welcome to unit 1 end of life and postmortem nursing care first we're going to cover end of Life Care end of Life Care is an essential part of nursing practice and patient care it's something that in the west is not necessarily well received it seems almost like in Western culture end of Life Care something that's hidden that's not something that's very public so there are a lot of recommendations for improving end-of-life care including widespread And Timely access to comprehensive coverage for palliative care services now really quickly before we continue on start separating hospice and palliative care palliative care can be end of life care but it's not always end-of-life care and we'll talk more about that here in a little bit also improving communication between providers that's something we've already covered within this unit and then lastly greater emphasis on Advanced Care planning having a living will having um Power of Attorney making plans for when the inevitable will occur more professional education and development helping nurses Physicians other Healthcare professionals really understanding the difference between palliative care and hospice care and bringing end-of-life care more to the Forefront with stronger public engagement and education so what is palliative care again palliative care is not always hospice care palliative care is an approach to care within a structure that aims to optimize the quality of life by anticipating preventing and treating suffering so it's all about quality of life a key piece to this is coordinating interdisciplinary care and communication across the trajectory of a serious chronic typically incurable disease and unfortunately this is currently not reimbursed outside of the hospice setting really ideally palliative care should be provided to all patients with chronic incurable diseases as palliative care again if we toggle back it's all about quality of life by anticipating preventing and treating suffering not necessarily curing but promoting quality of life and it has been shown that palliative care can improve quality of life and extend life and Stave off or prevent Hospice Care altogether the emphasis of palliative care quality of life includes psychological social and spiritual problems addressing those control of pain and physical symptoms such as shortness of breath fluid overload and the overall goal is to improve the patient and the family's quality of life that's a key thing here that it's not just about the patient but it's also about the patient's family as well there are various settings where you might see palliative care the inpatient setting and really palliative care should be provided along medical uh just standard medical treatment because if you think about the purpose of it it's to reduce suffering isn't that what we do already you also see it in skilled nursing facilities sometimes called a sniff however there is poor access to palliative care within these types of settings because skilled nursing facilities are primarily geared towards a restorative focus of care and not so much just managing something that is chronic and like I said before typically incurable now outpatient palliative care is for those who are not eligible for hospice or for those who ought out of home hospice so let's talk about hospice hospice is just like palliative care a coordinated interdisciplinary program for patients with serious Progressive illnesses that are not responsive to a cure that cannot be cured with hospice is always for an incurable condition whereas palliative care may or may not be for a totally incurable condition it's important to understand eligibility for hospice it has to be a serious Progressive terminal illness something that will ultimately result in the death of the patient they have a limited life expectancy and this gets a little bit tricky because it is very difficult Healthcare Providers aprns Physicians struggle with this as it's very difficult to truly pinpoint the the time frame within someone is expected to expire but you can give an estimate the patient has to have an informed choice of palliative type care over only cure focused treatment so it's more about quality of life comfort in the absence of any kind of cure Focus treatment and the patient has to accept death they have to understand that this is all about providing comfort and support until the end of their life now Medicare Medicaid reimbursement life expectancy has to be less than or equal to six months again that's a hard thing to pinpoint sometimes patients live longer than six months so they have to be readmitted to hospice but that's a key thing to think about with General Hospice Care eligibility is they try to shoot for less than or equal to six months Physicians have to certify that it's a terminal illness and it has to be care provided by a certified and structured program overall principles of hospice care we already talked about how death must be accepted or understood Total Care must be managed in an interdisciplinary way amongst those who communicate with the patient and the family regularly because oftentimes you're managing multiple things constipation nutrition Skin Integrity whatever pain or problem the condition itself is causing pain and other symptoms must be managed we'll talk more about that patient and family like palliative care in hospice care as well patient and the family should be viewed as a single unit of care because it's not just the patient that is going through this but the family members as well there has to be some aspect of a home care for the dying so whether it's family friends who are you know committing to providing home care for the patient there has to be some kind of home support bereavement care must be provided to the family members and typically that's provided for 13 months after the patient's death as oftentimes that one year anniversary of the patient's death is very very difficult and research and education should be ongoing within Hospice Care to understand more about it what's best for patients and Families but this is a difficult area to study because elderly end of life those type of people tend to fall within something called the vulnerable or a vulnerable population and so research is usually approached in a very cautionary way with such a vulnerable population foreign most common diagnoses for hospice care it used to be previously that it was primarily cancer and I think that's what most people associate with hospice care is cancer but now that's only about 36.6 percent of hospice patients have a cancer diagnosis again as we discussed previously in this unit that people are living longer and they're living longer with chronic and multiple chronic illnesses so you see many more conditions that are just more chronic such as heart disease and heart failure lung disease COPD is very common and things like dementia this has already been mentioned but to further dive into it Physicians are typically not always and aprns reluctant to refer to hospice as again it's difficult to make a terminal prognosis especially with those who don't have a cancer diagnosis it can be very hard to pinpoint that time frame there are a lot of advances in Curative treatment options in late stage illness if someone is on hospice for say COPD and then a Curative option crops up that can create a conflict also there are a lot of financial pressures on healthcare providers that may cause them to retain rather than refer patients who are eligible for for hospice Hospice Care can be very extensive especially when you look at home care people coming into the home hospital beds oxygen pain medications nutrition so on and so forth that really can add up and if this patient doesn't expire within that six-month period it is just very resource intensive and expensive so sometimes that pressure within the system can make it difficult for providers to make those decisions so now that we've talked about hospice and palliative care I want to further take a moment and truly divide these two you hear a lot of compassionate care and comfort care so compassionate and comfort care are really one in the same you see these terms used interchangeably a lot in the hospital setting so there's a big need for education for nurses Physicians and current practice and and we're moving towards people better understanding palliative versus hospice care with the transitions of care programs that are now put into place as we discussed before for the long-term chronic illnesses and palliative care is coming more to the Forefront for more chronic care that supports symptom management and quality of life so overall hospice and palliative care fall under the umbrella of compassionate slash Comfort Care hospice always includes palliative care because hospice is end of life but end of life also includes quality of life and symptom management you can have palliative care without hospice care and palliative care again is for those who have typically incurable but chronic long-term illnesses but they're not at their end of life they just need quality of life support and symptom management to extend their life to have a better life maybe even Stave off or prevent hospice altogether as the nurse managing bad news can be a challenge so if we reflect on therapeutic versus social communication this is where in all of nursing therapeutic communication is very very important but I would venture to say that in these situations that therapeutic approach is even more important that it's not about us however sometimes it's very difficult for us to manage our own emotions in the situation especially when we get attached to patients I've experienced that myself this was as a an undergrad I was an extern and became very attached to a patient on the oncology floor and it was it was very upsetting uh when she passed so here's some key things to think about when communicating with these patients and their families so assess understanding both for your own and for the patients restate what they say summarize what they say review what they say and and make sure that what you have heard is what they're truly communicating it's that closed-loop communication avoid distractions put away the cell phone if you have it on you in practice try to find a quiet room to have a discussion practice just being avoid that impulse to fill the empty space with talking sometimes just that quiet space is what the patient and family need to process to let emotions settle or just move through that emotional process and avoid the impulse to give advice that can be very challenging as well we want to help people that's that's what nurses do but oftentimes in these situations that's more of a that's a social approach that's more about us wanting to help them and not so much that therapeutic communication that allows for them to make their own decisions and lastly avoid canned responses such as I know how you feel because really truly we don't know how anyone else feels and that is also a very social and not therapeutic response it can be very diminishing to what someone is going through ask questions things like tell me more about how you're feeling tell me more about your plans for end of life care with your father your spouse open-ended questions are really important at this time and allow time for reflection like that pause don't try to just fill up the the quiet space give them time for thought and responses and just processing to these very difficult and usually very emotionally written questions so here are some general tips for when someone is dying now if you look at these from a personal perspective they're highly appropriate for when maybe you have a family member or a friend that is dying but these are also ways that you can help your patients family approach some of the difficult topics and emotions during this time so we're talking about spiritual care spiritual care can mean different things it can be within the context of maybe subscribing to religious beliefs such as Islam Christianity Buddhism Judaism Etc but spirituality it's not a subscription to a structured set of beliefs like religiosity or religion is spirituality is how a person derives meaning and purpose in life where they find their source of Hope and their overall attitude towards death there is a spiritual assessment mnemonic that is very helpful in these types of situations especially for the healthcare professional it's called the FICA spiritual assessment tool F stands for Faith or beliefs I importance or influence of that faith and beliefs what is their Community or C and then a how can we help to address the importance of their beliefs at this time you do have a link in your unit 1 resources to a website that delineates this spiritual assessment tool