The Lightbulb Moment Eureka!! Presented by: CNS Mary Corcoran CNM Avril Finnerty

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1 The Lightbulb Moment Eureka!! Presented by: CNS Mary Corcoran CNM Avril Finnerty

2 Presenters Mary Corcoran CNS & RNP with Laois/Offaly Specialist Palliative Care Service Avril Finnerty CNM with Oakdale Nursing Home - Portarlington

3 Palliative Care for All Responds to need rather than diagnosis Has led to an increase in the number of patients referred to the SPCS Further expected growth in referrals due to an ageing population and an increase in patients diagnosed with disease

4 The Irish National Dementia Strategy Estimates a projected growth in the number of people with dementia up to 2046 For example, in the age bracket, from 12,265 in 2016 to 33,196 in 2046

5 The Irish National Dementia Strategy The role of multidisciplinary generalist palliative care providers is fundamental to the provision of high quality care for people with dementia. The needs of many patients with dementia can be appropriately and effectively met by generalist palliative care providers alone. Specialist support can be sought when necessary Specialist palliative care can be provided in cases where an individual experiences unstable symptoms, or problems of high intensity / complexity at end of life

6 Centre for Gerontology & Rehabilitation Physical Symptoms: Weight Loss Dysphagia Falls & Injuries Pain Dyspnoea Psychological Symptoms: Anxiety & Fear Confusion Depression Frustration Delusions Hallucinations

7 CNS Role Direct Role Care and support to patient and family Indirect Role Support and education to generalist staff Research, audit and practice development

8 I have been providing a CNS role to the residents and staff at Oakdale Nursing Home since 2009 Initially I provided maximum support and direct role to referrals from the nursing home Simultaneously I provided education and role modelling to staff Over the years a body of knowledge and experience has built up within the nursing team at Oakdale My role has evolved from a predominantly direct one to a more indirect one

9 The Lightbulb Moment! A patient with end stage dementia was referred to the SPCS I met with the staff at Oakdale Nursing Home in preparation of seeing this new patient Staff had carried out a holistic assessment of the patient and family.and put a plan in place to meet her end of life care needs I asked if I needed to be involved? Yes just in case we need a syringe pump!

10 The Lightbulb Moment! There was an end of life care plan in place for the patient and their family The staff felt confident and competent to manage the patient s symptom control needs with the use of a syringe pump if needed They literally needed a piece of equipment! Avril and I felt this potential should be realised We discussed with our prospective line managers

11 Eureka!! SPCS provided a syringe pump to the Nursing Home GP and nursing staff assess and determine a patient s level of palliative care need Referrals to the SPCS would continue as necessary The CNM and nursing staff are empowered to provide holistic care to their residents at end of life The CNS is empowered in her supportive role to the nursing home

12 Eureka!! One weekend on call I was asked to accept an urgent referral for a patient at the nursing home I attended the patient and family and advised and supported the staff on duty that day I was conscious while there, that there was another resident at end of life with a syringe pump in progress that had not been referred to our service. As a CNS this was my Eureka moment We have developed practice and made best use of resources, experience and expertise!

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14 Oakdale opened in February deaths 21 died in hospital 3 unexpected 20% of these residents have a diagnosis of dementia. Palliative care referrals were sent for all residents approaching End of Life.

15 Our Light Bulb Moment - Eureka Met with Palliative care CNM3 end January 2015 Since then 18 deaths, palliative care involvement 3.

16 Case study Elizabeth Jones, 94 years of age. Admitted June Medical history Hypertension, Hypothyroidism, Vertigo Dementia. N.O.K. sister Maura, 1 st contact Maura s son Tom. On Admission No problems with communication, Mobilised independently with a stick, Short term memory loss (MMSE 13), Occasional disorientation Evidence of difficulty making decisions Shared a room with a lady called Ann who she became best friends with.

17 Case study Elizabeth loved the company of others and participated in all organised activities. She played the accordion and sang. Loved to talk of her times in the U.S. Ann was her roommate for two years. The start of Elizabeth s decline became apparent when Ann s health deteriorated in April Ann died in June 2014.

18 Case study Memory loss more evident Withdrew from activities, stopped singing and playing the accordion. Poor special awareness and started falling Irritable and tearful Misplaced personal items Familiar tasks difficult to perform Decline in judgement giving property away Loss of interest in eating and drinking

19 June 2014 January 2015 Barthel - 17 Weight 46kg MUST 1 Fall risk score Medium Independent and safe to mobilise with her walking stick Barthel - 11 Weight - 41kg MUST 2 Falls risk score High (5 falls between October and January) Assistance of two for all transfers and mobilising. Recurrent RTI s Reluctant to get out of bed. Swallowing difficulties.

20 Case study February 2nd 2015 MDT and Family meeting. Comfort measures, symptom management. Not for further transfers to the acute services. DNAR agreed All unnecessary medications discontinued Palliative meds prescribed Lorazepam 1 mg PRN PO and paracetamol PRN PO/PR. Two weeks later Buscopan 20mg PRN, Midazalom 1.5 5mg PRN, Haloperidol 1.5 5mg PRN and Morphine Sulphate 2.5-5mg PRN (all s/c).

21 Case study 19/2/15 syringe pump commenced. Midazalom 5mg, Buscopan 40mg and Morphine Sulphate 2.5mg Paracetamol PR QDS Plus PRN Medication. 21/2/15 syringe pump medications adjusted in accordance with the PRN medication required in addition to syringe driver. Midazalom 5mg, Buscopan 60mg and Morphine Sulphate 5mg. Paracetamol PR QDS Plus PRN Medication.

22 Case study 22/2/ hrs Pulse 50 bpm Temp 35.8 O2 Saturations 98% Comfortable with satisfactory symptom control. Clammy to touch Elizabeth died peacefully at hrs in the company of a nurse and health care assistant (Family contacted but unable to attend). May she Rest in Peace.

23 Reflection On reflecting on Elizabeth s death we asked ourselves What did we learn? What would we have done differently? Were we happy with the care we gave her? Did she die in peace and comfort, with dignity and all her wishes fulfilled? Would Elizabeth be happy with the last few days of the life she embraced.

24 Reflection We Realised "Eureka We are And knowledgeable skilled autonomous competent practitioners we are more than capable of delivering a high standard of end of life care.

25 Reflection We know them well enough to recognise they are preparing for their final farewell We care enough to want them to live and die like we would want our loved ones to live and die. We know their loved ones so well we can empathise with them. We don t give ourselves enough credit.

26 Reflection We Realised Our Residents are as lucky to know and have the benefit of our knowledge and wisdom as we are to know them and have the benefit of their knowledge and wisdom.

27 Experienced Up to it Respectful Enthusiastic Knowledgeable Able Thankyou