Evaluations
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We deeply value your feedback, and will
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End of Life & Hospice Care
Presented by Care and Compliance Group, Inc.
Before We Begin…
• Let’s take a brief moment to evaluate your
knowledge of end of life issues and working
with residents on hospice care.
Initial Evaluation Assessment
• When a resident is in the end of his/her life
stage, pain is no longer an issues, as his/her
nervous system shuts down.
a. True?
b. False?
Initial Evaluation Assessment
• When a resident is in the end of his/her life
stage, pain is no longer an issues, as his/her
nervous system shuts down.
a. True?
b. False?
Initial Evaluation Assessment
• When a resident is nearing end of life, his/her
appetite will generally ____________.
a. Decrease
b. Increase
c. Not be affected
Initial Evaluation Assessment
• When a resident is nearing end of life, his/her
appetite will generally ____________.
a. Decrease
b. Increase
c. Not be affected
Initial Evaluation Assessment
• Not every state uses a POLST.
a. True?
b. False?
Initial Evaluation Assessment
• Not every state uses a POLST.
a. True?
b. False?
Initial Evaluation Assessment
• A Living Will is the same as a DNR Order.
a. True?
b. False?
Initial Evaluation Assessment
• A Living Will is the same as a DNR Order.
a. True?
b. False?
Initial Evaluation Assessment
• A resident who is receiving hospice care no
longer needs your assistance and participation
in care.
a. True?
b. False?
Initial Evaluation Assessment
• A resident who is receiving hospice care no
longer needs your assistance and participation
in care.
a. True?
b. False?
Responding With Compassion And Care
Life is a brief intermission,
Between birth and death,
Enjoy it.
~ M.K. Soni ~
Defining End Of Life
• Health changes
associated with end of
life…
• Decreased Desire To Eat
The resident may experience
an uncommon drop in
appetite during this phase of
life. Resident may refuse food
or beverage.
Digestive system begins to
shut down.
• Non-Responsive
Resident may become less responsive or less
alert. May become incontinent towards the
end of life.
However, despite the resident’s unresponsive
state, it is essential to continually provide for
his/her care needs (repositioning and
cleanliness).
• Become Bedridden
Due to the increased weakness
or other health complications,
the resident may become
immobile.
• Changes In Breathing
The resident may experience “apnea” –(when
the person stops breathing for 10 – 20 seconds).
May experience Cheyenne-Strokes breathing –
(where the person breathes very rapidly for a
moment and stops breathing the next).
• Changes In Breathing, Continued…
Irregular breathing may occur such as what is
known as “wet breathing”. –(When the person’s
breathing creates a “wet” sounding noise when
exhaling).
• Changes In Breathing, Continued…
Any of these breathing irregularities can cause
extreme concern for the family and/or
responsible party of the dying resident.
• Other Changes In Physical Care Include:
- Nausea and/or vomiting
- Constipation
- Skin breakdown
- Pain
• What are some
emotional changes
you have seen with
residents at the end
of his/her life?
Important factors to keep in mind when caring
for a resident at the end of his/her life:
• A resident with a terminal illness, (medically
diagnosed with 6 months or less to live), will
likely have changes in his/her care needs.
• Staff will need to anticipate and respond to
changes in the level of involvement of family
members and relatives, depending on the
situation.
• Maintain Respect and Dignity
• Know and
understand any
advanced
directives in
place
Continual Communication Is Key!
First Response
• Address any changes that need to take place
to the resident’s care and services.
• Implement
resident’s
communicated
preferences for
end of life
care.
What you need to know
HOSPICE CARE REGULATIONS
CCLD Title 22 Regulations
RCFE Title 22 Regulations regarding hospice care
standards and procedure policies.
• Defined in Regulation 87101(h)(6) “Hospice or
Hospice Agency”; 87101(f)(1) “Facility Hospice
Care Waiver”; and 87101(h)(7) “Hospice Care
Plan”
Regulations
87101
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
DEFINITIONS (Continued)
87101 (Cont.)
87101
(7)
"Existing Facility" means any facility operating under a valid license on the date of
application for a new license.
(1)
"Facility Hospice Care Waiver" means a waiver from the limitation on retention of residents
who require more care and supervision than other residents and residents who are bedridden
other than for a temporary illness. The Hospice Care Waiver granted by the Department will
permit the retention in a facility of a designated maximum number of terminally ill residents
who are receiving hospice services from a hospice agency. The Facility Hospice Care
Waiver will apply only to those residents who are receiving hospice care in compliance with
a hospice care plan meeting the requirements of Section 87633, Hospice Care for Terminally
Ill Residents.
(2)
"Federal Bureau of Investigation (FBI) Clearance" means an individual has no felony or
misdemeanor convictions reported by the FBI. The individual may also have been arrested
with no criminal conviction, convicted of a minor traffic offense or adjudicated as a juvenile.
(g)
(1)
"Guardian" means a person appointed by the Superior Court pursuant to Probate Code section
1500 et seq. to care for the person, or person and estate, of a child.
(h)
(1)
"Healing wounds" include cuts, stage one and two dermal ulcers as diagnosed by a physician,
and incisions that are being treated by an appropriate skilled professional with the affected
area returning to its normal state. They may involve breaking or laceration of the skin and
usually damage to the underlying tissues.
(2)
"Health Care Provider" means those persons described in Probate Code section 4621: "an
individual licensed, certified, or otherwise authorized or permitted by the law of this state to
provide health care in the ordinary course of business or practice of a profession."
(3)
"Health Care Surrogate Decision Maker" means an individual who participates in health care
decision making on behalf of an incapacitated resident. Health care surrogate decision maker
may be formally appointed (e.g., by the resident in a Durable Power of Attorney for Health
Care or by a court in a conservatorship proceeding) or, in the absence of a formal
appointment, may be recognized by virtue of a relationship with the resident (e.g., the
resident's next of kin). The licensee or any staff member of the facility shall not be appointed
health care surrogate decision maker.
(4)
"Health Condition Relocation Order" means written notice by the Department to a licensee
requiring the relocation of a resident from a residential care facility for the elderly because
the resident has a health condition which cannot be cared for within the limits of the license,
requires inpatient care in a health facility or has a prohibited health condition as specified in
Section 87615, Prohibited Health Conditions.
(f)
CALIFORNIA-DSS-MANUAL-CCL
MANUAL LETTER NO. CCL-08-01
Page 15
Effective 3/5/08
87101 (Cont.)
87101
(i)
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
DEFINITIONS (Continued)
Regulations
87101
(5)
"Home Economist" means a person who holds a baccalaureate or higher degree in home
economics and who specialized in either food and nutrition or dietetics.
(6)
"Hospice or Hospice Agency" means an entity which provides hospice services to terminally
ill persons, is Medicare certified for hospice, and holds either a Hospice license or a Home
Health Agency license from the California Department of Health Services.
Any
organizations, appropriately skilled professionals, or other professional persons or entities
that are subcontracted by the hospice or hospice agency for the provision of specified hospice
services to the resident are included within the definition. The hospice agency providing
services in an RCFE shall not subcontract with the licensee or any facility staff for the
provision of services.
(7)
"Hospice Care Plan" means the hospice agency's written plan of care for a terminally ill
resident. The hospice shall retain overall responsibility for the development and maintenance
of the plan and quality of hospice services delivered.
(1)
"Immediate Need" means a situation where prohibiting the operation of the facility would be
detrimental to a resident's physical health, mental health, safety, or welfare. Examples of
immediate need include but are not limited to:
(A)
A change in facility location when residents are in need of services from the same
operator at the new location;
(B)
A change of facility ownership when residents are in need of services from the new
operator.
(2)
"Initial Certification Training Program Vendor" means a vendor approved by the Department
to provide the initial forty (40) hour certification training program to persons who do not
possess a valid residential care facility for the elderly administrator certificate.
(3)
"Initial Vendor Application" means the application form, LIC 9141, used to request approval
from the Department to become a vendor for the first time.
(4)
"Instruction" means to furnish an individual with knowledge or to teach, give orders, or
direction of a process or procedure.
CALIFORNIA-DSS-MANUAL-CCL
MANUAL LETTER NO. CCL-08-01
Page 16
Effective 3/5/08
Hospice Waiver
• RCFE Title 22 Regulation 87632 – Hospice Care
Waiver
• Regulation 87633 and 87716 – Hospice Care
For Terminally Ill Resident
Total Care Plans
• What is allowed, restricted or prohibited in
assisted living and residential care?
• What information do you need to know when
contacting the hospice agency?
Hospice Assistance
• It is vitally important to work as a team
• Caregivers and
Hospice Agency
Staff must work
together to provide
the highest quality
of care for the
resident and
his/her family
during this stage of
life.
Fulfilling Resident’s Expressed Wishes
ADDRESSING ADVANCE DIRECTIVES
Because I could not stop for death
He kindly stopped for me
The carriage held but just ourselves
And immortality
~ Emily Dickinson ~
• What is an
advanced directive?
Advanced Directives
• Advance directives are legal documents that
allow the resident to convey his/her decisions
about medical and end of life care.
– May be used if the resident becomes ill and is
unable to communicate his/her wishes.
Advanced Directives May Include:
• Medical Power of Attorney
• Living Will
• Request to forego resuscitation (DNR)
• POLST (Physician’s Orders For Life-Sustaining
Treatment)
Putting It In Layman’s Terms…
• Medical Power of Attorney
A document that legally states a person selected
by the resident to make decisions about his/her
medical care if he/she is temporarily or
permanently unable to communicate and make
decisions for himself/herself.
Effective when physician declares resident
unable to make decisions.
Putting It In Layman’s Terms…
• Living Will
A living will contains instructions given by the
resident specifying what actions should be taken
for his/her health in the event that the resident
is no longer able to make decision due to illness
or incapacity.
A living will usually
provides specific
directions about the
course of treatment
that is to be followed
by health care
providers and
caregivers.
A living will may forbid the use of various kinds
of burdensome medical treatments, express
wishes about the use of food and water if
supplied via tubes or other medical devices.
• DNR
DNR stands for Do Not
Resuscitate.
• DNR
It is a very specific type of advance directive
requested by the resident to not have CPR if
his/her heart stops beating or if he/she stops
breathing.
DNR Orders:
• Must be signed by both the resident and
physician (not valid if not signed by the
physician)
• Allows a person to forego resuscitation in an
emergency situation
• Is capable of being revoked
• Is not required by law
• POLST Form
Is a written physician’s
order that documents
a resident’s wishes for
life sustaining
treatment.
The POLST form goes with the resident during a
medical emergency requiring transfer by
emergency medical personnel or others.
It ensures readily available information for
health care providers about resident’s treatment
preferences and complements the advance
health directive.
The POLST form is not used in every state.
The POLST form is not required by law.
As a person comes to
the end of life or
becomes terminally
ill, he/she has the
choice whether or not
to receive CPR in an
emergency situation.
If the individual does
want to receive CPR,
then he/she would not
need to take any
further action.
If the individual chooses
not to receive CPR, then
he/she would need to
speak with his/her
physician about signing a
DNR Order to ensure that
his/her wishes are
followed if/when the
person stops breathing or
his/her heart stops
beating.
Understand this may not be a simple choice for
the resident.
Encourage your resident and their families to
consider all the options and discuss while the
resident is able to decide for himself/herself.
Do you have any additional questions about DNR
Orders, the POLST Form or other Advanced Directives?
www.polst.org or
http://www.nlm.nih.gov/medlineplus/ency/patientins
tructions/000473.htm
Honoring Resident’s Wishes
• What would you do?
Understanding where your resident is at in the process
FIVE STAGES OF GRIEF AND LOSS
Denial
Anger
Bargaining
Depression
Acceptance
Working through these stages with your resident
at the end of life and providing support for
his/her family.
How Would You Respond?
• Take a moment to examine several case
studies regarding examples of
residents/families going through various
stages of grief and loss.
• What would your response be and why?
Finding useful support to provide quality assistance
COMMUNITY RESOURCES
Community Resources
• Grief/Loss counseling groups
• Clergy
• Online resources
To Sum It Up…
• It is important to recognize and respond to the
physical and psychological changes that may
take place in the resident during this phase of
life. Many times, the care extends beyond the
resident and may include immediate family
members, close relatives, and lifelong friends.
Responding in a compassionate and
understanding way can be a huge key for
success at providing the highest quality of care!
Perhaps they are not stars, but
rather openings in heaven
Where the love of our lost ones
pours through and shines down
upon us to let us know they are
happy
~ Eskimo Proverb ~
Discovering what you have learned
CHECK FOR UNDERSTANDING
Check For Understanding Exam
1. Which of the following feelings are included
in the five stages of grief and loss?
a. Denial
b. Acceptance
c. Anger
d. All of the above
Check For Understanding Exam
2. When a person is diagnosed with a terminal
illness, this means they have less than _____
to live?
a. One year
b. 6 months
c. 2 years
d. 3 months
Check For Understanding Exam
3. _____ is the attempt to restart breathing
and/or the heartbeat of a person who is no
longer breathing or his/her heart has
stopped beating.
a.
b.
c.
d.
Mechanical Ventilation/Respiration
Intravenous Fluids
Cardiopulmonary Resuscitation
Physician Orders for Life Sustaining Treatment
Check For Understanding Exam
4. A Living Will is the same as a DNR Order.
a. True
b. False
5. Not every state has a POLST Program.
a. True
b. False
Check For Understanding Exam
6. Depression is an unnatural emotion that
should never be experienced when dealing
with end of life.
a. True
b. False
Check For Understanding Exam
7. When a person is nearing the end of life, they
generally ________
a. Become more responsive
b. Become less responsive
c. Show same level of responsiveness
Check For Understanding Exam
8. A DNR Order _______________
a. Must be signed by both the physician and
resident
b. Allows a person to forego resuscitation in
an emergency situation
c. Can be revoked
d. All of the above
Check For Understanding Exam
9. The POLST form should be maintained in a
location recognized by the emergency
medical responders.
a. True
b. False
Check For Understanding Exam
10. The licensee shall be permitted to retain
terminally ill residents who receive hospice
services from a hospice agency in the facility
if all of the conditions specified in Title 22 are
met:
a. True
b. False
Start here. Go anywhere.
Thank you for choosing Care and Compliance
Group, Inc. for your educational needs. For any
additional information please feel free to call us
or visit our website at:
www.careandcompliance.com
(800) 321-1727
Additional Resources
Total Care Exceptions
First Aid, CPR, and DNRs
Total Care
BACKGROUND
WHAT IS TOTAL CARE?
• Total care is defined as
a condition where
residents depend on
others to perform all of
their activities of daily
living.
• A prohibited condition,
per regulation 87615.
BACKGROUND
•
•
An exception must be
obtained to retain a
resident who requires
total care in an RCFE
Old process:
Obtain hospice waiver
Accept/retain resident
on hospice
Resident becomes “total
care”
Request total care
exception
New CCL Total Care Policy
NEW CCL TOTAL CARE POLICY
•
•
•
CCL has updated their total care policy to
streamline and expedite the process.
Update is in section 87632 of the RCFE Evaluator
Manual. Available at www.ccld.ca.gov
As written it only applies to “total care” residents
who are receiving hospice services.
NEW CCL TOTAL CARE POLICY
•
New policy in a “nutshell:”
Submit 2 (of 3) required exception
components in advance as part of
your hospice waiver
(Total Care Plan)
NEW CCL TOTAL CARE POLICY
•
All exception requests must include (87616):
1. Documentation of the resident's current health condition
including updated medical reports, other documentation
of the current health, prognosis, and expected duration of
condition.
2. The licensee's plan for ensuring that the resident's health
related needs can be met by the facility.
3. Plan for minimizing the impact on other residents.
NEW CCL TOTAL CARE POLICY
•
New Total Care Policy
SUBMIT
ADVANCE
AS
1. Documentation of the resident's
currentINhealth
condition
PART
OFdocumentation
HOSPICE
including updated medical reports,
other
WAIVERduration of
of the current health, prognosis, and expected
condition.
2. The licensee's plan for ensuring that the resident's health
related needs can be met by the facility.
3. Plan for minimizing the impact on other residents.
NEW CCL TOTAL CARE POLICY
•
New Total Care Policy
1. Documentation of the resident's current health condition
including updated medical reports, other documentation
of the current health, prognosis, and expected duration of
condition.
2. The licensee's plan for ensuring that the resident's health
related needs can be met by the facility.
3. Plan for minimizing the impact on other residents.
MET VIA RESIDENT”S
HOSPICE CARE
(RETAIN ON FILE)
NEW CCL TOTAL CARE POLICY
Obtain Total Care Plan Approval
Request total care exception request when notifying CCL of
the initiation of hospice services
Propose hospice care plan as variance to 87616(1)
NEW CCL TOTAL CARE POLICY
What if I already have a hospice waiver?
Submit an addendum to the existing hospice care
waiver plan that includes the total care component. If
the Department approves this addendum, the
licensee may then use the option of requesting the
total care exception under the simplified methods
noted above.
The Total Care Plan
TOTAL CARE PLAN
•
•
Submit in advance as part of hospice waiver.
Must include:
• The licensee’s plan for ensuring that current total
care residents’ health related needs can be met, or
provisions made for them to be met by the licensee.
• How it will minimize this impact on the other
residents.
TOTAL CARE PLAN
PLAN FOR ENSURING HEALTH RELATED
NEEDS CAN BE MET:
•
Staff training
•
Additional support from hospice care staff
•
Family/volunteers
•
How will you manage medications?
•
Bedridden?
TOTAL CARE PLAN
MINIMIZING IMPACT ON OTHER RESIDENTS:
•
Private rooms
•
Ensuring “sufficient” staff
•
Adjustments to staff schedules
•
Backup staff
First Aid, CPR, and DNRs
EFFECTIVENESS OF CPR
•
CPR is not like you see
in movies and television.
EFFECTIVENESS OF CPR
5-10%
of people who undergo CPR
will survive
EFFECTIVENESS OF CPR
15-24%
of people who undergo CPR
in the hospital will survive
to discharge
EFFECTIVENESS OF CPR
0-5%
of frail nursing home
residents survive CPR
EFFECTIVENESS OF CPR
3x
persons with advanced
dementia have survival
rates 3x lower than those
without dementia
First Aid and CPR Requirements
FIRST AID AND CPR REQUIREMENTS
•
•
•
87411
Personnel requirements
“Staff providing care shall receive appropriate
training in first aid…”
FIRST AID AND CPR REQUIREMENTS
•
•
•
First aid kits
Advanced directives
AED
Advanced Directives
ADVANCED DIRECTIVES
Health and Safety Code § 1569.156:
• Not condition the provision of care or otherwise
discriminate based on whether or not an individual
has executed an advance directive, consistent with
applicable laws and regulations.
ADVANCED DIRECTIVES
Health and Safety Code § 1569.156:
• Provide education to staff on issues concerning
advance directives.
• Provide written information, upon admission, about
the right to make decisions concerning medical
care, including the right to accept or refuse medical
or surgical treatment and the right, under state law,
to formulate advance directives.
• Provide written information about policies of the
facility regarding the implementation of the rights
described
ADVANCED DIRECTIVES
•
•
•
Must give to all residents
PUB 325
www.ccld.ca.gov
ADVANCED DIRECTIVES
•
•
•
POLST
Standardized
advanced directive
format
www.capolst.org
ADVANCED DIRECTIVES
ADVANCED DIRECTIVES
ADVANCED DIRECTIVES
ADVANCED DIRECTIVES
HONORING A DNR
•
•
•
87469
If a resident who has a DNR
on file experiences a medical
emergency, facility staff shall
do one of the following:
Immediately telephone 9-1-1,
and present the DNR to the
responding emergency
medical personnel
HONORING A DNR
•
•
•
87469
If a resident who has a DNR on file
experiences a medical emergency,
facility staff shall do one of the
following:
Immediately give the DNR to a
physician, RN, or LVN, if in the
resident's presence at the time of
the emergency and assumes
responsibility
HONORING A DNR
•
•
H&S Code Section 1569.73
“A facility that has obtained a hospice waiver from
the department pursuant to this section need not
call emergency response services at the time of a
life-threatening emergency if the hospice agency is
notified instead…”
AEDs
AED
•
•
87607
RCFEs are permitted to
maintain and operate
automated external
defibrillators (AED)
AED
•
•
•
•
Must notify CCL in writing
Staff who will operate
must have a valid
“operator’s certificate”
Must document quarterly
proficiency
demonstrations
Must maintain an AED
supply kit
Common Questions
COMMON QUESTIONS
What should our policy be?
• No simple answer
• Depends on your organization and your staff
• Options:
•
•
•
•
No CPR, call 9-1-1
Caregivers no CPR, nurses can do CPR, call 9-1-1
Train everyone in CPR
Train at least one person in CPR
COMMON QUESTIONS
What do I tell my staff?
• Tell them to call 9-1-1
• Nurses can initiate CPR based on their clinical
judgment and comfort level
COMMON QUESTIONS
What do I tell my residents?
• Make sure they are aware of your CPR policies
• Talk to them about end of life wishes
Evaluation
www.careandcompliance.com/eval
If you have not completed your
evaluation please take time to complete
when time permits, your feedback is
greatly appreciated.