1. Module 1: Introduction to Palliative Nursing Care

2. Veterans Affairs Motto
“…to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow, and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”
President Abraham Lincoln
2nd Inaugural Address

3. Veterans’ preferences for care at end
Mission of the Department of Veterans Affairs Hospice and Palliative Care Program
“To honor
Veterans’ preferences for care at end
of life.”
Department of Veterans Affairs Office of Geriatrics and Extended Care

4. Demographics of Veterans
Projected
Over 5,000,000 Veterans cared
for at a VA facility/year
US Veterans: 23,442,000
Deaths of WW II Veterans/day:
900
% of Veterans over the age of
65: 39.4%
National Center for Veterans Analysis and
Statistics, 2009; Casarett et al., 2008a

5. The Facts About Veteran Deaths
More than 50,000 Veterans die a month (600,000/year)
23,000 die in VA inpatient
settings/year
Veteran deaths account for almost 28% of all deaths in the US
Approximately 85% do not receive care in a VA facility
Only 4% die in a VA facility
NHPCO, 2010

6. Veterans in the Community
Nearly 40% of enrolled Veterans live in rural communities
121,000 Veterans are without shelter or healthcare, hence no access to hospice/palliative care
NHPCO, 2010

7. Nurses Caring for Veterans at the End of Life Must Understand the Culture
Enrolled Veterans
Social isolation
Lack of family support
Low income
Military camaraderie
Culture of stoicism
US Department of VA Affairs, VA Health Administration, 2005

8. Characteristics of VHA and Unique Characteristics of Enrolled Veterans
The largest integrated healthcare
system in the US
Multi-layered benefits system
Large elderly population
Higher percent of homelessness
than in general population
Multiple co-morbidities
Back et al., 2005; Casarett et al., 2008a; Finlay et al., 2008

9. Various Experiences Can Affect a Veterans Dying
What branch of service?
Enlisted? Drafted? Rank?
Age?
Combat and/or POW experience?
PTSD (assess for social isolation, alcohol abuse, anxieties)?
Stoicism
Department of Veterans Affairs, VA Health Administration & Office of Geriatrics and Extended Care, 2005

10. We Do Not Always Die the Way We Would Prefer
Care at home
Fear of pain
Financial burden
Invasive, painful treatments
Dependence on others
Role changes
Elderly caring for the sick
Boni-Saenz et al., 2005; Egan-City & Labyak, 2010

11. Hospice and Palliative Care
Most intense form of
palliative care
Less than 6 months to
live
Agrees to enroll in
hospice
Chooses not to receive
aggressive care
PALLIATIVE CARE
Ideally begins at the time
of diagnosis
Can be used to
complement
treatments
NCP, 2009

12. Hospice and Palliative Care cont.
BOTH
Interdisciplinary care
Provide pain and symptom
management
Physical, emotional, social
and spiritual care

13. Palliative Care
NCP, 2009

14. Death and Dying in America: Today
Over 4700 hospice programs in the US
Average length of stay in hospice is 69 days (median=21 days)
In 2007: 1,560,000 patients received hospice services and 41.6% of all deaths in the US were under the care of a hospice program
Patients with chronic illnesses make up the majority of hospice patients (i.e. heart disease, dementia, etc)
NHPCO, 2005 & 2010a

15. Barriers to Quality Care at End of Life
Failure to acknowledge limits of medicine
Lack of training for healthcare providers
Hospice/palliative care services are misunderstood
Many rules and regulations
Denial of death
Glare et al., 2003

16. History of Palliative Care in VA
1992: Policy— “All Veterans should be provided access to a hospice program…”
: VA Faculty Leaders Project for Improved Care at the End of Life
2001: Training and Program Assessment for Palliative Care (TAPC)
: TAPC launched the VA Hospice & Palliative Care Initiative (VAHPC)
VAHPC Launched Hospice-Veteran Partnership (HVP)
NHPCO, 2010b

17. History of Palliative Care in the VA (cont.)
2003-Present: Palliative Care Consultative Team (PCCT) and Accelerated Administration & Clinical Training (AACT)
2009- Comprehensive End of Life Care Initiative (CELC)
PROMISE

18. Palliative Care in the VA Today
VA provides palliative care consultation services at
ALL of its medical centers
Many Community Living Centers (CLC)
And contracts with community-based hospice programs to enhance VA’s ability to meet the end-of-life services of its Veterans
Over 60% of all Veterans who die in VA facilities receive care from a palliative care team
Department of Veteran Affairs, VA Public Affairs, 2008

19. Benefits of Palliative Care Consultation Teams (PCCT) in VA
Veteran’s goals of care are identified
Less likely to be admitted to ICU
Laboratory and technological tests decreased
Communication between PCCT and Veteran allow goals to be honored
Penrod et al., 2006

20. Differences in Cause of Chronic Illness and Death by Wars
World War II
Korean War
Vietnam
Gulf War
Operation Enduring Freedom/Operation Iraqi Freedom

21. Eligibility for VA Hospice Benefit
Included in the Medical Benefits Package (both inpatient or home settings)
Eligible for both VA and Medicare may elect to have hospice paid for under Medicare Hospice Benefit
Department of Veterans Affairs, VA Health Administration & Office of Geriatrics and Extended Care, 2005

22. Providing Hospice Services to a Veteran who Becomes an Inpatient
GENERALLY, VA provides needed inpatient hospice care at a VA facility (preferred option)
VA may utilize Community Nursing Home (CNH) contracts
VA may purchase inpatient hospice services from a community provider
Department of Veterans Affairs, VA Health Administration & Office of Geriatrics and Extended Care, 2005

23. Prognostication: May Be Used to Establish Goals of Care
Performance status
ECOG and Karnofsky are
poor indicators
Multiple symptoms
Biological markers
Albumin, etc.
“Would I be surprised if this Veteran died within the next 6 months?”
Glare et al., 2010; Lamont & Christakis, 2007; Lynn et al., 2000

24. Two Palliative Care Frameworks for Assessing Patients
Making Promises Document:
Begin by envisioning what a
better care system would
look like
Quality of Life Model:
Identify physical,
psychological, social, and
spiritual aspects of care

25. Making PROMISES: Changing Systems of Care
Good Medical Treatment
Never Overwhelmed by Symptoms
Continuity, Coordination, & Comprehensiveness
Well Prepared, No Surprises
Customized Care, Reflecting Your Preferences
Consideration for Patient and Family Resources
Make the Best of Every Day
Lynn et al., 2000

26. QUALITY OF LIFE MODEL: Addressing Four Dimensions of Care

27. Role of the Nurse in Improving Palliative Care for All Patients
More time at the bedside than other healthcare providers
Some things cannot be “fixed”
Use of therapeutic
presence
Maintain a realistic perspective
Keep Veteran’s goals first in all communication with the team

28. Maintaining Hope in the Midst of Death
Experiential processes
Spiritual processes
Relational processes
Rational thought processes
Ersek & Cotter, 2010

29. Extending Palliative Care for Veterans Across Various Settings
Nurses are the constant caregivers
In-patient settings
Clinics
Community living centers
Expand the concept of healing
Become well-educated
Willing to be a “change agent”

30. Final Thoughts
Quality palliative care addresses quality of life for ALL patients
Increased nursing knowledge is essential
“Being with”
Interdisciplinary care is vital

31. Consider…….
What steps do you need to take to improve palliative care at your institution so that you and other members of the team are prepared to “care for him who shall have borne the battle…?”