The Oncology Social workers Role in Palliative care'

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The Oncology Social workers Role in Palliative
care.

• A Review of the unique and pivotal role the
  oncology social work plays in the Palliative care
  team.

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Road Map

• Importance Advance care planning
• (speaking about the unspeakable )
• Preparation for end of life care
• Professionals role in facilitating open
  communication as part of persevering dignity
  (Intervention strategies that preserve dignity
  and allow for meaning making )
• Preserving Dignity in Palliative care setting

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WHO Palliative Care Skills

• Communication
• Decision making
• Management of illness and treatment complications
• Symptom control
• Psychological spiritual care of patient and
  family
• Care of the dying
• Any National cancer plan should address
  palliative care

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Model Organisations of Palliative care

• Fully developed palliative care programs now
  include the following
• Homecare
• Hospital based consultation services
• Daycare
• Inpatient care
• Bereavement support
• Training programs/Research
• Internet based virtual services

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Good and Bad Deaths

• Bad Death
• Characterized by needless suffering, disregard of
  patient and familys wishes or values sense among
  participants that decency have been offended.
  Death resulting from neglect, violence or
  unwanted and senseless treatment

• Good Death
• Free from avoidable distress and suffering for
  the patient, family and caregivers in general
  accord with patients family wishes
  reasonability consistent with clinical cultural
  and ethical standards.
• Encourages
• Sensitive regard for the dying patient and how
  life can be lived in the face of death
• Comes with reasonable warning
• Occurs in the company of loved ones
• Provides opportunity for reconciliation with
  family, friends and achieves peace, meaning and
  transcendence

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Professional Quality End of Live care

• Overall quality of Live
• Physical well being and functioning
• Psychological well being and functioning
• Spiritual well being
• Patient perception of care
• Family well being and perceptions of care

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Patient Perspective on Quality End of Live care

• Adequate pain and symptom management
• Avoiding inappropriate prolongation of dying
• Achieving a sense of control
• Relieving the burden
• Strengthening relationships

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Dignity and Palliative care

• Working in palliative care needs a sensitive
  multidisciplinary team that allows for
  interpersonal refection and growth to prevent
  compassion fatigue and burnout.
• How do we as team members choose to be present
  for our patients in the palliative care setting
  and how are we addressing the needs of our
  patients and their families .
• Focus on the authenticity of the relationships we
  build with our clients and on intervention
  strategies that have these values at its core .
• Team Question
• DID WE DO ENOUGH TO ACHIEVE CURE ,PROLONG
  SURVIVAL?

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9 dimensionsof assessment

• 1. Illness / treatment summary
• 2. Physical
• 3. Psychological
• 4. Decision making
• 5. Communication

• 6. Social
• 7. Spiritual
• 8. Practical
• 9. Anticipatory planning for death

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Moving Beyond Symptom management

• Symptom management as our first priority but not
  ultimate goal
• Provide symptom management while not being blind
  to the profound personal nature of the dying
  experience

• Shift from seeing dying as a time of unavoidable
  suffering to understanding dying as a normal
  and valuable part of a full and healthy life a
  time of opportunity for growth, enhanced meaning
  and a sense of completion
• To achieve this professionals have to be trained
  in working with the concepts redirecting f hope,
  meaning making as part of end of life care

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2 Roads to death
THE DIFFICULT ROAD
Confused
Tremulous
Restless
Hallucinations
Normal
Mumbling Delirium
Sleepy
Myoclonic Jerks
Lethargic
Seizures
Obtunded
THE USUAL ROAD
Semicomatose
Comatose
Death
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Fixed characteristics of the patient
Diagnosis, prognosis
Race, ethnicityand culture
Religion
Socioeconomicclass
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Modifiable dimensions
Spiritual, cultural,existential beliefs
Economicdemands
Physical symptoms
Patient
Caregivingneeds
Hopes,expectations
Social relationships, support
Psychological, cognitive symptoms
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Health system interventions
Community
Institutions
Family /friends
Health professionals
Patient
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Patient
Utilization
Pain /symptom relief
Qualityof life
Satisfaction
Outcomes
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5 steps for successful advance care planning

• Introduce the topic
• Engage in structured discussions
• Document patient preferences
• Review, update
• Apply directives when need arises

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The Patients story as part of assessing
suffering

• Hearing the narrative of what the suffering is
  about.
• Hear the language that is used .
• Hear the metaphors patients use to describe their
  pain and sense of loss .
• Listen for
• Physical pain
• Psychological pain
• Spiritual pain
• Allowing a process of validation and ascribing
  meaning to their experience assist in creating
  meaning threw the suffering

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Meaning of illness

• Fears concerns
• Illness
• Death dying
• Changes and losses
• Family / self / role
• Control

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Emotional responses to illness

• Avoidance, denial
• Fear, anger
• Lability, irritability
• Intellectualization
• Grief
• Acceptance, spiritual peace

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Fears

• Loss of control, dignity
• Loss of relationships
• Being a burden
• Physical suffering

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Elicit the patients values and goals

• Ask about past experiences
• Describe possible situations
• Write a letter

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Common pitfalls

• Failure to plan
• Proxy absent for discussions
• Unclear patient preferences
• Focus too narrow
• Communicative patients are ignored
• Making assumptions

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. . . Preparation for last hours of life

• Educating / training patients, families and
  caregivers
• communication
• tasks of caring
• what to expect
• physiologic changes, events
• symptom management
• Advance planning
• personal choices
• caregivers
• setting
• Loss, grief, coping strategies

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Choice of caregivers

• Be family first, caregivers only if comfortable
• everyone comfortable in the role
• seek permission
• change roles if stressed

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Choice of setting . . .

• Burdens, benefits weighed
• Minimize family burden
• risk to career, personal economics, health
• ghosts
• Permit family presence
• privacy
• intimacy

Alternate setting as backup
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Anticipatoryplanning for death

• Current losses
• Anticipated losses
• Advance care planning
• Advance planning for last hours and after death

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Elicit the patients values and goals

• Ask about past experiences
• Describe possible situations
• Write a letter

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Preparation for the last hours of life . . .

• Advance planning
• personal choices
• caregivers
• setting
• Loss, grief, coping strategies

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Advance practical planning . . .

• Financial, legal affairs
• Final gifts
• bequests
• organ donation
• Autopsy
• Burial / cremation
• Funeral / memorial services
• Guardianship

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Choice of caregivers

• Be family first, caregivers only if comfortable
• everyone comfortable in the role
• seek permission
• change roles if stressed

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. . .Choice of setting

• Burdens, benefits weighed
• Permit family presence
• privacy
• intimacy
• Minimize family burden
• risk to career, personal economics, health
• ghosts
• Alternate setting as backup

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. . . Preparation for last hours of life

• Educating / training patients, families and
  caregivers
• communication
• tasks of caring
• what to expect
• physiologic changes, events
• symptom management

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. . . Teamwork

• Teamwork usually includes
• physicians
• nurses
• social workers
• chaplains
• others
• Hospice philosophy can be integrated into
  mainstream practice
• The whole person goes through the dying process,
  not just his / her physiology
• No one person can meet all the needs

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Barriers

• Institutional
• Regulations
• Reimbursement
• Attitudes

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Families . . .

• How we die is an important personal legacy
• Dying well often demands
• the chance to be close to family, friends
• family / proxy assistance with decisions
• good communication

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Redirection of Hope

• Alternatives to Hope for Cure
• Hope for symptom control
• Hope for quality of life until death
• Hope for a dignified death
• Hope for sustained meaning
• Hope for reconciliation
• Hope for forgiveness
• Hope for a legacy

• Task of the patient at end of Life
• Sense of completion of worldly affairs
• Sense of completion of relationships with family
  and friend
• Sense of meaning about ones life
• Experience love of self and others
• Acceptance of finality of life and ones
  existence as an individual
• Surrender to the unknown-
• letting Go

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Tasks for relationship Completion

• Expression of regret
• Expression of Forgiveness
• Acceptance of gratitude and appreciation
• Leave taking

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What we need to say before we die

• I forgive you
• Please forgive me
• I love you
• Thank you for loving me
• Goodbye

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Dignity Psychotherapy Model / QuestionDignity
is in the eye of the Beholder By Havey Max
Chochinov

• Protocol
• Tell me a little about your life history the
  parts that you either remember most important?
• When did you feel most alive?
• Are there specific things that you would want
  your family to know about you, and are there
  particular things you would want them to
  remember?
• What are the most important accomplishments, and
  what do you feel most proud of?
• Are there particular things that you feel still
  need to be said to your loved ones or things that
  you would want to take the time to say once
  again?
• What are your hopes and dreams for your loved
  ones?
• What have you learned about life that you would
  want to pass along to others?
• What advice or words of guidance would you wish
  to pass along to your (son, daughter, husband,
  wife, parents, others?
• Are there words or perhaps even instructions that
  you would like to offer your family to help
  prepare them for the future?
• In creating this permanent record, are there
  other things that you would like to include?

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Havey Max Chochinov et al Dignity therapy model
Havey Max Chochinov et al Dignity therapy model
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Dignity categories/ themes
From Dignity is in the eye of the Beholder By
Havey Max Chochinov
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William BreitbartGroup work program Meaning
Centered Psychotherapy A spiritual intervention
for Loss of Meaning and Hopelessness

• 8 session group work model
• Concepts of Meaning
• Cancer and Meaning
• Meaning in the Historical Context of Life
• Legacy project
• Meaning and Attitudinal Values Limitations,
  finiteness life
• Meaning and creativity responsibility , deeds
• Meaning Experience (Nature,Art, Humor)
• Termination, Goodbyes Hope for the future

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Resources and Acknowledgments
1
2
Dignity is in the eye of the Beholder By Havey
Max Chochinov
3. Reframing Hope Meaning - Centered
care for patients near the end of Life By
William Breitbart
4
Palliative Care The Basics for Psycho-oncologist
William Breitbart Steven Passik
Communicating with Realism and Hope Incurable
cancer patient's Views on Disclosure of
prognosis.
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