JULIET I SANTOS

Understand the importance of psychosocial and spiritual care.Know how to provide psychosocial and spiritual care interventions for a resident during the later stages of life.Understand the regulatory requirements for meeting the needs of residents as whole persons.

PhysicalPsychosocial Spiritual

Palliative Care Team:nursefamilyaidepatientsocial workerphysicianchaplainvolunteercounselor

PurposefulConversationsPurposeful Observations

On-going as the patients condition changes.Documented to show individualization and coordination of care.Note: Advance directives are one way to document patients wishes; however, purposeful conversations are still necessary.

Patients cultural and religious beliefsValuesPreferencesFearsView of quality of lifeFamily relationships

Views of dyingDesire for CPR, artificial nutrition and hydrationUnderstanding of diagnosis and prognosisDesired/acceptable treatments

Psychosocial and spiritual suffering is real, but can be difficult to recognize and treat.Psychosocial and spiritual suffering can be translated into physical complaints.Listening is the best assessment tool.Listen for hope vs. fear, joy vs. sadness, good memories vs. missed opportunities.

Facility staff listens and reports signs and symptoms to the appropriate healthcare professional for further intervention.Facilities should develop access to community professional spiritual caregivers of all faiths.Facility staff may consider accessing the services of a hospice agency.

Customary RoutineUsually attends church, temple, etc.Finds strength in faith

Psychosocial well-being1. Sense of initiative/involvementEstablishes own goalsPursues involvement in life in facility

Unsettled relationshipsOpenly expresses conflict/anger with family/friendsAbsence of personal contact with family/ friendsPast rolesStrong identification with past roles and life statusExpresses sadness/anger/empty feelings over lost roles/status

Past roles, cont.Resident perceives that daily routine is very different from prior pattern in the community.Activity Pursuit Patterns:General Activity PreferencesSpiritual/religious activities

Encompasses both cognitive function and emotional health.Calls for openness and sensitivity to feelings and emotional needs of the resident and the family.Caregiving typically combines clinical and nonclinical interventions.

Emotional pain is the dimension of end of life care that: 1. Causes the most suffering.2. Is the most difficult to treat.3. Requires most interventions by staff. a) clinicalb) non-clinical

Symptoms associated with emotional and spiritual suffering:AnxietyDepressionHelplessnessAlonenessFinancial distressMeaninglessness

Need for forgivenessFear of the unknownLoss of important rolesConflicted relationshipsHopelessnessInability to enjoy/celebrateNeed to forgive

Residents are diverse in their spiritual needs.Facilities and caregivers are diverse in their ability to meet spiritual needs.Some facility staff may feel uncomfortable or inadequate in the role of meeting spiritual or psychosocial needs.

World Health Organization (WHO)

Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and psychological, social, and spiritual problems is paramount.

The search for peace and inner healing, replacing fear and despair with hope and serenity.Basic tenet is to view the individual as a whole being-physical, psychological, social, and spiritual being.All team members can listen and refer.Professional caregivers-chaplain, priest, psychologist, or social worker is needed for more intensive spiritual or psychological interventions.

Inability to cure physical disease does not necessarily equate to lost hope. Providers behaviors interpreted by patients as abandonment.

Physical healingComfortPersonal growthLove ReconciliationCourageSelf-forgivenessFulfillment of ones afterlife belief

Religion and Spirituality are different.Religion, according to Webster, is belief in a divine or superhuman power or powers to be obeyed and worshiped as the creator and ruler of the universe---.Spirituality, according to Webster, is of the spirit or soul as distinguished from the body or material matters.Spirituality explores the inner meaning of life now and after death.

Hope is an ongoing need throughout life.Support depends on knowing what the resident or family is hoping to achieve.Listening to what the resident or family hopes for and validating the residents feelings provides groundwork for meaningful support.

Identify problems and concerns.Establish patient centered goals.Write interventions that include family and patient involvement. Be sure and clearly identify scope and frequency of interventions provided by SNs, Hospice, Counselor or Spiritual Support staff. Designate responsible discipline/organization.

Basic caregiving involves listening.Professional caregiving involves listening and seeking further explanation of life stories involving fear, anger, and other affective states.Referral to other professionals frequently needed, i. e., chaplain, psychologist, social worker.

The following can be helpful:Put aside your tasks and offer your presence.Arrange for a spiritual leader to visit if desired.Listen to stories or life reviews.Allow expressions of anger, guilt, hurt and fear. Encourage the resident to acknowledge these feelings, and then let them go.Avoid clichs like It is Gods will. Never say Everything is going to be all right or You shouldnt feel that way.

Read scriptures or other materials if the resident wishes.Encourage appropriate joy and humor. Laughter lifts the spirit, celebrates life and keeps things in perspective.Share prayers, meditation or music if the resident wishes.Use massage and relation to help the resident relax.Encourage completion of funeral arrangements.

Encourage the resident to accept gratitude from others.Identify what constitutes a good death.Identify specific rituals or ceremonies important to the resident/family.Identify cultural issues that affect the resident/family.Encourage the family to give the resident permission to let go, when appropriate.

Explain that it is alright to cry; tears are normal and show caring.Encourage expressions of affection.Be present with the resident and family if they want support.Listen to the last wishes and regrets of the resident.Communicate that what is happening is natural.

Assist the resident in reframing goals that are attainable and meaningful.Help the resident identify relationships that need closure.

42 CFR Section 483.25 (a)

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho-social well-being in accordance with the comprehensive assessment and plan of care.

State Licensure Requirement19 CSR 30-88.010 (30)Each resident shall be permitted to participate, as well as not participate, in activities of social, religious or community groups at his/her discretion, both within the facility, as well as outside the facility , unless contraindicated for reasons documented by physician in the residents medical record.

Federal Requirement42 CFR Section 483.15 (d), F245

A resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility.

F245, Interpretive Guidance to Surveyor

The facility, to the extent possible, should accommodate an individuals needs and choices for how he/she spends time, both inside and outside the facility.

Federal Requirement42 CFR Section 483.15 (g), F250The facility must provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

F250 Interpretive Guidance to Surveyor

Medically related social services means services provided by the facilitys staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental or psychosocial needs.

Interpretive Guideline, samples:Maintain contact with family to report changes and encourage participation in care planning.Assisting staff to inform residents of their health status, health choices, and ramifications.Assist resident with financial and legal matters.Providing or arranging for counseling services; identify and seek ways to support residents individual needs and preferences, customary routines, concerns, and choices.

Interpretive Guidelines, samples, cont:Building relationships between residents and staff and teaching staff how to understand and support residents individual needs.Assisting residents to determine how they would like to make decisions about their health care and whether or not they would like someone else to be involved in those decisions.Finding options that most meet the residents physical and emotional needs.

Interpretive Guidelines, samples, cont:Providing alternatives to drug therapy or restraints by understanding and communication to staff of why residents do what they doand what needs the staff must meet.Meeting the needs of residents who are grieving.Finding options, which most meet their physical and emotional needs.

You matter because you are you. You matter to the last moment of your life, and we will do all we can not only to help you die peacefully, but also to live until you die. -Cicely Saunders-