Palliative Care

Our Palliative Care team works with people who have been diagnosed with a chronic, life-limiting condition. Our team of skilled clinicians engage patients and families in goals of care discussions, provide support with navigating the health care system, and education regarding symptom management and treatment options. Our goal, to improve quality of life and enhance comfort and wellbeing for those we serve, is always front and center of everything we do.

ASSISTANCE COMPLETING ADVANCE DIRECTIVES

• Ensure Health Care Power of Attorney (HC-POA) is complete, up to date, and available.

• Evaluate patients for any changes in decision making capacity and activate HC-POA, if needed and appropriate.

• Education regarding financial power of attorney.

EDUCATION AND ASSISTANCE ON DNR/DNI OR FULL CODE STATUS

• Can start the conversation of DNR/DNI and full code and what that means and complete necessary documentation and provide DNR bracelet, if needed. 

ASSISTANCE IN COMMUNICATION WITH PROVIDERS

• Recommendations including increasing or changing antidepressant medication due to patients worsening symptoms, pain medication recommendations or alternatives, medication for sundowning/agitation for dementia and more.

• Collaboration regarding plan of care and “closing the loop” of multiple providers for patient and family.

PROVIDE PATIENT/FAMILY EDUCATION ON THE TOPICS OF:

• Fall prevention.

• DNR/DNI and full code along with HCPOA education.

• Disease progression teaching.

• Reasons to call MD or go to ER.

• Medication side effects, uses, things to watch for, purpose of medication.

• Teaching of palliative vs. hospice and services included.

• Resources such as ADRC, Meals on Wheels, Grief resources and other services the patient may qualify for.

• Nutrition education and pressure ulcer prevention education.

ASSISTANCE IN GAINING NEEDED SUPPLIES

• Assist the family in locating supplies such as walkers, wheelchairs, commodes, and other needed supplies along with resources for those who cannot afford these items.

• Assist in obtaining life alert devices for falls.

HOME SAFTEY RECOMMENDATIONS

• Assess safety, fall risks and problem solve with the patient/family.

• Notify providers if there is concern of worsening symptoms and/or reiterate medication changes and purpose of the change.

• Assess appropriateness of hospice and patient/family willingness to transition to hospice.

• Referral to Meals On Wheels recommendation for assistance with getting proper meal delivery.

GOAL OF CARE CONVERSATIONS

• Continued discussion of goals of care and concerns around evolving and ever-changing chronic conditions.

• How to prevent re-hospitalization by taking medications as prescribed, monitoring for symptoms and communication with providers.

• Provide empathetic listening and suggestions to ease burden of caretaking/disease process.

• Discuss options of support groups and or self-care techniques.

• Caregiver support and discussion of in-home assistance, private duty caregiver support, home nursing, and placement options, if deemed appropriate.

EVALUATE FOR CHANGE IN CAPACITY TO MAKE DECISIONS