1. 1 The Goals of End of Life Care Adapted from:The PERT Program Pain & Palliative Care Research Department Swedish Medical Center, Seattle, Washington Module 22 Geriatric Aide Curriculum NC Division of Health Service Regulation

2. 2 The Goals of End of Life Care Objectives 1. Describe why it is important to identify and communicate resident/family goals, values, and wishes. 2. Describe decisions that are made at the end of life.

3. 3 The Goals of End of Life Care Objectives 3. Define advance directives. 4. Describe the different types of advance directives. 5. Explore how decisions are made at the end of life.

4. 4 Importance of Goals of Care Protects resident’s freedom of choice Decreases family conflict/uncertainty Provides care wanted by resident/family Guides our actions Keeps us from providing unwanted care

5. 5 Role of Nurse Aide in Goals Listening to residents and families Communicating resident/family goals, values, and wishes to other team members. Encouraging residents and families to discuss their goals and wishes with other team members such as MD, chaplain, social worker or nurse.

6. 6 Goals of Medical Therapies Medical therapies should be directed by goals of care –Cure –Control –Comfort/Palliation

7. 7 Decisions at the End of Life Should I continue with treatments aimed at curing my disease or condition? OR Should the focus of my medical care be on keeping me comfortable?

8. 8 Decisions at the End of Life If my condition gets worse or I develop a medical problem: Do I want to be transferred to a hospital? OR Do I want to be cared for at the my “home,” wherever that may be?

9. 9 Decisions at the End of Life If I can no longer make decisions for myself, who should make the decisions for me?

10. 10 Decisions at the End of Life What decisions do I need to make to get my affairs in order? Includes funeral & financial arrangements

11. 11 Decisions at the End of Life Would I want to receive those therapies? OR Do I want nature to take its course? If I needed machines and other medical treatments to stay alive:

12. 12 Treatment Options CPR/mechanical ventilation Kidney dialysis Diagnostic tests Hospitalization Antibiotics Blood Transfusions Tube feeding/ intravenous fluids Pain management and comfort care Decision maker(s) need to understand risks/benefits and probable outcomes of different types of therapy:

13. 13 Exploring Values and Beliefs  Who should speak for me?  What makes my life worth living?  What are personal and spiritual beliefs that influence decisions?  Hope for recovery?

14. 14 Advance care planning, informed consent, and medical decision making are PROCESSES.

15. 15 Ideally, identifying goals of care occurs before a major change in resident status or a medical crisis.

16. 16 Ideally, the Resident is Able to Make Decisions The resident: Understands the information given Thinks clearly about treatment options Can communicate decisions

17. 17 Residents Who Might Not be Able to Make Decisions Include Those: With advanced dementia Who have had strokes that decrease their ability to understand or to speak Who are in a coma Who have a serious mental disease

18. 18 Don’t Assume a Resident is Unable to Make Good Decisions Because the Resident: Is strange or odd Doesn’t speak your language Is not well educated Is physically handicapped Is deaf Disagrees with the family or the health care team

19. 19 Ideally, the resident who makes the decisions is fully informed about his/her disease, prognosis, and treatment choices.

20. 20 Ideally, the resident decides freely without feeling forced.

21. 21 Autonomy “Autos” = self “Nomos” = rule or law A person’s freedom to choose for him- or herself

22. 22 Family Physicians Interpreter Clergy Spouse Resident may receive input.

23. 23 Autonomy = The resident decides

24. 24 Advance Directives: Are written instructions (directives) to a health care provider before (in advance of) the need for medical treatment. Ensure that your wishes are followed in the event that a future accident or illness makes it impossible for you to communicate your wishes. In an advance directive, you can refuse or consent to future treatment.

25. 25 Types of Advance Directives Durable Power of Attorney for Health Care (DPOA, Health Care Agent) Living Will (Health Care Directive) No Code/Do Not Resuscitate (DNR) Anatomical Gifts - tissue/organ/body donation Do Not Hospitalize (DNH)

26. 26 Purposes of Advance Directives To help a person maintain autonomy if no longer able to make decisions Provides guidance to family and caregivers about type/goals of care. Can decrease family and caregiver distress about decision making. Can decrease conflict around end of life decision making.

27. 27 Revoking Advance Directives You may revoke your health care power of attorney at any time, so long as you are able to make and communicate your medical care decisions. The revocation may be in writing or by any means that you are able to communicate your intent to revoke to your doctor and health care agent.

28. 28 Cultural Differences in Medical Decision Making  Individual autonomy vs. family duty  Informing vs. “inflicting” truth  Control over life and death vs. trust in others or in God, Allah

29. 29 Who Can Make Health Care Decisions if the Resident Isn’t Capable? Next of kin –Spouse –Children over 18 –Parents –Adult sisters and brothers Health care power of attorney Appointed guardian

30. 30 What Do You Do in the Case of Disagreements?

31. 31 Refusing Life-Prolonging Therapies Refusing Aggressive Comfort Measures 

32. 32 Comfort Measures Positioning Hygiene Cold compresses Mouth care Touch Talking to resident Paying attention to resident’s condition

33. 33