Preserving Dignity and Communication at End of Life

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Preserving Dignity and Communication at End of
Life

• Michelle Tristani
• Rehab Clinical Specialist - Speech Pathology
• Linda Bowen
• Senior Director, Clinical Services
• Peoplefirst HomeCare Hospice
• ASHA Convention 2007

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The Natural Dying Process

• Emotional-spiritual-mental
• The physiology of dying

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Identifying End of Life

• Tools for identifying palliative care criteria
• Clinical settings across the continuum of care
• Implication of facility location

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End Of Life Issues

• Quality of life dignified end
• Education and counseling component
• Respect for patient / family wishes
• Facility professionals as one

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Advanced Care Planning

• Advanced Directives
• Living Will
• Durable POA for healthcare
• Physician Orders
• DNR / DNI
• Care Plan
• Pain Management
• Previously stated wishes

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State Specific Regulations and Their Impact
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SLP Role in Palliative Care

• Quality of life related to communication and
  swallowing
• SLP Competency and Involvement
• Medical and Respiratory Status - Acuity level
• SLP training in ethical and legal frameworks
• SLPs objective input to the team process

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Communication Best Practices at End of Life

• Facilitate communication of last wishes and
  expressions
• Communication Eval Determine communication modes
• Cognition - Identification of decision making
  capacity
• Assessing verbal and non-verbal communication
  options
• Identification of communication opportunities
• Facilitation of patient communication priorities

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Communication Needs Opportunities

• Basic human need
• Dignity
• Emergent communication
• Express medical and basic needs
• Expressions of thoughts, plans, ideas
• Spiritual
• Pain

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Cognition and Determining Decision Making
Capacity
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Patient Rights

• Patient right to refuse
• The team decision making process

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Competence and Informed Consent / Refusal

• Legal
• Cognition and decision making capacity
• Reasons why patients refuse
• When patients choose different tx
• Waiver Issues
• Only as useful as the discussion
  
  
  
  that leads to informed
  consent / refusal
• May be viewed as coercive
• May limited modifications later
• May conflict w/ MD order

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Dysphagia Care End of Life

• End of Life Population
• Seriously ill patients exhibiting multiple
  comorbidities
• Advanced age
• Terminal illness
• Progressive / chronic disease
• Advanced dementia
• Does not include patients in persistent
  vegetative state

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Dysphagia Care End of Life

• The Dilemma
• Artificial hydration and nutrition
• Benefit versus harm
• American Academy of Hospice and Palliative
  Medicine AHN is potentially harmful
• Can the body adequately utilize nutrition and
  hydration at EOL?
• Can withholding AHN increase patient comfort?
• The medical communitys longstanding assumption
• AHN Benefits prolongs life, minimizes
  aspiration, promotes nutrition, heals wounds,
  improves function NOT in EOL population.

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American Academy of Hospice and Palliative
Medicine

• Position Statement on Artificial Nutrition and
  Hydration

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Dysphagia Care End of Life

• Identifying the EOL Patient
• Communication with the healthcare team
• Browns End of Life Decision Tool
• Compares PLOF to medical status
• Treatment Plan Development
• Trial treatment / Short term treatment (Safety
  focus)
• Prerequisite discussions medical indications,
  patient preferences, quality of life and
  contextual features.
• Feeding versus Non-feeding options
• Oral / Enteral / Parenteral / Combo / Withholding
  All

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Dysphagia Care End of Life

• Support the patients right to decide
• Emphasize education and training
• Give families the confidence to provide comfort
  care
• State laws for EOL care
• Documentation
• Diagnoses, prognoses
• Risks and benefits of all options discussed
• Dysphagia clinical presentation
• Patient and family wishes / decisions
• Legal documents and MD code orders

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Dysphagia Care End of Life

• The vital role of the SLP with EOL patients
• Helping the patient achieve a dignified death
• For complex cases Refer to the ombudsman or
  ethics committee

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Question Answer Period