Is There a Role for the Registered Psychiatric
Nurse on the Palliative Care Team?
22nd Annual Manitoba Provincial Hospice & Palliative
Care Conference
September 26, 27, 2013
Winnipeg, Manitoba
Faculty/Presenter Disclosure
Speaker:
Debra Dusome R.N., B.A. (Hons.), Ex.A.T., M.A.
Relationships with commercial interests:
Other:
Debra is an Assistant Professor in the Faculty of Health Studies
at Brandon University and teaches in the Bachelor of Science
in Psychiatric Nursing Program
Disclosure of Commercial Support
 This presentation has received no financial support
 This presentation has received no in-kind support
 Potential for conflict(s) of interest:
 Brandon University does seek placement
opportunities for their B.Sc.P.N. students
Mitigating Potential Bias
 Although I may visit potential clinical placement sites
to assess whether sites can meet student learning
objectives, I do not personally arrange and negotiate
student placements
 Student placements are arranged through the
Brandon University Clinical Co-ordinators: Betty
Wedgewood and Jacqueline Pentney
 All placements are negotiated using HSPnet and
employers always have the right to accept or decline
requests
Learning Objectives:
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Participants will learn about the Brandon University Psychiatric
Nursing Curriculum
Participants will learn about the skill set of Registered
Psychiatric Nurses
Discussion of needs of individuals with Serious Mental Illness in
the Palliative Care Setting
Mental Status Examination – Assessing for Depression and
Suicide Risk in the Palliative Care Setting
Intervention strategies to manage depression and suicidal
thoughts
Open dialogue about preparing students for Palliative and
Hospice Care work
Respond to questions from participants
Curriculum – Year One
Pre-Psychiatric Nursing Year
 Health Promotion: Developmental Transitions Throughout
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the Lifespan
Fundamentals of Psychiatric Nursing Practice I
Introduction to Interpersonal Communication
Intro Psychology
Intro Sociology
The Sociology of Medical Systems
Human Anatomy and Physiology
Introduction to Statistics/Data Analysis/Fundamentals of
Psychological Research/Social Research Methods
Curriculum – Year Two
 Fundamentals of Psychiatric Nursing Practice II (Lab)
 Principles of Health Assessment (Lab)
 Psychopharmacology
 Fundamentals of Psychiatric Nursing Practice III (Lab)
 Integrated Practicum I (3 weeks)
 Principles of Individual Counselling (Lab)
 Medical Nursing for Psychiatric Nurses (Clinical 1
day/wk for the Winter Term)
 Psychopathology
 Integrated Practicum II (3 weeks)
Curriculum – Year Three
 Psychiatric Nursing for Elderly Persons
 Introduction to Palliative Care
 Community Health (Field Work)
 Therapeutic Groups (Lab)
 Acute Mental Health Challenges I
 Family Counselling (Lab)
 Developmental Challenges (Field Work)
 Addictions
 Interpersonal Abuse
 Integrated Practicum III (6 weeks)
Curriculum – Year Four
 Psychiatric Nursing with Children and Adolescents
 Psychiatric Rehabilitation and Recovery (Field Work)
 Philosophical Perspectives for Practice
 Introduction to Health Research Methods
 Leadership in Professional Practice
 Contemporary Perspectives on Professional Health Issues
 Integrative Clinical Practicum (8 weeks)
Skill Sets
 Infection Control (includes hand hygiene,
 Intravenous Therapy (includes calculation of
 Vital Signs
 Oxygen Therapy
 Airway Management (includes inserting
 Wound Care (includes sterile technique, dry
 Mobility and Safety
 Hygiene
 Elimination (includes specimen collection,
 Documentation
 Medication Administration (all routes,
personal protection gear, universal/routine
precautions & practices)
airways, suctioning, mouth care, tracheostomy care and
tracheostomy suctioning)
urinary and bowel care, ostomy care, cathether
insertion, care and removal)
 Nutrition (includes assisted feeding with
dysphagia, tube feeding and medication administration
via jejunostomy or gastrostomy tubes)
BU, BScPN Fundamental Psychiatric Nursing Skills
Portfolio (2012)
flow rates, maintenance and care of peripheral I.V’s
gravity fed and via pump, regulating I.V. flow,
discontinuing peripheral I.V.’s, changing solutions and
tubing and discontinuing peripheral I.V.’s)
dressings and packing, wound irrigation,
assessment, prevention and treatment of pressure
ulcers, suture and staple removal, and hydrocolloid
dressings)
cannot give I.V. medications as students)
 Health Assessment (includes full systems
assessment including mental status exam and the minimental status exam to assess cognitive functioning)
 Blood Sugar Monitoring
 Post Mortem Care
Introduction to Palliative Care Course
Course Description
This course is a 1.5 CH course that meets 1.5 hours per week for 12 weeks
with a group presentation requirement. Students in this course will gain
knowledge of the principles of palliative care for persons with life
threatening and life-ending illnesses. Emphasis is placed on
understanding within a familial context from the perspective of an
interdisciplinary team. Students have the opportunity to explore their
own beliefs and values about living and dying and to examine how their
own experiences contribute to their professional practice role in
palliative care.
Course Text
Zerwekh, J.V. (2006). Nursing care at the end of life: palliative care for
patients and families. Philadelphia, PA:F.A. Davis.
The Hospice Family Care-giving Model
Zerwekh, (2006)
Course Topics
 The Context of Palliative
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Care
Historical Evolution of
Palliative Care
Sustaining Yourself as a Nurse
Palliation in Severe and
Persistent Mental Illness
Children Facing Death
Cultural Humility in
Palliative Care
Communication in Palliative
Care
 Legal and Ethical Issues in
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Palliative Care
Symptom Management (Pain)
Management of Physical NonPain Symptoms
Strengthening the Family
Spiritual Care
The Final Hours
Personal Reflections and
Learnings Regarding the Role
of the Psychiatric Nurse in
Palliative/Hospice Care
W.R.H.A. Tool Kit Re: Staff Mix
Identifying Potential Areas of Practice for
RPN’s
 “At a 2009 meeting of the W.R.H.A. Nursing Leadership
Council, discussions regarding the appropriate utilization
of R.P.N.’s within the health care system in Winnipeg
resulted in the agreement that other patient populations
would benefit from the addition of a RPN to the health
care team.”
Tool Kit for the Introduction of Registered Psychiatric Nurses in NonIdentified Mental Health Settings – Introduction and Background, Feb.
2011.
Staff Mix
 Decisions as to the appropriate staff mix for a particular unit,
program or service and the potential benefit of introducing a
RPN role are complex and need to consider a number of
factors including:
 Needs of the patient population (for example, prevalence of mental
health issues, complex family dynamics, need for psychosocial
interventions and therapies. etc.)
 Scope of practice of the LPN, RN and RPN
 Scope of practice of other health care providers on the current health
care team
 Environmental factors (for example, practice supports, consultation
resources, and the stability/predictability of the environment) (CLPNM,
CRNM, & CRPNM, 2010; College of Nurses of Ontario, 2009) Tool Kit Feb. 2011.
Populations that are Underserved in
Palliative Care
 People with Serious and Persistent Mental Illness
 People with Intellectual Disability
 People experiencing Dementia
 People with Significant Substance Abuse and Dependence
 Individuals who are Homeless
 People who are Incarcerated
Baker (2005), Woods et al. (2008), Goldenberg et al. (2000), Foti, (2003), Webber
(2012), Cross et al. (2012), McGraft & Jarrett (2007), Ellison (2008), Albisson &
Strang (2003),Aminoff & Adunsky (2005), Diwan et al. (2004), DRC (2006),
McCarron & McCallion (2007), Robinson et al. (2005), Davis & Bucknell, (2011),
Hughes, (2001).
Barriers to Access to Palliative Care
 Care provider concern that they do not have the theoretical and practical
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skill sets to work with these populations of individuals with specialized
needs
Issues related to competency re: consent for treatment, making
informed decisions and designating substitute decision makers
Communication issues i.e., individuals who are non-verbal or who
possess limited speech, individuals who experience ongoing delusional
thinking and hallucinations who are difficult to engage in conversation
related to illness and/or issues of trust
Behavioural issues: concerns that patients may be aggressive, elopement
risks, non-compliance with treatment and odd behavioural presentations
Reciprocal Stigma
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McCasland (2007), Cross et al. (2012), Foti (2003), Baker (2005), Woods et al.
(2008), Goldenberg et al. (2000), McGrath & Jarrett (2007)
Stigma During End-of-life Care
“Individuals with a terminal illness in psychiatric facilities can have multiple
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stigmatized social identities as they are not only considered mentally ill,
but are often imprisoned, aged, and have other illnesses or disabilities
apart from the fact that they are also dying. The impact of multiple
stigmatising social identities may affect not only the institutionalized
individual with a mental illness seeking end-of-life care but also the
service providers who care for them.”
The Park Centre for Mental Health Study
For many staff had become family – reluctance to move patients to
unfamiliar settings
Palliative Care Consultation – desire for more on-site support
Reciprocal stigma
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McGraft, P. & Jarrett, V. (2007). The Problem of Stigma during End-of-life Care at a
Psychiatric Institution. International Journal of Psychosocial
Rehabilitation. 11 (2), 19-30.
Palliative Care and the Seriously Mentally Ill
 Schizophrenia
 Bipolar Disorder
 Major Depression
 Dementia
 Schizoaffective Disorder
 Significant Substance Abuse/Dependence
 Personality Disorders/Complex PTSD
 Anorexia Nervosa
 Co-Occurring Disorders
The Prevalence of Medical Illness in People
with Mental Illness
 People with mental illness have high mortality and
morbidity rates associated with high suicide rates, accident
rates and the incidence of alcohol and drug problems
 This population also has high rates of unrecognized medical
disorders and consequent neglect of physical problems
 Late diagnosis and early death is considered to be a normal
statistic for people with SPMI
Hahm & Segal (2005), McCasland (2007), Foti (2003),Ellison (2008), Davie
(2006), McGrath et al, (2004), Goldenberg et al. (2000), Woods et al., (2008)
Needs of Individuals with Serious Mental
Illness in the Palliative Care Setting
 Engaged treatment relationship with people they know and trust as
much as possible
 Earlier identification of medical illnesses and treatment
 Cross-training of palliative care and mental health care providers
 Involvement as much as possible in end-of-life decisions with use of both
psychiatric advance directives and end-of-life medical care advance
directives
 Education, care, support, assistance, and bereavement counselling by
providers who value collaboration, advocacy and research
 Access to compassionate end-of life care in a variety of settings (ideally
involving client choice)
Woods et al. (2008), Baker, (2005),Goldenberg et al. (2000), Tate & Longo
(2005), Foti (2003), Webber (2012)
Serious Mental Illness and the Capacity to Make
Decisions Regarding End-of-Life Care
 “Do It Your Way” : A Demonstration Project on
End-of-Life Care for Persons with Serious Mental
Illness – Foti, M. E. (2003)
 End of Life Care for People with Mental Illness –
Inner City Health Associates, Toronto, Mission Hospice
Program, Ottawa Inner City Health, Florida, U.S.A.
“Just-Do-It” approach – Webber, T. (2012)
Service Delivery Settings for Individuals with
Serious and Persistent Mental Illness
Hospice/Palliative Care Units
Long Term Care Units in Psychiatric Institutions
Long Term Care Units In Nursing Home, PCH Settings
Psychiatric Rehabilitation Group Homes
Own Homes with Intensive Psychiatric Support & Palliative Home
Care Support
 Home of Family Members or Significant Others
 Combination Medical/Psychiatric Units
 On the Street (Shelter and Mobile Services)
**Majority of research does not support palliative care delivery on
acute psychiatric units
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Baker (2005), Davie (2006), Foti (2003),Goldenberg et al. (2000), Hughes (2001),
McCasland (2007), Woods et al. (2008), Webber (2012)
Recommended Reading
Bartok, Mira, (2011). The Memory Palace. Free
Press, Simon & Schuster, Inc., New York: N.Y.
Depression Experienced by Individuals
Receiving Palliative Care
 Depression is common in hospice and palliative care settings with
prevalence ranges of 1% - 42% and 0% - 58% in patients with
cancer, a rate 4x’s that of the general population, other studies
have rates of 25% - 50%
 Under recognition leads to under treatment and unwanted
outcomes
 Depression can interfere with an individual’s capacity to
understand his/her situation, make decisions, interact with
caregivers and to reach final goals
 Those with depression have increased illness severity and pain and
depression increases the risk of suicide
Irwin et al. (2008), McCabe et al. (2012)
Mental Status Assessment
 General Description
 Perceptual Disturbances: including
 Attention Span: digit repetition
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forward and backward
Orientation: time, place, person
Memory: good, fair, poor
Fund of Knowledge: good, fair, poor
Judgment: good, fair, poor
Insight: good, fair, poor
Thought Processes: including
conceptual ability, organization,
speed/flow, content, delusional
ideations, preoccupations, affect, and
mood
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hallucinations; auditory, visual,
gustatory, olfactory, tactile and
command, illusions, déjà vu,
depersonalization, and derealization
Motor Activity Disturbances: agitation,
catatonia, tremors, mannerisms,
retardation, stereotypy
Coping/Stress Tolerance: identification
of current stressors and coping skills
and strategies
Aggression Potential: high, moderate,
or low
Suicide/Lethality: high moderate or
low
Summary of Mental Status
Mini-Mental Status Examination: Assess cognitive functioning
Assessing for Depression and Suicide Risk
in Palliative Care
 Explore DSM-IV-TR criteria for depression i.e. at least 2 weeks
depressed mood or loss of interest and at least four additional symptoms
of depression; changes in appetite or weight, sleep, and psychomotor
activity, decreased energy, feelings of worthlessness or guilt, difficulty
thinking and concentrating or making decisions, recurrent thoughts of
death or suicidal ideation, plans or attempts to commit suicide. The
symptoms must be different from person’s pre-morbid state and must
persist for most of the day, every day for at least two weeks.
 In Palliative Care recognize that somatic symptoms are less reliable as
they often overlap with symptoms related to terminal illness
 Use of instruments to measure levels of depression
Suicide Risk and Lethality Assessment
 Are there current thoughts of suicide? How often do these thoughts occur? Assess
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for feelings of hopelessness, helplessness, worthlessness and guilt. Does the
individual feel they are a burden to others?
Does the individual have a plan? How detailed is the plan? Has the person made
plans to avoid discovery?
Is the individual seeking death or a relief from suffering?
Does the individual have the means to complete the plan?
How lethal is the methodology i.e. use of guns, hanging, jumping, CO2 poisoning,
drug overdose, cutting, deliberate car accident ?
Does the individual have a past history of suicide attempts and/or history of
previous depression? What happened related to past attempts? Does the individual
have access to drugs and/or alcohol and are they regularly under the influence of
these substances?
Has a significant other successfully completed suicide?
Is there anything that prevents individual from acting on thoughts i.e. doesn’t want
to hurt loved ones, religious beliefs, stigma associated with suicide, loss of insurance
for family?
Suicide Risk and Lethality Assessment
(cont.)
 Is there estrangement or family conflict?
 Does the individual fear abandonment by significant others or care-givers due to
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increased level of dependence and care required?
Is the individual experiencing pain and/or other illness symptomatology that is
untenable and/or frightening i.e. nausea, failing cognition, air hunger, terminal
restlessness, loss of bowel and bladder control, ability to swallow? Does the
individual feel their life no longer has dignity? How does the individual imagine his
last days or hours? Are these perceptions accurate?
Is the person experiencing a loss of a sense of self?
Is the individual frightened of dying and the letting go of control? Do they fear
retribution for past sins or transgressions?
Is the person angry and if so what is the anger related to? Is there the potential for
aggressive behaviours towards self and others?
LISTEN, LISTEN, LISTEN
Intervention Strategies to Manage
Depression and Suicidal Thoughts
 Identify if individual is at significant risk of harming self or others
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and inform treatment team so that additional support and
observation can be given in addition to developing safety plans for
individual and others – referral for psychiatric consultation
Does assessment indicate underlying depression that may respond
to treatment – if yes – referral for psychiatric consultation
If individual has detailed plan and means – remove means if
possible
Address suffering – Ask individual what they think might help and
assist with suggested interventions
Work on affirming life affirming beliefs and values
Address family estrangement and conflict if possible and individual
is supportive of this intervention
Intervention Strategies to Manage
Depression and Suicidal Thoughts (cont.)
 Address fears of abandonment and feelings about loss of control and
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increased dependency
Allow as much room for autonomy and choice in making end of life
decisions – act as an advocate for the individual with the treatment team
and significant others
Provide options i.e. referral to spiritual care, Dignity Therapy,
involvement in preparatory bereavement groups, an opportunity to
express self through the arts, ongoing 1:1 engagement or counselling to
facilitate expression of feelings and to let individual know they are not
alone, visits from Artists in Healthcare, palliative care volunteers,
opportunities for sharing life review with others
Provide positive outlets for the expression of angry feelings
Assist and support in the saying goodbye process
Intervention Strategies to Manage
Depression and Suicidal Thoughts (cont.)
 Talk about fears of dying for clarification of what individual
concerns are
 Provide education re: what will be experienced in the last
weeks, days and hours and indicate what comfort measures
can be provided
 If medication is ordered, administer as ordered and provide
psycho-education re: expected effects, possible side effects
and monitor individual response to treatment and maintain
ongoing 1:1 engagement – treat individual as collaborative
partner in care
Distinguishing Depression from Preparatory Grief
Depression
Preparatory Grief
 Appetite & weight changes, fatigue,
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low energy, sleep disturbances &
sexual dysfunction
Persistent flat affect
Negative self-image
Anhedonia
Hopelessness, tearfulness
Prolonged social withdrawal
Ongoing persistent agitation
Active desire for early death,
suicidal ideation and plans
Decreased ability to concentrate
and make decisions
 Appetite & weight changes, fatigue,
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low energy, sleep disturbances &
sexual dysfunction
Mourning the multiple losses
associated with dying
Intense grieving that comes in waves,
temporary social withdrawal
Grieving individuals usually maintain
a normal sense of self-esteem
Still experience pleasure in
connecting with others and look
forward to special events
Maintain a sense of hope
Desire for continuing social
interaction
Periyakoii & Hallenbeck (2002), Axtell, (2008), Noorani & Montagnini (2007)
Intervention Strategies to Manage
Anxiety in the Palliative Care Setting
 Spend 1:1 time with individual to explore anxiety i.e. fears, specific triggers, past
history of anxiety, previous treatment interventions – which ones worked
 Explore previous coping strategies for managing anxiety and support individual to use
effective interventions
 Teach self-soothing , grounding strategies, mindfulness-based stress reduction
techniques, relaxation therapy, meditation, use of music, lullabyes, singing
 Address specific fears and concerns similar to interventions on previous slides i.e. are
they specifically related to the dying process?
 Assess whether anxiety is related to loved ones left behind re: emotional, financial
security etc. these may be very valid fears – assist to plan for care of loved ones – referral
to social worker on team
 Possible psychiatric consultation and medication assistance – administer and monitor
effectiveness of medication – provide education to individual about medication – act as a
collaborative partner in care
Ideological Interface of Palliative Care and
Psychiatric/Mental Health Care
McGrath, P. & Holewa, H. (2004)
 Person-centered practice
 Relationship-based connectedness
 Belief in compassionate, holistic care
 Respect for autonomy and choice
 Quality of Life issues
 Family as the unit of care
 Need for democratic multidisciplinary team work – flat
structure
 Need of special personality attributes for staff
Similarities Between Psychiatric Nursing and
Palliative Care Nursing
Cutcliffe, J. R. et al. (2001)
Psychiatric Nursing
Palliative Care Nursing
 Holistic, biopsychosocial and
 Holistic, biopsychosocial and spiritual
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spiritual approach
Recovery oriented focusing on best
QOL i.e. finding a meaningful life
path in spite of chronic illness – focus
on care VS cure
Focus on psychosocial, emotional
needs
Primacy of the nurse/client
relationship and therapeutic use of
self
Support individual autonomy and
decision making
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approach
Active total care of patients whose
disease is not responsive to curative
treatment
Focus on symptom control and
management enabling best QOL and
meaningful experience until death
Focus on psychosocial, emotional needs
Relationship is one of the essential
tenets of care
Support individual autonomy and
decision making
Similarities Between Psychiatric Nursing and
Palliative Care Nursing (cont.)
Cutcliffe, J. R. et al. (2001)
Psychiatric Nursing
 Connecting with individuals who are
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distressed and suffering
Focus on ‘being with’ rather than
‘doing for’
Primacy of providing non-physical
psychosocial support
True ‘presence’ with individual and
family required
Use of intuitive knowing
Focus on the phenomenological
understanding of the person and
their world
Collaborative relationship in which
care is negotiated
Palliative Care Nursing
 Connecting with individuals who are
distressed and suffering
 Focus on ‘being with’ rather than ‘doing
for’
 Primacy of providing both physical and
non-physical psychosocial support
 True ‘presence’ with individual and
family required
 Use of intuitive knowing
 Focus on the phenomenological
understanding of the person and their
world
 Collaborative relationship in which care
is negotiated
Dignity Therapy and
Recovery Narrative
Psychiatric Nursing Skills Sets Related to
Palliative Care
Strengths
Areas for Further
Development
 Communication and counselling
 Increased knowledge re: pain
skills for individuals, families
and groups
 Specialist knowledge re: mental
illness, developmental
challenges, addictions, forensic
nursing, addictions,
interpersonal abuse and
psychosocial rehabilitation and
recovery
management and
pharmacological
interventions in palliative
care
 Increased knowledge re: lifethreatening and life–ending
illnesses
Dialogue
Questions ???
References
 A Reference Sheet Handout will be available
to all participants.