What does a palliative approach look like in residential care
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This document provides an overview of a palliative care pilot project in residential care facilities. The goals were to enhance end-of-life care for residents and their families, improve the care team experience, and reduce hospitalizations. The project team implemented educational sessions, palliative care rounds, and engaged physicians. Early results found decreased hospital admissions and increased confidence in conversations about palliative care. Evaluation included focus groups with staff, families and the project team to assess the impact and identify factors for successful implementation.
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What does a palliative approach look like in residential care
- 1. What Does A Palliative Care Approach Look Like In Residential Care? Richard Sawatzky, RN, PhD Professor & Canada Research Chair person-centred outcomes School of Nursing, Trinity Western University; Centre for Health Evaluation and Outcomes Sciences, Providence Health Care Carolyn Tayler, RN, MSA, CON(C) Director Strategic Initiatives, BC Centre for Palliative Care Jill Gerke, BA, MA Counselling Psychology Regional Program Manager, Palliative & End of Life Care, Island Health
- 2. Overview Foundations of a palliative approach Application of a palliative approach Focus on residential care 2
- 3. Emphasis on integrating a palliative approach across sectors of healthcare for all people who have life-limiting chronic illnesses * Residential care * Hospital-based care * Community-based primary care Kelli Stajduhar RN, PhD, FCAHS Professor | School of Nursing/Institute on Aging & Lifelong Health University of Victoria Carolyn Tayler RN, MSA, CON(C) Director Strategic Initiatives BC Centre for Palliative Care
- 4. iPANEL As researchers, clinicians, and administrators, we work collaboratively to synthesize evidence and conduct research on integrating a palliative approach into the care of those facing advancing chronic life-limiting illness. 4
- 5. Chronic Disease Management and Palliative Care Implications of life-limiting illness while acknowledging the uncertainty/lack of prognostic clarity “The healthy optimism of self-care management with profound compassion of a person-centred approach” Thorne, S., Roberts,D., & Sawatzky, R. (2016) 5
- 6. Knowledge Synthesis: Conceptual foundation of a palliative approach 6
- 8. ADOPT AN UPSTREAM ORIENTATION towards the needs of people who have life-limiting illnesses and their families A Palliative Approach is not focused on or limited to care for the imminently dying Two conditions required of care providers to achieve an upstream orientation: 1. Understanding different chronic life-limiting illness trajectories 2. Identifying where people are on those trajectories - ongoing process 8
- 9. ADAPT PALLIATIVE CARE KNOWLEDGE AND EXPERTISE Two questions guide this adaptation: 1. Which principles and practices from palliative care should be applied to people with chronic life-limiting illnesses more generally? 2. How do these principles and practices need to be adapted to ensure their fit with the needs of disease-specific patient populations? 9
- 10. INTEGRATE & CONTEXTUALIZE WITHIN HEALTH CARE SYSTEM Two requirements: 1. Greater capacity within the healthcare system to fully address the evolving end of life care needs of people with chronic life-limiting illnesses 2. Partnerships with a range of healthcare providers— generalists, pc specialists, chronic disease specialists, community partners, people with lived experience 10 Models for Integration & Contextualization • “Early” palliative care • Integration into generalist practice • Disease/condition-specific models for care delivery
- 11. Relating outcomes and indicators to palliative approach conceptual foundations 11
- 12. Further information Sawatzky, R., Porterfield, P., Lee, J., Dixon, D., Lounsbury, K., Pesut, B., Roberts, D., Tayler, C., Voth, J., & Stajduhar, K. (2016). Conceptual foundations of a palliative approach: A knowledge synthesis. BMC Palliative Care, 15(5). doi: 10.1186/s129040160076 Sawatzky, R., Porterfield, P., Roberts, D., Lee, J., Liang, L., Reimer- Kirkham,S., Pesut, B., Schalkwyk, T., Stajduhar, K., Tayler, C., Baumbusch, J. & Thorne, S. (2016). Embedding a palliative approach in nursing care delivery: An integrated knowledge synthesis. Advances in Nursing Science, online first. doi: 10.1097/ANS.0000000000000163 12
- 13. Provincial Survey of nurses and healthcare workers Leaders: Dr. Richard Sawatzky and Della Roberts MSN 13
- 14. Mixed-methods provincial survey Survey includes: • Registered nurses • Licensed practical nurses • Health care workers Acute medical care Home care Residential care To obtain baseline descriptive information relevant to the integration of a palliative approach in a variety of nursing care settings that do not specialize in palliative care 14 R e s e a r c h f o r n u r s e s , b y n u r s e s .
- 15. Sampled nursing care settings in BC (N = 114) 15
- 16. In your practice, how many patients out of 10 have a life limiting condition? 16
- 17. In your practice, how many patients out of 10 with life limiting conditions would benefit from a palliative approach? 17
- 18. Application of a palliative approach 18
- 19. Key findings Improved recognition of the life‐limiting nature of chronic conditions is needed There is a need for consistent application of a palliative approach for people with chronic life‐limiting conditions in all settings There is a need for improved confidence and knowledge regarding a palliative approach 19
- 20. iPANEL Knowledge Translation GOAL: Translate key iPANEL findings into action Help care practitioners and health systems to embed a palliative approach into current care delivery systems, part of the core service. GUIDED by our findings & beliefs “Knowledge-As- Action”1: Evidence becomes knowledge when it is enacted (“actionable”). Research-derived knowledge and practice-embedded knowledge come together in KT; both are invaluable and must be merged “in the gap” between knowing and doing. 20
- 21. Shift your care to a palliative approach 1 21
- 22. Key Features of a Palliative Approach • Involves life-limiting illnesses such as heart, lung, and kidney disease, dementias, frailty, and cancer • Integrates chronic disease management and palliative care principles • Includes conversations about serious illness, personal preferences and goals of care • Understands where the person is in the course of their chronic illness • Orients care to the whole person and their family • Prepared for illness progression, while recognizing uncertain prognosis 22 • Offered across settings including acute, home, and long term care • Consults with specialist palliative care providers, as needed
- 23. Aligns treatment decisions better with goals and wishes Improves quality of life when preferences are known and respected Reduces inappropriate or futile treatments Encourages health care teams to “get on the same page” as the person and family Supports communication and shared care planning among teams caring for the person Gives team members permissions to have conversations with the person and family about serious illness 23
- 24. A palliative approach is different than specialized palliative care. It takes the principles of palliative care and ADOPTS, ADAPTS, EMBEDS SHIFT YOUR THINKING ADOPT principles EARLY (as soon as diagnosis) in the course of a person’s life-limiting condition ADAPT strategies to meet patient and family needs, blend principles of palliative care with chronic disease management EMBED practices into usual care in settings not specialized in palliative care - 24
- 25. A palliative approach takes principles of palliative care and ADOPTS them EARLY in the course of person’s life-limiting condition SHIFT YOUR PRACTICE ADOPT 25
- 26. A palliative approach takes principles of palliative care and ADAPTS strategies to meet patient and family needs SHIFT YOUR PRACTICE ADAPT 26
- 27. A palliative approach takes principles of palliative care and EMBEDS practices into usual care in settings that do not specialize in palliative care SHIFT THE SYSTEM EMBED 27
- 28. Where to find these resources? 28 www.ipanel.ca or email ipanel@uvic.ca
- 29. Project Overview Improving End-of-Life Outcomes in Residential Care Facilities: pilot project to enhance palliative care in the long term care setting In partnership with 4 residential sites in 3 geographies within Island Health, an inter-professional palliative care specialty team co-developed and facilitated the implementation of a 2.5-year quality improvement and knowledge translation pilot project.
- 30. Lead by Palliative Care (PC) Specialist Physician Dr. Leah MacDonald, Medical Director, and supported by Jill Gerke MA, Regional Manager, both of Palliative and End of Life Care Program within Island Health, members of the Implementation Team were: Palliative Physician Advisor Dr. Christine Jones – PC Physician Lead for Victoria Dr. Valorie Masuda – PC Physician Lead for Duncan Dr. Marlene van der Weyde – PC Physician Lead for Parksville Dr. Christian Wiens – PC, Geriatric Psych Specialist Physician, Advisor Palliative Care Nurse Advisor Della Roberts CNS - Knowledge, Education and Research Advisor to Project Jamie Linstead RN - PC Specialist Nurse, Victoria (Link Nurse) Charlotte Robinson RN - PC Specialist Nurse, Duncan & Parksville (Link Nurse)
- 31. Pilot Project Goals enhance the care experience of residents with progressive life-limiting illness and their families; improve the experience of the care team in providing care for the dying; encourage collaborative practice between clinicians in residential care and palliative care; and, reduce emergency department use and hospitalizations of residents who are dying (supporting residents’ dying in place).
- 32. Core Activities awareness raising about the role of a palliative approach to care in long term care (professional and non-care staff, residents’ families or close ones, general public); inter-professional, care team-based as well as group peer-learning palliative care education adapted for the long term care setting; identification of opportunities for organizational (culture) shift and system change to support integration or enhancement of a palliative approach to care; engagement of family physicians and specialist physicians in the conversation about a palliative approach to care as best practice for individuals living with progressive life-limiting illness in the residential care setting.
- 38. Early Learnings & Results Supporting (multidisciplinary) champions (eg. SW, dietician) Role of the Health Care Aid Across all four sites there was a decrease in hospital admissions in last 14 days of life for those residents who were identified early Cultural Shift - Seeing “palliative care” as a process rather than event” New confidence levels with “conversations” Facility leadership involvement critical - CNL, Medical Co-ordinator, Manager
- 39. Palliative Care Rounds Essential To address the staff’s educational and emotional needs around palliative and end of life care Opportunity to review and “identify” residents early as a team An opportunity to reflect on deaths and any emerging concerns or issues.
- 40. Evaluation – iPAC - RC The iPAC-RC project is guided by the following three objectives: • Assess the impact of the implementation project from the perspective of administrative and clinical personnel (i.e., managers, directors of nursing, physicians, and medical directors), family members, and paid workers (RNs, LPNs, RCAs); • Assess indicators of quality of care at the end of life pre- and post-IEOL implementation; and • Identify the process for successful implementation of the project in Island Health, influencing contextual factors (i.e., facilitators and barriers to implementation), and lessons learned for scaling up into other facilities
- 41. Data Collection – iPAC-RC Completed: Nurse/LPN focus groups Care Aide focus groups Family Council focus groups IPEOL team focus group (time 1) In Progress: (individual) Nurse/LPN surveys Care Aide surveys Bereaved family member surveys Schedule IPEOL team (individual) and Time 2 and Time 3 focus groups
- 42. Next Steps developing evidence-informed recommendations for integrating and scaling up a palliative approach into LTC facilities; packaging the suite of practice support tools to facilitate transitions in the care journey; and developing an evaluation framework including outcome measures and benchmarks. EMBED practices into usual care in settings not specialized in palliative care
- 43. Take home messages Palliative approach is NOT a service — clarity in understanding & language… Understanding a palliative approach (shift your thinking!) before introduction of practice tools — a palliative approach is not an “add on” or a “tick box “ Empowering staff within a team-based approach Communication that is patient - centred — respectful, sensitive, contributes to continuity in care Evidence — need for research, especially including patient reported outcomes Others… your thoughts and questions? 43