Palliative Care in the Nursing Home

1
Palliative Care in the Nursing Home
2
Objectives

• Develop an awareness of how a palliative care
  environment can be created.
• Recognize the need for changes in existing
  facility policies and procedures to promote the
  goals of palliative care.
• Become familiar with quality improvement tools
  that support excellence in palliative care.

3
Creating a Palliative Care Environment

• Quality of Care Each resident must receive and
  the facility must provide the necessary care and
  services to attain or maintain the highest
  practicable physical, mental, and psychosocial
  well-being, in accordance with the comprehensive
  assessment and plan of care
• F309 Long Term Care Regulations
  and Guidance to Surveyors

4
Creating a Palliative Care Environment

• Quality of Care, continued
• Highest practicable level is defined as the
  highest level of functioning and well-being
  possible, limited only by the individuals
  presenting functional status and potential for
  improvement or reduced rate of functional
  decline. Highest practicable is determined
  through the comprehensive assessment by
  thoroughly addressing the needs of the
  individual.

5
Quality of Life

• A facility must care for its residents in a
  manner and in an environment that promotes
  maintenance or enhancement of each residents
  quality of life.
• F240 Long Term Care Regulations and
  Guidance to Surveyors

6
Quality of Life

• The intention of this requirement is to
  specify the responsibilities toward creating and
  sustaining an environment that humanizes and
  individualizes each resident.

7

• The facilitys leadership must embrace the
  palliative care philosophy and incorporate the
  goals of care within the daily practices and
  operating philosophy of the facility.

8
Recognize the differences in Goals of Care

• Rehabilitative Goals
• Maintenance Goals
• Preventive Goals
• Palliative Goals

9
Evaluate Current Practices

• Assess staff perceptions of residents needs and
  care goals through
• Staff Meetings
• Surveys
• Assessment tools
• Review job descriptions/role identification

10
Evaluate Current Practices, continued

• Assess physical plant
• Private areas
• Noise levels
• Phone availability
• Provision of food and beverages between meals
• Review orientation and education regarding end of
  life care for all staff.
• Review policies/procedures to evaluate how they
  reflect/integrate palliative care goals in
  delivery of care.

11
CMS suggests surveyors review the following
related to end of life care

• Policies and procedures for providing end of life
  care
• Palliative care protocols for pain management
• Palliative care protocols for treatment of
  distressing symptoms
• Care directives to maintain the residents
  dignity
• Care directives to assisting the
  family/significant other in the loss

12
Policies and procedures for review and revision

• MDS/RAI and Goals of Care in Care Planning
• Advance Directives
• Palliative Care Decision Making/ Care Planning
• Pain Management

13
Policies and Procedures continued

• Nutrition and hydration
• Spiritual and Psychosocial Interventions
• Hospice Collaboration
• Imminent Death Interventions

14
MDS/RAI and Goals of Care Planning

• Review existing policies for development of MDS
  and Care Plan
• Review policy for significant change assessment,
  need for ongoing assessment and revisions to
  plan of care as condition declines

15
Advance Directives

• Documentation of individual with decision making
  authority and when authority becomes effective
• Assurance of compliance with advance directives
• Documentation for residents without decision
  making ability
• CPR policies

16
Palliative Care Decision Making/Care Planning

• Refusals of Care
• Use of skilled therapies or restorative services
• Treatment of wounds
• Use of restraints, bed rails, catheters,
  equipment, specialty mattresses
• Prevention and intervention for falls
• Role of attending physician and Medical Director

17
Pain Management

• Staff education regarding pain
• Ongoing assessment of pain
• Timeframe for providing pain medications
• Availability of stock pain and emergency
  medications
• Use of prn medication

18
Pain Management continued

• Resident/family education regarding pain
• Documentation of pain effectiveness and follow-up
• Monthly drug regime reviews
• Utilization of pharmacy consultant
• Use of non-pharmacological approaches

19
Nutrition and Hydration

• Appropriate goals related to diet and weight loss
• Provision of pleasure feedings, availability of
  food when desired
• Education to staff and family regarding nutrition
  goals
• Symptom management and tube feedings
• Dehydration issues

20
Spiritual and Psychosocial

• Availability of spiritual support for patient/
  family
• Communication with significant others and family
• Staff education regarding communication

21
Hospice Collaboration

• Contracts
• Process for referrals and determination of
  Hospice appropriateness
• Procedures for admission/discharge
• Documentation
• Care Plan
• Hospitalizations and emergency care

22
Hospice collaboration continued

• Medical records management
• Use of therapies
• Respite Care
• Acute inpatient care
• Business office procedures

23
Imminent Death

• Staff education
• Communication and support to family
• Recognition and accommodation of family needs
• Time of death procedure

24
Quality Assurance Monitoring Tools

• MDS Quality Indicator Review
• Medical Record Pain Management Audit
• Hospice Collaboration Tool
• Checklist Review Following an Expected Death

25

• Communication, leadership and accountability
  are key. All of these factors in combination can
  result in positive resident outcomes

26
(No Transcript)