Module 1: Module 1: Introduction to Palliative Nursing ... · majority of hospice patients (i.e....

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EndEnd--ofof--Life Nursing Education ConsortiumLife Nursing Education Consortium

ELNEC- For Veterans

Palliative Care For Veterans

Module 1: Module 1: Introduction to Introduction to

Palliative Nursing Palliative Nursing CareCare

Veterans Affairs MottoVeterans Affairs Motto

“…“…to bind up the nation’s wounds, to care for him who shall have borne the battleand for his widow, and his

EE LL NN EE CC For Veterans CurriculumFor Veterans Curriculum

orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”

President Abraham LincolnPresident Abraham Lincoln22ndnd Inaugural AddressInaugural Address

Mission of the Department of Veterans Mission of the Department of Veterans Affairs Hospice and Palliative Care Affairs Hospice and Palliative Care ProgramProgram

“To honor Veterans’“To honor Veterans’


To honor Veterans To honor Veterans preferences for care at preferences for care at end of life.”end of life.”

Department of Veterans Affairs Office of Geriatrics and Department of Veterans Affairs Office of Geriatrics and Extended Care http://www.va.govExtended Care http://www.va.gov

Hospice Education Network - ELNEC - For Veterans Module 1 - Introduction to Palliative Care

Hospice Education Network (c) 2010

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Demographics of VeteransDemographics of Veterans•• ProjectedProjected

–– Over 5,000,000 Veterans Over 5,000,000 Veterans cared for at VA cared for at VA facilities/year facilities/year


–– US Veterans: 23,442,000US Veterans: 23,442,000

–– Deaths of WW II Deaths of WW II Veterans/day: 900 Veterans/day: 900

–– % of Veterans over the age % of Veterans over the age of 65: 39.4%of 65: 39.4%

National Center for Veterans Analysis and National Center for Veterans Analysis and Statistics, 2009; Casarett et al., 2008aStatistics, 2009; Casarett et al., 2008a

The Facts About Veteran DeathsThe Facts About Veteran Deaths•• More than 50,000 Veterans die a More than 50,000 Veterans die a

month (600,000/year)month (600,000/year)

–– 23,000 die in VA inpatient23,000 die in VA inpatient

settings/yearsettings/year


•• Veteran deaths account for Veteran deaths account for almost 28% of all deaths in the almost 28% of all deaths in the USUS

•• Approximately 85% do not Approximately 85% do not receive care in a VA facilityreceive care in a VA facility

•• Only 4% die in a VA facilityOnly 4% die in a VA facility

NHPCO, 2010NHPCO, 2010

Veterans in the CommunityVeterans in the Community

•• Nearly 40% of enrolled Nearly 40% of enrolled Veterans live in rural Veterans live in rural communitiescommunities


•• 121,000 Veterans are 121,000 Veterans are without shelter or without shelter or healthcare, hence no healthcare, hence no access to access to hospice/palliative carehospice/palliative care




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Nurses Caring for Veterans at the End of Nurses Caring for Veterans at the End of Life Must Understand the CultureLife Must Understand the Culture

•• Enrolled VeteransEnrolled Veterans

––Social isolationSocial isolation

L k f f il tL k f f il t


––Lack of family supportLack of family support

––Low incomeLow income

•• Military camaraderieMilitary camaraderie

•• Culture of stoicismCulture of stoicism

US Department of VA Affairs, VA Health Administration, 2005US Department of VA Affairs, VA Health Administration, 2005

Characteristics of VHA and Characteristics of VHA and Unique Characteristics of Enrolled Unique Characteristics of Enrolled VeteransVeterans

•• The largest integrated The largest integrated healthcare system in the UShealthcare system in the US

•• MultiMulti layered benefits systemlayered benefits system


Back et al., 2005; Casarett et al., 2008a; Finlay et al., 2008

•• MultiMulti--layered benefits system layered benefits system •• Large elderly populationLarge elderly population•• Multiple coMultiple co--morbiditiesmorbidities•• Higher percent of Higher percent of

homelessness than in general homelessness than in general populationpopulation

Various Experiences Can Affect a Various Experiences Can Affect a Veterans DyingVeterans Dying

•• What branch of service?What branch of service?•• Enlisted? Drafted? Rank?Enlisted? Drafted? Rank?•• Age?Age?


Department of Veterans Affairs, Department of Veterans Affairs, VA Health Administration, 2005VA Health Administration, 2005

•• Combat and/or POW Combat and/or POW experience?experience?

•• PTSD (assess for social PTSD (assess for social isolation, alcohol abuse, isolation, alcohol abuse, anxieties)?anxieties)?

•• StoicismStoicism



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We Do Not Always Die the We Do Not Always Die the Way We Would Prefer Way We Would Prefer

•• Care at homeCare at home•• Fear of painFear of pain•• Financial burdenFinancial burden


Financial burdenFinancial burden•• Invasive, painful treatmentsInvasive, painful treatments•• Dependence on othersDependence on others•• Role changesRole changes•• FinancesFinances•• Elderly caring for the sickElderly caring for the sick BoniBoni--Saenz et al., 2005; Saenz et al., 2005;

EganEgan--City & Labyak, 2010City & Labyak, 2010

Hospice and Palliative CareHospice and Palliative Care

•• PALLIATIVE CAREPALLIATIVE CARE

––Ideally begins at the Ideally begins at the time of diagnosistime of diagnosis

•• HOSPICEHOSPICE

––Most intense form of Most intense form of palliative carepalliative care

L h 6 hL h 6 h


gg

––Can be used to Can be used to complement treatmentscomplement treatments

––Less than 6 months to Less than 6 months to livelive

––Agrees to enroll in Agrees to enroll in hospice programhospice program

–– Chooses not to Chooses not to receive aggressive receive aggressive carecare NCP, 2009NCP, 2009

Hospice and Palliative Care Hospice and Palliative Care cont.cont.

•• BOTHBOTH

Interdisciplinary careInterdisciplinary care


–– Interdisciplinary careInterdisciplinary care

–– Provide pain and symptomProvide pain and symptom

managementmanagement

–– Physical, emotional, socialPhysical, emotional, social

and spiritual care and spiritual care



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Palliative CarePalliative Care


NCP, 2009NCP, 2009

Death and Dying in America:Death and Dying in America:TodayToday

•• Over 4700 hospice programs in the USOver 4700 hospice programs in the US•• Average length of stay in hospice is 20 daysAverage length of stay in hospice is 20 days•• In 2007: 1,400,000 patients received hospice In 2007: 1,400,000 patients received hospice


servicesservices•• 38.8% of all deaths in the US were under the 38.8% of all deaths in the US were under the

care of a hospice programcare of a hospice program•• Patients with chronic illnesses make up the Patients with chronic illnesses make up the

majority of hospice patients (i.e. heart disease, majority of hospice patients (i.e. heart disease, dementia, etc) dementia, etc)

NHPCO, 2005 & 2009NHPCO, 2005 & 2009

ffBarriers to Quality Care at End of Barriers to Quality Care at End of LifeLife

•• Failure to acknowledge limits of medicineFailure to acknowledge limits of medicine•• Lack of training for healthcare providersLack of training for healthcare providers


•• Lack of training for healthcare providersLack of training for healthcare providers•• Hospice/palliative care services are Hospice/palliative care services are

misunderstoodmisunderstood•• Many rules and regulationsMany rules and regulations•• Denial of deathDenial of death

Glare et al., 2003Glare et al., 2003



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History of Palliative Care in VAHistory of Palliative Care in VA

•• 1992: Policy1992: Policy—— “All Veterans should be provided “All Veterans should be provided access to a hospice program…”access to a hospice program…”

•• 19981998--2000: VA Faculty Leaders Project for 2000: VA Faculty Leaders Project for Improved Care at the End of LifeImproved Care at the End of Life2001 T i i d P A t f2001 T i i d P A t f


•• 2001: Training and Program Assessment for 2001: Training and Program Assessment for Palliative Care (TAPC)Palliative Care (TAPC)

•• 20012001--2003: TAPC launched the VA Hospice & 2003: TAPC launched the VA Hospice & Palliative Care Initiative (VAHPC)Palliative Care Initiative (VAHPC)

–– VAHPC Launched HospiceVAHPC Launched Hospice--Veteran Veteran Partnership (HVP)Partnership (HVP)


History of Palliative Care in the History of Palliative Care in the VA (cont.)VA (cont.)

•• 20032003--Present: Palliative Care Present: Palliative Care Consultative Team (PCCT) and Consultative Team (PCCT) and


Accelerated Administration & Clinical Accelerated Administration & Clinical Training (AACT)Training (AACT)

•• 20092009-- Comprehensive End of Life Care Comprehensive End of Life Care Initiative (CELC)Initiative (CELC)

–– PROMISEPROMISE

Palliative Care in the VA TodayPalliative Care in the VA Today

•• VA provides palliative care consultation services at VA provides palliative care consultation services at

–– ALL of its medical centersALL of its medical centers–– Many Community Living Centers (CLC)Many Community Living Centers (CLC)

And contracts with communityAnd contracts with community--based hospicebased hospice


–– And contracts with communityAnd contracts with community--based hospice based hospice programs to enhance VA’s ability to meet the programs to enhance VA’s ability to meet the endend--ofof--life services of its Veteranslife services of its Veterans

•• Over 60% of all Veterans who die in VA facilities Over 60% of all Veterans who die in VA facilities receive care from a palliative care teamreceive care from a palliative care team

Department of Veteran Affairs, VA Pubic Affairs, 2008Department of Veteran Affairs, VA Pubic Affairs, 2008



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Benefits of Palliative Care Consultation Benefits of Palliative Care Consultation Teams (PCCT) in VATeams (PCCT) in VA

•• Veteran’s goals of care are identifiedVeteran’s goals of care are identified•• Less likely to be admitted to ICULess likely to be admitted to ICU


yy•• Laboratory and technological tests Laboratory and technological tests

decreaseddecreased•• Communication between PCCT and Communication between PCCT and

Veteran allow goals to be honoredVeteran allow goals to be honoredPenrod et al., 2006Penrod et al., 2006

Differences in Cause of Chronic Differences in Cause of Chronic Illness and Death by WarsIllness and Death by Wars

•• World War IIWorld War II

•• Korean WarKorean War


•• VietnamVietnam

•• Gulf WarGulf War

•• Operation Enduring Operation Enduring Freedom/Operation Freedom/Operation Iraqi FreedomIraqi Freedom

Eligibility for VA Hospice BenefitEligibility for VA Hospice Benefit

•• Included in the Medical Benefits Package Included in the Medical Benefits Package (both inpatient or home settings)(both inpatient or home settings)


•• Eligible for both VA and Medicare may Eligible for both VA and Medicare may elect to have hospice paid for under elect to have hospice paid for under Medicare Hospice BenefitMedicare Hospice Benefit

Department of Veterans Affairs, Department of Veterans Affairs, Veterans Health Administration, 2005Veterans Health Administration, 2005



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Providing Hospice Services to a Providing Hospice Services to a Veteran who Becomes an InpatientVeteran who Becomes an Inpatient

•• GENERALLY, VA provides GENERALLY, VA provides needed inpatient hospice care at needed inpatient hospice care at

VA f ilit ( f d ti )VA f ilit ( f d ti )


a VA facility (preferred option)a VA facility (preferred option)•• VA may utilize Community VA may utilize Community

Nursing Home (CNH) contractsNursing Home (CNH) contracts•• VA may purchase inpatient VA may purchase inpatient

hospice services from a hospice services from a community providercommunity provider

Department of Veterans Affairs, Department of Veterans Affairs, VA Health Administration, 2005VA Health Administration, 2005

Prognostication: May Be Used to Prognostication: May Be Used to Establish Goals of CareEstablish Goals of Care

•• Performance statusPerformance status

–– ECOG and Karnofsky are poor ECOG and Karnofsky are poor indicatorsindicators


•• Multiple symptomsMultiple symptoms•• Biological markersBiological markers

–– Albumin, etc.Albumin, etc.•• “Would I be surprised if this “Would I be surprised if this

Veteran died within the next 6 Veteran died within the next 6 months?”months?” Glare et al., 2010; Lamont & Christakis, 2007; Glare et al., 2010; Lamont & Christakis, 2007;

Lynn et al., 2000Lynn et al., 2000

Two Palliative Care Frameworks Two Palliative Care Frameworks for Assessing Patientsfor Assessing Patients

•• Making Promises Making Promises Document:Document:

––Begin by envisioning what aBegin by envisioning what a


g y gg y gbetter care system would better care system would look like look like

•• Quality of Life Model:Quality of Life Model:––Identify physical, Identify physical, psychological, social, and psychological, social, and spiritual aspects of carespiritual aspects of care



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Making PROMISES:Making PROMISES:Changing Systems of CareChanging Systems of Care

•• Good Medical TreatmentGood Medical Treatment

•• Never Overwhelmed by SymptomsNever Overwhelmed by Symptoms

•• Continuity Coordination & ComprehensivenessContinuity Coordination & Comprehensiveness


•• Continuity, Coordination, & ComprehensivenessContinuity, Coordination, & Comprehensiveness

•• Well Prepared, No SurprisesWell Prepared, No Surprises

•• Customized Care, Reflecting Your PreferencesCustomized Care, Reflecting Your Preferences

•• Consideration for Patient and Family ResourcesConsideration for Patient and Family Resources

•• Make the Best of Every DayMake the Best of Every Day

Americans for Better Care of the Dying, 1999Americans for Better Care of the Dying, 1999

QUALITY OF LIFE MODEL: Addressing Four QUALITY OF LIFE MODEL: Addressing Four Dimensions of CareDimensions of Care

PhysicalPhysicalFunctional AbilityStrength/Fatigue

Sleep & RestNausea

AppetiteConstipation

Pain

PsychologicalPsychologicalAnxiety

DepressionEnjoyment/Leisure

Pain DistressHappiness

FearCognition/Attention


Pain Cognition/Attention

Quality of LifeQuality of Life

SocialSocialFinancial BurdenCaregiver Burden

Roles and RelationshipsAffection/Sexual Function

Appearance

SpiritualSpiritualHope

SufferingMeaning of Pain

ReligiosityTranscendence

Adapted from Ferrell et al., 1991Adapted from Ferrell et al., 1991

Role of the Nurse in Improving Role of the Nurse in Improving Palliative Care for All PatientsPalliative Care for All Patients

•• More time at the bedside than More time at the bedside than other healthcare providersother healthcare providers

•• Some things cannot be “fixed”Some things cannot be “fixed”


•• Use of therapeuticUse of therapeuticpresencepresence

•• Maintain a realistic Maintain a realistic perspectiveperspective

•• Keep Veteran’s goals first in Keep Veteran’s goals first in all communication with the all communication with the teamteam



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Maintaining Hope in the Midst of Maintaining Hope in the Midst of DeathDeath

•• Experiential processesExperiential processes

•• Spiritual processesSpiritual processes


p pp p

•• Relational processesRelational processes

•• Rational thought Rational thought processesprocesses

Ersek & Cotter, 2010Ersek & Cotter, 2010

Extending Palliative Care for Extending Palliative Care for Veterans Across Various Settings Veterans Across Various Settings

•• Nurses are the constant Nurses are the constant caregiverscaregivers

–– InIn--patient settingspatient settings


–– ClinicsClinics

–– Community living centersCommunity living centers

•• Expand the concept of healingExpand the concept of healing

•• Become wellBecome well--educatededucated

•• Willing to be a “change agent”Willing to be a “change agent”

Final ThoughtsFinal Thoughts•• Quality palliative care Quality palliative care

addresses quality of life addresses quality of life for ALL patientsfor ALL patients


•• Increased nursing Increased nursing knowledge is essentialknowledge is essential

•• “Being with”“Being with”

•• Interdisciplinary care is Interdisciplinary care is vital vital



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Consider…….Consider…….

What steps do you need to What steps do you need to take to improve palliative take to improve palliative care at your institution socare at your institution so


care at your institution so care at your institution so that you and other that you and other members of the team are members of the team are prepared to “care for prepared to “care for him who shall have borne him who shall have borne the battle…?”the battle…?”



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