Improving Home Death Down Under

Transcription

1 Specialist health care at home Improving Home Death Down Under Compassion Respect Robert Molenaar Nurse Practitioner South East Palliative Care Excellence

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3 NP- Background Commenced at SEPC, a community palliative care organisation 7 years ago and have had roles as Intake Nurse and Team Leader Previous experience had been in inpatient palliative care 2.5 year NP Candidacy commenced July 2010 Endorsement as NP via AHPRA in February this year

4 SEPC Nurse Practitioner Model Evolving model Original focus was on patients with very complex palliative care needs Focus now changing to patients with complex palliative care needs who are in the later stages of their illness

5 Preliminary auditing Rate of home death of palliative care patients at SEPC had decreased 28% to 20%. After auditing several months of all deaths some of the reasons for this were: complex physical needs complex symptomatology inadequate access to respite inadequate nursing follow-up, management and carer education

6 SSP Development Structured support program (SSP) intervention Developed in conjunction with Monash University (Frankston campus) Palliative Care Research Team Three-visit program of support provided by NPC Development of an anticipatory care plan to provide guidance for future support for the patient and the carer Focus on patients with complex palliative care needs who are in the later stages of their illness.

7 SSP Intervention - aims Does a SSP provided by an advanced practice nurse improve patient and carer outcomes compared to regular support? Specific study aims were to: improve symptom relief enhance psychosocial support for patients and carers facilitate place of death according to patient and carer choice articulate a Nurse Practitioner (NP) model supporting complex End of Life (EOL) care

8 SSP Intervention outline (See SSP Visit Outline handout for more detail) Provided information to patients and their carers in different formats Conducted informal family meetings with the main caregivers and the patient to establish needs Outlined in detail home, inpatient and residential care respite options Increased psycho-educational support and referrals Clearly established the possible venue of care preference of the patient and of their carer(s)

9 Proposed outcomes The intervention was provided by a NPC, for the purpose of the study it was possible to identify where an endorsed NP would enhance access to medications and diagnostic tests/investigations. Comparison was made between the SSP group and the group receiving regular support from the SEPC nursing team on various symptom and psychosocial outcomes such as: resolution of problem severity scores for symptoms rate of referrals to respite, support services number, type and rate of hospital admissions home death rate and preferred versus actual site of death.

10 SSP Intervention - process (See Referral Triage Form + SSP Pathway for more detail) Complex patient group identified by the intake team using SEPC s referral triage form Explanatory statement and consent form was provided at initial admission visit Once consent given, patient allocated to either SSP group or routine care group (RCG) NPC provided the SSP group three visits

11 Visit sequence First Visit - Within 1 week of admission Second Visit - Within 1 month of first visit or if decline in AKPS to <60 or increase in Problem Severity Score or change of phase from stable to unstable, deteriorating or terminal Third Visit - Within 2 weeks of second visit or indicated that a change from oral to s/c medication is required.

12 Some parameters After each SSP visit by NPC, the subsequent visit was,(if possible), made by a member of the regular nursing team This enabled more objective reporting of the problem severity scale by another nurse (not the NPC) NPC was still available for other patients as required

13 Complications There were a larger than anticipated number of consents not asked or obtained by nursing staff at admission interview or declined by family or patient (21 patients in refused group) This slowed recruitment substantially for SSP and RCG groups (15 patients in each) Smaller sample size than hoped

14 SSP Intervention Actual Outcomes Improved resolution of problem severity scores for symptoms Improved rate of referral to respite, support services and hospital admissions for respite Decreased rate of non respite admissions Improved correlation between the wishes of the carers and the patients preferred site of care and actual site of death

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16 NPC Involvement % Yes No SSP RCG Refused Yes No

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18 Site of Death % SSP RCG Refused Home PCU Public Private Current SSP RCG Refused

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20 Preference Met % SSP RCG Refused 10 0 Yes No Current SSP RCG Refused

21 Referrals Referrals SSP - NPC SSP - f/up RCG - nurse RCG - f/up

22 Change in Problem Severity Score PSS better PSS worse 0-5 SSP - NPC RCG - nurse -10

23 Why difference between groups Poor documentation (RCG ) in care plan SSP care plan issues clearly outlined referrals done and symptom interventions This modelled behaviour for subsequent visits by other nurses and documentation of care plan issues improved Less involvement of NPC with RCG Experience/skill set of NPC.

24 NP - future Majority of patients had easily identifiable gaps in access to palliative care medications that could of been addressed by NP Non respite admissions were reduced in SSP group More difficult to discern the need for diagnostic tests/investigations in this patient group SSP Intervention clarifies direction of NP model Implementation of NP model

25 Acknowledgements I would like to acknowledge the entire SEPC team, without whom this project could not have come to fruition. A special thanks to: All staff at SEPC particularly: Helen Wearne, Michelle Wood, Shyla Mills, Marnie Grace, Penny Vaudeau, Val Boyd and Val Neatnica Louise Peters (Monash University) Prof Margaret O Connor (Monash University)