Palliative
Care
 |
Neville
E. Strumpf, PhD, RN, C, FAAN, recently
completed a three-year project to implement a
model of palliative care in nursing homes under
the auspices of the Robert Wood Johnson Foundation.
This recent work built on her seminal work (with
Lois
Evans) on the use of restraints among the
elderly that eventually led to a reduction in
restraints for frail older people in hospitals
and nursing homes.
This
innovative project was a partnership with Genesis
ElderCare, the third largest long-term care network
in the country. It focused on staff training in
palliative care, use of interdisciplinary care
teams, and nurse consultation to improve advanced
care planning, pain and symptom management, and
psychosocial support. |
|
Dr.
Neville E. Strumpf |
Palliative
Care in Nursing Homes Study
Abstract:
We implemented a program of
palliative care in community nursing homes that emphasized
advance care planning, pain and symptom management, and
psychosocial support. Six community nursing homes in Maryland,
their residents, and staff participated. Four intervention
homes received on of two conditions: training in an integrated
palliative care approach coupled with four to five hours
per week of nurse consultation, or the training/consultation
plus development of an interdisciplinary palliative care
team. Two homes served as controls. We categorized three
key transitions in the implementation of palliative care:
introducing the concept, overcoming barriers, and achieving
sustainability. We concluded that palliative care can
be integrated into the practice of community nursing homes
if there is committed leadership, active involvement of
the Medical Director, training, and availability of ongoing
nursing expertise.
Each
year approximately 500,000 persons die in U.S. nursing
homes, most without benefit of any palliative care services.
Thus, with funding from the Robert Wood Johnson Foundation's
Promoting Excellence in End-of-Life Care Program, Dr.
Neville Strumpf and her collaborator Dr. Howard
Tuch at Genesis ElderCare, implemented a program of
palliative care in community nursing homes that emphasized
advance care planning, pain and symptom management,
and psychosocial support for nursing home residents
in the last stages of life. They examined the effects
of training and palliative care interventions on pain
and symptom management, attitudes of nursing home staff,
and events at the end of life.
Six
Genesis nursing homes participated in the study. Two
nursing homes serve as control sites, providing the
usual standard of care. At another two nursing homes,
all staff receives training in the concepts and practice
of palliative care, emphasizing comfort as well as psychological,
social and spiritual well being. Another two nursing
homes complemented this training with a team of palliative
care professionals whose members focus on controlling
symptoms and improving the patient's quality of life.
The four intervention homes also received 4-5 hours
per week of consultation from a nurse with expertise
in palliative care.
In
the team homes, the Medical Director led team mentors
in a weekly meeting to identify patients appropriate
for palliative care. The team reviewed advanced directives
and monitored the effectiveness of palliative interventions.
At
the conclusion of the project, resident, staff, and
facility outcomes were evaluated. Currently, Genesis
is expanding the program in the Chesapeake region, and
we are considering a broader replication of the model.
Our
appreciation goes to corporate leaders at Genesis ElderCare
and the staff of six participating Genesis facilities
and to the staff of the National Program Office for
"Promoting Excellence in End-of-Life Care"
at the Practical Ethics Center, University of Montana,
and to the Robert Wood Johnson Foundation.
| SYMPOSIUM
on PALLIATIVE CARE |
presented
at the Annual Meeting of the Gerontological Society of
America
(Chicago, November, 2001)
THE
IMPACT OF PALLIATIVE CARE PROGRAMMING IN NURSING HOMES:
A Symposium
Organizer: N. Strumpf
, University of Pennsylvania School of Nursing, 420
Guardian Drive, Philadelphia, PA 19104 - (The Gerontologist,
41, Special Issue I, 153.)
Click
here to download
powerpoint presentation.
PALLIATIVE
CARE IN NURSING HOMES: ASSESSMENT AND TREATMENT OF PHYSICAL
AND EMOTIONAL SYMPTOMS. N. Strumpf, H.Tuch, P. Parmelee,
& D. Stillman, University of PA and Genesis Health
Ventures.
Recent
studies point out that pain is frequently reported by
nursing home residents, often goes unrecognized, and
is routinely under treated. We explored the ongoing
impact, over an 18 month period, of a systematic palliative
care program in six nursing homes (2 control, 4 intervention)
on the assessment and treatment of physical and emotional
symptoms. An investigator-generated symptom tracking
form was used to review health care records monthly
for evidence of any documented assessment and/or treatment
plan on consented participants (N=151). Preliminary
analyses indicate that there were no significant differences
in assessment and treatment of symptoms between those
residents judged appropriate for palliative care and
those who were not, nor between intervention and control
homes. Assessment and treatment were more likely to
be recorded for physical rather then emotional symptoms,
and consistent documentation of an assessment linked
to a treatment plan was often missing. Since nurse specialist
field notes and other data suggest that in the intervention
homes, staff were attending to physical symptoms (especially
pain), ongoing issues of
accurate documentation in health records are discussed.
QUALITY
OF DEATH IN NURSING HOMES: EVALUATION OF A PALLIATIVE
CARE INTERVENTION. P. Parmelee, H. Tuch, N. Strumpf,
D. Stillman, A. Lewis. Genesis Health Ventures &
Univ. of PA School of Nursing.
This presentation explores how implementing a palliative
care (PC) program affected "quality of death"
in long-term care, i.e., care received and symptoms
experienced during the last days of life. Data were
collected for all deaths in 9 Maryland SNFs from 04/99
- 12/00. For each, nursing staff reported advance directives
and PC planning; cause & site of death; routine,
palliative, and life-sustaining treatments; acute syndromes
& symptoms; cognition & mood; pain, suffering,
and the moment of death. Logistic regression identified
differences among centers receiving 3 levels of PC programming:
full implementation & consultation, brief education
only, and no intervention. PC programming was associated
with clear differences in planning for death, life-sustaining
interventions, and pain management. PC sites also identified
more symptoms of physical and emotional suffering, perhaps
due to heightened sensitivity to those issues. Results
are discussed in terms of effects of active PC training
upon quality of death. Methodological issues are also
explored in terms of effects of conducting intervention
research upon overall quality of care in SNFs.
WHAT
WILL IT TAKE TO IMPROVE PALLIATIVE CARE IN A NURSING
HOME?
H.Tuch & N.Strumpf. Genesis ElderCare & University
of PA.
Nearly 20% of all deaths in the US occur in nursing
homes, about 500,000 people annually. The medical literature
raises significant concerns about the quality of end-of-life
care that is currently provided to these residents.
Our experience, derived form a 3-year project supported
by the Robert Wood Johnson Foundation ("Palliative
Care in the Nursing Home"), will be described within
the context of policy changes we believe necessary to
improve palliative care in nursing home settings. Specific
reimbursement mechanisms tied to the RAI and RUGS categories,
diminishing regulatory barriers, changes in staff training
and support, increased community involvement, and changes
in institutional processes and culture will be addressed.
Palliative care should be considered skilled care, reimbursed
appropriately and monitored effectively. In the absence
of systemic change, meaningful or sustained improvement
in palliative care in the nursing home is unlikely.
(For
information about presenters, click
here)
| SELECTED
LINKS on PALLIATIVE CARE |
PowerPoint
Presentations:
-
-
Palliative
Care/ Geriatric Nursing Education: Model Curriculum
by Arlene D. Houldin, PhD, RN, CS, JoAnne Reifsnyder
PhD, RN, AOCN, Neville Strumpf, PhD, RN, FAAN, Eileen
Sullivan Marx, PhD, RN, FAAN, Valerie Cotter, MSN,
RN, CS, Anne Keane, EdD, RN, FAAN
(click
here for abstract)
-
Palliative
Care Resources and Tools
Books
Arlene
Houldin's book, Patients with
Cancer: Understanding the Psychological Pain
(2000) helps the reader understand the unique needs and
strengths of the patient suffering from cancer and their
family in order to create an individual plan of care that
promotes optimal psychological adaptation and functioning
throughout the illness.
For
more information about Penn Nursing's research on Palliative
Care in Nursing Homes,
please contact Dr.
Neville Strumpf.
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request a CONSULTATION, please contact |
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