By: Carey Burleigh RSW and Clara Nisan, NP-PHC
Mackenzie Health LTC, Richmond Hill
Providing high quality palliative care is essential for meeting the changing needs of long-term care (LTC) residents. Ontario seniors are remaining at home longer. They are being admitted to LTC with later stage and end stage health conditions. Care providers need to be prepared to meet the complex palliative care needs of these residents and their families.
At Mackenzie Health LTC, we strive to provide our residents with the highest quality of care possible. We plan care with their values and wishes in mind. We aim to improve the quality of living and quality of dying for residents diagnosed with end stage disease and life limiting illnesses. This involves keeping residents as comfortable as possible in their final days and hours. We also focus on supporting residents and their families throughout the collaborative process of preparing for dying.
With leadership support, we worked on staff capacity building and program development to enhance the quality of palliative care at our home. We found many excellent resources on pain and symptom management in the RNAO LTC Best Practices Toolkit.
Our RNAO LTC Best Practice Coordinator, Sue Bailey, presented an end of life care webinar that we attended along with other Central LHIN LTC staff. This review of the RNAO Best Practice Guidelines for end of life care helped us with implementing our program. We also attended RNAO’s LTC Best Practices Program webinar on ‘Comfort Feeding Only’.
Our home is participating in the IDEAS Advanced Learning Program for Palliative Care, in order to learn about quality improvement strategies and apply new processes to enhance palliative care delivery in long-term care.
At Mackenzie Health LTC, we integrate the philosophy of aging in place, from pre-admission to death. We begin, as early as possible, to identify residents who are approaching end of life. The physician or nurse practitioner completes clinical assessments. We use the Gold Standard Framework and the Palliative Performance Scale to identify residents at risk for significant decline. Residents and families then participate in goals of care discussions with the inter-professional team. Together we determine how best to support end of life needs and wishes. This can be challenging at times. Some do not feel comfortable having this type of conversation. Some have unrealistic expectations that need to be addressed. It is so important to develop trusting relationships with our residents and families, to provide them with choices that help with decision-making, and to respect their values and beliefs.
Residents may or may not have an Advanced Care Plan to refer to and integrate into their plan of care. Either way, we work with families and SDMs to develop a care plan that most closely reflects the resident’s wishes regarding end of life care.
If a resident is identified as being palliative, our inter-professional palliative care team is notified. A discussion then takes place with frontline staff regarding the change in level of care. We inform our residents and families about available spiritual support. Our Chaplain is notified if support is requested. In order to provide optimal pain and symptom management, our team refers residents to the Clinical Nurse Consultant of the Hospice Palliative Care Team, from the Central LHIN. If one of our residents receiving hemodialysis is identified as palliative, we meet with the Dialysis Team.
Our holistic approach to palliative care includes addressing psychosocial, physical and spiritual needs. Residents, families and LTC staff work together to develop and revise care plans, to meet the changing needs of our residents.
Our home has implemented the use of Comfort Carts. Each cart is equipped with a CD player, an essential oil machine, calming oils, and lotion for hand massage. We also have books and magazines on the cart and refreshments for the family. Each resident nearing end of life receives a hand knitted blanket that the family can keep.
We provide families with information about what to expect at the end of life. Families wishing to spend the night with their loved ones are provide with a chair that converts to a bed. Complimentary meal tickets are also provided. We offer volunteer support to residents who do not have family or have limited family involvement in their care. If required, we refer families to visiting hospice for bereavement support.
To honor a resident in their final journey, we call a "Code Butterfly". We create a quiet environment by turning off the television and stopping the work we are doing to show respect for the resident and family. Staff, residents, and families are invited to take a moment of pause as the body is escorted out of our home. This practice has been fully adopted by the staff on all shifts.
The outcomes of having a formal palliative care program in long-term care are many. Both residents and families have responded positively to our palliative care approaches. The promotion of aging in place and improved quality of care has resulted in reduced emergency department transfers. This has freeing up hospital beds. Residents are more comfortable now that they have better pain and symptom management. Staff is more knowledgeable, and feels more confident in providing end of life care. Residents and families feel more satisfied with the care provided after being part of the care planning process.
Our palliative care residents and their families are receiving the right care at the right time by the right providers. Although the loss of any resident is difficult for us all, we know that we are doing the best we can to allow our residents to die with dignity and to honour the lives they lived.
-About Mackenzie Health Long-Term Care Facility-
Mackenzie Health LTC is a 168-bed not-for-profit home in Richmond Hill, Ontario, in the Central LHIN. It is attached to the Mackenzie Health Hospital and is managed by Universal Care, Inc.