b2 rapid fire: supporting the journey to end of life - w. robinson

Incorporating Supportive Care within Chronic Disease Management The Renal End-of-Life Initiative

at Providence Health Care

Wallace A Robinson MSW RSW

Project Leader

BCPSQC Forum - March 8, 2012

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Disclosure Statement

We do not have any affiliation (financial or otherwise) with a commercial organization that may have a direct or indirect connection to this initiative or the content of this presentation.

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Why focus on Renal supportive/palliative care?

•Comparable mortality rates to cancer

•High symptom burden

•35-50% report severe pain

•Pain/symptoms under-diagnosed & under-treated

•Most renal patients do not have ACPs

•Predicting individual life expectancy is difficult

•50% are incapable at time of withdrawal

1. Palliative Immersion Program (PIP)

2. Advance care planning

3. Pain & symptom management

4. Bereavement support

REOL Primary Components

Initial implementation focus on SPH in-centre hemodialysis unit, with a goal to reach all Renal sub-programs & clinics through next phase

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Palliative Immersion Program

Renal/Palliative pilot for renal inpt nurses:

•To increase palliative comfort/competencies•1 to 1 training over 4 days on PCU•Reading resource manual •Pre- & post- learning components

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Palliative Immersion Program(RN Evaluation)

Majority reported a ‘shift’ in understanding:

•Recognizing the priority of pain and symptom management

•Changed definition of palliative care: starts earlier & focuses on quality of life

•Increased comfort/confidence in the challenging conversations with patients/families facing a terminal illness

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Advance Care Planning on in-centre hemodialysis unit

Systematic approach to ACP on the unit:

•In-depth facilitation skills training

•Core ACP Practice group (SW, PC, NP, MD, RN)

•ACP as a process & team approach

•PDSA pilot: initiate with 5 pts in 1 month

•Development of ACP Record/Procedures

•Use of My Voice & VCH/PHC brochure

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Advance Care Planning audit

40% (91 patients) had ACP Records with conversations noted:•42% had more than 1 ACP conversation•25% had conversations with 2 or more staff•11% had completed My Voice on the chart•92% had wishes consistent with DNAR orders•2 patients wishes & DNAR did not match

Increase in ACP practitioner confidence

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Pain & Symptom Management

Modified ESAS for quarterly assessment

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Pain & Symptom Management

Modified ESAS for quarterly assessment

•Introduced to all 275 patients by the nurses

•Patients complete or with caregiver or RN

•Results entered in PROMIS

•Pain >7 Pain Assessment Level 1•Pain Rounds: >7 pain, itch, insomnia

•Psychosocial Rounds: >7 depression, anxiety

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ESAS Scores at Baseline and 1 Year

• Global symptom burden & severity >7 trended down

• Statistically significant decreases with tiredness, depression and drowsiness

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0.5

1

1.5

2

2.5

3

3.5

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ESAS Symptoms

Mean

Sco

re

Baseline

1 Year

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Bereavement protocols

•Condolence call from nephrologist/other staff

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•Bereavement card

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• Pain & symptom management• Advance care planning • Palliative immersion program (pilot)• Bereavement support

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•Bereavement card

•Follow-up card at 1 year

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•Bereavement card


•Memorial plaque

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•Bereavement card


•Memorial plaque

•Renal memorial service for staff

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From: Cheung, Lawrence [PH]

Sent: Monday, December 19, 2011 3:00 PM

To: Robinson, Wallace [PH]

Subject: Recently

Hi Wallace,

We have had quite a few deaths the last couple of weeks within our renal family. While this is not surprising based on past history (they all come in bunches), it was still hard on all of us (hemo, home hemo, PD and 6B) as we witness mortality unfold in this holiday season.

I want you to know EVERY single family of our recent deceased patients came to me and express their gratitude and thankfulness for the EOL measures we have in place. Our palliative protocols make a difference in our patients' last days and the families were given chances to say their goodbyes.

Thank you for championing this noble and sacred task. I am honored to be part of this process.

With thanksgiving,

Lawrence T. Cheung Site-Coordinator, Pastoral Care Service,

St. Paul's Hospital

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Success Contributors

• Commitment from program leadership

• Staff engagement: it’s the right thing to do

• Working Group/REOL champions

• Patient/family receptivity

• BCPRA EOL Steering Committee

• PHC Mission & Values

• Funding support from the SPH/Carraressi Foundations

b2 rapid fire: supporting the journey to end of life - w. robinson

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