Nursing Needs for Older Person

Palliative and End-of-Life Care

Joshua Jaime P. Nario RN

Nurse Educator
Nursing Education Research and Development
Makati Medical Center
Objectives
• At the end of the 30-minute session, participants
must be able to:
– Review key concepts in Palliative and End-of-
Life Care
– Learn issues in older adult palliative care and
hospice
– Discuss the different needs of older patient in
palliative care and final hour
Review of Concepts

Nursing Needs for Older Person

Palliative and End-of-Life Care
“ I told the doctor that I never wanted to go
back to the hospital again. It’s torture –
you have no control and can’t do
anything for your self. And you get
weaker and sicker. Every time I'm in the
hospital it feels like I’ll never get out”
--- 88 year old man with mild dementia
Palliative Care
• An approach that improves the quality
of life of patients and their families
facing the problem associated with life-
threatening illness, through the
prevention and relief of suffering by
means of:
– early identification
– impeccable assessment
– treatment of pain and other physical ,
psychosocial and spiritual problems – WHO,
2005
QUESTION: If you need palliative
care, does that mean you’re dying?

Receiving palliative care DOES

NOT necessarily mean you’re
dying.
 Current Practice of Hospice and
Palliative Care

Curative Palliative
Treatment Care

Hospice
ELNEC Core Curriculum
 Continuum of Care
Death

Disease-Modifying
Treatment
Hospice
Care
Palliative Care Bereavement
Support

Terminal Phase of
Illness

ELNEC Core Curriculum

National Quality Forum, 2006
Geriatric Palliative Care
• Approach to care for the chronically ill
and frail elderly
– Focus on Quality of life
– Support for functional independence
– Centrality of the patient’s values and
experiences in determining the goal of
medical care
- Morrison & Miere, 2003
Benefits of Palliative care to older Adult
• Improve caregiver well being
• Increase patient , family and health care
provider satisfaction
• Treatment of distressing symptoms by
interdisciplinary team translate to reduce
medical complications and hospital utilization
• Expertise on symptom management
• Expertise in the conduct of conversation with
families and patients
Background in Older Adult
Palliative and EOL Care

Nursing Needs for Older Person

Palliative and End-of-Life Care
Background: PALLIATIVE CARE

Palliative Background
• International
–World Health Organization
• Palliative care, while still a relatively new
component to modern healthcare, is
increasingly recognized as an essential
part of all healthcare systems.

COPYRIGHT © 2014 by Worldwide Palliative Care Alliance, All Rights Reserved.

The World Health Organization has granted Worldwide Palliative Care Alliance permission for the reproduction
of Chapter 2, entitled How many people at the end of life are in need of palliative care worldwide? WHO retains
copyright of Chapter 2 and grants permission for use in this publication. © World Health Organization 2014
 Background: PALLIATIVE CARE
• Isolated palliative care

Palliative Background
provision. characterized
by:
– the development of palliative
care activism that is patchy in
scope and not well
supported; sourcing of
funding that is often heavily
donor dependent;
– limited availability of
morphine; and a small
number of hospice-palliative
care services that are often
home-based in nature and
relatively limited to the size of
the population.
Background: PALLIATIVE CARE
• National

Palliative Background
– “The Palliative and Hospice Care Act of 2013”
• House Bill Act 49 during the 15 Congress, no further action was
taken due to time constraints
• Highlight the following section:
– Services and Site of Care
– Compassionate Care Leave Benefits
– Mandatory Palliative Care and Hospice Services
– Accreditation
– Education and Training Health care Professional
– Continuing Research
– Designation of National Palliative and Hospice Care Council of the
Philippines
• PROCLAMATION 1110 by GMA
– 1st week of October of each year as

Palliative Background
“National Hospice and Palliative Care
Week“
• PROCLAMATION 936 by GMA
– National hospice and palliative care
council of the Philippines ( HOSPICE
PHILIPPINES) as one of the major
conduits of the department of heath
in the distribution of morphine
 Background: PALLIATIVE CARE
• Joint Commission International

Palliative Background
requirement
– Standard ACC.2.1 Patient needs for
preventive, palliative, curative, and
rehabilitative services are prioritized
based on the patient’s condition at the
time of admission as an inpatient to
the hospital.
– Standard COP.7 The hospital addresses
end-of-life care.
– Standard COP.7.1 Care of the dying
patient optimizes his or her comfort
and dignity.
Background: EOL
• Dying patients frequently do not receive
basic nursing care or assistance with
eating and drinking (Rogers, 2003)
• Alternatively staff may focus on meeting
physical needs at the expense of
psychological and spiritual care
• Comorbidity and drug reactions make
symptom control more difficult
Background: EOL
• Older people are less likely to receive
appropriate pain control than their
younger counterparts.
• Older people are less likely to receive
hospice care
• In care homes end of life care may be
impeded by inadequate staff training,
poor symptom control and lack of
psychological and emotional support
Types of Dying Awareness

Closed Suspicion
awareness awareness

Mutual Open
pretense Awareness-
Types of awareness of dying
• Closed awareness- the patient is
unaware of impending death while the
staff and/or family engage in tactics to
avoid disclosure

• Suspicion awareness- suspects his

prognosis but the family and staff do not
confirm, tactics to avoid the subject.
• Mutual pretense-all parties are aware of
the dying but agree to act as if the person
is going to live. Tact and silence dominate
the environment.
– when pt is crying the Nurse change the topic
• Open Awareness- occurs when both
staff/family and patient acknowledge
dying
-opportunity to bring closure
-sorry, goodbye, I’m sorry
Markers for Initiation of Palliative
and EOL Care in Geriatrics

Nursing Needs for Older Person

Palliative and End-of-Life Care
3 classifications

Disease Non Disease

Specific Specific
Markers Indicators
Core End-
Stage
Indicators
1. Disease Specific Markers
• Symptomatic CHF
• Dementia
• Stroke
• Cancer
• Recurrent Infections
• Degenerative joint Disease causing
functional impairment and chronic
pain
2. Non Disease Specific Indicators
• Due to progressive
Frailty decline of function

Functional • Dependence to others

Dependence
Cognitive • Changes in memory ,
attention, thinking,
Impairment language etc.

Family Support • patient/ family

Needs and/or caregivers
3. Core End-Stage Indicators
• Indicating terminal
phase of chronic Illness
are:
– Physical decline
– Weight loss
– Multiple co
morbidities
3. Core End-Stage Indicators
• Indicating terminal
phase of chronic Illness
are:
– Serum albumin of < 2.5
g/dL
– Dependence on
assistance with most
activities of daily living
– Karnofsky Performance
Score of less than 50%
General Needs of Older Person in
Palliative Management

Nursing Needs for Older Person

Palliative and End-of-Life Care
•Subjective
•Depends on
preference, culture
and belief
Needs of Older Person in Palliative Care

• Continuity and
coordination of care
that responds to
episodic and long
term chronic
illnesses and
transitioning
between levels of
care
Needs of Older Person in Palliative Care

• Management of chronic Illnesses

• Assistance in navigating a complex medical
system
• Maintaining functional independence
Needs of Older Person in Palliative Care

• Decision making
regarding care and
treatment
decisions
• Pain and
symptoms control
Needs of Older Person in Palliative Care
• Determining risk
versus benefits of
treatment
• Home support for
family and care
givers
• Community
Resource
information and
access assistance.
Needs of Older Person in the FINAL
Hours (End-of-Life Nursing)

Nursing Needs for Older Person

Palliative and End-of-Life Care
TRAJECTORIES on DYING
Sudden Death, Unexpected Cause

Steady Decline, Short Terminal Phase

Slow Decline, Periodic Crises Death

Lingering, Expected Death

 TRAJECTORIES on DYING

Field and Cassel, 1997

Field and Cassel, 1997

Field and Cassel, 1997

Roads to DEATH
Usual
road

Difficult
road
 Two Roads to Death
THE DIFFICULT
Tremulous ROAD
Confused Hallucinations
Restless Mumbling Delirium
NORMAL
Myoclonic Jerks
Sleepy
Lethargic Seizures
Obtunded
THE USUAL Semicomatose
ROAD
Comatose

DEAD Ferris et al., 2003

1. The Nurse, Dying and Death
• Nurses provide
support to :
• Staff
• Patients
• Families
• Interpersonal
competence
• “Bearing witness”
• Interdisciplinary
care
 2. Dying is an Individualized
Personal Experience

• There is no typical death

• Patient preferences
• Nurses advocate for choices
– Setting of death
– Support

ELNEC Core Curriculum

3. Older Adult needs Open,
Honest Communication
• Convey caring,
sensitivity,
compassion
• Provide information
in simple terms
• Patient awareness of
dying
• Maintain presence

ELNEC Core Curriculum

 4. Psychological and Emotional
Considerations
• Fear of dying process
• Fear of abandonment
• Fear of unknown
• Nearing death awareness
• Withdrawal
Berry & Griffie, 2010

ELNEC Core Curriculum

5. Cultural Considerations

• Death rites
• Rituals
Lipson & Dibble, 2005
 What can each of you do?
1. Recognize patients who may benefit from
palliative care
2. Start interdisciplinary discussion about palliative
and end-of-life care
3. Ask about symptoms, physical and emotional
(holistic approach)
4. Talk with patient and family about concept of
palliative/supportive care
5. Know the available palliative care resources in
your institutions
Any Question ?
Final Thoughts
• Quality palliative care addresses quality-of-life
concerns
• Increased HCP knowledge is essential
• “Being with” – one care needs of older patient
• Importance of interdisciplinary approach to
care
• Nurses play a big role in addressing the needs
and supporting dying patient and their
significant others.
THANK YOU VERY MUCH!

Nursing Needs for Older Person

Palliative and End-of-Life Care

Joshua Jaime P. Nario RN

Nurse Educator
Nursing Education Research and Development
Makati Medical Center
 References
• Edmonds P., Rogers A. If only someone had told me. A review of
patients dying in hospital. Clin Med 2003 3, 149-152.
• Global Atlas of Palliative Care program , 2015
• Department of Health , Philippines, 2015
• ELNEC, Core Curriculum
• Pincombe J., Brown M., Thorne D., Ballantyne A., McCutcheon, Care
of Dying Patients in the Acute Hospital. Prog Palliative Care 2000, 8,
71-7.
• Ellershaw J., Foster A., Murphy D., Shea T. and Overhill S.:
Developing an integrated care pathway for the dying patient. Eur J
Pall Care, 1997, 4 (6) 203-207
• Burns E. 2012. Palliative and End of Life Care for Older People.
British Geriatrics Society