Caring House The Smarties Series Care Planning for Smarties 1. The - PDF document

Caring House The Smarties Series Care Planning for Smarties 1. The Six Keys to Care Planning Success 2. Who Ya Gonna Name? Plus Advance Directives 101 Care Lingo Decoded Plus CA End of Life Option Act 3. What Ya Gonna Tell Em? 4. I’ve Been Named. How Do I Do an Amazing Job? October 16, 2018 5. Care Lingo Decoded. Plus California’s End Providing peace, comfort and of Life Option Act support to men and women at the ends of their lives Background Handouts, Slides and More  Ellen Gorbunoff, RN  Ed Long, JD You can get all class materials and be notified about future classes by signing up at  Handouts  Time YourCaringHouse.org/materials  Questions Core Concepts Success as an Agent 1. You have a right to decide whether to -- start, -- decline or Success as an Agent is 75% preparation. -- stop available medical treatment (“care The other 75% is caring. decisions”). 2. You have a right to name another person to make care decisions for you. Page 1

What is Death?  Jahi McMath case Neurological Death Cardiopulmonary Death  Irreversible cessation of function of  Circulatory (heart and blood flow) and  Respiratory (breathing) Page 2

POLST  Physician Orders for Life-Sustaining Treatment (POLST)  What is it?  Who creates it?  When should it be done?  Person is seriously ill or frail and MD wouldn’t be surprised if person died within a year  NNNY (not now, not you) POLST Lingo CPR Background  CPR / DNR / AND  C ardio P ulmonary R esuscitation  Cardio (heart) and Pulmonary (lungs)  For when heart stopped or breathing stopped CPR Background (cont’d) CPR Background (cont’d)  Originally for accidents or surprises  After CPR, overall 15.2% survived to hospital discharge  Has become standard in hospitals and nursing homes  But , less than 2% survived to hospital discharge if already  Can involve  Had more than two medical problems or  Chest compressions  Unable to live independently or  Mouth-to-mouth  Had a terminal disease  Electric shock (defibrillation)  Intubation and respirator Page 3

More Info on CPR DNR and Codes  Hard Choices for Loving People, by Hank  DNR (do not resuscitate) Dunn  DNAR (do not attempt resuscitation)  At hardchoices.com  AND (allow natural death)  See Chapter One – Cardiopulmonary  Full Code = use all interventions to bring Resuscitation be back  Code Blue = page in a hospital calling team to do CPR CPR Video CPR Video  American Heart Association demonstration of in-hospital CPR.  A training video, using a dummy.  Warning. This may be disturbing. Artificially Administered Nutrition  Hydration? Fluids?  ANH (Artificial Nutrition and Hydration)  Trial period (Time-limited trial) Page 4

ANH Use Positive Examples Principal ANH Approaches  Otherwise healthy, intestine failure (IV  Nasogastric (NG), Nasoduodenal (ND), feeding) Nasojejunal (NJ) tubes (nose to . . . )  Stroke causing inability to swallow, body  Gastric (G), Gastrojejunal (GJ) and Jejunal otherwise functioning, believed/hoped will (J) tubes (through the skin to . . . ) recover ability to swallow  Total Parenteral Nutrition (TPN) bypasses  Trauma to throat or esophagus (car the digestive system and drips through an accident) with expected “normal” life IV into a vein More Info on ANH  Hard Choices for Loving People, by Hank Dunn  At hardchoices.com  See Chapter Two – Artificial Hydration and Nutrition About Caring House Jose’s Story  The first and only non-medical home in Los Angeles County totally focused on end-of-life care  An IRC 501(c)(3) nonprofit  Volunteer originated, professionally staffed, volunteer supported  Revenues from resident/family payments and community donations Page 5

POLST (Section B) POLST (Section B) Section B, Step 1  Climbing the steps 3 2 Includes pain management, oxygen, 1 Step Comfort-Focused Primary goal of suctioning, airway clearing, 1 Treatment maximizing comfort etc. Pain Pain  Pain  Impacts quality of life of person and family  “A physical or emotional experience due to  Severe pain is draining and can affect damage.” mood  Suffering  "A state of severe distress; related to the meaning of the experience to the person." Page 6

The Pain Scale Opioids  Pain and Suffering  Or opiates, a class of drug  Pain Scale  Include morphine and codeine (from opium poppies)  Include Vicodin, Percodan, oxycodone, heroin  Use for serious pain and to ease feeling of shortness of breath 58 Opioids POLST (Section B)  About addiction  Climbing the steps  Data: 9% will misuse / become addicted  End-of-life experts focus on pain relief and not concerned about addiction 3  About “hastening death” 2  If used properly, do not hasten death 1 Section B, Steps 1 + 2 POLST (Section B)  Climbing the steps Goal of treating Adds to below: medical medical conditions treatment, IV antibiotics 3 Step Selective while avoiding and IV fluids, noninvasive 2 Treatment burdensome measures airway pressure, etc. 2 Includes pain management, oxygen, Step Comfort-Focused Primary goal of suctioning, airway clearing, 1 1 Treatment maximizing comfort etc. Page 7

Section B, Steps 1 + 2 + 3 Intubation Goal of prolonging life Adds to below: intubation,  Medical procedure Step by all medically respirator, cardioversion, 3 Full Treatment effective means etc.  Plastic tube into throat, trachea (windpipe) Goal of treating Adds to below: medical  Endotracheal tube (ET tube) medical conditions treatment, IV antibiotics Step Selective while avoiding and IV fluids, noninvasive 2 Treatment burdensome measures airway pressure, etc. Includes pain  Ventilator (or respirator) – a machine management, oxygen, Step Comfort-Focused Primary goal of suctioning, airway clearing, connected to the ET tube to assist or fully 1 Treatment maximizing comfort etc. breath for patient Renal Failure and Dialysis “Life Support”  Renal Failure Keeps the body alive by helping with bodily functions  Kidneys fail to perform normal functions (chemical balance, removing waste and toxins  Breathing: Ventilator from the blood).  Heart: Defibrillation and/or medication  Kidney: Dialysis  Dialysis  Swallowing/digestion: ANH  Uses a machine to remove waste and toxins from the blood. Discharge Planning Page 8

Discharge Planning (cont’d) Discharge Planning (cont’d) When, What, Where, Who?  When move to the next level? Start discharge planning  What services and equipment needed? on or before the day of admission  Where can services be provided?  Who will provide the care? Discharge Planning (cont’d) Discharge Planning (cont’d) Challenges: Role of Agent:  MDs don’t know  Be proactive  MDs don’t tell  Obtain and review Written Discharge Plan  Too much care vs. too little  Consider appealing the discharge order  Better to stay, or better to go? End of Life Option Act  Act authorizes  an adult  who is terminally ill  and mentally competent  to request, obtain and use an aid-in-dying drug. Page 9

Questions for You EOL Option Act - Eligibility  The Act is a law of the State of California.  Resident of California  Prognosis of six months or less remaining life  Circumstances arguing for the law?  Able to make own decisions  Able to self-administer: eat, drink or  Why need a law? swallow drug EOL Option Act - Steps EOL Option Act – 2017  Minimum of six steps  577 were prescribed EOL drug  First oral request to MD #1  374 died after taking the EOL drug  Second oral request to MD #1  At least 15 days after first request  68.5% had cancer  Witnessed written request to MD #1  50.8% female; 47.1% male; 2.1%  Private discussion with MD #1 unknown  Meeting and confirmation by MD #2  90.4% age 60+; 66.9% age 70+  Document within 48 hours before drug use More Info on EOL Option Act  Coalition for Compassionate Care of California  at coalitionccc.org  California Board of Registered Nursing Overview of Act at RN.ca.gov/endoflife.shtml Page 10

Series 10 Top Take-Aways Series 10 Top Take-Aways 1. Advance care planning is for all adults – 6. Two monologues do not equal a dialogue. not just those older than me. 7. Stay up to date – Life brings changes. 2. People-work before paperwork. 8. Focus on goals of care. 3. Choose the best Agent for you. 9. Time-limited trials are crucial. 4. Figure out your wishes, values and views. 10. Success as an Agent is 75% preparation; 5. Communicate your wishes, values and the other 75% is caring. views. Handouts, Slides and More You can get all class materials and be notified about future classes by signing up at YourCaringHouse.org/materials Page 11