1. End of Life & Hospice Care Presented by Care and Compliance Group, Inc.

2. Before We Begin… • Let’s take a brief moment to evaluate your knowledge of end of life issues and working with residents on hospice care.

3. Initial Evaluation Assessment • When a resident is in the end of his/her life stage, pain is no longer an issues, as his/her nervous system shuts down. • True? • False?

4. Initial Evaluation Assessment • When a resident is in the end of his/her life stage, pain is no longer an issues, as his/her nervous system shuts down. • True? • False?

5. Initial Evaluation Assessment • When a resident is nearing end of life, his/her appetite will generally ____________. • Decrease • Increase • Not be affected

6. Initial Evaluation Assessment • When a resident is nearing end of life, his/her appetite will generally ____________. • Decrease • Increase • Not be affected

7. Initial Evaluation Assessment • Not every state uses a POLST. • True? • False?

8. Initial Evaluation Assessment • Not every state uses a POLST. • True? • False?

9. Initial Evaluation Assessment • A Living Will is the same as a DNR Order. • True? • False?

10. Initial Evaluation Assessment • A Living Will is the same as a DNR Order. • True? • False?

11. Initial Evaluation Assessment • A resident who is receiving hospice care no longer needs your assistance and participation in care. • True? • False?

12. Initial Evaluation Assessment • A resident who is receiving hospice care no longer needs your assistance and participation in care. • True? • False?

13. Responding With Compassion And Care

14. Life is a brief intermission, Between birth and death, Enjoy it. ~ M.K. Soni ~

15. Defining End Of Life • Health changes associated with end of life…

16. Decreased Desire To Eat The resident may experience an uncommon drop in appetite during this phase of life. Resident may refuse food or beverage. Digestive system begins to shut down.

17. Non-Responsive Resident may become less responsive or less alert. May become incontinent towards the end of life. However, despite the resident’s unresponsive state, it is essential to continually provide for his/her care needs (repositioning and cleanliness).

18. Become Bedridden Due to the increased weakness or other health complications, the resident may become immobile.

19. Changes In Breathing The resident may experience “apnea” –(when the person stops breathing for 10 – 20 seconds). May experience Cheyenne-Strokes breathing –(where the person breathes very rapidly for a moment and stops breathing the next).

20. Changes In Breathing, Continued… Irregular breathing may occur such as what is known as “wet breathing”. –(When the person’s breathing creates a “wet” sounding noise when exhaling).

21. Changes In Breathing, Continued… Any of these breathing irregularities can cause extreme concern for the family and/or responsible party of the dying resident.

22. Other Changes In Physical Care Include: • Nausea and/or vomiting • Constipation • Skin breakdown • Pain

23. What are some emotional changes you have seen with residents at the end of his/her life?

24. Important factors to keep in mind when caring for a resident at the end of his/her life: • A resident with a terminal illness, (medically diagnosed with 6 months or less to live), will likely have changes in his/her care needs. • Staff will need to anticipate and respond to changes in the level of involvement of family members and relatives, depending on the situation.

25. Maintain Respect and Dignity

26. Know and understand any advanced directives in place

27. Continual Communication Is Key!

28. First Response • Address any changes that need to take place to the resident’s care and services.

29. Implement resident’s communicated preferences for end of life care.

30. What you need to know Hospice care regulations

31. CCLD Title 22 Regulations RCFE Title 22 Regulations regarding hospice care standards and procedure policies. • Defined in Regulation 87101(h)(6) “Hospice or Hospice Agency”; 87101(f)(1) “Facility Hospice Care Waiver”; and 87101(h)(7) “Hospice Care Plan”

34. Hospice Waiver • RCFE Title 22 Regulation 87632 – Hospice Care Waiver • Regulation 87633 and 87716 – Hospice Care For Terminally Ill Resident

35. Total Care Plans • What is allowed, restricted or prohibited in assisted living and residential care?

36. What information do you need to know when contacting the hospice agency?

37. Hospice Assistance • It is vitally important to work as a team

38. Caregivers and Hospice Agency Staff must work together to provide the highest quality of care for the resident and his/her family during this stage of life.

39. Fulfilling Resident’s Expressed Wishes Addressing Advance Directives

40. Because I could not stop for death He kindly stopped for me The carriage held but just ourselves And immortality ~ Emily Dickinson ~

41. What is an advanced directive?

42. Advanced Directives • Advance directives are legal documents that allow the resident to convey his/her decisions about medical and end of life care. • May be used if the resident becomes ill and is unable to communicate his/her wishes.

43. Advanced Directives May Include: • Medical Power of Attorney • Living Will • Request to forego resuscitation (DNR) • POLST (Physician’s Orders For Life-Sustaining Treatment)

44. Putting It In Layman’s Terms… • Medical Power of Attorney A document that legally states a person selected by the resident to make decisions about his/her medical care if he/she is temporarily or permanently unable to communicate and make decisions for himself/herself. Effective when physician declares resident unable to make decisions.

45. Putting It In Layman’s Terms… • Living Will A living will contains instructions given by the resident specifying what actions should be taken for his/her health in the event that the resident is no longer able to make decision due to illness or incapacity.

46. A living will usually provides specific directions about the course of treatment that is to be followed by health care providers and caregivers.

47. A living will may forbid the use of various kinds of burdensome medical treatments, express wishes about the use of food and water if supplied via tubes or other medical devices.

48. DNR DNR stands for Do Not Resuscitate.

49. DNR It is a very specific type of advance directive requested by the resident to not have CPR if his/her heart stops beating or if he/she stops breathing.

50. DNR Orders: • Must be signed by both the resident and physician (not valid if not signed by the physician) • Allows a person to forego resuscitation in an emergency situation • Is capable of being revoked • Is not required by law