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End-of-life issues

August 1, 2010
by Liza Burger, MSW
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Planning ahead maintains resident dignity

At a glance…

The staff of Groton Community Health Care Center has made it a priority to honor their residents at the time of death. Interdisciplinary cooperation among the team ensures dignity is maintained and support is offered to family members.

For this afternoon, the dining room feels more like a sacred space, as residents, staff members, and loved ones take a moment to focus on the glow of the individual candles that represent those residents we are honoring. Tears are shed, but there is laughter and telling of stories, too, reminding those present of how we've been touched by those we have lost.

Dealing with the intricacies of end-of-life care, including how to best support not only the residents we serve at end of life, but also family members, other residents, and staff, is an area that warrants attention in the long-term care setting, and one which I feel is well addressed in the skilled nursing facility where I work.

It is imperative to have an ongoing discussion with oriented residents regarding individual wishes about their care and treatment. Outlining resident wishes about such choices as CPR vs. DNR, artificial nutrition and hydration, or intubation on a MOLST (Medical Orders for Life Sustaining Treatment) provides the clinical team with guidelines for care and empowers the resident to make decisions or initiate discussions with loved ones. If residents lack the capacity to outline their wishes because of impaired cognition, many may still have the capacity to designate a healthcare proxy to assist in these important decisions.

Quarterly review

A review of the wishes outlined on the MOLST form occurs quarterly in our facility, more often if desired by a resident or medical decision maker, or if a significant change in a resident's condition occurs. By outlining residents' wishes soon after admission, the stress of making such decisions in a time of crisis is avoided. Loved ones can find reassurance at the end of life in knowing that a resident's previously noted wishes about care and treatment are being honored, and focus their attention on the resident's current needs.

If it becomes apparent that a resident has had a significant decline in his/her condition, our healthcare team considers whether the decline is related to an acute episode from which a resident is likely to recover or whether a resident may be nearing the end of his/her life. If appropriate, a discussion takes place with the resident or his/her medical decision maker, with input from the attending physician, about involving hospice services in the long-term care setting. While our own team of professionals provides excellent care at the end of life, the hospice team can work hand in hand with our team to address such areas as pain management, spiritual care, supplemental hands-on assistance, and family support both at the end of life as well as for a year following a resident's death.

Support

When residents are nearing the end of life, much attention is given to supporting them and their loved ones through this journey. The physician and nursing staff closely monitor pain levels and resident comfort, while also being attentive to questions or concerns expressed by loved ones. Social work staff offer supportive visitation when desired, which often leads to helping residents explore any unfinished business or doing a life review; similar discussions with loved ones take place to support them in dealing with feelings surrounding the gradual decline of the resident.

Additional ways we have supported residents and their loved ones include offering pastoral support, providing music at the bedside that a resident may find to be meaningful, and offering snacks or beverages for loved ones who are visiting for long periods of time. If a dying resident is in a semi-private room and more space and privacy is desired, the resident and his/her family are offered the use of a more spacious palliative care room in the final days of the resident's life. This room has been designed by staff members to provide a comfortable homelike setting that accommodates both the resident, as well as overnight visitors.

When residents are nearing the end of life, much attention is given to supporting them and their loved ones through this journey.

Honoring the dead

Our staff has made it a priority to honor the residents of our facility at the time of death. Following a death, a community memorial quilt, made by a volunteer staff member, is draped over the deceased resident, and the body is personally escorted out of the building by a staff member. Each deceased resident's name is then inscribed on the quilt. Support is offered to loved ones in the form of a personal acknowledgment by the social worker whenever possible, or with a phone call. A note of sympathy is then sent to the family from staff.

Finally, the importance of acknowledging the death of residents with other residents and staff members at our facility has not been overlooked. Unless we are notified that services are private, the social worker posts an obituary or information on family-planned services for staff members who may be interested in attending a service in the community. In addition, a quarterly memorial service is held at our facility to celebrate and honor those residents who have died. Loved ones, residents, and staff members gather in what has become a heartwarming occasion, complete with candles, music, and most importantly, stories shared about individuals who have touched our lives in so many ways. This meaningful time of reflection encourages staff to step away from their busy roles and give thanks for those residents for whom they've had the honor of caring.

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