Improving Home Death Down Under

Improving Home Death

Down Under

Robert Molenaar Nurse Practitioner

South East Palliative Care

[email protected] Specialist health care at home Compassion Respect Excellence

NP- Background

• Commenced at SEPC, a community palliative care organisation 7 years ago and have had roles as Intake Nurse and Team Leader

• Previous experience had been in inpatient palliative care

• 2 .5 year NP Candidacy commenced July 2010 • Endorsement as NP via AHPRA in February

this year

SEPC Nurse Practitioner Model

• Evolving model

• Original focus was on patients with very complex palliative care needs

• Focus now changing to patients with complex palliative care needs who are in the later

stages of their illness

Preliminary auditing

• Rate of home death of palliative care patients at SEPC had decreased 28% to 20%. After

auditing several months of all deaths some of the reasons for this were:

• complex physical needs • complex symptomatology

• inadequate access to respite

• inadequate nursing follow-up, management and carer education

SSP Development

• Structured support program (SSP) intervention

• Developed in conjunction with Monash University (Frankston campus) Palliative Care Research Team • Three-visit program of support provided by NPC • Development of an anticipatory care plan to

provide guidance for future support for the patient and the carer

• Focus on patients with complex palliative care

needs who are in the later stages of their illness.

SSP Intervention - aims

• Does a SSP provided by an advanced practice nurse improve patient and carer outcomes compared to regular support?

Specific study aims were to: • improve symptom relief

• enhance psychosocial support for patients and carers

• facilitate place of death according to patient and carer choice • articulate a Nurse Practitioner (NP) model supporting complex

End of Life (EOL) care

SSP Intervention outline

• (See SSP Visit Outline handout for more detail)

• Provided information to patients and their carers in different formats

• Conducted informal family meetings with the main caregivers and the patient to establish needs

• Outlined in detail home, inpatient and residential care respite options

• Increased psycho-educational support and referrals • Clearly established the possible venue of care

preference of the patient and of their carer(s)

Proposed outcomes

• The intervention was provided by a NPC, for the purpose of the study it was possible to identify where an endorsed NP would enhance access to medications and diagnostic

tests/investigations.

Comparison was made between the SSP group and the group receiving regular support from the SEPC nursing team on

various symptom and psychosocial outcomes such as: • resolution of problem severity scores for symptoms • rate of referrals to respite, support services

• number, type and rate of hospital admissions

• home death rate and preferred versus actual site of death.

SSP Intervention - process

• (See Referral Triage Form + SSP Pathway for more detail)

• Complex patient group identified by the intake team using SEPC’s referral triage form

• Explanatory statement and consent form was provided at initial admission visit

• Once consent given, patient allocated to

either SSP group or routine care group (RCG) • NPC provided the SSP group three visits

Visit sequence

• First Visit - Within 1 week of admission

• Second Visit - Within 1 month of first visit or if decline in AKPS to <60 or increase in Problem Severity Score or change of phase from stable to unstable, deteriorating or terminal

• Third Visit - Within 2 weeks of second visit or indicated that a change from oral to s/c

medication is required.

Some parameters

• After each SSP visit by NPC, the subsequent visit was,(if possible), made by a member of the regular nursing team

• This enabled more objective reporting of the

problem severity scale by another nurse (not the NPC)

• NPC was still available for other patients as required

Complications

• There were a larger than anticipated number of consents not asked or obtained by nursing staff at admission interview or declined by family or patient (21 patients in “refused” group)

• This slowed recruitment substantially for SSP and RCG groups (15 patients in each)

• Smaller sample size than hoped

SSP Intervention – Actual

Outcomes

• Improved resolution of problem severity scores for symptoms

• Improved rate of referral to respite, support services and hospital admissions for respite • Decreased rate of non respite admissions

• Improved correlation between the wishes of the carers and the patients preferred site of care and actual site of death

NPC Involvement %

Specialist health care at home

SSP RCG Refused Yes 80 33 24 No 20 67 76 0 10 20 30 40 50 60 70 80 90 Yes No

Site of Death %

Specialist health care at home

Home PCU Public Private Current

SSP 47 27 7 0 19 RCG 33 20 0 13 34 Refused 24 29 18 0 29 0 5 10 15 20 25 30 35 40 45 50 SSP RCG Refused

Preference Met %

Specialist health care at home

Yes No Current SSP 60 20 20 RCG 33 33 33 Refused 33 38 29 0 10 20 30 40 50 60 70 SSP RCG Refused

Referrals

SSP - NPC SSP - f/up RCG - nurse RCG - f/up

Referrals

Change in Problem Severity Score

Why difference between groups

• Poor documentation (RCG ) in care plan

• SSP care plan issues clearly outlined referrals done and symptom interventions

• This modelled behaviour for subsequent visits by other nurses and documentation of care plan issues improved

• Less involvement of NPC with RCG • Experience/skill set of NPC.

NP - future

• Majority of patients had easily identifiable gaps in access to palliative care medications that could of been addressed by NP

• Non respite admissions were reduced in SSP group

• More difficult to discern the need for diagnostic tests/investigations in this patient group

• SSP Intervention clarifies direction of NP model • Implementation of NP model

Acknowledgements

I would like to acknowledge the entire SEPC team, without whom this project could not have come to fruition. A special thanks to:

• All staff at SEPC particularly: Helen Wearne, Michelle Wood, Shyla Mills, Marnie Grace, Penny Vaudeau, Val Boyd and Val Neatnica

• Louise Peters (Monash University)

• Prof Margaret O’Connor (Monash University)