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Improving EOL Care – A Holistic Approach
Anita J. Tarzian, PhD, RN UM Schools of Nursing & Law
atarzian@law.umaryland.edu (410) 706-1126
Improving EOL Care A Holistic Approach Anita J. Tarzian, PhD, RN - - PowerPoint PPT Presentation
Improving EOL Care A Holistic Approach Anita J. Tarzian, PhD, RN - - PowerPoint PPT Presentation
Improving EOL Care A Holistic Approach Anita J. Tarzian, PhD, RN UM Schools of Nursing & Law atarzian@law.umaryland.edu (410) 706-1126 VALUES IN CONFLICT Prolonging life Palliating suffering Minimizing future regrets Stewardship of
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TIMING OF B.R.’s DEATH
DIED PREMATURELY
DYING PROLONGED
DIED “AT HER RIGHT TIME”
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Mortality awareness part of human experience
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“It doesn’t matter how long your therapy session is, you always have your breakthrough 10 minutes before the end.”
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Embracing death to embrace life
http://considertheconversation.com/ http://deathoverdinner.org/ http://deathcafe.com/ http://celebrationsoflife.net/ethicalwills/ http://GetPalliativeCare.com https://www.hospicenet.org/
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http://www.ted.com/talks/candy_chang_before_i_die_i_wan t_to?language=en
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What IS “Comfort Care”?
Prevent/manage symptoms Offer information about dying process Elicit religious/spiritual traditions Identify those who need to say goodbye Decide where last days should be spent
Arnold, B. (2011). What to do after the patient is made comfort measures only. Institute to Enhance Palliative Care, University of Pittsburgh Medical Center, 11(2).
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Tasks of Dying (& Living!)
Byock (2004) The Four Things that Matter Most
Ask for forgiveness Offer:
–forgiveness (to others & self) –heartfelt thanks –sentiments of love
Say goodbye
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“There’s nothing we can do.”
The toll a mishandled death takes on survivors in terms of negative mental health consequences, lost productivity, diminished human flourishing, is as real a health issue as any other. Preventing these outcomes is NOT “doing nothing”!
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NURTURING THE CAREGIVERS
Jeffrey Rothenberg, M.D. IU School of Medicine
3 breathing exercises by Andrew Weil: http://www.drweil.com/drw/u/ART00521/three-breathing-exercises.html
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DIFFICULT CONVERSATIONS
http://depts.washington.edu/oncotalk/
Meier, D. (May 19, 2014). Teaching doctors when to stop treatment. (excerpted from journal Health Affairs). Available at: http://www.washingtonpost.com/national/health-science/teaching- doctors-when-to-stop-treatment/2014/05/19/e643d190-caf5-11e3-93eb-6c0037dde2ad_story.html
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UNECESSARY CONFUSION & DISTRESS
PROBLEM
Consensus on standard
- f care unrecognized
Variability in practice & changing staff Fragmented care, no captain mixed messages
REMEDY
Evidence-based practice, team huddles
http://www.choosingwisely.org/
IPE training/education at all levels; organizational buy- in Identify & support lead clinician; ethics consult
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MOVING THE LINE
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“RITUAL CPR”
B.R.’s husband’s perspective “She would want to live.” “I have to know I did everything possible.” “I can’t live without her.” Staff’s perspective “Attempting CPR won’t achieve its goal.” Breaking ribs and shocking her heart is not respectful or dignified. “You are not alone.”
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What Every Patient Deserves…
Symptoms managed Family supported Religious/spiritual traditions honored Goodbyes facilitated (esp. with children!) Choice of where to die offered
Arnold, B. (2011). What to do after the patient is made comfort measures only. Institute to Enhance Palliative Care, University of Pittsburgh Medical Center, 11(2).
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MORE ONLINE RESOURCES
Maryland MOLST
– http://marylandmolst.org/
Massachusetts MOLST video
– http://molst-ma.org/molst-stories
Respecting Your Choices
– http://www.gundersenhealth.org/respecting- choices
Chronic Disorders of Consciousness & Patients’ experiences on film
– http://cdoc.org.uk & http://www.healthtalk.org/
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Sit, be still, and listen, because you're drunk and we're at the edge of the roof.
- Rumi
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Staying Present
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Embracing Palliative Care
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TIMING & TRUST
“It is essential to ensure that some level of trust and rapport has been established with the family before conversation begins about POLST, while also assessing cultural considerations and the context of familial hope … pushing this discussion … is not effective or helpful in assuring best patient care.”
- Maureen Horgan, program coordinator for
Stepping Stones Pediatric Palliative Care and Hospice Program in Seattle, WA http://med.fsu.edu/userFiles/file/POLST%20in%20Pedi atrics.pdf
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Informed consent
Understand relevant information Appreciate choices & consequences Reason about options
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Difference between “being disabled” and “dying”
“… a progressive decline despite appropriate intervention and treatment gives a clear message: the individual is dying, not because
- f a disability, but because the body is failing.”
- Sheehan, M. (2003). Theoretical Medicine, 24, 525-533
Easier said than done with modern technology!
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Continued life may not be in best interest when …
Treatment ineffective; only prolongs dying Irreversible coma or permanent vegetative state Treatment itself would impose excessive pain and suffering
Principles: Dignity, Respect for Autonomy, Life, Equality - American Association on Intellectual and Developmental Disabilities - Position Statement on Caring at the End
- f Life (2012) http://aaidd.org/news-policy/policy/position-statements/caring-at-the-
end-of-life#.UxN9h4Wtyi0
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WHO IS TARGET OF CARE?
ELLIE FAMIILY NOW FAMILY FUTURE
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