Evaluations www.careandcompliance.com/eval We deeply value your feedback, and will utilize it in the ongoing development of our courses and services. End of Life & Hospice Care Presented by Care and Compliance Group, Inc. 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. 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. a. True? b. False? 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. a. True? b. False? Initial Evaluation Assessment • When a resident is nearing end of life, his/her appetite will generally ____________. a. Decrease b. Increase c. Not be affected Initial Evaluation Assessment • When a resident is nearing end of life, his/her appetite will generally ____________. a. Decrease b. Increase c. Not be affected Initial Evaluation Assessment • Not every state uses a POLST. a. True? b. False? Initial Evaluation Assessment • Not every state uses a POLST. a. True? b. False? Initial Evaluation Assessment • A Living Will is the same as a DNR Order. a. True? b. False? Initial Evaluation Assessment • A Living Will is the same as a DNR Order. a. True? b. False? Initial Evaluation Assessment • A resident who is receiving hospice care no longer needs your assistance and participation in care. a. True? b. False? Initial Evaluation Assessment • A resident who is receiving hospice care no longer needs your assistance and participation in care. a. True? b. False? Responding With Compassion And Care Life is a brief intermission, Between birth and death, Enjoy it. ~ M.K. Soni ~ Defining End Of Life • Health changes associated with end of life… • 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. • 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). • Become Bedridden Due to the increased weakness or other health complications, the resident may become immobile. • 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). • 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). • Changes In Breathing, Continued… Any of these breathing irregularities can cause extreme concern for the family and/or responsible party of the dying resident. • Other Changes In Physical Care Include: - Nausea and/or vomiting - Constipation - Skin breakdown - Pain • What are some emotional changes you have seen with residents at the end of his/her life? 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. • Maintain Respect and Dignity • Know and understand any advanced directives in place Continual Communication Is Key! First Response • Address any changes that need to take place to the resident’s care and services. • Implement resident’s communicated preferences for end of life care. What you need to know HOSPICE CARE REGULATIONS 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” Regulations 87101 RESIDENTIAL CARE FACILITIES FOR THE ELDERLY DEFINITIONS (Continued) 87101 (Cont.) 87101 (7) "Existing Facility" means any facility operating under a valid license on the date of application for a new license. (1) "Facility Hospice Care Waiver" means a waiver from the limitation on retention of residents who require more care and supervision than other residents and residents who are bedridden other than for a temporary illness. The Hospice Care Waiver granted by the Department will permit the retention in a facility of a designated maximum number of terminally ill residents who are receiving hospice services from a hospice agency. The Facility Hospice Care Waiver will apply only to those residents who are receiving hospice care in compliance with a hospice care plan meeting the requirements of Section 87633, Hospice Care for Terminally Ill Residents. (2) "Federal Bureau of Investigation (FBI) Clearance" means an individual has no felony or misdemeanor convictions reported by the FBI. The individual may also have been arrested with no criminal conviction, convicted of a minor traffic offense or adjudicated as a juvenile. (g) (1) "Guardian" means a person appointed by the Superior Court pursuant to Probate Code section 1500 et seq. to care for the person, or person and estate, of a child. (h) (1) "Healing wounds" include cuts, stage one and two dermal ulcers as diagnosed by a physician, and incisions that are being treated by an appropriate skilled professional with the affected area returning to its normal state. They may involve breaking or laceration of the skin and usually damage to the underlying tissues. (2) "Health Care Provider" means those persons described in Probate Code section 4621: "an individual licensed, certified, or otherwise authorized or permitted by the law of this state to provide health care in the ordinary course of business or practice of a profession." (3) "Health Care Surrogate Decision Maker" means an individual who participates in health care decision making on behalf of an incapacitated resident. Health care surrogate decision maker may be formally appointed (e.g., by the resident in a Durable Power of Attorney for Health Care or by a court in a conservatorship proceeding) or, in the absence of a formal appointment, may be recognized by virtue of a relationship with the resident (e.g., the resident's next of kin). The licensee or any staff member of the facility shall not be appointed health care surrogate decision maker. (4) "Health Condition Relocation Order" means written notice by the Department to a licensee requiring the relocation of a resident from a residential care facility for the elderly because the resident has a health condition which cannot be cared for within the limits of the license, requires inpatient care in a health facility or has a prohibited health condition as specified in Section 87615, Prohibited Health Conditions. (f) CALIFORNIA-DSS-MANUAL-CCL MANUAL LETTER NO. CCL-08-01 Page 15 Effective 3/5/08 87101 (Cont.) 87101 (i) RESIDENTIAL CARE FACILITIES FOR THE ELDERLY DEFINITIONS (Continued) Regulations 87101 (5) "Home Economist" means a person who holds a baccalaureate or higher degree in home economics and who specialized in either food and nutrition or dietetics. (6) "Hospice or Hospice Agency" means an entity which provides hospice services to terminally ill persons, is Medicare certified for hospice, and holds either a Hospice license or a Home Health Agency license from the California Department of Health Services. Any organizations, appropriately skilled professionals, or other professional persons or entities that are subcontracted by the hospice or hospice agency for the provision of specified hospice services to the resident are included within the definition. The hospice agency providing services in an RCFE shall not subcontract with the licensee or any facility staff for the provision of services. (7) "Hospice Care Plan" means the hospice agency's written plan of care for a terminally ill resident. The hospice shall retain overall responsibility for the development and maintenance of the plan and quality of hospice services delivered. (1) "Immediate Need" means a situation where prohibiting the operation of the facility would be detrimental to a resident's physical health, mental health, safety, or welfare. Examples of immediate need include but are not limited to: (A) A change in facility location when residents are in need of services from the same operator at the new location; (B) A change of facility ownership when residents are in need of services from the new operator. (2) "Initial Certification Training Program Vendor" means a vendor approved by the Department to provide the initial forty (40) hour certification training program to persons who do not possess a valid residential care facility for the elderly administrator certificate. (3) "Initial Vendor Application" means the application form, LIC 9141, used to request approval from the Department to become a vendor for the first time. (4) "Instruction" means to furnish an individual with knowledge or to teach, give orders, or direction of a process or procedure. CALIFORNIA-DSS-MANUAL-CCL MANUAL LETTER NO. CCL-08-01 Page 16 Effective 3/5/08 Hospice Waiver • RCFE Title 22 Regulation 87632 – Hospice Care Waiver • Regulation 87633 and 87716 – Hospice Care For Terminally Ill Resident Total Care Plans • What is allowed, restricted or prohibited in assisted living and residential care? • What information do you need to know when contacting the hospice agency? Hospice Assistance • It is vitally important to work as a team • 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. Fulfilling Resident’s Expressed Wishes ADDRESSING ADVANCE DIRECTIVES Because I could not stop for death He kindly stopped for me The carriage held but just ourselves And immortality ~ Emily Dickinson ~ • What is an advanced directive? 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. Advanced Directives May Include: • Medical Power of Attorney • Living Will • Request to forego resuscitation (DNR) • POLST (Physician’s Orders For Life-Sustaining Treatment) 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. 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. A living will usually provides specific directions about the course of treatment that is to be followed by health care providers and caregivers. 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. • DNR DNR stands for Do Not Resuscitate. • 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. 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 • POLST Form Is a written physician’s order that documents a resident’s wishes for life sustaining treatment. The POLST form goes with the resident during a medical emergency requiring transfer by emergency medical personnel or others. It ensures readily available information for health care providers about resident’s treatment preferences and complements the advance health directive. The POLST form is not used in every state. The POLST form is not required by law. As a person comes to the end of life or becomes terminally ill, he/she has the choice whether or not to receive CPR in an emergency situation. If the individual does want to receive CPR, then he/she would not need to take any further action. If the individual chooses not to receive CPR, then he/she would need to speak with his/her physician about signing a DNR Order to ensure that his/her wishes are followed if/when the person stops breathing or his/her heart stops beating. Understand this may not be a simple choice for the resident. Encourage your resident and their families to consider all the options and discuss while the resident is able to decide for himself/herself. Do you have any additional questions about DNR Orders, the POLST Form or other Advanced Directives? www.polst.org or http://www.nlm.nih.gov/medlineplus/ency/patientins tructions/000473.htm Honoring Resident’s Wishes • What would you do? Understanding where your resident is at in the process FIVE STAGES OF GRIEF AND LOSS Denial Anger Bargaining Depression Acceptance Working through these stages with your resident at the end of life and providing support for his/her family. How Would You Respond? • Take a moment to examine several case studies regarding examples of residents/families going through various stages of grief and loss. • What would your response be and why? Finding useful support to provide quality assistance COMMUNITY RESOURCES Community Resources • Grief/Loss counseling groups • Clergy • Online resources To Sum It Up… • It is important to recognize and respond to the physical and psychological changes that may take place in the resident during this phase of life. Many times, the care extends beyond the resident and may include immediate family members, close relatives, and lifelong friends. Responding in a compassionate and understanding way can be a huge key for success at providing the highest quality of care! Perhaps they are not stars, but rather openings in heaven Where the love of our lost ones pours through and shines down upon us to let us know they are happy ~ Eskimo Proverb ~ Discovering what you have learned CHECK FOR UNDERSTANDING Check For Understanding Exam 1. Which of the following feelings are included in the five stages of grief and loss? a. Denial b. Acceptance c. Anger d. All of the above Check For Understanding Exam 2. When a person is diagnosed with a terminal illness, this means they have less than _____ to live? a. One year b. 6 months c. 2 years d. 3 months Check For Understanding Exam 3. _____ is the attempt to restart breathing and/or the heartbeat of a person who is no longer breathing or his/her heart has stopped beating. a. b. c. d. Mechanical Ventilation/Respiration Intravenous Fluids Cardiopulmonary Resuscitation Physician Orders for Life Sustaining Treatment Check For Understanding Exam 4. A Living Will is the same as a DNR Order. a. True b. False 5. Not every state has a POLST Program. a. True b. False Check For Understanding Exam 6. Depression is an unnatural emotion that should never be experienced when dealing with end of life. a. True b. False Check For Understanding Exam 7. When a person is nearing the end of life, they generally ________ a. Become more responsive b. Become less responsive c. Show same level of responsiveness Check For Understanding Exam 8. A DNR Order _______________ a. Must be signed by both the physician and resident b. Allows a person to forego resuscitation in an emergency situation c. Can be revoked d. All of the above Check For Understanding Exam 9. The POLST form should be maintained in a location recognized by the emergency medical responders. a. True b. False Check For Understanding Exam 10. The licensee shall be permitted to retain terminally ill residents who receive hospice services from a hospice agency in the facility if all of the conditions specified in Title 22 are met: a. True b. False Start here. Go anywhere. Thank you for choosing Care and Compliance Group, Inc. for your educational needs. For any additional information please feel free to call us or visit our website at: www.careandcompliance.com (800) 321-1727 Additional Resources Total Care Exceptions First Aid, CPR, and DNRs Total Care BACKGROUND WHAT IS TOTAL CARE? • Total care is defined as a condition where residents depend on others to perform all of their activities of daily living. • A prohibited condition, per regulation 87615. BACKGROUND • • An exception must be obtained to retain a resident who requires total care in an RCFE Old process: Obtain hospice waiver Accept/retain resident on hospice Resident becomes “total care” Request total care exception New CCL Total Care Policy NEW CCL TOTAL CARE POLICY • • • CCL has updated their total care policy to streamline and expedite the process. Update is in section 87632 of the RCFE Evaluator Manual. Available at www.ccld.ca.gov As written it only applies to “total care” residents who are receiving hospice services. NEW CCL TOTAL CARE POLICY • New policy in a “nutshell:” Submit 2 (of 3) required exception components in advance as part of your hospice waiver (Total Care Plan) NEW CCL TOTAL CARE POLICY • All exception requests must include (87616): 1. Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. 2. The licensee's plan for ensuring that the resident's health related needs can be met by the facility. 3. Plan for minimizing the impact on other residents. NEW CCL TOTAL CARE POLICY • New Total Care Policy SUBMIT ADVANCE AS 1. Documentation of the resident's currentINhealth condition PART OFdocumentation HOSPICE including updated medical reports, other WAIVERduration of of the current health, prognosis, and expected condition. 2. The licensee's plan for ensuring that the resident's health related needs can be met by the facility. 3. Plan for minimizing the impact on other residents. NEW CCL TOTAL CARE POLICY • New Total Care Policy 1. Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. 2. The licensee's plan for ensuring that the resident's health related needs can be met by the facility. 3. Plan for minimizing the impact on other residents. MET VIA RESIDENT”S HOSPICE CARE (RETAIN ON FILE) NEW CCL TOTAL CARE POLICY Obtain Total Care Plan Approval Request total care exception request when notifying CCL of the initiation of hospice services Propose hospice care plan as variance to 87616(1) NEW CCL TOTAL CARE POLICY What if I already have a hospice waiver? Submit an addendum to the existing hospice care waiver plan that includes the total care component. If the Department approves this addendum, the licensee may then use the option of requesting the total care exception under the simplified methods noted above. The Total Care Plan TOTAL CARE PLAN • • Submit in advance as part of hospice waiver. Must include: • The licensee’s plan for ensuring that current total care residents’ health related needs can be met, or provisions made for them to be met by the licensee. • How it will minimize this impact on the other residents. TOTAL CARE PLAN PLAN FOR ENSURING HEALTH RELATED NEEDS CAN BE MET: • Staff training • Additional support from hospice care staff • Family/volunteers • How will you manage medications? • Bedridden? TOTAL CARE PLAN MINIMIZING IMPACT ON OTHER RESIDENTS: • Private rooms • Ensuring “sufficient” staff • Adjustments to staff schedules • Backup staff First Aid, CPR, and DNRs EFFECTIVENESS OF CPR • CPR is not like you see in movies and television. EFFECTIVENESS OF CPR 5-10% of people who undergo CPR will survive EFFECTIVENESS OF CPR 15-24% of people who undergo CPR in the hospital will survive to discharge EFFECTIVENESS OF CPR 0-5% of frail nursing home residents survive CPR EFFECTIVENESS OF CPR 3x persons with advanced dementia have survival rates 3x lower than those without dementia First Aid and CPR Requirements FIRST AID AND CPR REQUIREMENTS • • • 87411 Personnel requirements “Staff providing care shall receive appropriate training in first aid…” FIRST AID AND CPR REQUIREMENTS • • • First aid kits Advanced directives AED Advanced Directives ADVANCED DIRECTIVES Health and Safety Code § 1569.156: • Not condition the provision of care or otherwise discriminate based on whether or not an individual has executed an advance directive, consistent with applicable laws and regulations. ADVANCED DIRECTIVES Health and Safety Code § 1569.156: • Provide education to staff on issues concerning advance directives. • Provide written information, upon admission, about the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right, under state law, to formulate advance directives. • Provide written information about policies of the facility regarding the implementation of the rights described ADVANCED DIRECTIVES • • • Must give to all residents PUB 325 www.ccld.ca.gov ADVANCED DIRECTIVES • • • POLST Standardized advanced directive format www.capolst.org ADVANCED DIRECTIVES ADVANCED DIRECTIVES ADVANCED DIRECTIVES ADVANCED DIRECTIVES HONORING A DNR • • • 87469 If a resident who has a DNR on file experiences a medical emergency, facility staff shall do one of the following: Immediately telephone 9-1-1, and present the DNR to the responding emergency medical personnel HONORING A DNR • • • 87469 If a resident who has a DNR on file experiences a medical emergency, facility staff shall do one of the following: Immediately give the DNR to a physician, RN, or LVN, if in the resident's presence at the time of the emergency and assumes responsibility HONORING A DNR • • H&S Code Section 1569.73 “A facility that has obtained a hospice waiver from the department pursuant to this section need not call emergency response services at the time of a life-threatening emergency if the hospice agency is notified instead…” AEDs AED • • 87607 RCFEs are permitted to maintain and operate automated external defibrillators (AED) AED • • • • Must notify CCL in writing Staff who will operate must have a valid “operator’s certificate” Must document quarterly proficiency demonstrations Must maintain an AED supply kit Common Questions COMMON QUESTIONS What should our policy be? • No simple answer • Depends on your organization and your staff • Options: • • • • No CPR, call 9-1-1 Caregivers no CPR, nurses can do CPR, call 9-1-1 Train everyone in CPR Train at least one person in CPR COMMON QUESTIONS What do I tell my staff? • Tell them to call 9-1-1 • Nurses can initiate CPR based on their clinical judgment and comfort level COMMON QUESTIONS What do I tell my residents? • Make sure they are aware of your CPR policies • Talk to them about end of life wishes Evaluation www.careandcompliance.com/eval If you have not completed your evaluation please take time to complete when time permits, your feedback is greatly appreciated.