End of Life Care

Over the many years of my nursing career, I have learned to acknowledge and appreciate change and I now look at  it as an improvement on the past. I firmly believe that a mind set of ongoing learning is the best quality of all caregivers.

In the past, people were reluctant to talk about death, although we realize that death is the final stage of life. All nurses should read Dr. Eleanor

Kubler-Ross’ book on “Death and Dying”. I have been fortunate enough to attend some of her lectures on the subject and I have achieved  a much greater understanding and acceptance of death. So in this blog I will discuss End of Life (EOL) Matters.

POLST (Physicians Orders for Life Sustaining Treatment) is an approach to end of life planning. All of the critical elements of EOL care are covered in this form. Completion of this is the responsibility of the Primary Care Physician. (PCP) but usually it is the social worker that  introduce EOL information to the Long Term Care (LTC) resident and family as well as schedule an appointment with the PCP.  This meeting should be conducted between the resident, loved ones and the PCP.  It ensures that seriously ill or frail residents can choose the treatment they want, or do not want and that their wishes are documented and honored.

POLST has been adopted by all but eight States. It gives seriously ill residents more control over their end of life care, including cardio pulmonary resuscitation (CPR), medical treatment and extreme endeavors like ventilation and tube feedings. It must be signed by the resident and physician.

The POLST form is copied on pink paper to ensure the document stands out in a resident’s file. However, copies and faxes in any color paper is considered legal. The POLST form is also accepted by emergency medical response teams.

Advance Directives inform the physician the kind of care, the resident has chosen, should they be unable to make a medical decision for themselves.

An Advanced Directive can include one or all of the following:

Living Will

Durable Power of Attorney (POA) for health care

Do Not Resuscitate (DNR) orders.

A Living Will is a signed and witnessed legal document, describing the kind of medical treatment, or life sustaining measures the person wants if they become seriously or terminally ill.

A Durable POA for health care is a document stating who has been chosen to make health care decisions for the person, if they are unable to do so themselves. This is also a legal document.

A DNR order informs the medical team that the patient does not want to be resuscitated in case of a life terminating medical event. The DNR should be signed by the physician and should be an ongoing part of the monthly Physician’s Order Sheet (POS).

Though it is not required in all states, it may be prudent for the LTC to have in the resident’s file a form covering Health Insurance Portability and Accountability Act (HIPAA ).That way the physician and facility will know to whom they can release information about the resident. It is important that all residents in Long Term Care (LTC) facilities have some end of life determination in place. Should a crises occur, the nurse should know  immediately how to respond.  There can be legal consequences to inappropriate response to end of life care.

The positive factors for POLST are many. The dignity and desires of the  residents  are safeguarded. The residents have a voice on how they are treated in a medical crises. The residents can request or refuse certain medical treatments, such as   CPR and hospitalization by selecting Comfort Measures Only in a POLST assessment. They can also request  limited  interventions, or they can choose full treatment which includes all measures to sustain life. As end of life approaches for the resident, family members may have significantly different emotional responses. It is very beneficial that the choice has been verified by the resident.

Long Term Facilities  can also use Hospice as a resource to ensure that appropriate EOL care is provided. There must be a signed contract between the LTC facility and the Hospice provider that outlines the roles and responsibilities of each.  The resident must be in agreement to receive hospice care. The LTC nurse should notify the hospice of any changes in the resident’s condition. It is also necessary the hospice nurse participates in the care plan documentation.

Falls, Incidents and Accidents

A fall is described as  involuntarily coming to rest on a lower surface, or “an unintentional loss of balance, causing one to make unexpected contact with the ground or floor”.(Texas A&M University, October 2013).

Whether a resident has been observed stumbling and has been assisted to the floor or the fall is an un-witnessed event that leads to an injury, all falls have to be reported and investigated. This will determine what interventions must be put in place to keep the resident safe. With  un-witnessed falls, we should play it safe by doing neurological checks on the resident.

All other incidents and accidents, including bruising and skin tears must be reported, investigated and interventions put in place to prevent any re-occurrence.

Falls are unfortunately a frequent occurrence in Long Term Care (LTC) facilities. Falls have an extremely adverse reaction both physically and psychologically on the elderly. Many residents die as a result of a fall and those who survive may sustain injuries that can cause functional decline, decreased mobility or permanent disability. Falls can also result in pain and discomfort. Psychological impacts can include loss of confidence, becoming socially withdrawn and feel less independent.  All or any of the above factors can reduce the resident’s quality of life.

LTC facilities should have in place the following procedures:

Fall Policy: There should be a process in place for investigation and treatment.

Fall Prevention Program: Many facilities have discreet programs in place to identify residents at risk (a sign of a falling leaf that would indicate to staff a resident at risk of falling, safety signs, colored bracelets) etc.

A Fall Team that should convene monthly to discuss current falls,  the reasons residents fell, interventions and measure outcomes for success or failure. A fall log should be maintained listing fall occurrences, interventions and outcomes including date and time of fall and of notification of physician and family. All staff should follow the facility policy for reporting to the proper state agency.

Everyone on staff should understand why falls are a risk factor and should know the residents who are frequently fall or those at a high risk for falls. The key is to be always watching the residents, to monitor what they are doing and interact with them as often as possible. Awareness of the legal liability associated with falls and resultant injuries should be a high priority for caregivers.

Caregivers should identify prevention techniques and therefore we should always be on the look out for any changes in the resident. The nurses aid is the eyes, ears and hands of the care team and detecting change is one of the most important things she/he can do. Knowing the resident’s ability to move around, transfer, perform Activity of Daily Living (ADL), and identifying a decline can predict the risk of falling.

Based on frequent assessments, the direct care staff should know if the residents can recognize their safety needs, can remember and understand those needs. Residents should be reminded frequently to call for help and they should be reassured that the nursing staff are there to help.

When a fall occurs it must be investigated immediately and completely.

Care and safety of the resident is always first. Some of the factors that need to be considered are:

Describe the fall scene, what was the resident attempting to do?

Was the call light on and unanswered?

Was it within reach of the resident?.

When was the resident last seen, toileted or medicated for pain, etc.

Were adaptive devices involved?.

Recreating the scene with witnesses and team members may be beneficial. Monitoring that all previous interventions are in place is necessary.

Identify and review all intrinsic and extrinsic factors.

Muscle weakness, gait impairment and poor balance are the most common causes for falls. Age related risks including  poor eyesight, disease progression, memory loss and poor judgement are all causal factors. Hypoglycemia, hypo-tension and medications that affect the Central Nervous System, such as sedatives and anti- anxiety medications also need to be checked.  The resident should be monitored for 72 hours following any changes in the dosage of these drugs.

Environmental hazards, such as  wet floors, poor lighting, rugs or carpets that are not properly secured and clutter can all contribute to falls and injuries. Equipment, including walkers, wheelchairs and lifts all need to examined to ensure they are properly maintained. Residents who use powered wheelchairs should be assessed frequently by the physical therapy to insure ability and safety. The maintenance department should examine all equipment routinely to determine safety and repair needs.

Interventions must be related to the cause of the fall. The care team should discuss the best one to keep the resident safe and avoid re-occurrence. For residents with cognitive problems, behavior strategies to help avoid hazardous situations may be necessary. All interventions must be included in the care plan and staff must be aware of them. Most important, the intervention must be used, for it to work.

Exercise programs to improve balance, physical functioning and ambulation ability may be provided by Physical Therapy or Restorative Nursing.

Complaint Investigations

All residents’ complaints, no matter how trivial, should be investigated and documented. A log should be maintained containing information about complaints such as the nature of the complaint,date, time, persons involved, witnesses, interventions and outcomes. During the compliance survey process, a state or federal surveyor may request to see the complaint log for the previous year.

When investigating a complaint, the resident’s version of the incident should  be given as much credence as the staff member’s. Residents with numerous complaints may require social service intervention to help identify reasons for any discontent/dissatisfaction. Good communication is vital and problem solving should  be proactive  not reactive.

The Elder Justice Act is a preventative law that protects the elderly from  abuse, neglect and exploitation. It is part of the Patient Protection Affordable Care Act (PPACA) passed in 2010.  Elder abuse refers to actions or lack of actions that can harm or place in harm’s way any elderly person. Nursing home personnel should acknowledge that abuse could happen in their facility and they should always be on the alert for prevention, intervention and treatment of elder abuse.

The law mandates reporting requirements. Federal regulations require all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator of the facility. A hotline for reporting should be available 24/7 and an abuse coordinator is usually the administrator or a designee if the administrator is unavailable.

If serious bodily injury occurs, a report must be made to the state survey agency (such as the Department of Public Health) and the local law enforcement  agency within 2 hours.  When a staff member is involved, he/she is immediately  suspended and must leave the facility until the investigation is completed. Less serious issues are reported to the state agency within 1 day and a final report including investigation, findings and interventions are reported in 5 days. Mistreatment, neglect and all forms of abuse, including verbal, mental, sexual and physical, injuries of unknown origin,and misappropriation of resident’s property are all reportable offences.

To assist in the prevention of abuse, the facility should post a list of residents’ rights and should provide  mandatory training on Abuse prevention and reporting.  Appropriate staff screening and signs and symptoms of staff burnout  should be monitored.  Awareness of staff attitudes and actions regarding  abuse reporting is important. Staff members should feel they can report problems without fear of reprisals or retaliation.

Clinicians should also monitor problems of aggression between residents and appropriate interventions for separation should be put in place.

Outcomes of visitation should always be positive. On one occasion a resident complained to me she had overheard a visitor verbally abusive to the other resident in the room. When the visitor left, the resident cried for long periods. An investigation determined that she was correct. The daughter of a resident was attempting to get money from the resident. The daughter was forbidden to visit except with supervision. The resident was brought to the dayroom during visitation, where staff could observe for any negative interactions.

As I have stated earlier the physician and family members  should be notified timely and the necessary documentation should be completed.

Communication and Documentation

                   

Communication is an essential component of any caregiving relationship. Studies have  shown  that a lack of communication can result in low self esteem and psychological disengagement, and can have a negative impact on the Quality of Life (QOC). This is one area of investigation conducted during a state/federal survey.

When communicating with a resident, the nurse should tell him/her in straightforward language what has to be communicated and ask if the resident understood what was said.

Barriers to good communication can include language differences, hearing problems, hearing aide inefficiency and environmental reasons, such as background noises, loud music and too frequent overhead paging.  These barriers need to be corrected. Inservice education should be available on communication skills. Also, caregivers need to recognize residents’  emotional  conflicts and how they can affect communication with the residents. During periods of care, discussion on the resident’s previous work, hobbies, family and travel experiences will engage the resident in a meaningful way.

On one occasion a resident remarked to me about a specific caregiver.

She stated the caregiver discussed  observations made on the way to work, weather, shopping experiences and interactions with others. The resident said ”I love when she is assigned to me as it gets me out of this room”.

It is very important that the nurse communicates with family frequently pertaining to any changes in the resident’s condition. Good communication goes a long way in alleviating stress and concerns, and helps to decrease any negative perceptions of the care provided by the facility.

When family knows they will be notified timely of any changes or concerns and are encouraged to participate in the resident’s care, they identify a partnership and become more trusting. The family should be notified of all relevant issues pertaining to the resident including changes in condition, medications, treatments and physician visits.

Good communication skills are beneficial when giving reports to the physician. Use of the INTERACT tool SBAR ( Situation, Background, Assessment and Request) should enable the nurse to make a good assessment and have a detailed report available. Physicians frequently say that the nurse did not provide an adequate report, resulting in the resident ‘s transfer to the hospital emergency department for evaluation and treatment.

All nurses should have access to  the  Minimum Data Set (MDS) which should help increase Interdisciplinary Team (IDT) communication.

All team members should be ready for a discussion of the resident’s condition at the care plan conference. When staff are assigned to work together on a project as an IDT, understanding and communication will be enhanced.

Documentation is the written form of communication. We all have heard the old cliche :   “If it wasn’t written down, it wasn’t done.”

Nursing documentation must provide an accurate and timely account of occurrences and must be reflective of observations, be legible and permanent.

Good documents  has six important characteristics:

Factual

Accurate

Complete

Current (timely)

Organized

Compliant with standards

The nurse should follow the policies of the facility, especially the  appropriate measures for correcting documentation errors. Charting requirements for Medicare residents should be complete and thorough.

If the nurse is unsure that her documentation is satisfactory, she should ask herself, “If another nurse had to take over for me right now, does the charting have enough information for the delivery of safe, competent and ethical care?”

Remember the resident’s record is a legal document. Documentation should provide a chronological record of events so that an ordered sequence or time line is easily recognized. Should the record be reviewed by a legal team, the nurse will be held accountable for lack of clarity. All documentation must be legibly signed and dated.

Observations, Reporting and Team Work

                         Observations, Reporting and Team Work

All nursing shifts should make frequent observations on a new resident, especially for the first 72 hours. This information is the basis for the development of a good careplan (CP). As the resident settles in and becomes acquainted with other residents and staff, you will often see a personality change. He or she sleeps better, is more relaxed and becomes involved in the routine of the facility. The charge nurse should meet with all shift direct care personnel to identify patterns for the Activities of Daily Living (ADLs), sleeping, eating, going to the toilet and any expressed concerns (such as pain), should also be identified and investigated. Awareness of the resident’s religious affiliations should also identified as he or she may wish to attend religious services provided by the facility.  

The other care disciplines involved in the resident’s care should also communicate their particular findings. That is the best way to begin the interdisciplinary care plan (IDC). All new interventions, involving the resident must be entered in the CP and updated or changed as necessary.

It has been my experience, that involving the Power of Attorney (POA) or family as much as possible is always a positive factor. The resident must also be allowed to participate in the CP if he is  adequately cognizant.

The other disciplines who are involved in a resident’s care, as needs are identified, are Dietary, Activities, Social Service and the Therapy Department, including Physical, Occupational and Speech. Also Rehabilitation/Restorative therapy may be included in the IDC. As the assessments are completed and care needs identified, the IDC will be established. As these various disciplines interact with the resident, sometimes on a daily basis, please be aware that Nursing interventions are 24/7.

It is imperative in care of the residents to have a good team approach. An acronym for team which is well known is

T--- Together

E----Each

A----Achieve

M----More

I have received many useful reports on observations made by maintenance, housekeeping and dietary staff but then I always encouraged the input and showed my appreciation for the information.

In some facilities, I have seen the INTERACT tools in use. (http://interact2.net/index.aspx) One of these tools which I have found very useful is the Early Warning Tool “Stop and Watch”. It can be used by the direct care staff or any department personnel, to provide input to the nurse.

Written statements concerning resident care are more beneficial than verbal ones, especially if the nurse is busy with the medication pass or on the phone with the physician or family.  A verbal statement may be misinterpreted or easily forgotten. All staff should share information that enables timely decision making by the direct resident care team. Feedback between staff should be delivered in a way that promotes positive interactions. All staff should understand their roles and responsibilities and should be held accountable for their actions.

Admission, Transition and Assessment of a New Resident

Having a good admission process will benefit the resident  during their stay in the facility. Greet the resident by name and welcome him or her to your facility. It is vital that a good assessment should be completed and documented as quickly as possible post admission. Tell them your name and position. Ask them how they would like to be addressed (Robert versus Bob, for instance). Get as much information as possible directly from the resident if they are cognizant or from the accompanying relative or power of attorney (POA), including history of any past illness. Introduce the resident to their roommate if they are sharing a room. It is important to realize if the resident is having a difficult time transitioning from home, hospital or other long term care facility. The resident will be amongst strangers again and may be suspicious, cantankerous and not compliant. It is your responsibility to ease their distress by being polite and caring.

Always remember that first impressions go a long way. You need to do a head to toe assessment specifically concentrating on the admitting diagnosis.

Scalp and hair: Any lesions or dandruff present?

Eyes: Glasses, contact lenses, cataracts removed.

Ears: How is the resident’s hearing? Do they use hearing aids?

Nose: Any history of Epistaxis (nosebleeds)?

Mouth: Do they have their own teeth? Edentulous (possessing no teeth). Is there any sores or redness?

Neck: Check for any swelling.

Lungs: Auscultation(using a stethoscope) the chest thoroughly. Any complaints of cough or shortness of breath?

Does the resident have a pacemaker? When was it last checked.? Check apical and radial pulses and heart sounds.

Check nail beds for any signs of cyanosis.

Breast examination: Observe for symmetry, bulging, retraction or fixation. Palpate the breast in a clockwise rotary motion. The areolas should be palpated to determine the presence of underlying masses. The nipples should be gently compressed for any discharge.

Abdomen: should be assessed for contour and distention. Any signs of peristalsis. Respiratory movement should be assessed. Observe for lesions, scar tissue, striae veins, and pigmentation. Check the umbilicus for any swelling. You may see aortic pulsation in very thin residents.

Use your stethoscope lightly to detect bowel sounds. You should listen in all quadrants for at least five minutes. Check for tenderness and muscle guarding.

Extremities: Observe for involuntary movement. Check the size, contours and bilateral symmetry. Check for edema, color, temperature and pluses. Preform range of motion and check for muscle strength. Check for tonicity of muscle.

Skin: a complete skin sweep must be performed. Observe for skin tears, bruises, scratches, scars and any signs of pressure sores (We are all aware of the difference between “admitted with’ versus “acquired at facility”). If possible, measurements and photographs should be taken (if it is your facility’s policy).

The other assessments required by your facility, fall risk, bowel and bladder, pain, etc., should all be completed timely. All your observances should be in the documentation, signed and dated. Base height, weight and vital signs should be recorded. Check the ability of the resident to care for glasses, hearing aids and dentures, if present. Do they require assistance?

I have decided to create a blog on some of the current problems relative to Long Term Care (LTC) facilities. It is my hope that discussing these issues will provide a helpful tool for caregivers. We are all aware that the acuity levels of residents’ illnesses have escalated dramatically and residents that are presently discharged very quickly post acute stage to LTC facilities.

All LTC employees should be aware of the federal regulations and state agency guidelines required to enable the facility be certified by Centers for Medicare and Medicaid (CMS) and licensed by the state.  This certification and licensure enables the facility participate in the Medicare and Medicaid reimbursement programs.

State and/or federal surveyors visit LTC  facilities at least annually to determine if these standards are maintained and to ensure the residents are receiving appropriate care.

I have worked in many areas of LTC over the past 40 years. Having concentrated on the overall  of resident care needs I have developed the Ten Commandments of LTC:

1. Admission, transition and assessment of a new resident.
2. Observation and reporting and Team work.
3. Complaints and Communication.
4. Falls, Incidents and  Accidents.
5. End of Life care POLST.
6. Psychotropic medication reduction.
7. Diabetic management.
8. Infections including UTI problems
9. Hospital readmission avoidance.

     (10) Dehydration and weight variance.     

These are not listed in any order of importance and are frequently interrelated. I will discuss these issues in future blogs.