1. No Place for a Hero Providing Palliative Care in the Field LeeAnne Douglas MScCH, AEMCA

2. Julia  Age 37  Mother of 2  Cervical cancer with mets to bone  BP 80/40  RR 8, with periods of apnea  HR 46

3. How would you care for her?

5. Palliative Care in the Field Pearls Community Palliative Care Dying

6. Palliative Care in the Field Pearls Community Palliative Care Dying

7. Where We Die 84% 70% Barbara et al., 2010; Statistics Canada

8. How We Die 70% due to chronic illness Cancer Heart Disease Stroke Statistics Canada, 2014

9. Sudden Glaser & Strauss, 1968; http://geri-em.com/symptom-management/global-eol- trajectories/

10. Terminal Illness

11. Frailty

12. Organ Failure

13. How would you want to die?

14. Palliative Care in the Field Pearls Community Palliative Care Dying

15. Palliative Care  Philosophy of care  Improve quality of lives of people and families facing life-threatening illness  Prevention and relief of suffering  Pain, physical, psychosocial, and spiritual issues

16. Palliative Care Bereavement Curative Care DiagnosisDying Death Adapted from Shreve, 2013 Bereavement Care

17. Reduced Function Illness Dyspnea Pain Seizure Lethargy Coma Death Adapted from Shreve, 2013 Emaciated Mottling Hallucinations Delirium Cheyne-Stokes Stop eating and drinking

18. Palliative Care in the Field Pearls Community Palliative Care Dying

19. Resuscitation Care Airway Breathing Circulation Disability

20. ABCDs of Dignity in Care Chochinov, 2007

21. Attitudes ‘I don’t know, I don’t know if I’d tell a person they’re going to die...if they only had a couple minutes left I don’t know if I’d want to know if it was my last couple minutes.’ Participant 4, Focus Group 4

22. Practice Points  Think about your attitudes and how they affect your communication How do my views on death affect how I communicate with people and families facing end of life?

23. Behavior ‘And you’re shifting gears, you’re shifting gears from being patient-centered and focused and task-oriented to switching back to the emotional side and...display[ing] the right level of empathy and trying to achieve the right level of connectedness so when you go and talk to these people.’ Participant 1, Focus Group 1

24. Practice Points  Our attitudes influence our behavior and how we communicate  Switch gears  Gather team for support  Think about what you will say  Set the stage with the family’s comfort in mind  Use effective nonverbal communication

25. Compassion ‘...when we left an entire group of people... had arrived and they made sort of an assembly line as we went by and they hugged both my partner and I as we were leaving the apartment...it was exhausting dealing with this family on such a close connected emotionally charged level, but at the end of the day I think we did right by them.’ Participant 1, Focus Group 1

26. Practice Points  Our feelings shape our approach to care What do I need to know about you as a person in order to give you the best care possible?  Acknowledge the intensity of the person’s and family’s experience

27. Empathy  Understand the person’s and family’s perspectives  Understand their feelings  Communicate based on this understanding

28. Dialogue  What’s most important to your loved one right now?  What are your expectations for their care?  What are your concerns? Shreves, 2012

29. Communication by the Numbers 60

30. Communication by the Numbers 60

31. 80 20

32. Practice Points  Understand the person’s and family’s needs  Ask about their ideas, concerns, and expectations for their care  Keep their comfort in mind  Consult

33. Changing the way we do things “The desire for everything crowds out the opportunity for peace and dignity in an inevitable death.” Shreve, 2012; Chapple, 2010

34. Changing the way we do things  “Do everything”  “Do nothing”  “What’s most important?”  “Do everything to support them” Shreves, 2012

35. Would you change anything about her care? Julia

36. End-of life Conversations  Be aware of your attitudes and behavior  Understand person’s and family’s needs  80/20 rule  Be compassionate and clear  Acknowledge impact of illness or death  Take time for yourself

37. Palliative Care in the Field Pearls Community Palliative Care Dying

38. Challenges and Opportunities  Comfort?  Time?  Prognostication?

39. Palliative Care in the Field Pearls Community Palliative Care Dying

40. Role of community paramedics?

41. leeannedouglas00@gmail.com @douglas_leeanne