Friday, March 23, 2012

Be Careful How You Say It

Communication is an art. It’s a two-way process that involves speaking as well as listening. Perhaps nine out of 10 people may hear the same sentence and understand it the way the speaker meant it; the 10TH person will hear something entirely different.

Recently, I was speaking with a group of nurses at our weekly hospice meeting. One of the nurses discussed how one of her home health patients had totally misunderstood his physician.

The patient, whom I’ll call Sam (for confidentiality reasons), was very sick with cancer. He had undergone major surgery and some chemo and radiation treatments. At a follow-up visit the physician ordered more tests. After those results came back, the physician told Sam that they had “done everything we can do for you.”

The physician was very fond of Sam, and it was quite difficult to deliver this news. He didn’t elaborate, thinking Sam understood that his treatment had not been successful and there were no more options. The doctor told Sam that he should prepare himself for an eventual death and get his affairs in order. He shook his hand and quietly left the room.

Sam was elated. He thought the news was great. His take on this was that his healthcare team had done everything they can. The treatments had worked and his cancer was cured. Now he didn’t need any more treatments and could get on with his life, and yes prepare for that eventual death down the road. 

Sam went home to celebrate. He called his home-health nurse and conveyed what the doctor said. She knew it was a misunderstanding and her heart sank for him. She called the physician and told him what had happened, who then called Sam to explain. The news was certainly not what Sam wanted to hear, but his prognosis was poor and he had decisions to make about his short-term future and end-of-life care.

This story gives us pause to be careful how we say things, and even when the conversation is painful, we should make sure the listener understands.

Saturday, March 17, 2012

Wear Your Green Today!

Enjoy a safe and Happy St. Patrick's Day.

Sunday, February 19, 2012

Important Terms Affecting End-of-Life Decisions

2013 ALTY Blog Award Nominee

When a diagnosis is bad and the prognosis perhaps even worse, the ability to cope and deal with a new set of terms and tasks can be overwhelming.

End-of-life care choices will be some of the most important decisions of a lifetime for anyone choosing to control how and where they will die. Choices made will guide and drive the matters that are most important to ensuring a peaceful, comfortable death with dignity and maximizing the quality of life up until the end.

Some of these decisions can be made long before end-of-life care ever comes into play. If these choices no longer fit they can be changed or revoked anytime. Understanding some important terms used in end-of-life decision making is vital to making appropriate choices.

Advance Directives
Advance directives or healthcare directives are general end-of-life care terms describing:
  • A Healthcare Proxy or Durable Power of Attorney for Health Care (DPOAHC) is a person (such as your spouse or adult child) you appoint to act on your behalf in the event you are unable to make decisions for yourself.
  • A list of instructions regarding your medical care wishes such as resuscitation (CPR) or inserting tubes i.e. to help you breath with artificial help (ventilator) or a feeding tube in the event you cannot swallow. These instructions can be as detailed as desired. Beware that advance directives can be treated differently by individual states or provinces. They do help to reduce the burden on family members.

Withdrawing Care
When everything possible has been done, the physician or nurse may mention the term “withdrawing care.” This important term means that the current course of aggressive care and treatment will end. For instance, treatments such as chemotherapy and radiation will be stopped. In advanced stages of illness or dying this can mean withdrawing various levels of life support measures such as ventilators, artificial feedings and dialysis.

What withdrawing care does NOT mean is that these measures should ever be abruptly ended and the patient sent home to die without any support systems in place. Hospice or palliative care should be brought in to help make this transition. For instance, even patients who have been on a ventilator won’t usually die immediately upon its withdrawal. They may experience some air hunger, which is a subjective experience of not being able to breathe in enough air. Comfort medications, such as low doses of morphine can help with the breathing difficulty, or Ativan to control the anxiety and panic associated with not being able to breathe adequately. These medications need to be available to ease these symptoms and allow the natural dying process to take its course.

Comfort Measures
Comfort measures is a term for the care which will be implemented to assist the patient as he moves into the next stages of dying. This may be accomplished with a variety of medications and treatments to manage such symptoms as pain, anxiety, depression, constipation or breathing difficulties. Comfort measures can also include non-medical techniques as massage, therapeutic touch and guided imagery along with spiritual and emotional support for the patient, family and caregivers.

Symptom Management
Hospice and palliative care often get the bad rap of “immediately putting patients on a morphine IV drip so they will die quickly.” Any quality hospice or palliative care organization does not do this. If this is the case for you or a loved one, you have the right to revoke and call in another team.

Over-the-counter medications may be used for mild pain in the beginning; as the pain increases, stronger medications can be used. Stronger comfort medications like Vicodin, Norco, dilaudid and morphine are commonly used for moderate to severe pain and/or advanced breathing difficulties. These medications are carefully titrated (doses increased in small increments) from very minute amounts until effective symptom management is achieved. Symptoms can often be controlled for a long time with very small doses.

For patients who might not be used to anything stronger than aspirin or ibuprofen, changing the strength (dose) of these stronger medications in small increments should be as slow as needed to achieve symptom control while maintaining the desired level of alertness for quality of life. This is just one reason why it is highly recommended to start palliative care or hospice early enough so that symptoms aren’t so far out of control and the patient is the stage of actively dying. It can take some time to reach proper symptom management.

Antidepressants, anti-anxiety medications, anti-nausea medications and bowel regimens (including medications, increased fiber and fluids, and daily habits) are useful in helping control other common end-of-life symptoms, such as depression, anxiety, nausea/vomiting and constipation or diarrhea.

End-of-life care and the dying process have so many unknowns that make it a scary experience for many people. Through knowledge and education many of these unknowns and fears can be conquered. The journey can become a more pleasant time to share the gift of spending the time left in peace and comfort in the company of family and friends.

Jeanette R. Stevens RN, BSN, CCRN, CHPN, “Care Until the End.” Nurseweek West, October 10,2011.

Mayo Clinic Staff; “End of Life: Caring for a Dying Loved One.”

“Pain Control Methods and Standards of Care.” Hospice Patients Alliance.


Thursday, January 26, 2012

Advance Directives Allow Choices and Support Medicare Savings

All the hoopla about “death panels” during the 2010 battle for healthcare reform spooked too many older adults into thinking they would be deprived of curative healthcare because they were older and the care too costly.

That talk has died down for the most part; however, the idea continues to haunt many when they think about end-of-life choices and hope their wishes will be honored and not limited to palliative care alone.

The results of a recent University of Michigan study, published in the Journal of the American Medical Association, show promise that advance directives and other end-of-life care choices have not had an impact on the quality of care provided. Nor have older Americans been denied curative care if they desired it, according to the study.

In regions of the country where curative care is the norm, the cost of medical care has surprisingly declined (and Medicare savings have increased) because of growth in the number of patients choosing palliative care instead of more costly aggressive care. The Michigan study showed that patients in those regions with advance directives received quality comfort care according to their final wishes. Many died at home instead of in hospitals, as was their wish.

The study’s results may encourage people to strongly consider their quality of life concerns and make their end-of life choices known to their families and their healthcare team. Even many study participants who chose treatment-limiting instructions also allowed for limited trials of intubation (inserting breathing or feeding tubes) and mechanical ventilation if needed. But their instructions also made it easier for their proxy (appointed person who has the legal power to make healthcare decisions if you cannot) to stop the treatments if they weren’t effective.

End-of-life care decisions require careful consideration; they can be as specific as you want or need them to be. Although impossible to address every scenario, it’s imperative to discuss the scope of your wishes with your family; your spokesperson and your healthcare team so that your intentions can be met. For instance, do you want everything possible done or do you want quality of life and freedom from pain and suffering (palliative care) if there is no hope of a cure?

If you would like to help people make important decisions in their healthcare, consider any of the online healthcare degrees.

Thursday, January 5, 2012

What is Palliative Care?

Palliative Care is about managing symptoms for those with chronic or fatal illnesses. It's something we're going to hear more about in the next few years.

Quality of life and managing pain and other symptoms instead of just prolonging life will help us all be comfortable in our last days.

Palliative Care also helps those with chronic symptoms of pain, nausea, shortness of breath, etc., from diseases such as Rheumatoid Arthritis, MS, and COPD, to live more comfortable lives with a better quality of life. Here's a great article to help you understand more about Palliative Care.

Friday, December 23, 2011