Ellen A. Ovson, M.D., F.A.S.A.M. Medical Director Bradford Health Services, Madison, Alabama.
Best Practices in End-of-Life Care Ellen L. Csikai, Ph.D School of Social Work The University of...
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Best Practices in End-of-Life Care
Ellen L. Csikai, Ph.DSchool of Social Work
The University of Alabama
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Critical Areas for Social Work Intervention
• Decisions to end aggressive cure-focused medical treatments or forgo life-sustaining treatments
• Transition to end-of-life care • Support through the dying process• Support for family caregivers• Grief/Bereavement
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Cancer Diagnosis and End-of-Life Issues
• Intervene with Fears, Anxieties, Issues of loss – Immediately following diagnosis• First thoughts: “Am I going to die?” • Treatment decisions
– Longer term survival– End of Life • Encouraging hope – in the face of dying• Saying final goodbyes
(Cancer Survivor Toolbox)
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Critical Roles for Social Workers
Liaison– between patients/families and health care
providers to gain access to information necessary for decision making
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Counselor – works with individuals who are dying and their
families on issues related to values clarification, emotional assessment, crisis intervention, goal-setting, decision making, dealing with transition and loss, active pursuit of interpersonal growth, and the pursuit of peace of mind
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Advocate – for patients’ access to medical care; aggressive
pain relief; financial assistance; access to mental health services and care for spiritual concerns
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Interdisciplinary team member– help patient and family identify and communicate
symptoms of physical pain and suffering; achieve a good dying process
– helps fellow team members with their emotional concerns related to providing end-of-life care
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Who uses hospice services in the U.S.?
• In 2005, about one-third of all those who died used hospice services
• 3/4 of hospice recipients died in a place that they considered “home”
• majority of hospice users are women• 4 out of 5 hospice patients were over age 65• 1/3 were over age 85• Hospice use tends to increase with age
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Diagnoses of patients receiving hospice services:
• In 2005, three of the top 10 diagnoses were cancer-related (lung, prostate, breast)– Accounts for a little more than 50% of all hospice
patients
• Alzheimer’s Disease is the fastest growing non- cancer-related diagnosis
• Diseases that had a more predictable prognosis leading to death
• Diseases that tend to impose a high burden on caregivers
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• In 2005, the average LOS was 59 days. • The median LOS was 26 days • Increase in the number of recipients receiving
services for greater than six months • Decrease in the number of recipients receiving
services for less that 7 days
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Hospice Admission Visit/Initial Assessment
• Conducted with the new enrollee and their identified primary caregiver(s)
• The purpose is to gather initial assessment information regarding biological, psychological, social, and spiritual issues that may be important
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• Social work participation in the admission visit contributes to positive outcomes
(Reese & Raymer, 2004)
• If not present for the admission visit, the social worker will make a home visit to complete a comprehensive psycho-social-spiritual assessment.
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The Social Work Assessment Tool (SWAT)
• Trend toward better assessing social work outcomes
• The SWAT is useful if used at each visit with patient and caregiver
• Psychosocial domains addressed in the SWAT:– spirituality– death anxiety– social support– denial– end-of-life care decisions
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– cultural group– safety– comfort– suicidal ideation– preferences about environment– assistance with financial resources– complicated anticipatory grief
(Reese et al., 2006)
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Social Work Interventions in HospiceAccording to the National Hospice and Palliative Care
Organization: • Assess, diagnose, screen, and document• Stimulate internal and psychosocial coping skills
through the use of models demonstrated to be effective
• Provide crisis intervention• Provide specific symptom relief through non-
pharmacological therapies such as cognitive behavioral interventions, expressive therapies, etc.
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• Enhance the responsiveness of the environment• Engage in evaluation of one’s own practice • Information and referral • Counseling re: dying process• Counseling re: anticipatory grief/bereavement• Reminiscence and life review/legacy projects• Decision making • Management of pain and suffering– relaxation therapy– resolving unfinished business
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NASW Standards for Palliative and End-of-Life Care (2004)
• Describes the background of the field, including definitions, enumerates standards of professional practice and standards for professional preparation and development
• Developed in a collaborative effort between NASW and experts in the field
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• The standards for practice cover: ethics and values, knowledge, assessment, intervention/treatment planning, attitudes/self-awareness, empowerment and advocacy, documentation, interdisciplinary teamwork, cultural competence, continuing education, and supervision, leadership, and training . These standards provide guidance to professionals and to agency administrators as to the appropriate and expected role of social workers in end-of-life care.
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Educational Resources
• NASW Webed Courses– Understanding End-of-Life Care– Achieving Cultural Competence to Reduce Health
Disparities in End-of-Life Care
• Social Work End-of-Life Educational Program• Post-masters Certificate Programs• Palliative Care Fellowships for Social Workers
• Journal of Social Work in End-of-Life and Palliative Care
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ReferencesNational Association of Social Workers. www.naswdc.org
National Coalition for Cancer Survivorship. Cancer Survivor Toolbox.
www.canceradvocacy.org/toobox
National Hospice and Palliative Care Organization (2008). Hospice Facts & Figures. www.nhpco.org
Raymer, M., & Reese, J. D. (2004). Relationships between social work involvement and hospice outcomes: Results of the national hospice social work survey. Social Work, 49(3), 415–422.
Reese, D. J., Raymer, M., Orloff, S. F., Gerbino, S., Valade, R.,Dawson, S., Butler, C., Wise-Wright, M., & Huber, R. (2006). Thesocial work assessment tool (SWAT). Journal of Social Work in End-of-Life & Palliative Care, 2(2), 65-95.
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