Long Term Care Administration

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Long Term Care Administration

• Thursday, March 19, 2009
• Week 11 - Chapter 15
• End-of-Life Issues

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End-of-Life Issues

• But in this world nothing can be said to be
  certain, except death and taxes.
• Benjamin Franklin

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End-of-Life Issues

• There are two certainties in life death and
  taxes.
• Little progress has been made identifying and
  addressing end-of-life issues.
• Grand Solutions those which address all people
  equally through a narrowly focused policy or
  single program.
• Death and dying one size does not fit all.

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• To the well-organized mind, death is but the
  next great adventure.
• J.K. Rowling

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End-of-Life Issues

• One Size Does Not Fit All
• Complex, ever changing interplay of culturally
  based traditions
• Socially and family defined values
• Individual interests and perspectives
• Health care developments
• Considerable number of other factors that
  influence on human needs and expectations

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• As a well-spent day brings happy sleep, so life
  well used brings happy death.
• Leondardo da Vinci

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End-of-Life Issues

• Where Does Death and Dying Occur
• (based on death certificate data)
• 71.2 of deaths occur in hospitals (1998).
• 3.2 of deaths in other institutions.
• 21.8 of deaths in other places.
• 3.9 of deaths unknown or missing.

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• Death ends a life, not a relationship.
• Mitch Albom

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End-of-Life Issues

• Hospital-Based Care
• Aggressive but futile diagnostic and
  cure-oriented treatment in hospitals.
• Public fear aggressive treatment.
• Fear of hospital MDs making decisions.
• Fear of life supporting treatment even when there
  is no hope of recovery.
• Advances in medical technology.

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• Death doesnt really worry me that much, Im not
  frightened about it I just dont want to be
  there when it happens.
• Woody Allen

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End-of-Life Issues

• Cardiopulmonary Resuscitation (CPR)
• Under 3 of patients receive CPR who died in a
  hospital.
• CPR provided for unexpected deaths.
• Do Not Resuscitate Order (DNR) is an advance
  directive.

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End-of-Life Issues

• For three days after death hair and fingernails
  continue to grow, bit phone calls taper off.
• Johnny Carson

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End-of-Life Issues

• Distributive Justice Use Scarce Resources
• Scarce and expensive hospital resources for care,
  could be used elsewhere.
• Dying people need nursing care which can be
  provided in home or long term care facilities
  which are less expensive.
• Slow death trajectories, alternates to hospitals
  care can be more easily arranged.

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End-of-Life Issues

• I have lost friends, some by death other
  through sheer inability to cross the street
• Virginia Woolf

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End-of-Life Issues

• California Daughter Syndrome
• Some children, who have not seen their parents
  for months or years and thus do not realize or
  have not come to terms with the fact that death
  was inevitably near.
• Children in this situation may insist on all
  possible treatment despite the existence of an
  advance directive.

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End-of-Life Issues

• Im completely in favour of the separation of
  Church and State. My idea is that these two
  institutions screw up enough on their own, so
  both of them together is certain death.
• George Carlin

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End-of-Life Issues

• Decision Making Can be regretted later
• Withdrawing life support perceived as euthanasia
  actively ending a life.
• Withholding treatment perceived as letting nature
  takes its course.
• Most family members are unaware of the care
  preferences of their loved ones.
• Most deaths in Canada after a long life.

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End-of-Life Issues

• Sleep, those little slices of death Oh how I
  loathe them.
• Edgar Allan Poe

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End-of-Life Issues

• Who Dies
• Gradual increase in the average age at the time
  of death.
• Two main contributing factors.
• Major reduction in infant mortality.
• Increasing proportion of seniors who reach an
  advanced old age.

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End-of-Life Issues

• Animals have these advantages over man they
  never hear the clock strike, they die without any
  idea of death, they have no theologians to
  instruct them, their last moments are not
  disturbed by unwelcome and unpleasant ceremonies,
  their funeral cost them nothing, and no one
  starts lawsuits over their wills.
• Voltaire

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End-of-Life Issues

• Some Statistics
• 41.9 80 years and older.
• 12.3 90 years and older.
• 12 of seniors served by home care.
• 5-7 of seniors reside in institutions.
• 84.2 average age of death in LTCF.
• 73.2 average age of death in Hospitals.

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End-of-Life Issues

• We believe that an informed citizenry will act
  for life and not for death.
• Albert Einstein

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End-of-Life Issues

• LTCF end-of-life care more likely for widowed
  persons.
• Married people more likely to receive short term
  end-of-life care in hospitals.
• Average stay in a LTCF is 3-4 years.
• More females than males died in LTCF and more
  males than females died in hospitals.

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End-of-Life Issues

• A single death is a tragedy a million deaths is
  a statistic.
• Joseph Stalin

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End-of-Life Issues

• Why do Canadians Die?
• 999 different causes of death
• 36.3 Cardiovascular Disorders
• 27.8 Cancer
• 11.1 other causes
• 10 respiratory disorders
• 6.1 injuries and suicides

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End-of-Life Issues

• A nation or civilization that continues to
  produce soft-minded men purchases its own
  spiritual death on an installment plan.
• Martin Luther King Jr.

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End-of-Life Issues

• When Does Death and Dying Occur?
• Two times as many deaths in the winter as in the
  summer.
• Winter-time flu, colds, falls related to winter
  conditions.
• Some people hold on to life until an important
  social event passes.
• Little research in this area.

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End-of-Life Issues

• I wish to be cremated. One tenth of my ashes
  shall be given to my agent, as written in our
  contract.
• Groucho Marx

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End-of-Life Issues

• What Also Influences Death and Dying?
• Long life expectation amongst Canadians.
• Premature death prevented in most cases.
• Gene therapy, advances in health care technology,
  and drug advances promise to prevent or abate
  illness.
• Health care utilization and costs increases, lead
  to health care system unsustainability

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• The valuing or sanctity of life is considered
  one of the prime values underlying Western
  society
• Beauchamp and Childress

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End-of-Life Issues

• Fears about Death and Dying
• Painful, drawn-out process, dependency
• Uncertainty of what comes next
• Irreversibility or finality of death
• Emotional, physical, financial impact on loved
  ones

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End-of-Life Issues

• It is the unknown we fear when we look upon
  death and darkness, nothing more.
• J.K. Rowling

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End-of-Life Issues

• Societal Value of Life - Taxes pay to preserve
  and sustain life
• Rescuers risk their life to save another.
• Safe air ground transportation.
• Safe hospitals and medications.
• Seatbelt laws, non smoking laws.
• Hospitals funded better than LTCF

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End-of-Life Issues

• Healthy children will not fear life if their
  elders have integrity enough not to fear death.
• Erik H. Erikson

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End-of-Life Issues

• Safe Society
• Most Canadians dont think about a premature
  death.
• Small proportion of people sign an organ donation
  card.
• 50 have a will for estate planning.
• Fewer have an advance directive.

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End-of-Life Issues

• I'd rather die while I'm living then live while
  I'm dead.
• Jimmy Buffet

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End-of-Life Issues

• Nurses, physicians, clergy, bereavement
  counsellors, funeral directors have taken over
  the role of family members.
• Palliative care is a noncurative,
  comfort-oriented care provided to dying persons
  and their families.
• Palliative care good, healthy death.
• Death tragedy, not ordinary experience.

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End-of-Life Issues

• In the stars is written the death of every
  man.
• Geoffrey Chaucer

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End-of-Life Issues

• Ageism
• Death is viewed negatively in Cdn Society
• Death is an event of old age.
• Death of an older person is a tragedy for the
  family, for a younger person to die it is a
  tragedy for society.
• Older people are often considered a burden on
  their family and society

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End-of-Life Issues

• It's funny the way most people love the dead.
  Once you are dead, you are made for life.
• Jimi Hendrix

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End-of-Life Issues

• Assisted Suicide and Euthanasia
• Bob Latimer and Sue Rodriguez to high profile
  cases in Canada not legal.
• Legalized in other jurisdictions such as Holland,
  Oregon.
• An aged society can expect to have different
  values and customs than a more youth-oriented
  one.

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End-of-Life Issues

• A beautiful death is for people who have lived
  like animals to die like angels.
• Mother Teresa

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End-of-Life Issues

• Options for End-of-Life Care
• Aggressive or non aggressive care.
• Choice of care setting when dying.
• Choice of caregivers formal or informal.
• Assistance in ending life or not.
• People differ in their preferences.

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End-of-Life Issues

• "Look, I don't want to wax philosophic, but I
  will say that if you're alive you've got to flap
  your arms and legs, you've got to jump around a
  lot, for life is the very opposite of death, and
  therefore you must at very least think noisy and
  colourfully, or you're not alive."
• Mel Brooks

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End-of-Life Issues

• Dying people are physically, mentally,
  emotionally dependent on others.
• Average end-of-life hospital stay 21 days.
• Dying patients can feed, bathe and speak for
  themselves until near the end.
• Dying in LTCF are dependent on others for months
  and sometime years.
• Resources are limited, few options exist.

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• I answer the heroic question "Death, where is
  they sting?" with "It is here in my heart and
  mind and memories."
• Maya Angelou

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End-of-Life Issues

• Palliative Care
• Community based programs increasing.
• Shrinking number of hospital beds.
• Started in Canada in the mid 1970s.
• Has competed unsuccessfully for hospital
  resources hospitals diagnose and cure.

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End-of-Life Issues

• "I am ready to meet my maker, but whether my
  maker is prepared for the great ordeal of meeting
  me is another matter."
• Winston Churchill

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Preparing for the End-of-Life

• DNR
• Most LTCF have DNR policies.
• Policies have developed on transfer to a
  hospital, the initiation of antibiotics and other
  potentially life-prolonging medications.
• Policies around living wills.

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End-of-Life Issues

• People say satire is dead. It's not dead. It's
  alive and living in the White House.
• Robin Williams

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End-of-Life Issues

• Private suite for dying patients families.
• Upgraded equipment and staff training.
• Commitment to aging in place.
• Training in-house palliative care expertise.
• Access to outside palliative care experts.
• Goal to improve are of dying seniors.

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On Death and Dying

• I've told my children that when I die, to
  release balloons in the sky to celebrate that I
  graduated. For me, death is a graduation.
• Elisabeth Kubler-Ross

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On Death and Dying

• The book introduced the author's seminal "stages
  of dying" or "stages of grief" model which is
  still widely quoted.
• According the Kübler-Ross model, there are five
  stages that a dying person goes through when they
  are told that they have a terminal illness.
• The five stages go in progression through denial,
  anger, bargaining, depression, and acceptance.
• This model has been widely adopted by other
  authors and applied to many other situations
  where someone suffers a loss or change in social
  identity.
• The model is often used in bereavement work.
• Not all workers in the field agree with the
  Kübler-Ross model, and some critics feel the
  stages are too rigid.

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On Death and Dying

• I always say that death can be one of the
  greatest experiences ever. If you live each day
  of your life right, then you have nothing to
  fear.
• Elisabeth Kubler-Ross

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On Death and Dying

• This is the world-famous best-seller by the woman
  who popularized the field of thanatology as a
  subject for general social commentary.
• Written in plain language that anyone can
  understand, this important book can help families
  understand what's going on as death of a loved
  one draws near.
• This was Elisabeth Kübler-Ross' first book on the
  topic.
• It is still considered a classic.
• It is required reading in many academic settings,
  including medical and nursing schools,
  theological seminaries, and popular psychology
  courses.

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End-of-Life Issues

• The prejudice surrounding AIDS exacts a social
  death which precedes the actual physical one.
• Tom Hanks

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St. Christophers Hospice

• Founded by Cicely Saunders in 1967 and
  her extraordinary contribution to alleviating
  human suffering has resulted in the hospice being
  considered a centre of innovation and insight
  ever since.
• Widely acknowledged as the pioneer of the modern
  hospice movement and has earned a reputation for
  excellence in clinical practice, research and
  education.

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St. Christophers Hospice

• Patients are treated as individuals and strives
  to understand and meet their unique needs, in the
  hospice or in the familiar surroundings of their
  own homes.
• Through bereavement counselling and advice
  families are helped, including children, to learn
  to face the future.
• When someone is very ill, all of the family is
  affected.
• Care extends beyond the treatment of physical
  symptoms to consider the emotional and social
  needs of patients, families and their friends and
  carers.

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St. Christophers Hospice
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Setting Limits Medical Goals in an Aging Society

• Faults the health care system for devoting
  disproportionate resources and technology on
  extending the lives of the elderly regardless of
  the quality of their lives.
• He also warns against the social and economic
  consequences of the increased ratio of old people
  in the population.
• Medical care, he suggests, should be allocated
  based on standards of need and priorities to meet
  them over a "normal life-span opportunity range,"
  limiting the use of new technology to that which
  improves the quality of life.
• He also discusses the ethics of withholding
  artificial sustenance from the terminally ill,
  euthanasia and assisted suicide.

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Setting Limits Medical Goals in an Aging Society

• "The proper question is not whether we are
  succeeding in giving a longer life to the aged,"
  he argues, but "whether we are making of old age
  a decent and honorable time of life."
• Daniel Callahan

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• The goal of all life is death
• Sigmund Freud