5 priorities of Care - PowerPoint Presentation

5 priorities of Care Day 2

Welcome back Any reflections from the last day? Any hopes for today?

Recognise Priority 1 The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly. Always consider reversible causes, e.g. infection, dehydration, hypercalcaemia, etc.

expanded When a person’s condition deteriorates unexpectedly, and it is thought they may die soon , i.e. within a few hours or very few days, they must be assessed by a doctor who is competent to judge whether the change is potentially reversible or the person is likely to die . If the doctor judges that the change in condition is potentially reversible, prompt action must be taken to attempt this, provided that is in accordance with the person’s wishes or in their best interests if it is established that they lack capacity to make the decision about treatment at that time. If the doctor judges that the person is likely to be dying, taking into account the views of others caring for the person, this must be clearly and sensitively explained to the person in a way that is appropriate to their circumstances (if conscious and they have not indicated that they would not wish to know), and their family and others identified as important to them. The person’s views and preferences must be taken into account , and those important to them must be involved in decisions in accordance with the person’s wishes. A plan of care must be developed , documented, and the person must be regularly reviewed to check that the plan of care remains appropriate and to respond to changes in the person’s condition, needs and preferences.

activity In groups discuss your statement(s) What are the possible complications, issues that may arise or impact you in your role? Will this help you in your role?

How do we KNOW if someone is dying?

3 triggers that suggest that patients are nearing the end of life are: 1. The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’? 2 General indicators of decline - deterioration, increasing need or choice for no further active care. 3. Specific clinical indicators related to certain conditions.

The End of Life Care Strategy (2008) recommends asking: “Would I be surprised if the person in front of me were to die in the next six months or year?” This is an intuitive question taking into consideration the stage and progression of the patient's disease, co-morbidities, frailty, age, social and other factors.

Recognising the Onset of Dying P hase Rapid progression of disease or co-morbid condition Greatly reduced mobility Increased frailty Accumulated complications of treatments, e.g. dialysis Infections becoming less responsive to treatment

Average 20 deaths per GP per year approx proportions

“ Dying is very complex. People are likely to die in old age after a prolonged decline beset by multiple conditions” Leadbetter & Garber, 2010

Is the Patient L ikely to be Aware of This?” Given the physical changes experienced O pportunity to tell you how they feel things are going. It may be that the patient has thought they are nearing the dying phase. T hey may be ready to have confirmation of this, and to discuss their end of life issues and concerns. On the other hand, it is important to be sensitive to patients who might not be ready to discuss this.

Signs of Approaching Death Last few days Your thoughts…….

Head and Face Patient will be more fatigued, tired, sleepy even semi-conscious Patient will have difficulty in concentrating on activities and conversations Patient may appear gaunt with sunken eyes, no sparkle and pale in colour Patient may experience a dry and sore mouth with the risk of oral thrush and ulcers developing Patient may experience visual changes.

Neck and Chest Patient’s fluid and food intake will decrease or cease Swallowing difficulties will be apparent and alternative routes for medication need to be sought Patients breathing pattern may change and be more laboured. Respiration with mandibular movement may be observed as patient is very close to death Patient may experience bubbly secretions at the back of the throat

Central body Patient is normally bed bound at this stage. Movement in the bed needs to be gentle as the patients joints can be very stiff, sore and painful. Skin is very dry and fragile. More likely to bruise. The patient is at a huge risk of pressure sores developing. With the disease progressing to this stage and the patient unlikely to have received adequate nutrition for a while they could look cachexic, especially around collar bone and ribs.

Lower body Patient may experience urinary retention or urinary and faecal incontinence as unable to mobilise or maintain control over bodily functions. A catheter maybe assessed as appropriate if not pads can be used but this could increase risk to pressure areas i.e. sacrum.

Extremities Patients are at risk of developing multi system failure. Both cardiac and renal failure can present themselves through: Oedematous legs Cyanosed/blue fingers and toes Cold arms and legs Bruising

Communication Withdrawn patient

Picking up on cues Open questions Educated guesses (tentative) Acknowledging/reflecting/paraphrasing as you go Checking what they know already Clarifying/Exploring anything you don’t 100% understand Use of appropriate silences to allow for reflection Summarising at the end of the conversation Facilitative skills: Key Communication Skills

After tea break in afternoon

What is the goal of good communication? To build positive relationships To ensure needs are accurately identified and responded to To allow for the feeling of being supported and listened to To ensure understanding of choices To learn what has been understood and what further information is needed or wanted To deliver new information helpfully, sensitively and at the right pace To provide space to talk about whatever they want to in order that the conversation may allow them to organise their thoughts and feelings in helpful ways… To enable planning of present and future care in a timely manner

Exercise: Get into pairs Both people in each pair should have a go at the following: Person 1 should spend 5 minutes talking to person 2 about a recent challenging experience at work Person 2 will be given a card and must do what it states on the card After 5 minutes reverse roles

Feedback What did you notice? How did you feel being the talker? How did you feel being the ‘unresponsive listener’? So: what ratio of importance do you think these ‘ingredients’ of communication hold: Content of Speech Vocal Characteristics (e.g. tone) Non-verbal Communication

If communication was a cake….. Words Non verbal Tone and pitch How big would the piece be…..

Barriers to communication In groups list the barriers you find in your work that effect yours or others communication skills

Behaviours that ‘block’ effective communication Being defensive Overuse of practical questions Changing topic or redirecting the conversation Lecturing (‘telling people what to do’) Collusion/hesitation to introduce topics Inappropriate information Closed questions Multiple questions Leading questions Passing the buck Jollying along Chit chat

30 Consequences of poor communication A significant potential for increased psychological distress for the service user and for their family Poor adherence to advice/guidance Reduced quality of life Dissatisfaction with services Complaints and litigation Potential burnout in health and social care professionals

What are Our worries? When someone has just died…….

Definitions Bereavement: describes the loss that people experience when someone close to them dies. Grief: describes the emotions that people go through as a result of the loss of someone close to them Mourning: describes the period of time when people are grieving.

However, Most people want to feel that others are supportive and care That they know what to expect Where they can get help if needed Grief is a difficult time but most people manage with their own support from family, friends and local organisations.

NICE (2004) identifies three levels to support bereaved people. 1) Those who have sufficient resilience and support to manage their grief but may lack understanding about grief. Offer information (largest group) 2) May need a formal opportunity to reflect on their loss as well as information. Offered by non specialist professionals, volunteer groups and community groups. 3) Will need more specialised help. Provided by trained bereavement counsellors, and psychotherapy services. (minority)

Loss Lets spend some time thinking about what we can lose?

Grieving is a personal and highly individual experience. How you grieve depends on many factors; personality and coping style, life experience, faith, and the nature of the loss.

1: We only grieve deaths. 2: Only family members grieve. 3: Grief is an emotional reaction. 4: Individuals should leave grieving at home. 5: We slowly and predictably recover from grief. 6: Grieving means letting go of the person who died. 7: Grief finally ends. 8: Grievers are best left alone.

Common Myths Myth 1: We only grieve deaths. Reality: We grieve all losses. Myth 2: Only family members grieve. Reality: All who are attached grieve. Myth 3: Grief is an emotional reaction. Reality: Grief is manifested in many ways.  Myth 4: Individuals should leave grieving at home. Reality: We cannot control where we grieve.

Myth 5: We slowly and predictably recover from grief. Reality: Grief is an uneven process, a roller coaster with no timeline. Myth 6: Grieving means letting go of the person who died. Reality: We never fully detach from those who have died. Myth 7: Grief finally ends. Reality: Over time most people learn to live with loss. Myth 8: Grievers are best left alone. Reality: Grievers need opportunities to share their memories and grief, and to receive support.

What emotions do you think people will experience?

Once the person has died numbness inability to accept the situation shock and pain relief anger and resentment guilt sadness feelings of isolation a feeling of lack of purpose.

Life function SHOCK PROTEST DISORGANISATION REORGANISATION GRIEF WHEEL DEATH

Dual Process Model of Coping with Loss Loss -oriented Restoration-oriented Grief work Intrusion of grief Breaking bonds and ties Denial/avoidance of restoration changes Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief to life changes New roles, Identities, relationships Everyday Life Changes

TEN WAYS TO HELP THE BEREAVED 1. By being there 2. By listening in an accepting and non-judgemental way 3. By showing that you are listening and that you understand something of that they are going through 4. By encouraging them to talk about the deceased 5. By tolerating silences 6. By being familiar with your own feelings about loss and grief 7. By offering reassurance 8. By not taking anger personally 9. By recognising that your feelings may reflect how they feel 10. By accepting that you cannot make them feel better

supporting staff

People will forget what you said, people will forget what you did, but people will never forget how you made them feel Maya A ngelou