Philosophy of Nursing Care in Hospice Palliative Care 10th Hong Kong Palliative Care Symposium The evolving role of the palliative specialist nurse palliative specialist nurse Ms. Ellen Yeung Nurse Consultant (Palliative Care) Hong Kong East Cluster Hospital Authority Date: 10 8 2013 Hospice palliative nursing is the holistic approach to meet the complex needs of individuals and their families / caregivers facing progressive life limiting illnesses. With the inter disciplinary approach, care is directed towards alleviating the physical symptoms as well as the psycho socio spiritual distress associated with the progressive life limiting illness. The focus of care is the promotion of comfort, improvement of quality of life and the preservation of dignity for the individuals. 1 History of Palliative Nursing Development in Hong Kong In 1982 Sister Helen Kenny, Dr Yu Wing Kwong and Ms Lucy Chung, a registered nurse piloted the first hospice care team and home care program at Our Lady of Maryknoll Hospital. Lucy pioneered the palliative nursing in HK with a mission of improving the quality of care for the terminally ill cancer patients. She is the awardee of 1993 The Ten Outstanding Young Person. She is the awardee of 1993 The Ten Outstanding Young Person. Guideline for Specialty Nursing Services (Hospice Palliative Care) Hospital Authority. 2012 History Sister Helen Marie Kenny was one of the original group of religious Sisters who opened OLMH in 1961 and spent 18 years as nurse, supervisor and nursing director. Her interest in providing end of life care for people with terminal illnesses began in the early 1970s. During that time, caring for dying patients was a completely new concept. Sister Helen is one of the active pioneers who led and promoted the hospice movement in HK. She participated in the planning and building of the first independent hospice in HK the Bradbury Hospice (BBH). Lucy History Sister Helen is the awardee of the Second Hong Kong Humanity Award in year 2009 1987 Hospice in patient service in NLH, HHH, RH, UCH Society for the Promotion of Hospice Care 1984 Sister Gabriel O Mahoney, Dr Vincent Tse, Dr Yu Wing Kwong, Lucy Chung, Reverend Ralph Lee and Revervend John Russell became the core group that found the Society for the Promotion of Hospice Care in 1986. 李潔靈修女 1986 Society for the Promotion of Hospice Care was established. 1988 Launched the 1st Hospice Home Care Nursing Program. 1992 Set up Bradbury Hospice. GH (Previous NLH Hospice Team) 1
RHTSK HHH 1992 Bradbury Hospice started its service (1st independent hospice in Hong Kong) Later, hospice palliative units were set up in 5 Hospitals CMC, HKBH, POH, SH & WTSH Development of Palliative Nursing Services in Clinical Oncology in HK 1994 TMH assigned 8 hospice beds in a oncology ward. The hospice service was gradually expanded to cover ambulatory care services with the opening of Hospice Day Centre in 1997. The Pok Oi hospice nursing team was integrated with TMH team. 1999 QMH Spearheaded the establishment of the Cancer Care and Support Unit at QMH, consisting of a roving palliative care team which supports all departments dealing with cancer patients. 2006 HKEC Opening of Integrated Palliative Day Care Centre in Tang Shiu Kin Community Ambulatory Day Care Centre. Supported by Community Partner Hong Kong Cancer Fund. Joint management by RH Palliative Physicians & PYN Clinical Oncologists. 2007 PYN integration of palliative care in oncology services. Provide full spectrum of palliative care services. Accredited Clinical Oncology Nurse Clinic (Palliative Care) in 2012. 2007 Lai Ka Shing Foundation support the development of palliative care ambulatory care services in all clinical oncology units and some palliative units. 2008 All Clinical Oncology Centers (QMH, QEH, PYNEH, PMH, PWH & TMH) provide palliative care service 2
Together with the palliative care clinics in oncology centers, there are all together 16 palliative care units 1995 Hospice Awareness 黃大仙醫院 2003 Palliative Nursing in SARS Many hospice palliative care wards close Many palliative nurses deployed to work in isolation wards Some specialist palliative nurses take up the role to counsel and support those colleagues and clients infected SARS Palliative home care nursing visits continue Develop Palliative Nursing Workforce Nurses represent a significant proportion of the health care workforce engaged in providing palliative care. 2012. 12. 31 Hospital Authority Palliative Nursing Manpower Review 231 RN/EN 66 APN or Above Rank Total 297 nurses engaged in palliative nursing services 52% (155 nurses) received specialty palliative care training Success of PC Team HKBH Integrated Palliative Care Unit 2008 HA Outstanding team Award 1993 Set up Hospice Care Ward Palliative Nursing Training & Professional Development English National Board (ENB) 931 Care of the dying patient & their family; ENB 285 The continuing care of the dying & their family Bradbury Hospice Bradbury Hospice Certificate in Hospice Care Certificate in Hospice Care PRCC & PREC in Hospice & Palliative Nursing Regular clinical meeting and commissioning training Local & overseas hospice palliative symposium, conference, clinical practicum 3
1992 A group of nurses of Bradbury Hospice received a month of palliative nursing training Post Registration Certificate Course Specialty nursing training for RN 1995 1st Post Registration Certificate Course in Hospice & Palliative Nursing (PRCC) organized by Bradbury Hospice and HA Post Registration Enrollment Course Specialty nursing training for EN Local & overseas symposium / conference Local & overseas symposium / conference 4
4 weeks studyfor 24 Palliative Nursing Leaders UK (Princess Alice Hospice/Royal Marsden/ Nottingham University Hospital) Sydney (Concord Hospital / Sacred Heart Hospice) Singapore (Dover Park/ HCA Hospice) (Dover Park/ HCA Hospice) Melbourne (Calvary Health Care Bethlehem) Taiwan (Tzu Chi General Hospital) Learning Objectives Acquire knowledge on contemporary Palliative Care service delivery model including cancer and non cancer patients Develop insights and evidence based practice on end of life care New insight and trend of full spectrum palliative care services development Share palliative assessment, audit, research and training information Palliative Care Con nsultative Serv vice Overseas Corporate Scholarship Program (2011 13) Palliative Care Service Model Othe er specialties Overseas Corporate Scholarship Program in Palliative Nursing Patients living in Home Care Service the community Inpatient PC service (Short stay Outpatient Service intense interventions) Phone consultation Phone consultation Day care Service Cluster based approach Cluster based approach Specialist led service Multi disciplinary support Community based service Bereavement care Non government Organization (Practical support) 26 Inpatient Service Home Care Home Care Nurse Clinic & Consultative Services Day Care Day Care TMH, RH, PYN, QEH Accredited Palliative Nurse Clinic by HA 5
Nurse Tel Consultation Services & Bereavement Care Volunteer Services Volunteer Services 31 Professional Nursing Specialization 1997 Set up Hong Kong Hospice Nurses Association Now renamed Hong Kong Palliative Nursing Association 1991 Hong Kong has begun its direction and journey to nursing specialization 1992 Pioneer Nurse Specialist (Hospice) in Nam Long Hospital Professional Nursing Specialization 2012 Establish the Provisional Hong Kong Academy of Nursing (PHKAN) Safeguard the quality of advanced nursing practice 37 Fellows of Medicine Palliative & 1 PHKAN Founding Fellow (Until May 2013) Hospice Palliative Nursing Group, HA Hospice Nursing Net Hospice Home Care Representative Group Specialty Advisory Group (Specialty Core Group) ¾ Discuss Discuss issues, contemporary trends and their impacts on nursing issues, contemporary trends and their impacts on nursing specialties. ¾ Formulate strategies and plans on specialty services and development. ¾ Identify and relate the needs of particular specialties, and provide professional inputs to the Training & Development, Nursing Quality ¾ Safety Subcommittees, COC(N) and related COCs. ¾ Co ordinate developments, implementation and evaluation of nursing specialty guidelines with periodic review. 6
10th Palliative Care Symposium Standards of Hospice Palliative Care Nursing Practice (Hospice Palliative Specialty Nursing Guideline, 2012) 1. Symptom Control 2. Psychosocial Care 3. Spiritual Support 4. Family Care 5. Bereavement Care 6. Legal & Ethical Practice 7. Palliative Care Team 8. Staff Support Palliative Nurse Career Progression The clinical career path of nurses has progressed from the establishment of Nurse Specialist (NS)post in 1992 to a higher level of Nurse Consultant (NC) post in 2008. Nine experienced hospice palliative nurses were promoted as NS to lead the clinical nursing 2012 in response to raising demand for quality end of life care in all settings, Palliative Nurse Consultant (NC) post was established. When does a service need an NC? 1. Escalating service demands: patient volume, waiting time and waiting list 2. Need for timely intervention or faster access to promote service and patient outcomes and safety 3. Complex patient care needs requiring cross specialty/ specialty/ cross system roles 4. Need for coordinated service development and care standardization to optimize resources 5. Nursing expertise is available to meet patient and service demands Acuity & Technological Complexity Intensity & Acute Emergency Complexity & Longer Term Management More Nursing Focused Gaps to fill, needs to meet Palliative care needs of patients with noncancer diseases, e.g. organ failure, dementia.. Aging population, more patients with chronic illnesses requiring end of life care Increased complexity of patients problems caused by societal changes Enhance palliative care in the community e.g. OAH, nursing home Study on the Review of Clinical Nursing Career Structure The Nethersole School of Nursing, The CUHK, 21 April 2010 Long Term & high volume 41 7
10th Palliative Care Symposium Service Model of Nurse Consultant (Palliative Care) 5 major roles & responsibility of NC Expert care and consultancy provide direct clinical service to cases with complex physical, psycho social & spiritual responses Lead palliative care consultation in acute and general care settings and the community Act as an advisor and consultant in the specialty Standard regulating and practice enhancement Develop, regulate and implement standards and protocols in palliative care such as end of life care pathway, advance directive and advance care planning Service planning and policy development Initiate plan for the service development at cross disciplines and institutional boundaries at cluster level and territory wide level. Knowledge development and transfer lead the whole spectrum of training from general to specialist level in palliative nursing lead research studies, transfer and disseminate evidence based practice Lead and evaluate service quality initiate audit program to evaluate service outcome and standards, palliative nursing standards and seek for service quality improvement. HKE Ellen KCC Faith NTW Red Need of palliative care for non cancer Curative Disease Modifying Palliative Disease Intervention and Disease Progression Bereavement EOL NC(PC) in KCC, HKEC, HKWC, NTEC & NTWC NTE Cecilia HKW Theresa Changing of disease trajectory Blurring of curative, disease modifying i and palliative i care phases Unmet needs and suffering amongst non cancer patients at EOL Burden of palliative care is escalating with the ageing population CMC started the renal palliative care service in 2008 Developed to all cluster since 4Q 2010 Patient group include patients with end stage organ failure Renal failure Respiratory failure Heart Failure. Improve Access to Palliative Care/EOL care in acute setting New PC teams in acute medicine for end stage organ failure patients e.g. TMH & QEH PC consultative services to acute wards for cancer/end stage disease patients (Renal, Pulmonary, Heart) Extended to all Clusters (intra and inter hospital palliative nurse / doctor consultation). Promote skill transfer & mutual learning. Implementation of EOL care plan for care of dying in various ward or acute setting e.g. Infirmary wards of HHH / Clinical oncology ward of PYN Training of ward staff in PC approach and use of the EOL care plan The care plan incorporates comfort measures, anticipatory drugs for symptoms control, discontinuation of inappropriate interventions, psychospiritual care and family support. Set up satellite PC day center or clinic in acute hospitals e.g. Palliative care center in NDH & Clinic in TKO Renal palliative care clinic in TWH, PYNEH Support Living / Dying in Place of Choice Initiate programs to support the seriously ill patients to live and/or die in home or nursing home For example: HKEC & KEC EOL care program palliative care teams collaborate with cluster A&E & Dept. of Pathology; set up Standard operative procedures for death certification and aftercare of palliative care patients die at home or nursing home. KEC Community care program Virtual Ward. Nurse provide daily home support to critically ill cancer patients who plan to stay at home as long as possible. 8
10th Palliative Care Symposium Enhance Psychosocial Service in Palliative Care Nurse collaborate with MSW & Clinical Psychologist Developing structured psychosocial care model in PC Adopt proactive & coordinated approach Support patient & family caregiver in the grief process Early identification and engagement of high risk patients and caregivers Intensified interventions for high risk clients Reduce risk of physical & psychological complications associated with bereavement Community Partnership Collaborate with C&A Home in provide EOL care for the frail & severely disabled clients e.g. GH PC Team support the clients of TWGHs Jockey Club Rehab Complex Lead and develop volunteers to support palliative care services Contribute to the development of hospice palliative website for the community www.hospicehome.hk Microsoft werpoint Presentat Co organize professional training activities e.g. annual HK Palliative Care Symposium, quarterly Multidisciplinary Palliative Clinical Meeting Engaging our health care colleagues Increase PC service coverage through Consultative Teams Promote skills transfer & mutual learning Collaborate with different specialties health professionals Advocate of advance care planning Palliative Care Health Outcome Empowerment of patient and family members Autonomy in decision making Understanding of illness and treatment options Comfort in physical, psychosocial & spiritual care Key Enablers Share overseas experience & evidences Professional standard and training Multidisciplinary inputs Collaboration with internal & external stakeholders Devise and adaption of local guidelines for care Management and service standard Promulgate environment conducive to end of life care Service evaluation, local research and pilot IT and system support Palliative clients appreciate most Who? Total 452 Thank You Card Received from patients or their families to a palliative Ward MSW HCA PT OT Nurse Doctor Target of appreciation 9
Palliative clients appreciate most What? Palliative clients appreciate most What? Staff Attitude 個人特質 工作態度 紓緩團隊的茁壯成長 來自無數勉勵與欣賞 紓緩團隊的茁壯成長 來自無數勉勵與欣賞 紓緩團隊的茁壯成長 來自無數勉勵與欣賞 紓緩團隊的茁壯成長 來自無數勉勵與欣賞 10
10th Palliative Care Symposium Essential of Care in Palliative Care It is important to involve all stakeholders patients, staff, carers, and families have opportunities to participate and are included in decisions about effective care using approaches that respect individual and collective values. Communication / Listening Being with Promoting self control l/ choices Privacy and dignity Individualize personal comfort care Relief physical and psycho spirtual distress Support family Comfortable environment and good facilities Continue ambulatory support Preventing risk and promoting Safety Learning and development culture Future key challenges Ageing patients with multiple co morbidities Difficulty on prognostic telling for non cancer diseases More options & aggressive treatments Patients & families less ready to accept EOL phase More psychosocial distresses of patient & family Public demand for increased autonomy over end of life treatment decisions Request for advance directives and advance care planning Increased demand for skilled, compassionate end of life care Interface between specialist and non specialist Much need to be done.. Thank You! 63 11