Few nursing home residents want to talk about dying. Silvercrest Center for Nursing and Rehabilitation, Briarwood, N.Y., has a regional expertise in caring for residents who are dependent on ventilators and/or feeding tubes, so it receives a high proportion of resident referrals who have experienced catastrophic accidents, incapacitating strokes and traumatic brain injuries. Some of these residents will recover well enough to go home again. But some will not.
Helping these residents and their families to understand the role of hospice care is a key factor in reducing avoidable hospital visits. But many of Silvercrest's residents arrive with no advanced directive and little understanding of hospice and palliative services.
During the initiative, Silvercrest educated its staff in advanced directives documentation, the Health Care Decision Act and the electronic Medical Orders for Life-Sustaining Treatment (eMOLST) protocols. Several staffers earned certification in palliative care, including the social services director, the vice president of nursing and the chief clinical dietitian.
Meanwhile, Silvercrest actively educated families and residents on advanced directives, symptom management and the concept of acceptance as a care plan. As a result, the number of residents embracing palliative care soared by 45 percent.
“We try to educate families on why aggressive care is not always the best choice,” says Denise Lawson Munroe, director of performance improvement and risk management. “Is taking the resident to the ER really going to make a quality difference for the resident?”
Silvercrest’s palliative care team meets weekly to discuss resident prognoses, and constantly grapples with the fact that most new residents don’t arrive with advanced directives. “Sometimes the families don’t even know what their choices are,” says Jennifer Yalch, CSW. “Conversations can start at the primary care level, but then we need to continue those conversations about end-of-life care.”
Silvercrest is fortunate to have a deep team of seven social services professionals onsite. Their involvement begins at intake, and continues daily throughout the resident’s stay. “We make sure residents and families have all the necesssary information to make educated choices, especially when it comes to the end of life,” says Maureen Peters, ACSW, LCSW, director of Social Services. “We explain that it’s about ‘what does the resident really want?’”
As an added factor, Silvercrest is located in one of the most ethnically diverse neighborhoods of New York, which includes some 200 different languages. The social services team provides communication relating to life quality and end-of-life choices, including explaining the resident’s condition and prognosis across language and cultural values. For some families, the team needs to address the patriarch; whereas for others, the matriarch or a sibling is the best place to start. In other situations, the resident’s own views will be expressed through a surrogate or translator, Peters explains. “Sometimes you need to speak with the son or daughter, in order to respect the resident’s way of life.”
These are the situations where the cross-team approach works best, says Elister Dennie, RN, clinical care coordinator, during the weekly ventilator rounds meeting. “Their culture affects their beliefs on health. We have to learn how to listen differently.”
When hospice care is involved, the care necessarily goes beyond the resident beds. “You have to treat the family as well as the resident,” says Mustafa Salehmohamed, DO, one of the pulmonologists who regularly does rounds here. “We determine the resident’s stability, but then we have to get to know them and their family.”
Working with hospice care residents requires high-level medication management, Dennie adds. “We want to get the [hospice] residents to the point where they’re comfortable, but not unable to enjoy a family visit, which keeps them happy in the quality of that moment.”
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