A FINAL GIFT: ADVANCE DIRECTIVES Midcoast Senior College Spring - - PowerPoint PPT Presentation

A FINAL GIFT: ADVANCE DIRECTIVES

Midcoast Senior College Spring Semester, 2019 Susan Flewelling Goran, MSN, RN

THE FACTS ABOUT END-OF LIFE WISHES

• 90% of people say that talking

with their loved ones about the end-of-life care is important.

• 27% have actually done so.
• 60% of people say that making

sure their family is not burdened by tough decisions is extremely important.

• 56% have not communicated

their wishes

• 80% of people say that if

seriously ill, they would want to talk to their doctor about wishes for medical treatment toward the end of their life.

• 7% report having had this

conversation with their doctor.

• 82% of people say it’s important

to put their wishes in writing.

• 23% have actually done it.

Survey of Californians by the California HealthCare Foundation (2012)

“In this world nothing can be said to be certain, except death and taxes.” Benjamin Franklin, 1789

National Healthcare Decisions Day

UNDERSTANDING THE ROLE OF THE ICU IN FINAL DAYS

Session 1: A Final Gift: Advance Directives April 1, 2019

OBJECTIVES

• Explain the purpose of the monitoring equipment located in

a patient’s room.

• Discuss the importance of balanced family visitation in the

patient healing process.

• Explore the various decisions families may be asked to make

for a loved one unable to participate in the decision- making process.

WHEN WAS THE ICU BORN?

• Crimean War (1850s): nurses keep critically

injured soldiers near the nursing station

• WW II: ‘Shock Units’ were created to care

for the severely wounded

• 1952: Polio epidemic and the

development of respiratory support via the Iron Lung

• Late 50’s, early 60’s: ECG/EKC monitoring
• 1960’s: Mechanical ventilation:

development of the use of positive pressure to assist in airway management

TODAY’S ICU

• Critical care is not an organ-based

specialty (cardiologist, anesthesiologist, pulmonologist, etc.); it is a stability and vulnerability-based specialty

• Treatment in a specific area of the

hospital

• Specially trained nurses closely

monitor the sickest patients and provide continuous bedside interventions

INTENSIVE CARE VS CRITICAL CARE

• SCU: Special Care Units
• ICU: Intensive Care Unit
• PICU: Pediatric or Pulmonary Care Unit
• SICU: Surgical ICU
• TICU: Trauma ICU
• MICU: Medical ICU
• NICU: Neonatal or Neuro ICU
• CICU: Coronary/Cardiac ICU
• CTICU: Cardio Thoracic ICU
• BICU: Burn ICU

A ROSE BY ANY OTHER NAME….

COSTLY VISIT

• Although patients admitted to the ICU

account for approximately one-quarter

• f hospitalized patients, they account

for half of total hospital expenditures in the United States, with costs estimated at $110 to $260 billion per year or approximately 1% of the gross domestic product.

• 20% of Americans dies in the ICU; 25% of

Medicare expenditures in last year of life

Angus DC & Truog RD. JAMA, 2016:315(3), 255.

BEEPING, BUZZING, BURPING NOISE IN THE ICU

• Most equipment simply provides information

that ICU staff analyze to determine the patient’s baseline status, or identify changes in status

• Patients are monitored both at the bedside

and at central monitors located at the nurses’ station or in hallways

• Alarms indicate a deviation from parameters

set by the nurse, but are not necessarily indication of a crisis

VITAL SIGN MONITORING

• EKG: rate and

waveform

• Respirations: rate

and waveform

• Blood pressure:

may be invasive (continuous) or automatic cuff (intermittent; waveform and result

• Temperature:

Celsius or Fahrenheit

ECG/EKG

• An electrical ‘picture’ taken of the

heart from various positions

• A 12-lead looks at frontal and

horizontal planes of the heart

• Indirect indication of blood flow

through the heart to the pacemaker of the heart

• Typically, in the ICU, 2-3 waves will

be monitored at a given time (depends on patient history)

BLOOD PRESSURE ASSESSMENT

• BP = HR X SV (heart rate/stroke

volume)

• A-Line: usually radial artery;

allows for beat by beat assessment; requires knowledge of the waveforms

• Allows for direct blood

sampling

• Complications: hemorrhage,

nerve damage, infection

PERIPHERAL CAPILLARY OXYGEN SATURATION(SPO2)

• Pulse oximetry is a noninvasive method for

monitoring a person's oxygen saturation (SO2)

• Safe, convenient, noninvasive, inexpensive
• Uses a probe on either a finger or earlobe
• Light is sent through the finger and measured
• n the other side. This quick, painless, non-

invasive test provides a measurement of the hemoglobin, red blood cells carrying oxygen, in a person’s blood.

• Used consistently in the ICU as part of the vital

signs

IV PUMPS

• Fluid replacement
• Nutrition
• Medication

administration

• Blood infusion
• Usually not all

infusing at the same time; frequent alarms.

CENTRAL LINE

• Multiple lumens allow for

several simultaneous fluid infusions

• Allows for harsh medication

infusion (potassium, vasopressors)

• Access for blood draws

during emergency

• Risk: infection,

pneumothorax, others

IT’S ALL ABOUT THE URINE

• “Pee is your friend”
• Kidneys reflect the strength of

the heart to circulate volume

• It takes adequate BP and

circulating volume for urine to be produced

• Infection is the #1 problem, so

catheter will be removed as quickly as possible

BREATHING TUBE / INTUBATION

• Failure to oxygenate; trauma,

hemorrhage, sepsis,

• Failure to ventilate; spinal cord

damage, severe asthma, COPD, severe pain, MS

• Inability to protect or maintain the

airway; facial trauma, anesthesia, drug /alcohol overdose, other

• The subsequent clinical course will be

improved by early intubation: trauma requiring CT scan, other tests while in severe pain, probable surgery

• Oral or nasal intubation: endotracheal

tube (endo tube)

MECHANICAL VENTILATION

• Patient frequently sedated;

uncomfortable as not normal breathing response

• Unable to speak as endotracheal

tube sits between the vocal cords

• Unable to take oral meds or

food/fluids

• Suction lung secretions through the

endo tube; stomach fluids drained via a nasogastric tube

• May require wrist restraints to

prevent self-extubation

VENTILATOR WEANING

• Gradual process of decreasing ventilator support
• Spontaneous breathing trials: Is the patient stable? Awake? Strong

cough? Adequate muscle strength? Limited sedation?

• May take days to weeks; may transfer out of the ICU to a specialty

unit for weaning and rehabilitation; will usually be trached prior to transfer

• Once adequacy of breathing is determined, patient will be extubated

and the endo tube removed

• Throat may be sore and voice raspy for a couple of days
• Care must be taken to ensure patient can swallow before starting oral

fluids and nutrition

TRACHEOSTOMY

• Original injury may require tracheostomy
• Long term (greater than 7-14 days)

mechanical ventilation with an endo tube

• May allow patient to speak, to eat, and to

more effectively wean from mechanical ventilation

• More comfortable for the patient
• Helps with early ambulation and

rehabilitation

• May allow transfer out of the ICU

IT TAKES THE TEAM….

SO MANY PHYSICIANS…

• Teaching versus non-teaching facilities
• Intensivists: critical care certified

physicians; coordinate medical care, usual liaison to the family

• Role of residents/ House Staff (physicians in

training)

• 4 years of undergraduate education
• 4 years of medical school
• 3-5 years of residency
• Optional Fellowship: 2-3 years
• Physician extenders / Mid-levels: Nurse

Practitioners & Physician Assistants

• Consultants: varying specialists including

Palliative Care

IN THE UNIT…

24/7 Nurse

• Respiratory therapist: helps with

respiratory care

• Spiritual care: provides support

and comfort

• Pharmacists: evaluates

medication plan and consults

• Social worker: family support;

arranges discharge plan; provides financial information

• Physical Therapy: helps with

patient mobility The nurse is there 24/7

INTERMITTENT VISITORS

• Phlebotomists
• Xray techs
• Environmental services
• Blood bank
• Security Officers
• Others as patient

condition changes

VISITORS IN THE ICU

• The nurse is responsible

for caring for the patient and also informing and caring for the family members that are visiting.

HISTORY OF VISITING HOURS

• Restricted hours for nonpaying patients in

an attempt to establish order in the general wards (late 1800’s)

• Paying patients had ‘open’ visitation
• 1960s, visiting hours restricted for both

paying and nonpaying patients to prevent exhaustion from too many visitors

• 2004: IHI challenged hospitals working
• n improvement of care to open their

ICUs with unrestricted visitation policies

ICU VISITATION

• Rest was a major intervention

and visitation was severely limited:

• 5 minutes X2/24 hrs;
• 2 visitors maximum
• No children <16

THE MOVE TO ‘OPEN’ VISITATION

Benefits

• Patients feel supported and

safe

• Families are more satisfied with

care and are less anxious

• Providers have increased
• pportunity for

communication and teaching

Gonzalez et al., Am J Crit Care, 2004; Garrouste-Orgeas et al., Crit Care Med, 2008;

• Kleinpell. Crit Care Med, 2008

Factors for Consideration

Patient perspective limited:

• Patients want some

limitations (only very close family) and restrictions

• Difficult to communicate;

very stressful when inability to communicate upsets families

Olsen, Intensive Crit Care Nurs, 2009.; Hardin et al., Dimens Crit Care Nurs, 2011.

CAREGIVER RESISTANCE...

Physiologic Stress

• Presence of family & friends

tends to reassure and soothe

• Family presence usually lowers

BP, HR, ICP

• Nursing visits increase physiologic

stress

• Decreased risk of cardio-

circulatory complications, lower mortality rates, less anxiety , and decreased stress hormonal profile Barriers to the Provision of Care

• Evidence suggests family serves

as a helpful support, increasing

• pportunities for patient family

education and facilitating communication.

• Family better able to provide

feedback to care team, improving the working relationship.

CAREGIVER RESISTANCE...

• Exhaustion of family and

friends

• Open visiting had a

beneficial effects of 88% of patients and decreased anxiety in 65% of families

• Engenders trust between

staff and family members

DEFINING ‘FAMILY’?

• In February 2007, Janice Langbehn was

denied the right to visit her same-sex partner in the intensive care unit at Jackson Memorial Hospital in Miami,

• Florida. Langbehn and her partner, Lisa

Pond, were vacationing with their three children when Pond suffered an

• aneurysm. At the hospital, nurses and

doctors refused to let Langbehn or her children see Pond, and they did not provide them with adequate updates on her condition. Pond eventually slipped into a coma and died while her family members were trying to persuade administrators to let them into her room.

ROLE OF THE GOVERNMENT

In a groundbreaking move greatly enhanced the ability of gays and lesbians to designate caregivers and medical decision makers, President Obama has ordered the U.S. Dept. of Health and Human Services to “respect the rights of patients to designate visitors.”

2010 VISITATION LAW

• Requirement of all hospitals who

accept Medicare or Medicaid reimbursement

• Allows adult patients to designate

visitors

• No requirement to be legally related by

either marriage or blood

• Non related visitor (per patient) must be

given the same visitation privileges as immediate family member.

WHO IS A PATIENT REPRESENTATIVE?

• Parent of a minor child
• Guardian
• DPOA of a patient who is incapacitated
• Support person/visitation advance

directive who is also referred to as the patient advocate the Joint Commission (called care partner by some hospitals)

• If patient has no advance directives on file

it can be whoever shows up and claims to be the patient representative like the spouse, same sex partner, friend, etc.

SUPPORT PERSONS RIGHTS

Right to be involved in the plan of care CMS says patient representative should sign the consent form even if the patient is competent CMS says the patient advocate or support person is to be given a copy of the patient rights even if the patient is competent. CMS says has right to chose who visitors will be if patient is not competent to make the decision Suggest a form be signed so patient is aware and to protect HIPAA rights

THE INCAPACITATED PATIENT

• If the patient is incapacitated and an individual presents with an AD or

durable power of attorney, then the hospital proceeds with its P & P

• The written advance directive takes precedence over anyone who

shows up and says they are the patient representative and wants to make the healthcare decisions

• Patient is incapacitated, unable to state wishes, and no AD and person

asserts claims spouse or domestic partner, hospital is expected to accept without demanding supporting documentation.

• If multiple claims as PR, ask for documentation (proof of marriage,

joint household, co-mingled finances, domestic partnership, or via state law)

ICU NURSE AS GATEKEEPER

• Reasons to restrict or limit visitation:
• Infection control issues
• May interfere with the care of other patients
• Existing court order restricting contact
• Visitors engage in disruptive, threatening, or

violent behavior

• Patient need rest or privacy
• Patient is undergoing care interventions
• It is the nurse who ultimately decides who is

allowed to visit, how many people may visit at

• ne time, and how long visitors may stay.

SUPPORT AND COMFORT TO THE PATIENT

• Be present
• Stay informed, “What is the plan for

today?”

• Emphasize recovery: once crisis is
• ver, “What can we do to improve

Mom’s function?”

• Can we minimize sedation
• Bring in essentials (hearing aids,

glasses, etc)

• Mobilize early
• Create an ICU diary

THE GOOD, BAD, AND UGLY IN THE ICU

• Delirium: severity of illness, “brain failure”, an acute state of mental

incoherence; incorporates reality into delusions; cannot tell what is real and what is not

• Post-ICU Syndrome:
• Muscle weakness
• Other physical impairments
• Problems with thinking and memory
• Depression, anxiety, and PTSD
• Complications: infection, medical error, surgical error, iatrogenic

complications, sleep deprivation, imposed bed rest

• Family stress and fatigue
• Cost: 25% of Medicare expenditures in the last year of life;

$60,000,000,000 in 2010

Jama, 2016: 315(13):255.

CHALLENGE OF THE ELDERLY IN THE ICU

• Increased life expectancy means

more elderly presenting for medical care/surgical procedures

• 50% of patients in the ICU >65 years
• Elderly have increased risk for

morbidity ("the quality of being unhealthful“) and mortality (death)

• Coexistent frailty independent

predictor of worse outcomes

• Increased proportion of patients > 80

years being admitted to ICUs

• No standard definition of elderly
• Regional life expectancy differs

EXPECTED OUTCOMES

• ¼ of patients >80 admitted to ICU in Canada survived and returned to

baseline levels of function at 1 year; mortality was 44% at 1 year

• Heyland et al, Critical Care Medicine: July 2015 - Volume 43 - Issue 7 - p

1352–1360

• 97% of patients >85 treated in the ICU for ‘circulatory failure’ died within

12 months of the life-threatening event, despite 37% survival to ICU discharge

• Biston et al, Intensive Care Med. Jan;40 (1): 50 – 6.
• 291 adults > 70 admitted to the ICU
• 52.3% regained their pre-ICU level of function: 47.7% became more

impaired or died

• Generally, physical recovery occurred within 6 months of discharge

THE COST OF FUTILE CARE

• Study conducted by researchers at the University of California, Los Angeles, and

RAND Health in Santa Monica, Cal

• 5 ICUs over 3 months, 1136 patients aged 15 – 99, interviewed 34 physicians
• Futile: “burden of such care vastly outweighed the benefits”; “never achieve the

patient's goals”

• 8.6 percent, or 98 patients, received "probably futile treatment," and 11 percent,
• r 123 patients, were perceived to have received futile treatment.
• For each decade increase in age, the likelihood of receiving futile treatment rose

by 1.6 percentage

• The cost of caring for the 123 patients whose treatment was perceived as being

futile was $2.6 million

https://www.livescience.com/39510-icu-treatment-

• verused.html

MAKING THE DECISIONS

We couldn’t bear being responsible for deciding to give up”

WHAT CAN WE GIVE YOU IN THIS DIFFICULT TIME

• Consider what

are the goals of

• ur treatment,

what burden will be borne and by whom.

GROUP DISCUSSION

• 1. Have you had a loved one in the ICU?

What was that experience like for you, for them?

• 2. If a positive experience, what made it

so?

• 3. If a negative experience, what would

you like to see changed?

• 4. What do you understand now that you

did not prior to this class?