Roland Munro was dying. High-risk surgery that resulted from a sudden fall and post-operative complications left the active, 87-year-old musician in unbearable pain and his children with a heartbreaking task – preparations for end-of-life care.
To provide comfort for their father in his final days, Roland’s children enlisted support from Sandra Del Signore, a Nurse Practitioner at The Scarborough Hospital and member of NPSTAT (Nurse Practitioners Supporting Teams Averting Transfers). This clinical outreach team is a collaborative effort by the Central East LHIN, TSH, the Central East Community Care Access Centre (CECCAC) and the Village of Taunton Mills to provide nursing home residents with the right care at the right time in the right place.
In addition to managing his care, Sandra worked with the long-term care physician, nursing home, TSH staff, and the family to ensure that Roland received care in his own bed. As a result of this team effort, Roland’s wishes to die peacefully and pain-free, surrounded by loved ones, were met.
About 90 per cent of nursing home residents have a life-limiting condition and may experience a long period of chronic illness with exacerbation of symptoms. Palliative care is usually initiated to provide comfort measures and reduce unnecessary suffering until the resident reaches the end-of-life stage.
“Our services allow residents to die in a place where they are comfortable, where the staff know them best, and where their wishes can be granted,” says Sandra. “If we recognize that they are dying and know they want comfort measures, we can facilitate this.”
Sandra adds that many of her patients have dementia and can become confused and distressed when removed from their nursing home and admitted to the hospital, particularly after a long wait in the emergency room.
NPSTAT was created as part of the LHIN’s overall strategy to decrease avoidable emergency department transfers and hospital ALC days. In addition to providing care to residents for acute and episodic illnesses, NPs work collaboratively as part of the interprofessional team to facilitate palliative and end-of-life care.
Thousands of long-term care residents across the CE LHIN benefit from this innovative program. According to Linda Dacres, NP and Clinical Director of NPSTAT, the result has been a 97 per cent reduction in emergency department transfers of LTC residents who were assessed and treated by the NPSTAT team. It is estimated that this represents a saving of several million dollars and thousands of emergency department (ED) hours.
“We believe the success of the program lies with our interprofessional approach to patient care,” says Susan Engels, Patient Care Director at TSH. “Our NPs work in collaboration with nursing home staff, physicians and hospital staff to provide LTC residents with care in their own beds.”
Whenever a transfer to the ED and/or admission to hospital are necessary, NPSTAT helps to facilitate a smoother and more coordinated return to the nursing home.
In addition to sharing best practices and healthcare initiatives, NPs also help to build capacity among nursing home staff by refreshing or introducing new skills and technologies such as initiating and managing IV antibiotics, rehydrating with hypodermoclysis, accessing and managing central access devices, maintenance of percutaneous drains and pain pumps, and changing G-Tubes.
“At end-of-life, there can be a lot of feelings of guilt,” explains NP Barbara Bickle, a TSH staffer and member of NPSTAT, adding that nurses feel obligated to send residents to the hospital to treat symptoms when care can be offered in the nursing home, where families wish them to stay. “If you’re really listening to the family and know they are speaking on behalf of the patient, they’re advocating for what he or she would have wanted.”
NPs also participate in family meetings to help address end-of-life issues and questions, explore family concerns, fears and wishes, assess family dynamics and expectations, and provide appropriate counselling.
“Families don’t want or expect heroics,” says Barbara. “They just want their loved one to be comfortable.”
Roland’s children, Dave Munro and Lynda Vera, appreciated the end-of-life care provided by Sandra in their father’s final days. In addition to collaborating with the attending physician, Sandra utilized her clinical expertise and skills to ensure Roland’s advance directives were met.
One such concern surfaced when Lynda and Dave remembered that their father had an internal defibrillator and they feared it would begin producing electric shocks as his heart shut down.
“We didn’t need him to be in any more pain,” says Dave. “Sandra went above and beyond, after hours, to work with the hospital and borrow a magnet that would stop the shocks from the defibrillator. My sister and I were so grateful she was there.”
Dave and Lynda remember their father as a jovial character who brought energy and joy to other residents in the nursing home. He lived there with his wife of 65-years, who suffers from dementia and who also received care from Sandra.
“In the end, the NPSTAT team considers it a gift to help LTC residents make the transition to a ‘good death’ and to hear families and staff tell us, ‘she or he died well’,” says Linda. “However, such deaths are exceptions in long-term care where the dying process is often unrecognized.”
She adds that a good death should be a healthcare priority – an indicator of our civility – as we plan our future state. Rather than interpreting the dying process as an end-point with no intrinsic value, it is imperative that we re-examine our commitment to do no harm – even at the threshold of death.