08/09/2015Home and Community Care1 Long Term Care Administration Thursday, March 19, 2009 Week 11 -...

23-04-19 Home and Community Care 1

Long Term Care Administration

Thursday, March 19, 2009

Week 11 - Chapter 15

End-of-Life Issues


End-of-Life Issues

“But in this world nothing can be said to be certain, except death and taxes.”

Benjamin Franklin


End-of-Life Issues

There are two certainties in life – death and taxes.

Little progress has been made identifying and addressing end-of-life issues.

Grand Solutions – those which address all people equally through a narrowly focused policy or single program.

Death and dying – one size does not fit all.


“To the well-organized mind, death is but the next great adventure.”

J.K. Rowling


End-of-Life Issues

One Size Does Not Fit AllComplex, ever changing interplay of

culturally based traditionsSocially and family defined valuesIndividual interests and perspectivesHealth care developmentsConsiderable number of other factors that

influence on human needs and expectations


“As a well-spent day brings happy sleep, so life well used brings happy death.”

Leondardo da Vinci


End-of-Life Issues

Where Does Death and Dying Occur(based on death certificate data)

71.2% of deaths occur in hospitals (1998).3.2% of deaths in other institutions.21.8% of deaths in other places.3.9% of deaths unknown or missing.


“Death ends a life, not a relationship.”

Mitch Albom


End-of-Life Issues

Hospital-Based CareAggressive but futile diagnostic and cure-

oriented treatment in hospitals.Public fear aggressive treatment.Fear of hospital MDs making decisions.Fear of life supporting treatment even

when there is no hope of recovery.Advances in medical technology.


“Death doesn’t really worry me that much, I’m not frightened about it… I just don’t want to

be there when it happens.”

Woody Allen


End-of-Life Issues

Cardiopulmonary Resuscitation (CPR)Under 3% of patients receive CPR who

died in a hospital.CPR provided for unexpected deaths. Do Not Resuscitate Order (DNR) is an

advance directive.


End-of-Life Issues

“For three days after death hair and fingernails continue to grow, bit phone

calls taper off.”

Johnny Carson


End-of-Life Issues

Distributive Justice – Use Scarce ResourcesScarce and expensive hospital resources

for care, could be used elsewhere.Dying people need nursing care which

can be provided in home or long term care facilities which are less expensive.

Slow death trajectories, alternates to hospitals care can be more easily arranged.


End-of-Life Issues

“I have lost friends, some by death… other through sheer inability to cross

the street”

Virginia Woolf


End-of-Life Issues

California Daughter SyndromeSome children, who have not seen their

parents for months or years and thus do not realize or have not come to terms with the fact that death was inevitably near.

Children in this situation may insist on all possible treatment despite the existence of an advance directive.


End-of-Life Issues

“I’m completely in favour of the separation of Church and State. My

idea is that these two institutions screw up enough on their own, so both of

them together is certain death.”

George Carlin


End-of-Life Issues

Decision Making – Can be regretted laterWithdrawing life support perceived as

euthanasia – actively ending a life.Withholding treatment perceived as letting

nature takes its course.Most family members are unaware of the

care preferences of their loved ones.Most deaths in Canada after a long life.


End-of-Life Issues

“Sleep, those little slices of death; Oh how I loathe them.”

Edgar Allan Poe


End-of-Life Issues

Who DiesGradual increase in the average age at

the time of death.

Two main contributing factors.Major reduction in infant mortality.Increasing proportion of seniors who

reach an advanced old age.


End-of-Life Issues

“Animals have these advantages over man: they never hear the clock strike, they die without any idea of death, they have no theologians to instruct them, their last

moments are not disturbed by unwelcome and unpleasant ceremonies, their funeral

cost them nothing, and no one starts lawsuits over their wills.”

Voltaire


End-of-Life Issues

Some Statistics41.9% 80 years and older.12.3% 90 years and older.12% of seniors served by home care.5-7% of seniors reside in institutions.84.2 average age of death in LTCF.73.2 average age of death in Hospitals.


End-of-Life Issues

“We believe that an informed citizenry will act for life and not for death.”

Albert Einstein


End-of-Life Issues

LTCF end-of-life care more likely for widowed persons.

Married people more likely to receive short term end-of-life care in hospitals.

Average stay in a LTCF is 3-4 years.More females than males died in LTCF

and more males than females died in hospitals.


End-of-Life Issues

“A single death is a tragedy; a million deaths is a statistic.”

Joseph Stalin


End-of-Life Issues

Why do Canadians Die?999 different causes of death36.3% Cardiovascular Disorders27.8% Cancer11.1% other causes10% respiratory disorders6.1% injuries and suicides


End-of-Life Issues

“A nation or civilization that continues to produce soft-minded men purchases

its own spiritual death on an installment plan.”

Martin Luther King Jr.


End-of-Life Issues

When Does Death and Dying Occur?Two times as many deaths in the winter

as in the summer.Winter-time flu, colds, falls related to

winter conditions.Some people hold on to life until an

important social event passes.Little research in this area.


End-of-Life Issues

“I wish to be cremated. One tenth of my ashes shall be given to my agent, as

written in our contract.”

Groucho Marx


End-of-Life Issues

What Also Influences Death and Dying?Long life expectation amongst Canadians.Premature death prevented in most cases.Gene therapy, advances in health care

technology, and drug advances promise to prevent or abate illness.

Health care utilization and costs increases, lead to health care system unsustainability


“The valuing or sanctity of life is considered one of the prime values

underlying Western society”

Beauchamp and Childress


End-of-Life Issues

Fears about Death and DyingPainful, drawn-out process, dependencyUncertainty of what comes nextIrreversibility or finality of deathEmotional, physical, & financial impact on

loved ones


End-of-Life Issues

“It is the unknown we fear when we look upon death and darkness, nothing more.”

J.K. Rowling


End-of-Life Issues

Societal Value of Life - Taxes pay to preserve and sustain life

Rescuers risk their life to save another.Safe air & ground transportation.Safe hospitals and medications.Seatbelt laws, non smoking laws.Hospitals funded better than LTCF


End-of-Life Issues

“Healthy children will not fear life if their elders have integrity enough not to fear

death.”

Erik H. Erikson


End-of-Life Issues

Safe SocietyMost Canadians don’t think about a

premature death.Small proportion of people sign an organ

donation card.50% have a will for estate planning.Fewer have an advance directive.


End-of-Life Issues

“I'd rather die while I'm living then live while I'm dead.”

Jimmy Buffet


End-of-Life Issues

Nurses, physicians, clergy, bereavement counsellors, funeral directors have taken over the role of family members.

Palliative care is a noncurative, comfort-oriented care provided to dying persons and their families.

Palliative care = good, healthy death.Death = tragedy, not ordinary experience.


End-of-Life Issues

“In the stars is written the death of every man.”

Geoffrey Chaucer


End-of-Life Issues

AgeismDeath is viewed negatively in C’dn SocietyDeath is an event of old age.Death of an older person is a tragedy for

the family, for a younger person to die it is a tragedy for society.

Older people are often considered a burden on their family and society


End-of-Life Issues

“It's funny the way most people love the dead. Once you are dead, you are made

for life.”

Jimi Hendrix


End-of-Life Issues

Assisted Suicide and EuthanasiaBob Latimer and Sue Rodriguez to high

profile cases in Canada – not legal.Legalized in other jurisdictions such as

Holland, Oregon.An aged society can expect to have

different values and customs than a more youth-oriented one.


End-of-Life Issues

“A beautiful death is for people who have lived like animals to die like angels.”

Mother Teresa


End-of-Life Issues

Options for End-of-Life CareAggressive or non aggressive care.Choice of care setting when dying.Choice of caregivers – formal or informal.Assistance in ending life or not.People differ in their preferences.


End-of-Life Issues

"Look, I don't want to wax philosophic, but I will say that if you're alive you've got to flap your arms and legs, you've got to jump around a lot, for life is the very opposite of death, and therefore you must at very least think noisy and

colourfully, or you're not alive."

Mel Brooks


End-of-Life Issues

Dying people are physically, mentally, emotionally dependent on others.

Average end-of-life hospital stay 21 days.Dying patients can feed, bathe and speak

for themselves until near the end.Dying in LTCF are dependent on others

for months and sometime years.Resources are limited, few options exist.


I answer the heroic question "Death, where is they sting?" with "It is here in

my heart and mind and memories."

Maya Angelou


End-of-Life Issues

Palliative CareCommunity based programs increasing.Shrinking number of hospital beds.Started in Canada in the mid 1970s.Has competed unsuccessfully for hospital

resources – hospitals diagnose and cure.


End-of-Life Issues

"I am ready to meet my maker, but whether my maker is prepared for the great ordeal of meeting me is another

matter."

Winston Churchill


Preparing for the End-of-Life

DNRMost LTCF have DNR policies.Policies have developed on transfer to a

hospital, the initiation of antibiotics and other potentially life-prolonging medications.

Policies around living wills.


End-of-Life Issues

“People say satire is dead. It's not dead. It's alive and living in the White House.”

Robin Williams


End-of-Life Issues

Private suite for dying patients & families.Upgraded equipment and staff training.Commitment to aging in place.Training in-house palliative care expertise.Access to outside palliative care experts.Goal to improve are of dying seniors.


On Death and Dying

“I've told my children that when I die, to release balloons in the sky to celebrate

that I graduated. For me, death is a graduation.”

Elisabeth Kubler-Ross


On Death and Dying

The book introduced the author's seminal "stages of dying" or "stages of grief" model which is still widely quoted.

According the Kübler-Ross model, there are five stages that a dying person goes through when they are told that they have a terminal illness.

The five stages go in progression through denial, anger, bargaining, depression, and acceptance.

This model has been widely adopted by other authors and applied to many other situations where someone suffers a loss or change in social identity.

The model is often used in bereavement work.Not all workers in the field agree with the Kübler-Ross

model, and some critics feel the stages are too rigid.


On Death and Dying

“I always say that death can be one of the greatest experiences ever. If you

live each day of your life right, then you have nothing to fear.”

Elisabeth Kubler-Ross


On Death and Dying

This is the world-famous best-seller by the woman who popularized the field of thanatology as a subject for general social commentary.

Written in plain language that anyone can understand, this important book can help families understand what's going on as death of a loved one draws near.

This was Elisabeth Kübler-Ross' first book on the topic. It is still considered a classic. It is required reading in many academic settings,

including medical and nursing schools, theological seminaries, and popular psychology courses.


End-of-Life Issues

“The prejudice surrounding AIDS exacts a social death which precedes the actual physical one.”

Tom Hanks


St. Christopher’s Hospice

Founded by Cicely Saunders in 1967 and her extraordinary contribution to alleviating human suffering has resulted in the hospice being considered a centre of innovation and insight ever since.

Widely acknowledged as the pioneer of the modern hospice movement and has earned a reputation for excellence in clinical practice, research and education.



Patients are treated as individuals and strives to understand and meet their unique needs, in the hospice or in the familiar surroundings of their own homes.

Through bereavement counselling and advice families are helped, including children, to learn to face the future.

When someone is very ill, all of the family is affected.Care extends beyond the treatment of physical

symptoms to consider the emotional and social needs of patients, families and their friends and carers.


Setting Limits: Medical Goals in an Aging SocietyFaults the health care system for devoting

disproportionate resources and technology on extending the lives of the elderly regardless of the quality of their lives.

He also warns against the social and economic consequences of the increased ratio of old people in the population.

Medical care, he suggests, should be allocated based on standards of need and priorities to meet them over a "normal life-span opportunity range," limiting the use of new technology to that which improves the quality of life.

He also discusses the ethics of withholding artificial sustenance from the terminally ill, euthanasia and assisted suicide.


Setting Limits: Medical Goals in an Aging Society

"The proper question is not whether we are succeeding in giving a longer life to the aged," he argues, but "whether we

are making of old age a decent and honorable time of life."

Daniel Callahan


“The goal of all life is death”

Sigmund Freud

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