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The What and When of How Hospice Nurses Prepare Families for Death (729)
Vol. 41 No. 1 January 2011
Schedule with Abstracts
Positive Impact: Integrating Palliative Care Education and Support in a Community Oncology Practice (728) Angela Kalisiak, MD, Hospice & Palliative Care of Washington County, Hillsboro, OR. Susan Hedlund, MSW LCSW, Hospice & Palliative Care of Washington County, Hillsboro, OR. Elizabeth Gandara, RN BS, Northwest Cancer Specialist, Portland, OR. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Describe a novel pilot program integrating palliative care education and support into a community oncology practice. 2. Identify two program components which decreased the percentage of patients receiving chemotherapy within 14 days of death, increased documented advance directives at the time of death, and improved staff satisfaction with end-of-life care. Background. Increasingly, cancer patients experience chronic illness prior to clinical decline and death. Predicted growth in the number of cancer patients will require better integration of palliative care in oncology practice to best serve patient and provider needs. In 2006, Northwest Cancer Specialists (NCS), a community oncology practice comprising 41 medical, radiation, and gynecologic oncologists at seven service sites, targeted improved palliative/end-of-life care as goals and initiated the CARES program. Research objectives. (1) Increase staff palliative care education/support. (2) Improve team communication about care goals, symptom management, and advance ccare planning (ACP). (3) Improve staff satisfaction with care delivered at end of life. (4) Increase percentage of patients receiving hospice services and with advance directives (AD) at the time of death. (5) Decrease percentage of patients receiving chemotherapy within 14 days of death. Methods. Two grants funded CARES activities at three sites over 18 months. Curriculum included communication workshops, education about decision making during treatment transitions, patient/family support, and ACP. A care conference model was implemented to facilitate discussion of patients with complex symptom management and psychosocial needs. Patient deaths (687) were reviewed in detail. Staff members were surveyed to assess satisfaction with patient care before and after program implementation.
289
Results. (1) Seventy-five percent of staff reported improved access to patient support services; 54% of RNs reported greater confidence in skills. (2) Percentage of patients receiving chemotherapy within 14 days of death declined: P ¼ 0.0255. (3) Percentage of patients receiving hospice: non-significant trend toward improvement. (4) Percentage of patients with documented AD improved: P ¼ 0.0275. Conclusion. This novel palliative care education/support program in a community oncology practice resulted in increased staff satisfaction and improvement in quality metrics. Implications for research, policy, or practice. Internal practice education/support programs benefit patients and providers and could enhance implementation of palliative care principles and skills to serve the growing oncology patient population across the continuum of care.
The What and When of How Hospice Nurses Prepare Families for Death (729) Karen Kehl, PhD RN ACHPN, University of WisconsineMadison, Madison, WI. (Kehl has disclosed no relevant financial relationships.) Objectives 1. Identify three issues that hospice nurses commonly include when preparing families for death. 2. Identify issues that affect tailoring preparatory messages for families facing death. 3. Identify issues in preparing patients for death that differ between hospice certified nurses and other nurses. Background. Hospice nurses are usually responsible for preparing the family for death, but little is known about what is included in such preparation. Research objectives. Identify the content and timing of nurses’ preparation of families for death. Describe how RNs tailor such messages and the differences between hospice-certified and other nurses concerning preparing families. Methods. Mailed surveys were sent to all 1,542 RN members of HPNA who identified ‘‘hospice’’ as their primary practice. Data was extracted from the survey using Cardiff Teleforms. Descriptive and comparative statistical analysis was conducted using R Project (http://www.r-project.org). Results. Most nurses agreed that families can be prepared for physical changes (97.7%) and for
290
Schedule with Abstracts
caregiving tasks (96.7%). Preparatory information is usually given at admission (88.0%) or when the patient’s condition (70.6%) changes. Preparation is usually done over time (79.6%). Most preparation is tailored. Factors affecting the tailoring of the messages include: patient signs/symptoms (85.7%), how much the family wants to know (84.9%), family cultural background (84.6%), and family education (84.4%). Certified nurses were more likely to work for a longer time in hospice, larger agencies and have case management responsibilities. There were no differences in educational status between groups. Certified nurses were more likely to agree that families can be prepared for care giving tasks (p ¼ 0.03), to use written materials (p ¼ 0.01), and to discuss symptoms such as dysphagia (p ¼ 0.02), cold extremities (p ¼ 0.02), and vital sign changes (p ¼ 0.07). Conclusion. There are some minor differences between hospice certified and other nurses in preparing families for death. Implications for research, policy, or practice. The results of this study may be used to support development and testing of education for nurses and a tailored intervention for family caregivers that will assist with preparation for the patient’s death.
A Case of Severe Pain Associated With Hypertrophic Osteoarthropathy (730) Malathy Kilaru, MD, Ann Arbor VA, Ann Arbor, MI. Caroline Vitale, MD, University of Michigan, Ann Arbor, MI. Marcos Montagnini, MD FACP, VA Ann Arbor Health Care System, Ann Arbor, MI. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Recognize clinical features of hypertrophic osteoarthropathy. 2. Discuss current evidence for treatment options in hypertrophic osteoarthropathy. Background. Hypertrophic osteoarthropathy (HPOA) is a paraneoplastic condition associated with intrathoracic malignancies manifested by pain, swelling and warmth of multiple joints. We present a case of HPOA with significant joint pain and summarize current therapies for this condition based on review of the literature. Case description. A 52-year-old male with history of hypertension and cigarette smoking presented
Vol. 41 No. 1 January 2011
with severe pain, swelling and redness affecting his ankles, knees and wrists. Laboratory work, including rheumatologic studies, were unremarkable. Chest X ray revealed mediastinal fullness and chest computerized tomography showed a left upper lobe necrotic mass. Joint films revealed diffuse periosteal reaction and soft tissue swelling, consistent with HPOA. A bronchoscopy with biopsy and PET scan revealed non-small cell lung cancer restricted to the chest. Over the next several weeks, patient’s pain intensified despite the titrated use of fentanyl transdermal patch 75 mcg/hr, ibuprofen 800 mg tid, prednisone 20 mg/daily, and oxycodone 20 mg po every 4 hours. He was admitted for pain control and started on a morphine IV drip, which was gradually titrated up to 400mg/day. A repeat PET scan demonstrated disease progression with metastases to ribs, scapula, femurs, and left iliac bone. He received palliative chemotherapy with etoposide and cisplatin, and zolendronic acid for bone metastases and HPOA-related joint pain. After four days of therapy with zoledronic acid, he was weaned of the morphine drip and was subsequently discharged on transdermal fentanyl 150 mcg/hr, ibuprofen 600 mg qid, and morphine IR 15 mg 1-2 tabs every 4 hours, as needed with satisfactory pain control. Conclusion. Pain related to HPOA can be disabling and difficult to treat. A literature review will be presented. Management of HPOA includes therapies for the underlying malignancy and analgesics; Bisphosphonates tend to be more effective than non-steroidals, glucocorticoids, colchicine, and opioids in patients with incurable cancer. Cervical vagotomy approach can be considered in refractory cases of HPOA.
Development and Psychometric Properties of a Korean Grief Reaction Scale (KGRS) for Families (731) Sanghee Kim, PhD RN, Yonsei University, Seoul, South Korea. Mi-Ra Lee, PhD RN, Daejeon Health Sciences College, Deajeon, South Korea. Jihyoun An, MSN(c) RN, Yonsei University, Seoul, South Korea. Won-Hee Lee, PhD RN, Yonsei University, Seoul, South Korea. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Discuss grief reaction for family with Korean cultural sensitivity.
Schedule with Abstracts
Positive Impact: Integrating Palliative Care Education and Support in a Community Oncology Practice (728) Angela Kalisiak, MD, Hospice & Palliative Care of Washington County, Hillsboro, OR. Susan Hedlund, MSW LCSW, Hospice & Palliative Care of Washington County, Hillsboro, OR. Elizabeth Gandara, RN BS, Northwest Cancer Specialist, Portland, OR. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Describe a novel pilot program integrating palliative care education and support into a community oncology practice. 2. Identify two program components which decreased the percentage of patients receiving chemotherapy within 14 days of death, increased documented advance directives at the time of death, and improved staff satisfaction with end-of-life care. Background. Increasingly, cancer patients experience chronic illness prior to clinical decline and death. Predicted growth in the number of cancer patients will require better integration of palliative care in oncology practice to best serve patient and provider needs. In 2006, Northwest Cancer Specialists (NCS), a community oncology practice comprising 41 medical, radiation, and gynecologic oncologists at seven service sites, targeted improved palliative/end-of-life care as goals and initiated the CARES program. Research objectives. (1) Increase staff palliative care education/support. (2) Improve team communication about care goals, symptom management, and advance ccare planning (ACP). (3) Improve staff satisfaction with care delivered at end of life. (4) Increase percentage of patients receiving hospice services and with advance directives (AD) at the time of death. (5) Decrease percentage of patients receiving chemotherapy within 14 days of death. Methods. Two grants funded CARES activities at three sites over 18 months. Curriculum included communication workshops, education about decision making during treatment transitions, patient/family support, and ACP. A care conference model was implemented to facilitate discussion of patients with complex symptom management and psychosocial needs. Patient deaths (687) were reviewed in detail. Staff members were surveyed to assess satisfaction with patient care before and after program implementation.
289
Results. (1) Seventy-five percent of staff reported improved access to patient support services; 54% of RNs reported greater confidence in skills. (2) Percentage of patients receiving chemotherapy within 14 days of death declined: P ¼ 0.0255. (3) Percentage of patients receiving hospice: non-significant trend toward improvement. (4) Percentage of patients with documented AD improved: P ¼ 0.0275. Conclusion. This novel palliative care education/support program in a community oncology practice resulted in increased staff satisfaction and improvement in quality metrics. Implications for research, policy, or practice. Internal practice education/support programs benefit patients and providers and could enhance implementation of palliative care principles and skills to serve the growing oncology patient population across the continuum of care.
The What and When of How Hospice Nurses Prepare Families for Death (729) Karen Kehl, PhD RN ACHPN, University of WisconsineMadison, Madison, WI. (Kehl has disclosed no relevant financial relationships.) Objectives 1. Identify three issues that hospice nurses commonly include when preparing families for death. 2. Identify issues that affect tailoring preparatory messages for families facing death. 3. Identify issues in preparing patients for death that differ between hospice certified nurses and other nurses. Background. Hospice nurses are usually responsible for preparing the family for death, but little is known about what is included in such preparation. Research objectives. Identify the content and timing of nurses’ preparation of families for death. Describe how RNs tailor such messages and the differences between hospice-certified and other nurses concerning preparing families. Methods. Mailed surveys were sent to all 1,542 RN members of HPNA who identified ‘‘hospice’’ as their primary practice. Data was extracted from the survey using Cardiff Teleforms. Descriptive and comparative statistical analysis was conducted using R Project (http://www.r-project.org). Results. Most nurses agreed that families can be prepared for physical changes (97.7%) and for
290
Schedule with Abstracts
caregiving tasks (96.7%). Preparatory information is usually given at admission (88.0%) or when the patient’s condition (70.6%) changes. Preparation is usually done over time (79.6%). Most preparation is tailored. Factors affecting the tailoring of the messages include: patient signs/symptoms (85.7%), how much the family wants to know (84.9%), family cultural background (84.6%), and family education (84.4%). Certified nurses were more likely to work for a longer time in hospice, larger agencies and have case management responsibilities. There were no differences in educational status between groups. Certified nurses were more likely to agree that families can be prepared for care giving tasks (p ¼ 0.03), to use written materials (p ¼ 0.01), and to discuss symptoms such as dysphagia (p ¼ 0.02), cold extremities (p ¼ 0.02), and vital sign changes (p ¼ 0.07). Conclusion. There are some minor differences between hospice certified and other nurses in preparing families for death. Implications for research, policy, or practice. The results of this study may be used to support development and testing of education for nurses and a tailored intervention for family caregivers that will assist with preparation for the patient’s death.
A Case of Severe Pain Associated With Hypertrophic Osteoarthropathy (730) Malathy Kilaru, MD, Ann Arbor VA, Ann Arbor, MI. Caroline Vitale, MD, University of Michigan, Ann Arbor, MI. Marcos Montagnini, MD FACP, VA Ann Arbor Health Care System, Ann Arbor, MI. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Recognize clinical features of hypertrophic osteoarthropathy. 2. Discuss current evidence for treatment options in hypertrophic osteoarthropathy. Background. Hypertrophic osteoarthropathy (HPOA) is a paraneoplastic condition associated with intrathoracic malignancies manifested by pain, swelling and warmth of multiple joints. We present a case of HPOA with significant joint pain and summarize current therapies for this condition based on review of the literature. Case description. A 52-year-old male with history of hypertension and cigarette smoking presented
Vol. 41 No. 1 January 2011
with severe pain, swelling and redness affecting his ankles, knees and wrists. Laboratory work, including rheumatologic studies, were unremarkable. Chest X ray revealed mediastinal fullness and chest computerized tomography showed a left upper lobe necrotic mass. Joint films revealed diffuse periosteal reaction and soft tissue swelling, consistent with HPOA. A bronchoscopy with biopsy and PET scan revealed non-small cell lung cancer restricted to the chest. Over the next several weeks, patient’s pain intensified despite the titrated use of fentanyl transdermal patch 75 mcg/hr, ibuprofen 800 mg tid, prednisone 20 mg/daily, and oxycodone 20 mg po every 4 hours. He was admitted for pain control and started on a morphine IV drip, which was gradually titrated up to 400mg/day. A repeat PET scan demonstrated disease progression with metastases to ribs, scapula, femurs, and left iliac bone. He received palliative chemotherapy with etoposide and cisplatin, and zolendronic acid for bone metastases and HPOA-related joint pain. After four days of therapy with zoledronic acid, he was weaned of the morphine drip and was subsequently discharged on transdermal fentanyl 150 mcg/hr, ibuprofen 600 mg qid, and morphine IR 15 mg 1-2 tabs every 4 hours, as needed with satisfactory pain control. Conclusion. Pain related to HPOA can be disabling and difficult to treat. A literature review will be presented. Management of HPOA includes therapies for the underlying malignancy and analgesics; Bisphosphonates tend to be more effective than non-steroidals, glucocorticoids, colchicine, and opioids in patients with incurable cancer. Cervical vagotomy approach can be considered in refractory cases of HPOA.
Development and Psychometric Properties of a Korean Grief Reaction Scale (KGRS) for Families (731) Sanghee Kim, PhD RN, Yonsei University, Seoul, South Korea. Mi-Ra Lee, PhD RN, Daejeon Health Sciences College, Deajeon, South Korea. Jihyoun An, MSN(c) RN, Yonsei University, Seoul, South Korea. Won-Hee Lee, PhD RN, Yonsei University, Seoul, South Korea. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Discuss grief reaction for family with Korean cultural sensitivity.