framework

• ..\Palliative care\The Gold Standards Framework
  (GSF).htm

http//www.goldstandardsframework.nhs.uk/
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Pathway

• To a good death(?)

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Pathway

• To a good death(?)
• Symptom Management

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Pathway

• To a good death(?)
• Symptom Management
• Pain Physical
• Psycho/Social
• Spiritual
• Existential

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Pathway

• To a good death(?)
• Symptom Management
• Location.

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support

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Pathway

• Security and Support
• advanced care planning
• integrated care
• around the clock
• acceptable risks
• preparations for crisis

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support
• Carers

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support
• Carers.Family, personal care workers
• nurses, doctors, volunteers
• bereavement

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support
• Carers
• Staff

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support
• Carers
• Staffconfident, competent, collaborating(?),
  CQI

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support
• Carers
• Staff

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Pathway

• To a good death(?)
• Symptom Management
• Location.
• Security and Support
• Carers
• Staff
• UK-GSF

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• Communication
• Case managed- Team approach
• Collaborative, integrated
  inter- professional
• Care plan
• Control of symptoms
• Continuity
• Continued learning
• Carer Support
• Care in the Dying Phase
• Liverpool Care Pathway

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Liverpool Care Pathway

• Evidence Based Framework
• Multi-professional
• Hospice Model gt other settings
• Education
• Replaces all other documentation
• Continuous Quality Improvement
• Not Just Standing Orders
• To the Core, embedded

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Liverpool Care Pathway

• PATHWAY

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Pathway

• Dictionary.com Unabridged (v 1.1) -
• noun
• 1.a path, course, route, or way.
• 2.Biochemistry. a sequence of reactions, usually
  controlled and catalyzed by enzymes, by which one
  organic substance is converted to another.

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Pathway

• Familiar / direct / has Hx
• Although the path to hell is paved ..
• get of the beaten path.
• EASIER

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Goals of care

• 18 areas of care/concern
• from d/c unnecessary meds to
• Pain Sx management to after
• death care.
• Easy, standardized. Auditable
• charting
• Consistent management decision paths

• http//www.mcpcil.org.uk/files/GoalDefinitiondatad
  ic_NEW_-Dec.pdf

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• http//Examples of LCP - Marie Curie Palliative
  Care Institute Liverpool

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• Challenges

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• 60,000 older
• A PC Consultation team
• (3 RN, .6 SW, program manager, Volunteer
  Coordinator
• Volunteers, 1 md )
• Most have FD (Little off hours)
• Dedicated CC Case Managers
• VON Community Nursing (24 hrs ph)
• Limited private nursing
• Provincial Home Care personal care
• Regular IP, Case managed Rounds-
• Some med coverage

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• Better integration
• Advanced proactive planning
• More education for docs, FLE, vol
• Common PT Chart
• ?Just In Case Drug Boxes
• LCP(?) ltc. Hospital, community???
• inPt unit?
• .
• .

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http//www.earlmountbattenhospice.org.uk/Professio
nal/JustinPDfs.html
Case pdfs Just in
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• Case
• George

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• Pathways are not always easy,
• Esp if any of the components are weak.
• Determination , Familiarity, Skill,
• and sometimes Luck will get
• us there.

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End of Life Care Pathways

• Talk about End of Life Care and problems
• Introduce Care Pathways
• Walk through the LCP
• Review some opportunities as we see them
• Questions and..
• SOMETHING ELSE?

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• C\Users\The Abriel's\Videos\RealPlayer
  Downloads\El Camino del Rey High Quality.flv