Training for terminal care - Montefiore Hospice's program

Nursing Homes, Nov-Dec, 1998 by F. Jennifer Hooks

While sound palliative care addresses the needs of the dying and their families on physical, emotional and spiritual levels, there are multiple problems associated with providing excellent end-of-life care.

One critical challenge in caring for the terminally ill is that we live in a death-denying society. For most, it is easier to avoid issues surrounding death rather than confronting our feelings of loss and confusion. Many people, including healthcare providers, still falsely believe that acknowledging death and talking with someone who is dying will take away that person's hope and result in an earlier death.

The second barrier to quality end-of-life care is poor pain management. Research has demonstrated that pain is not managed well in either hospitals or nursing homes. The undertreatment of pain continues to be one of the most frustrating and persistent problems within the medical profession, largely because many patients and healthcare providers believe that narcotics are too dangerous to be given to the terminally ill. The public falsely believes that narcotics may cause premature death, are highly addictive and are not generally safe and effective.

Lastly, we know that nurses and physicians receive little, if any, education regarding pain management. Research has shown that baccalaureate graduates receive less than four hours of education on pain management during their training. The leading eight geriatric nursing textbooks do not include a single chapter dedicated to this topic.

To address these problems, Montefiore Hospice of Cleveland, Ohio, began in March 1995 to offer educational programs to enhance the standard of care for the dying patient, dispel myths about pain medication and empower our staff to feel more comfortable about issues associated with death and dying. Since then, Montefiore has made care at the end of life a priority in its staff education programming, even incorporating an end-of-life care component during new-employee orientation. This education is ongoing within our skilled nursing facility. Intensive sessions and regular in-services are given to continually address pertinent information as it becomes available.

This program was, in fact, initated by a dying patient's family member who felt that some staff were not sensitive to the needs of their loved one. The family generously donated funds to sponsor mandatory eight-hour staff training. The program was well received by staff, who were eager to gain insight on these often-ignored topics. From this, an ongoing series of programs has been presented for which nurses and social workers can earn continuing education units.

Montefiore provides education on pain and symptom management, nutrition and hydration, communicating with dying residents and their families, ethical dilemmas and problem solving, spiritual care, bereavement and staff support. Montefiore hospice staff and experts from the community present these in-services. All staff and volunteers are encouraged to attend, and more than 300 staff members and several volunteers have taken advantage of the opportunity.

We have also offered these programs free to other area nursing facilities. Because our hospice contracts with a variety of nursing facilities, it is to our advantage to have the staff at these facilities knowledgeable about palliative care. Feedback has been excellent. We also take advantage of local television and radio spots to promote awareness of hospice and end-of-life care.

We already had a good background in providing this kind of community instruction, because since November 1992, we have been holding annual community forums to increase public awareness of the general topics of pain management, hospice and end-of-life care. In these forums, nationally recognized speakers have addressed topics such as spirituality, advanced directives, assisted suicide, bereavement and how to talk to a sick or dying loved one. These lectures are free and open to the public. In the last five years more than 800 people have attended, and all of the programs so far have received positive feedback from the 150-plus attendees we have averaged per program. In a separate, more intimate setting, the distinguished guest lecturers who have presented the community forums have also provided a 60-minute program to our staff on a topic selected by Montefiore employees.

Each program is evaluated by the attendees. Included on the evaluation is the opportunity for staff to make suggestions to improve the workshops. One suggestion sparked development of a forum for Montefiore's medical staff and consulting physicians. For our most recent full-day training session, we utilized an alternative method of evaluation. We asked nursing staff to take pre- and post-tests. The first pre- and post-test addressed factual information about pain management. The second asked questions about attitudes and myths surrounding death and dying. Test scores demonstrate that the staff members' attitudes did, in fact, change and that they had gained new information.