Amanda Pate Project Proposal for Care Bag

Cancer Treatment Centers of AmericaAmanda Pate, BSN, RN

Proposal for Care Bag

We understand death for the first time when

he puts his hand upon one whom we love.

— Madame deStael (1766-1817)

I. SUMMARY.........................................................................................................4

II. BACKGROUND...................................................................................................5

III. OTHER EVIDENCE/STORIES.................................................................................6

IV. ITEMS POSSIBLY PLACED IN THE BAG.................................................................8

V. NEEDS/PROBLEMS..............................................................................................9

VI. GOALS/OBJECTIVES...........................................................................................9

VII. PROCEDURES/SCOPE OF WORK.........................................................................10Other risk factors/predictors of short-medium term death........................................................11Evidence of frailty: 2 or more of these:..............................................................................12

VIII. TIMETABLE.....................................................................................................15

IX. BUDGET..........................................................................................................15

X. KEY PERSONNEL..............................................................................................16

XI. EVALUATION...................................................................................................16

XII. ENDORSEMENTS..............................................................................................17

XIII. NEXT STEPS.....................................................................................................17

XIV. APPENDIX........................................................................................................18

of 20

I. Summary

I am currently pursuing my Master's degree in nursing and of course this requires

research and lots of it. While looking for some evidence based information on a separate

subject I ran across an article that states families at times need a transition item to help

with the adjustment of losing a loved one. A blanket was used in the experiment and the

families seemed to better cope with the loss verses those who did not receive a

transitional item. So this made me think, why do we not have something like that here?

We give the care that never quits! It shouldn't quit because the patient has passed.....

This program will begin on the inpatient unit and once the patient is approved to

be in the program we will give the patient and their family a "care bag" which is a canvas

bag with a blanket inside and a few other items such as lotions, information on grief,

information on counseling, tissues, notepad and pen, and a card which we will remove

before giving to the family and have all staff on the floor sign. We will send the card after

the patient's passing to his or her address and address it "to the family of" the patient. The

lotion will be for the family to rub the patient as he or she is passing so that the

helplessness that is many times felt may be lessened and possibly the patient will feel

more relaxed. The pad and pen is for anything that needs to be written down and may be

forgotten due to the stress of having just lost a loved one. Finally the blanket is something

that the family is able to cover the patient with and then take with them as a transition

item after the patient's passing.

The patient must be actively dying and meet the criteria set forth later in this

proposal.

Evidence shows that a transitional item helps family members transition into a life

without their loved one.

Most of the items will be donated.

Bags will be donated by CTCA with our name on it.

of 20

Our chaplains will be asked to provide information on grief.

Our care managers led by Roxanne Mcintyre, mind and body team and spiritual

team will be asked to provide information on local counseling to include in the bag for

the family.

Our discharge planners will also be included due to a need for referral to hospice.

Our pastoral care team led by Chip Gordon will be asked to provide spiritual

guidance for our patient and their family.

Growth, led by Nina Dobbs, will also be included for the marketing and public

relations aspect of the program.

II. Background

As we know our goal is cure and we provide hope to our patients and their

families but unfortunately at times we try with everything we have but there are other

plans for that patient and they must leave their families to "go home". I would like to

begin a program here for those patient's families to help them with the transition of life

without their loved one. Here a little background of how the idea was born and more

information on the program:

I have personally had this experience when my father passed away this past May

from lung CA. I mentioned this idea to him and he loved it. When he was told he had

lung cancer and decided to receive chemo I went to the store and bought him a blanket,

some comfortable clothing, snacks, juices, etc. and placed it all along with his kindle in a

cloth bag I had at my home. We called this his chemo bag. I always took him to his

chemo appointments and would ask every time if he wanted his blanket to cover up and

every time he would say "nope, they will give me one." He never would use that darn

blanket!

On the day of his death, as always my mother asked what she could fix him to eat

and he said nothing. She asked him if he wanted anything and he said "yes, bring me my

blanket". Of course she had no idea what he meant because he never used it, until he said

of 20

it was in his "chemo bag". She retrieved it for him and he covered up with it all that day.

When I arrived at my mother's and father's house after my husband came to my work tell

me my father had passed away and I saw that blanket lying next to him and knew that he

did that for me. I cherish that blanket and it has helped me greatly to deal with his death a

little better. I wrap it tightly around me when I start to really miss him. It is as if he is

hugging me tightly.

III. Other Evidence/Stories

I recently had a patient that I believed his wife would benefit from this. I stopped

on my way to work and purchased a blanket from our gift shop. Unfortunately when I

arrived he was already gone and she had already left the building. I found her address and

mailed her the blanket. She sent me a message a few weeks later and told me that she

wanted many times to say thank you but had been unable to because of sadness. She told

me that the blanket helped her tremendously and that day was actually their wedding

anniversary. She said when she wrapped it around her it was as if he was giving her a

huge hug which made her feel closer to him. Of course it is not about the blanket so much

as it is about the need for a human connection.

There are so many uplifting stories to tell concerning this type of program: “One

of our volunteers comes in every Wednesday at 1 p.m.; she visited with an elderly

woman, her son and daughter. The woman seemed alert, but very ill. After talking with

the family, the volunteer decided she’d appreciate having a prayer shawl from the cart

and read the accompanying note: ‘This shawl was crafted with prayers for your healing

body, mind and spirit. As you wear this shawl, may you feel the divine warm embrace.’

The woman, even though frail, reached for the shawl and quickly wrapped it tightly

around her. One week later, the volunteer returned. This time the woman was very quiet

and uncommunicative. She learned from the family that she hadn’t taken the shawl off.”

She passed away the following day and the family knew how much the shawl meant to

her so in turn it meant so much to them.

“Consider the case of Tom Stephens, a man in his 50s who suffered a rupture of

an aneurysm of the aorta. By the time he arrived at the hospital, Mr. Stephens had nearly

of 20

bled to death. Although the physicians and nurses involved in his care did everything

right, including replacing lost blood and repairing the tear in his aorta, he suffered severe

brain damage. For almost two weeks, he lingered in a coma, suffering respiratory failure

and other medical complications.”

During this time his family had great hope that he would recover. Sadly he was

not going to recover so the family decided to focus on his comfort until the end of his life

verses trying to prolong his life. This was found in a new kind of cart that is being

implemented at a number of hospitals across the country: the comfort cart. (Gunderman,

2012) Unlike the crash cart, it does not contain a cardiac defibrillator, endotracheal tubes,

or powerful medications such as epinephrine and dopamine. Instead it contains much

lower-tech but nonetheless powerful items, including music, scriptures in various faith

traditions, and a variety of homemade “love” blankets. For the patient’s family, it also

includes information on grief, the dying process, and lists of area support groups, funeral

homes, and community assistance programs for burial. Finally, it contains a plaster kit for

making a cast of the dying patient’s hand.

Mr. Stephens’ boys both got to pick out a blanket. Each of his sons could keep his

dad warm while he was dying and also help to inject some warmth into the otherwise

cold and impersonal process of dying in the hospital. After their father was gone, they

could take it home with them, keeping it in their room, or perhaps even using it on their

own bed. (Caring, 2015) Such blankets help to create a sense of community around dying

patients and their families. . The blanket becomes what psychologists and anthropologists

sometimes refer to as a “transitional object,” providing something to cling to throughout

the dying process, the funeral, and after. They help to create a caring atmosphere that

lives on in memory long after the patient is gone.

of 20

IV. Items possibly placed in the bag

Information on grief

Information on counseling

Condolence card (To be taken out and mailed at a later time)

“In Memory of” label to be included in the condolence card for the blanket

Tissues

Music and nature sounds CDs

Guided imagery and relaxation tapes

Soft blankets

Crossword and Sudoku puzzles

Lavender-scented eye packs

Prayer shawls and beads

Books

Battery-operated candles

Combs/Brushes

Soothing creams and lotions

Hope Stones

Spiral notebooks for journaling

of 20

V. Needs/Problems

Our patients receive wonderful care while here with us at Cancer Treatment

Centers of America and we offer the care that never quits. However, if the patient is not

able to beat the cancer they are fighting our care should not stop there. This is where the

care bag can help. As the patient is actively passing we are supporting the patient and the

family with this program. After the patient passes we are supporting the family by

helping with grief counseling and reminding them we still care by sending the

condolence card that will be included with the care package.

CTCA can show our families that our care truly never quits.

This program is in the infant stage and may have rough ends to smooth out.

We can show our community we care also by informing the local newspapers

through growth.

The leaders of each department will need to be committed to working on this

project in order to make this program a success. Leaders such as Chip

Gordon, Lakeisha Henderson, Kim Dunn, Roxanne McIntyre, and Nina

Dobbs, along with all other leaders of the departments here at CTCA.

VI. Goals/Objectives Provide grief counseling for our patient’s families.

Working with upper management in order to smooth out any issues that may arise.

Ensure condolence cards are signed by all staff possible, in memory of label included and sent out to the family of.

Inform our local newspapers of this new program.

Show our patients and their families that our care really never quits.

of 20

Increase patient/family satisfaction.

VII. Procedures/Scope of Work The program will begin with collection of all required items to prepare the bags

which is currently underway. A team has been put into place to help the beginning

management of the program and will continue to manage with the future growth

of the program.

The nurses will be taught to use a calculator for identifying how close death

possibly is. The program for the calculator will be discussed further on in this

proposal.

The primary nurses will be taught to request the bag once it is imminent that the

patient is going to pass.

The charge nurse or house supervisor will issue the bag for the family removing

the condolence card before it is given to the family.

Some of the physical signs that a person is about to pass are:

Shortness of breath

Depression

Anxiety

Tiredness and sleepiness

Mental confusion

Constipation or incontinence

Nausea

Refusal to eat or drink

According to research that was published in the British Medical Journal there are

twenty-nine items that can determine when a patient is close to death. The name of this

list is Critera for Screening and Triaging to Appropriate aLternative care, or CriSTAL for

short. The proposed components that make up the 'The Critera for Screening and

of 20

Triaging to Appropriate aLternative care, or CriSTAL to identify end-of-life status before

hospital admission are listed below. (Cardona-Morrell, 2015)

Age ≥65 AND admitted via emergency this hospitalization (associated with 25%

mortality within 1 year)

Decreased LOC: Glasgow Coma Score change >2 or AVPU=P or U

Systolic blood pressure <90 mm Hg

Respiratory rate <5 or >30

Hypoglycemia: BGL

Repeat or prolonged seizures

Low urinary output (<15 mL/h or <0.5 mL/kg/h)

OR MEW (modified early warning) or SEWS score >

Pulse rate <40 or >140

Need for oxygen therapy or known oxygen saturation <90%

Other risk factors/predictors of short-medium term death

Personal history of active disease (at least one of):

Advanced malignancy

Chronic kidney disease

Chronic heart failure,

Chronic obstructive pulmonary disease

New cerebrovascular disease

Myocardial infarction

Moderate/severe liver disease

Evidence of cognitive impairment (eg, long-term mental disorders, dementia,

behavioral alterations or disability from stroke)

Length of stay before this RRT call (>5 days predicts 1-year mortality)

Previous hospitalization in past year10

Repeat ICU admission at this or previous hospitalization (associated with a

fourfold increase in mortality)

of 20

Evidence of frailty: 2 or more of these:

Unintentional or unexplained weight loss (10 lbs in past year)

Self-reported exhaustion (felt that everything was an effort or felt could not get

going at least 3 days in the past week)

Weakness (low grip strength for writing or handling small objects, difficulty or

inability to lift heavy objects ≥4.5 kg)

Slow walking speed (walks 4.5 m in >7 s)

Inability for physical activity or new inability to stand

Nursing home resident/in supported accommodation

Proteinuria on a spot urine sample: positive marker for chronic kidney disease &

predictor of mortality: >30 mg albumin/g creatinine

Abnormal ECG (Atrial fibrillation, tachycardia, any other abnormal rhythm or ≥5

ectopics/min, Changes to Q or ST waves.

Each of these symptoms, taken alone, is not a sign that someone is dying.

But, for someone with a serious illness or declining health, these might suggest that that

person is nearing the end of life. In addition, closer to death, the hands, arms, feet, or legs

may be cool to the touch. Some parts of the body may become darker or blue-colored.

Breathing and heart rates may slow. Some people hear a death rattle. (NIA, 2014)

Hospital mortality may be calculated using the following equation:

logit=−7.7631+0.0737∗Score+0.9971∗ln(Score+1)Mortality=elogit1+elogit

In order to make things easier, we will use the Simplified Acute Physiology Score

(SAPS II) Calculator that is based on seventeen factors to determine a score for the

possibility of demise. This platform was developed by Le Gall, Lemeshow, Saulnier in

1993 thus making this program the most current evidence based over the previous

mortality score APACHE II.

SAPS II was designed to measure the severity of disease for patients admitted

to Intensive care units aged 15 or more. We will be using SAPS II throughout the

inpatient units. Twenty four hours after admission, the measurement has been completed

and resulted in an integer point score between 0 and 163 and a predicted mortality

of 20

between 0% and 100%. No new score can be calculated during the stay. If a patient is

discharged from the hospital and readmitted, a new SAPS II score can then be calculated.

The point score is calculated from 12 routine physiological measurements during

the first 24 hours, information about previous health status and some information

obtained at admission.

The parameters are:

Age

Heart Rate

Systolic Blood Pressure

Temperature

Glasgow Coma Scale

Mechanical Ventilation or CPAP

PaO2

FiO2

Urine Output

Blood Urea Nitrogen

Sodium

Potassium

Bicarbonate

Bilirubin

White Blood Cell

Chronic diseases

Type of admission

In contrast to APACHE II, the resulting value is much better at comparing patients

with different diseases. The calculation method results in a predicted mortality, which is

pure statistics. The nurses will be taught to use this online calculator to receive the

patients’ “score”. Then use the included scale to determine if the patient is currently

eligible for the program.

of 20

Mortality

SAPS II

Score

10%29 pts

25%40 pts

50%52 pts

75%64 pts

90%77 pts

of 20

(http://clincalc.com/icumortality/SAPSII.aspx)

VIII. Timetable

Description of Work Start and End Dates

Phase OneCollection of items for the care bag

06/01/15-06/15/15

Phase TwoTraining of staff/Assembly of bags

06/16/15-06/23/15

Phase ThreeFinality of planning and beginning of project

06/24/15

IX. Budget

Description of Work Anticipated Costs

Phase OneCollections of items for the care bag. (Approximate)

$600.00

Phase TwoTraining of staff/Assembly of bags

$0.00

Phase ThreeFinality of planning and beginnings of project

$0.00

Total 600

of 20

X. Key

Personnel

XI. Evaluation

The program will start with a small group of stakeholders managing then

hopefully grow into a multitude of small groups with many mangers. Each

current member of the beginning group will be responsible for different tasks

such as inventory, collection of items/money, and assembly of the bags. The

primary nurse will determine with other interdisciplinary team members if the

patient is actively dying. The charge nurse or house will be responsible for

determining if the patient is currently eligible for the program.

The program can be evaluated by the satisfaction survey that is normally

sent out. The increase in patient satisfaction score should reflect how well the

program is performing and if it should be continued. Also, the nurses and others

involved in the program will be polled to see if the team members are satisfied

with the way the program is running as well.

XII. Endorsements

of 20

Amanda Pate, BSN, RN

Kimberly Crum, BSN,

RN

Angelisse Martinez, RN

Tonya Wisenbaker,

RN

Amanda Pate 238 Hannah Court, Greenville, Ga. 30222

Tonya Wisenbaker 600 Celebrate Life Highway, Newnan, Ga. 30265

Kimberly Crum 600 Celebrate Life Highway, Newnan, Ga. 30265

Angelisse Martinez 600 Celebrate Life Highway, Newnan, Ga. 30265

Shelia Martin 34562 Main Highway, Douglasville, Ga. 30134

Patty Calhoun P.O. Box 246 Luthersville, Ga. 30251

Mrs. Ritchie~ Address Private

XIII. Next Steps

Receiving approval of this project.

Inpatient staff will collect more blankets for the program.

Pate will receive pricing for canvas bags with CTCA printed on them from growth.

Information needs to be sent to every stakeholder to spread awareness of the program and promote donations via the growth department.

Reaching out to the financial department for the financial management side of the project.

of 20

XIV. Appendix

End-of-life care is the term used to describe the support and medical care given

during the time surrounding death. Such care does not happen just in the moments before

breathing finally stops and a heart ceases to beat. An oncology patient is often living, and

dying, with one or more chronic illnesses and needs a lot of care for days, weeks, and

sometimes even months. Comfort care is an essential part of medical care at the end of

life. It is care that helps or soothes a person who is dying. The goal is to prevent or

relieve suffering as much as possible while respecting the dying person’s wishes.

Generally speaking, people who are dying need care in four areas—physical comfort,

mental and emotional needs, spiritual issues, and practical tasks. (NIA, 2014)

A patient may be uncomfortable due to many reasons such as pain, breathing

problems, skin irritation, digestive problems, temperature sensitivity, and fatigue. Pain,

digestive and breathing problems are normally handled medically. Skin irritation,

temperature sensitivity and fatigue can be treated with this program using the lotion and

blanket given to the family. Mental and emotional needs can also be met with this

program due to the human connection that we create when implementing the care bag

program. The family rubbing lotion on the patient to help relax will also help with this

need. Spiritual issues will be handled by our pastoral team. Finally, practical tasks will

also be fulfilled due to the patient knowing that the family will be taken care of after he

or she is gone by offering the family information on grief and counseling.

Death is a fact of life and death is a life stressor. With the loss of someone close

to you, you are also going through a normal life crisis. You too, need a period of

adjustment. How do you deal with the powerful emotions that threaten to overwhelm

you? It is likely that you have no guide to follow during that painful period after the

death of a loved one. You have no preparation for your new role as mourner. In our

society there is no formalized way to sever the relationship you have maintained with the

deceased. What are you to do with the emotional investment of a lifetime? The body

may be buried, but the emotions of those who lost the deceased continue to survive. This

of 20

is where the blanket may be able to help with the transition of life without the deceased.

(McCullough, 2009)

It is not the blanket, of course, that is transitional. The blanket represents the

family members transition from a state of being merged with the deceased loved one to a

state of being in relation to the deceased as something outside and separate. The feeling

of loss of contact with the loved one is diminished due to having the last object the

patient touched while here and alive. This continues the contact physiologically and helps

the family members cope more effectively.

Words of compassion and acts of kindness are more healing that all of the

medicine in the world. We at Cancer Treatment Centers of America have the opportunity

to help these family members get through their crisis and life stressor and prove that our

care never ever quits.

of 20

References

Cardona-Morrell M, et al. BMJ Supportive & Palliative Care 2015;0:1–13.

doi:10.1136/bmjspcare-2014-000770 1

Caring Connections. (2015). Retrieved January 9, 2015, from http://www.caringinfo.org

Crowther, B. (2015). Dad’s spirit warms us in our comfort blankets. Retrieved January 9,

2015, from http://www.theguardian.com/lifeandstyle/2015/jan/24/dads-spirit-

warms-us-in-our-comfort-blankets

Engals-Smith, J. (2013). Transition Blanket. Retrieved January 15, 2015, from

https://www.shamanportal.org/article_details.php?id=825

Gunderman, R., & Nelson, P. (2012). Exchanging a Blanket for a Code Blue. Retrieved

January 7, 2015, from

http://www.theatlantic.com/health/archive/2013/08/exchanging-a-blanket-for-a-

code-blue/279125/

Hospital based comfort carts lifts spirits, unites a community in caring. (2012). Pain

Community News, 8-9.

Jean-Roger Le Gall, MD; Stanley Lemeshow, PhD; Fabienne Saulnier, MD. (1993). A

New Simplified Acute Physiology Score (SAPS II) Based on a European/North

American Multicenter Study. JAMA. 1993;270:2957-2963

McCullough, C. (2009). A Child's Use of Transitional Objects in Art Therapy to (1st ed.,

Vol. 26, pp. 19-25). Mahopac, NY: Journal of the American Art Therapy

Association.\

National Institute on Aging. (2014). End of life: Helping with comfort care. Retrieved

January 6, 2015, from

http://www.nia.nih.gov/sites/default/files/end_of_life_helping_with_comfort_care

_0.pdf

of 20

http://www.nia.nih.gov/sites/default/files/end_of_life_helping_with_comfort_care_0.pdf

http://www.nia.nih.gov/sites/default/files/end_of_life_helping_with_comfort_care_0.pdf

http://www.theguardian.com/lifeandstyle/2015/jan/24/dads-spirit-warms-us-in-our-comfort-blankets

http://www.theguardian.com/lifeandstyle/2015/jan/24/dads-spirit-warms-us-in-our-comfort-blankets

http://www.caringinfo.org/

Sympathy Throws. (2015). Retrieved January 10, 2015, from http://www.keepsakes-

etc.com/sympathygift.html

Temes, R. (2002). Living with an Empty Chair. Philip A. Pecorino.

Winnicott, D. (n.d.). 1. In Transitional objects and transitional phenomena (2nd ed., Vol.

34, pp. 1-18). London, England: Tavistock Publications.

of 20

Amanda Pate Project Proposal for Care Bag

Documents

Transcript of Amanda Pate Project Proposal for Care Bag