End-of-Life Education Among Respiratory Therapists PDF

End-of-Life Education Among Respiratory Therapists Chip Zimmerman, PhD, RRT-NPS, FAARC Department of Respiratory Therapy Georgia State University Any man’s death diminished me, because I am involved in mankind. John Donne, 1623 Meditation XVII By the end of this presentation,...

End-of-Life Education Among Respiratory Therapists Chip Zimmerman, PhD, RRT-NPS, FAARC Department of Respiratory Therapy Georgia State University Any man’s death diminished me, because I am involved in mankind. John Donne, 1623 Meditation XVII By the end of this presentation, participants will be able to… Have a basic understanding of the history of end-of-life education in the United States and apply the associated concepts to their daily practice. Be able to apply interventions designed to mitigate the impact of compassion fatigue to their daily practice in an effort to create opportunities for increased resilience in the workplace. 96% of practicing respiratory therapists have personally removed ventilator support from terminal patients. Willms and Brewer, 2005 Federal Uniform Determination of Death Act Prior to 1981, states defined death on their own Approved by AMA & ABA Offered no specific medical testing Irreversible circulatory/respiratory cessation or cessation of ALL brain function (including stem) What is Death? Clinical death No longer defined as cessation of heartbeat Brain death And Cortical death Persistent vegetative state Wakefulness with no detectable awareness Cellular/biological death Vernacular of Death as the Layman May Hear It Life support Implies that person is still alive Brain dead Suggests only the brain is dead Kept alive & allowed to die Suggest that loved one is still alive Shorthand Used for the Hospital Order That Means Do Not Call a Code…. Ochsner J. 2011 Winter; 11(4): 302–306; Copyright Academic Division of Ochsner Clinic SMOReS  Survival to Discharge for in-house Cardiac Arrest Survival from in-hospital cardiac arrest during nights and weekends. 14.7% at night 19.8% during the day/evening Peberdy MA, et al, National Registry of Cardiopulmonary Resuscitation Investigators.JAMA. 2008 Feb 20; 299(7):785-92 Mitigating Factors The science of healthcare is new to nearly all of our traditional students At the same time, you’re all trying to learn how to deal with a normal response (stress) caused by very abnormal circumstances (dealing with death on a day- to-day basis) In contrast to other students 1997 report from the Institute of Medicine (Approaching Death) Large gaps in knowledge of care at the end of life which demands attention from healthcare providers Major barrier to improvement of services Recommendation #4 of 7 “Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have the attitudes, knowledge, and skills to care well for dying patients.” So…How Are We Doing? “Although education in palliative care has made clear progress, it has yet to be incorporated fully into the fabric of medical education.” Aulino & Foley, Professional Education in End-of-Life Care: A US Perspective A View of Death as Failure Many in the medical community see death as a failure to save Sometimes it is… Sometimes it isn’t… Litigious society Is this related wrongful death lawsuits? There is a time and place for this…But it’s not every time & every place! Factors that Influence a Student’s Perspective on Death In no certain order: Religion Past experiences /Exposure Culture Education Well Dad, there aren’t many agnostics in healthcare, either… “There are no atheists in foxholes…” Definitions  Palliative Care an approach that improves the quality of life of patients and their family facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (World Health Organization, 2011)  End-of-Life Education education aimed at instilling healthcare providers with the social, physical, and emotional tools necessary to provide proper palliative care to their patients and obtain an understanding of the coping mechanisms associated with caring for the dying (Yale School of Medicine, 2011).  Terminal Extubation the withdrawal of mechanical ventilatory support from a patient who is expected to die as a result of the removal of support (Truog et al., 2001).  The Problem RT education programs need to integrate practitioners’ lived experiences with palliative care into all levels of education in an effort to teach future therapists how to better cope with the stress associated with providing end-of-life care. Giordano, 2000  Purpose To better understand the lived experiences of respiratory therapists who provide end-of-life care to their patients in an effort to determine the adequacy of EOL education in the undergraduate RT curriculum. Literature Review  Background/Context Author(s) Outcome National Institute of Medicine (1997) Large gaps in knowledge among providers. 7 recommendations Aulino and Foley (2001) Progress made Still not incorporated  Resilience Theory Author(s) Outcome APA (2015) Resilience is not a trait…it can be learned. Cope, Jones, and Hendricks (2014) Burnout and compassion fatigue = attrition Lowe (2013) A “wholistic” approach is best (mind/body/spirit)  Stress Author(s) Outcome Glasber, Eriksson, and Norberg (2007) 40% of stress is that of conscience ”Deaden” conscience to do job = stress Schwenzer and Wang (2006) Work related stress in RTs = attrition  End-of-Life Education Author(s) Outcome Kubler-Ross (1969) 5 stages Denial, Anger, Bargaining, Depression, Acceptance Abbott (2011) Students are exposed to death on a regular Doucette, et al. (2007) basis during their critical-care rotations. Dickinson (2007) Nursing curriculum is leading the way. 80% include 15% semester course Brown-Saltzman et al. (2010) All RTs participate, few have training.  Research Questions RQ: What are the lived experiences of respiratory therapy students regarding palliative care? SQ1: How to recent RT graduates perceive their ability to perform end-of-life tasks? SQ2: To what extent are recent RT graduates emotionally affected by a lack of end-of-life education? SQ3: To what extent do recent RT graduates believe that their ability to perform their jobs is influenced by their experience with end-of-life education? SQ4: To what extent to recent graduates perceive that the current program adequately addresses the topic of end-of-life education?  Research Design Epistemology Theoretical Methodology Method Perspective Constructionism Phenomenology Interpretive Individual Interviews Phenomenological Analysis  Methodology Interview RT Graduates Single site >5 years experience BS/MS only Recruited via email Consent form/study description In order of response Transcribed/Hand-coded Peer debriefing Member checking Inquiry audit  8-Step Analysis (Palmer, et al., 2010) 1. Focus, Summarize, & Sort objects of concern experiential claims 2. Explore Role of Facilitator subjectively re-read capture relationship 3. Examine References to Others understand relationships consider background data  4. Examine References to Organizations better understand meanings & expectations 5. Examine Stories re-read focusing on structure, imagery, & tone 6. Dissect the Language discern patterns look for context  7. Adapt Themes to Recently Discovered Information return to themes in step 1 8. Integrate Multiple Cases consider build an overall analysis commonalities/differences  Limitations & Delimitations Limitations Personal/Professional bias of researcher Subjects may not reveal all Subjects influenced by presence of researcher Delimitations Telephone interviews prevent visual cues Only RTs being interviewed Only RTs from last 3-5 years who are currently working Experience in EOL care varies according to state/region  Major Findings Demographics 8 subjects (4 male, 4 female) Average of 2.88 years experience 2 MS, 6 BS 1 ACCS, 1 AE-C, 1 COPDE, 1 CPFT, 6 NPS 2 PICU, 5 Adult, 4 NICU, 1 LTAC 3 Superordinate Themes Needs for the Patient Needs for the Family Needs for the Caregiver  Master Table of Themes Superordina Sub- Emergent Themes # of te Themes Superordin (Codes) participants ate with sub- Themes superordinate themes Needs for the Suffering Comfort, QOL, Futility 7 Patient Time Timeliness, Prepare/Say Goodbye, 7 Honesty Educate 6 What to Expect, Discussion Avoidance Needs for the Support Support for Family, Support for Patient 5 Family Compassion Calm Environment, Respect for Patient 4 Engagemen Knowledge of Wishes, Allowed to 6 t Participate Needs for the Memorable Positive, Negative, Difficult, 8 Care Provider Experiences Appreciation Coping 7 Stress Friends, Retreats, Self-Care, Chaplain 5 Discussion of Findings  Needs for the Patient Suffering Duty to minimize patient suffering Time Patients deserve to be made aware of their condition in a timely fashion. Allow them to grieve, prepare, and say goodbye. Honesty Brutal honesty is preferable to no discussion.  Needs for the Family Support For patient (physical, spiritual, emotional) For family (spiritual, emotional, psychological) Compassion Very stressful to family if lacking. Engagement Important for family to be present and involved  Needs for the Care Provider Memorable Experiences Positive is better. Negative are just as memorable. Coping Mechanisms vary according to the individual. Retreats are a novel, and apparently effective, idea. Stress Emotional demand of role. Negative impact on attrition. Education Need for more both in school and as continuing education. 8/8  Conclusions and Recommendations Providing end-of-life care as a RT is very stressful, emotionally demanding work. EOL education is yet to be fully integrated into the RT curriculum. Educational leaders must embrace the need for more EOL education in order to prepare students for their post-graduate experiences. Hospital leadership should provide ongoing education opportunities for their employees.  Recommendations for Future Research Curriculum Survey Where (if at all) is EOL education occurring? Interview Department Educators Is EOL education part of orientation curriculum? Expand size RTs from other regions Role of physical exhaustion/sleep deprivation on stress associated with EOL care Impact of palliative care retreats on care providers  Student Quote from Living, Dying, Grieving by Dixie Dennis One of the patients in the hospital was so close to death, and we [the student & supervisor] did not want her to be alone, so I decided to provide support. It was so peaceful. She exhaled gently, and then, in less than a minute, she gently exhaled again. And then she was gone… I had another patient who was swinging her arms in the air and screaming “Leave me alone, I do not want to go!” It just so happened [perhaps through divine intervention] that her pastor stopped by, and he prayed with her. She calmed down…and then she died… Each day when I leave the hospital, I reflect on life itself. We  In Conclusion… Death is not an easy topic to discuss, nor an easy situation to put yourself in the middle of. Your jobs will do just that. Our work is very demanding. If you need help, or information, or education, please ask for it. Know that you are not alone. Donne (1623) Revisited No man is an island, Entire of itself. Each is a piece of the continent, A part of the main. If a clod be washed away by the sea, Europe is the less. As well as if a promontory were. As well as if a manor of thine own Or of thine sfriend's were. Each man' death diminishes me, For I am involved in mankind. Therefore, send not to know For whom the bell tolls, It tolls for thee. Thank You! [email protected]