Nursing Needs for Older Person

Palliative and End-of-Life Care

Palliative Care
• An 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 identification
– impeccable assessment
– treatment of pain and other physical ,
psychosocial and spiritual problems – WHO,
2005
 WHAT IS PALLIATIVE CARE?
Goal :
 to prevent and alleviate suffering
 assist towards the best possible quality of
life
 optimize function
 assist with decision making for patients with
serious illness and their families.
 can be the main focus of care or offered
concurrently with all other life - prolonging
medical treatment.
 WHAT IS “HOSPICE”?
 Location
 Place for the care of dying patients

 Group
 Organization that provides care for the
dying patient

 Approach to care
 Philosophy of care for the dying
patient

 A Medicare benefit
Adapted from Geriatrics Review Syllabus, Sixth Edition
QUESTION: If you need palliative
care, does that mean you’re dying?

Receiving palliative care DOES

NOT necessarily mean you’re
dying.
 Current Practice of Hospice and
Palliative Care

Curative Palliative
Treatment Care

Hospice

ELNEC Core Curriculum

 Continuum of Care
Death

Disease-Modifying
Treatment
Hospice
Care
Palliative Care Bereavement
Support

Terminal Phase of
Illness

ELNEC Core Curriculum

National Quality Forum, 2006
Geriatric Palliative Care
• Approach to care for the chronically ill
and frail elderly
– Focus on Quality of life
– Support for functional
independence
– Centrality of the patient’s values and
experiences in determining the goal of
medical care
- Morrison & Miere,
2003
 Benefits of Palliative Care to Older Adult
AImprove caregiver well being
• Increase patient , family and health care
provider satisfaction
• Treatment of distressing symptoms by
interdisciplinary team translate to reduce medical
complications and hospital utilization
• Expertise on symptom management
• Expertise in the conduct of conversation with
families and patients
Background in Older Adult
Palliative and EOL
Care

Nursing Needs for Older Person

Palliative and End-of-Life Care
Background: PALLIATIVE CARE

Background
Palliative
• International
–World Health Organization
• Palliative care, while still a relatively new
component to modern healthcare, is
increasingly recognized as an essential
part of all healthcare systems.

COPYRIGHT © 2014 by Worldwide Palliative Care Alliance, All Rights Reserved.

The World Health Organization has granted Worldwide Palliative Care Alliance permission for the reproduction of
Chapter 2, entitled How many people at the end of life are in need of palliative care worldwide? WHO retains
copyright of Chapter 2 and grants permission for use in this publication. ©
World Health Organization 2014
 Background: PALLIATIVE CARE
• Isolated palliative care

Background
Palliative
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.
Background: PALLIATIVE CARE
• National

Background
Palliative
– “The Palliative and Hospice Care Act of 2013”
• House Bill Act 49 during the 15 Congress, no further action was
taken due to time constraints
• Highlight the following section:
– Services and Site of Care
– Compassionate Care Leave Benefits
– Mandatory Palliative Care and Hospice Services
– Accreditation
– Education and Training Health care Professional
– Continuing Research
– Designation of National Palliative and Hospice Care Council of the
Philippines
• PROCLAMATION 1110 by GMA
– 1st week of October of each year as

Background
Palliative
“National Hospice and Palliative Care
Week“
• PROCLAMATION 936 by GMA
– National 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
 Background: PALLIATIVE CARE
• Joint Commission International

Background
Palliative
requirement
– Standard ACC.2.1 Patient needs
for preventive, palliative,
curative, and rehabilitative
services are prioritized based on
the patient’s 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.
Background: EOL
• Dying 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 care
• Comorbidity and drug reactions make
symptom control more difficult
Background: EOL
• Older people are less likely to receive
appropriate pain control than their
younger counterparts.
• Older people are less likely to receive
hospice care
• In care homes end of life care may be
impeded by inadequate staff training,
poor symptom control and lack of
psychological and emotional support
Markers for Initiation of Palliative
and EOL Care in Geriatrics

Nursing Needs for Older Person

Palliative and End-of-Life Care
3 classifications

Disease Non Disease

Specific Specific
Indicators
Markers
Core End-
Stage
Indicators
1. Disease Specific Markers
• Symptomatic CHF
• Dementia
• Stroke
• Cancer
• Recurrent Infections
• Degenerative joint Disease causing
functional impairment and
chronic pain
2. Non Disease Specific Indicators
• Due to progressive
Frailty decline of function

Functional • Dependence to others

Dependence
Cognitive • Changes in memory ,
attention, thinking,
Impairment language etc.
Family Support •• patient/ family
Needs and/or caregivers
3. Core End-Stage Indicators
• Indicating terminal phase
of chronic Illness are:
– Physical decline
– Weight loss
– Multiple co-
morbidities
3. Core End-Stage Indicators
• Indicating terminal
phase of chronic Illness
are:
– Serum albumin of < 2.5
g/dL
– Dependence on
assistance with most
activities of daily living
– Karnofsky Performance
Score of less than 50%
Legal and Ethical Principles in the Analysis
of Complex Issues related to Care of Older
Adults
 Informed Consent
 Refusal of Treatment
 Advance Directives
 Informed Consent

 a legal doctrine requiring the disclosure of

information about a proposed treatment before
obtaining consent for its performance.
involves providing factual information,
including the benefits and burdens of an action,
and determining a person’s understanding of
that information.
 Informed Consent

 After being given information, a person is

thought to be able to give informed consent if
they:
 can make a choice
 understand and appreciate the issues
 rationally manipulate information
 make a stable and coherent decision.
 Refusal of Treatment

As at any age, older adults with decision-making

capacity have the right to refuse treatment, even if
such refusal hastens or results in their death
 Advance Directives

 allow individuals to exercise control over their

bodies and direct their health-care in the event
they will lack decision-making capacity at the
time a medical decision needs to be made

 Older adults are more likely to develop impaired

decision-making capacity than are younger
people
 Most commonly used Advance Directives

 Living Wills

 Durable Powers of Attorney for Health Care

(DPOAHC), also known as a Health-Care Proxy

 Advance Health Care Directive Informed Consent

 Living Will

 provides specific instructions about the

particular kinds of treatments / interventions an
individual would or would not want to prolong or
sustain life.

 Living Wills are generally used to declare wishes,

to refuse, limit, or to withhold life sustaining
treatment under certain circumstances should
the individual lose capacity and become unable
to communicate
Durable Powers of Attorney for Health Care
(DPOAHC) or Health-Care Proxy
 is an individual designated, and who is presumably
known and trusted by the older adult, to make
health-care decisions for them should they lose
decision-making capacity.
 The agent or surrogate can interpret the
individual’s wishes as medical circumstances
change.
 one who makes decisions on behalf of
another who is unable to make decisions for
him- or herself, can be designated either
informally or formally.
 Advance Health Care Directive

 it combines the features of a Living Will and a

Durable Power of Attorney for Health Care
along with some other options
General Needs of Older Person in
Palliative Management

Nursing Needs for Older Person

Palliative and End-of-Life Care
•Subjective
•Depends on
preference, culture
and belief
Needs of Older Person in Palliative Care

• Continuity 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 Care

• Management of chronic Illnesses

• Assistance in navigating a complex medical
system
• Maintaining functional independence
Needs of Older Person in Palliative Care

• Decision making
regarding care and
treatment
decisions
• Pain and
symptoms control
Needs of Older Person in Palliative Care
• Determining risk
versus benefits of
treatment
• Home 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 DYING
Sudden Death, Unexpected Cause

Steady Decline, Short Terminal

Phase

Slow Decline, Periodic Crises Death

Lingering, Expected Death

Roads to DEATH

Usual

road
Difficult
road
 Two Roads to Death
THE DIFFICULT
Tremulous ROAD
Confused Hallucinations
Restless
Mumbling Delirium
NORMAL
Sleepy Myoclonic Jerks
Let Seizures
hargic Obtunded
THE USUAL Semicomatose
ROAD
Comatose

DEAD Ferris et al., 2003

1. The Nurse, Dying and Death
• Nurses provide
support to :
• Staff
• Patients
• Families
• Interpersonal
competence
• “Bearing
witness”
• Interdisciplinary
 2. Dying is an Individualized
Personal Experience
• There is no typical death
• Patient preferences
• Nurses advocate for choices
– Setting of death
– Support

ELNEC Core Curriculum

3. Older Adult needs Open,
Honest Communication
• Convey caring,
sensitivity,
compassion
• Provide information
in simple terms
• Patient awareness of
dying
• Maintain presence

ELNEC Core Curriculum

4. Psychological and Emotional
Considerations
• Fear of dying process
• Fear of abandonment
• Fear of unknown
• Nearing death awareness
• Withdrawal
Berry & Griffie, 2010
5. Cultural Considerations

• Death rites
• Rituals
Lipson & Dibble, 2005
 What is the Place of Nursing in
End-of-Life Care?

Nurses Role In The Preparation Of Older Adult

Towards End Of Life

 Direct Care Provider

 Information Broker
 Supporter And
 Advocate.
Any Question ?
Final Thoughts
• Quality palliative care addresses quality-of-
life concerns
• Increased health care personnel
knowledge is essential
• “Being with” – one care needs of older
patient
• Importance of interdisciplinary
approach to care
• Nurses play a big role in addressing the
needs and supporting dying patient and
their significant others.
Caring is an aging process
To rediscover Self