ethical dilemmas in residential aged care
TRANSCRIPT
Ethical Dilemmas in Residential Aged Care
Australian Association of Gerontology1 May 2018
Dr Michal BoydAssociate Professor and Nurse Practitioner
Place of Death in New Zealand 2000-2013
Data Source: Prof. Heather McLeod, NZ Ministry of Health MORT data 2000-2013
Over the period there has been a proportional decline in deaths in public hospital and other settings, with a substantial increase in the proportion of deaths in residential care.
*
ELDER (n=286)Mean SM-EOLD Sub-Scores: Last MONTH of Life
• Physical Sx: • Pain• Breathlessness• Skin Breakdown
• Psychological Sx:• Calm• Depression• Fear • Anxiety• Agitation• Resistive to care
6.7
5.15.9
11.5
13.8
12.0
Cancer Dementia Chronic Illness
lower score = worst symptoms
Subscale Physical Symptoms Subscale Psychological Symptoms
*
*p<0.05
Dying with Dementia Last Month of LifeVandervoort, 2013 (JAMDA 14:485) n=198,
Boyd et al., ELDER, 2018 (under review) n=158
Dementia Care Planning
▪ Communication and collaboration with loved ones is the most important
▪ Advanced Dementia Clinical Course
• Mitchell, et al., 2009 Pneumonia, febrile episodes, and eating problems are frequent
complications in patients with advanced dementia, complications are associated with high 6-month mortality rates Residents with Families that understood likely complications had less
hospitalisations
Mitchell SL, Teno JM, Kiely DK, Shaffer ML, Jones RN, Prigerson HG, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-38.
5
ELDER: Physical symptoms in the last week of life
Cachexia versus Starvation
Starvation Cachexia
Appetite Late suppression Early suppression
BMI Not predictive of mortality Predictive of mortality
Albumin Low in late phase Low in early phase
Cholesterol May remain normal Low
Total lymphocyte
count
Low, responds to
re-feeding
Low, no response to
re-feeding
Cytokines Little data Elevated
Inflammation Usually absent Present
With re-feeding Reversible Resistant
Thomas, D. “Distinguishing Starvation from Cachexia.” Clinics in Geriatric Medicine. 2002; 18: 883-891
7
8
First line treatment
• 5% Weight loss in a month, or 10% weight loss in 6
months
• Treat contributing factors e.g. constipation
• Implement basic oral nutrition support:
small nutrient dense frequent meals & snacks,
assistance or prompting to eat, food charts
• Weekly weight for 4 weeks
• Reassess:
if weight loss continues move to 2nd line treatment
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Second line treatment• Continue weekly weighs
• Contact GP (may request lab tests - thyroid function, full blood count, serum transferase, albumin)
• SLT referral if appropriate
• Dietitian referral
• Increase energy & protein intake with nutritious fluids, smoothies, complan etc
• Reassess:
Is the resident refusing to eat?1. Is cessation of eating in keeping with overall deterioration in resident’s health
status?
1. Exclude possibility of treatable condition e.g. infection that could affect cognitive ability & appetite
2. May still be appropriate to offer small amounts of food & fluids, even if person is dying — always defer to resident’s cues.
• Assess personal preferences and whether the resident is enjoying their meals
• Discuss care plan with the family/EPOA• Palliative approach
(National Health and Research Council. Guidelines for a palliative approach in residential aged care; page 59 May 2006)
17.418.9
21.1
30.4
5.4
11.5
0
5
10
15
20
25
30
35
Cancer Dementia Chronic Disease
End of life pathway used Local hospice involvement?
End of Life Care Support:% by primary diagnosis
A ‘good’ death is not dying alone
• And that they feel like they’re not alone, you know, that’s really, like, I can’t bear the thought of them lying there dying alone. You know, with no one. And if family can’t be there it’s nice that you, you feel like you can be there. (HCA)
• I mean, it’s the end of their lives, . . . but we don’t have that capacity of giving them one on one care . . . Which is quite sad, you know? That would be good if there was someone that can stay with them bedside, and, you know, just be there, you know, with them. Who would like to die alone? (RN Manager)
Lack of acknowledgement of the Relationship between the older person and staff
• …when the funeral director came to pick up Mum [the staff] …sort of all line up to sort of farewell… and it was also providing Mum with dignity but, you know, I think for them…coz it was Mum and they had a relationship with Mum themselves. (family)
• And we’re always very aware of other people around because you know, you don’t want death. . . . So we will always make sure that the funeral directors arrive out of busy hours. So not around lunchtime when there’s lots of people in the dining area, and you go past.
• Quick turn around of the room
• Very little debriefing occurs or processing of grief
Staff Support
• There’s not even a debriefing of staff. We used to sit down and talk about the person years back, but we don’t do anything like that now. It’s almost like they’re just a patient; they’re not your family - why are you worried about it - why does it upset you? If you’ve nursed someone, or had them and their families - the nursing home is different to a hospital; you do become part of their lives -they become part of yours.
Tension between Culture and Religious Beliefs
• Strong religious/spiritual influence and religious affiliation were associated with lower scores for burnout.
• Level of religious/spiritual influence does make a difference in the strategies employed by staff in coping with death and dying.
