...on Future and End-of-Life Care with a Person with Dementia.
PALLIATIVE CARE FOR THE PERSON WITH DEMENTIA
GUIDANCE DOCUMENT 1
Facilitating discussions on future and end-of-life care with a person with dementia
This guidance document is a product of the Irish Hospice Foundation’s Changing Minds Programme. Changing Minds is a three year project which is co-funded by the Irish Hospice Foundation and The Atlantic Philanthropies. This document entitled “Facilitating discussions on future and end-of-life care with a person with dementia” is the first in a series of guidance documents for healthcare staff in promoting and enabling excellence in end-of-life care for people with dementia.
Acknowledgements This guidance document has been produced in a collaborative manner with significant input from a number of key individuals. The input and editing was coordinated by Carmel Collins, Marie Lynch and Sarah Cronin. The literature searches were carried out by Deirdre Shanagher, Joanna Leneillon and Niamh O’Donnell. The appraisal of literature search and editing was overseen by the Expert Advisory Group. The group would like to acknowledge the work of Lasarina Maguire and Evelyn Reilly for their input on Case Study 3. The Irish Hospice Foundation would like to thank all of the individuals and organisations who gave feedback as part of the consultation process.
Reference This guidance document should be cited as follows:
The Irish Hospice Foundation (2015). Guidance Document 1: Facilitating discussions on future and end-of-life care with a person with dementia. Dublin: The Irish Hospice Foundation; 2015.
The Irish Hospice Foundation, 2015.
Contents
1. Background and Context
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2. Introduction
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2.1 Scope of this guidance document
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2.2 Who is this document for?
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2.3 How to use the document
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2.4 Structure of guidance document
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3. Five Key Considerations to Inform Good Practice
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3.1 Recognise that communication is always possible with a person with dementia
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3.2 Develop knowledge about the progression of dementia and key triggers for end-of-life care discussion
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3.3 Plan future care to optimise comfort
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3.4 Promote personhood throughout the person’s journey
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3.5 Record future wishes when they are expressed.
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4. Guidance and Resources
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4.1 Communication skills
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4.2 Capitalising on informal opportunities
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4.3 Facilitating discussions
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4.4 Hosting formal family meetings
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5. Additional Resources
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5.1 Understanding the progression of dementia
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5.2 Factsheet to accompany this guidance document
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5.3 Leaflet on communicating with a person with dementia
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6. Appendices 39 Appendix 1: Membership of the Expert Advisory Group and the Project Advisory Group 39 Appendix 2: Methodology 40 Appendix 3: List of submissions received during consultation process 43 7. References 44
Facilitating discussions on future and end-of-life care with a person with dementia
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Section 1
BACKGROUND AND CONTEXT Dementia is an umbrella term which is used to describe a condition which may be caused by a number of illnesses in which there is progressive decline in multiple areas of function including; decline in memory, reasoning, communication skills and in the ability to carry out daily activities (1). The number of people living with dementia in Ireland today is estimated to be around 48,000 and this number is set to treble by 2045 (2). Dementia is a chronic, life limiting condition (3–5). People with dementia have a unique set of care needs which include; a progressive cognitive impairment, diminishing capacity, communication difficulties, possible responsive behaviours and a prolonged illness trajectory leading to uncertainty in relation to prognosis (1,6). People dying with and or/from dementia are therefore a particularly vulnerable group who require staff to have knowledge, skills, competence and confidence in both dementia and palliative care (7). Palliative dementia care involves supporting the person with dementia and their family to address and relieve the pain, distress and discomfort associated with advancing dementia and inviting them to participate in making decisions about future care needs (8). Providing this care and comfort presents services with a significant challenge as each person’s journey through dementia is unique with huge variability in the length of the final phase, difficulties in communication and a lack of awareness about the terminal nature of dementia (5,9). This is often compounded by staff lacking basic knowledge, awareness and skills in supporting people with dementia (1,4). It is recommended that palliative care principles are introduced in the person’s care early on, ideally soon after diagnosis when the person can meaningfully engage in discussions about their future care (3,8,9). As illustrated, there has been growing recognition of the complexities involved in providing end-of- life care for people with dementia in the literature; however, there is a notable void of practice guidelines to support healthcare staff in delivering excellence in end- of-life care for people with dementia. In order to support staff in meeting the palliative care needs of people with dementia, there was a call for the development of practice guidelines for the Irish context (8,10–12). In 2013, the Irish Hospice Foundation (IHF) embarked on a three year programme entitled Changing Minds: Promoting excellence in end-of-life care for people with dementia. The aim of this programme is to enable more people, particularly those living with dementia to live and die with dignity at home or in residential care settings. The programme seeks to achieve the following: • Ensure that palliative care for people with dementia is prioritised and developed in all care settings and more people are supported to be able to die well at home. • Better end-of-life care in residential care settings for older people, with a particular focus on people with dementia. • Increased public discourse on death and dying, with a focus on those with dementia engaging in early advance planning. The programme has six projects, one of which has a dementia specific focus. The overall aim of this dementia specific project is to develop and adapt practice tools and service models for people with dementia. The project committed to develop a suite of guidance documents in order to support
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Facilitating discussions on future and end-of-life care with a person with dementia
healthcare staff working with people with dementia across all care settings in addressing specific aspects of dementia palliative care. This work was overseen by a Project Advisory Group (see Appendix 1 for membership). These documents aim to consider all stages of dementia and will include consideration of all people who have dementia (e.g. people with young onset dementia, people with intellectual disabilities etc.). In order to determine the focus for the guidance documents, a desktop review of Irish literature on the topic of dementia and palliative care was completed and compared against an Irish review of the educational needs of staff working with dementia. Following a process of consultation and feedback with the Project Advisory Group, the following care domains were agreed upon as a focus for the suite of guidance documents: 1. Communication skills 2.
Facilitating discussions on end of life care
3. Advance healthcare directives and advance care planning 4. Bereavement 5. Intellectual disability 6. Hydration and nutrition 7. Pain assessment and management 8. Ethical decision making 9. Medication.
At the time of this guidance document going to print (June 2015), these have been further condensed into the following guidance documents: 1. Facilitating discussions about end-of-life care with the person with dementia 2. Advance healthcare directives and advance care planning 3. Bereavement 4. Hydration and nutrition 5. Pain assessment and management 6. Ethical decision making 7. Medication. When completed, it is envisaged that a final composite guidance document will be prepared based on key findings from those developed.
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Section 2
INTRODUCTION
“The lack of public understanding of dementia and the lack of willingness to discuss death and dying in society combine to create a double stigma around dementia and death. This means that it is rarely thought about and conversations that could achieve positive outcomes for personal choice at the end of life do not take place” (13). Creating early and repeated opportunities for discussions on future and end-of-life care with a person with dementia is recognised as best practice and should be considered as part of routine care planning (5,15–22). This allows the person’s will and preferences to be recorded and honoured throughout their condition in order to enable them to live well up to the time of their death (23,24). Furthermore, it supports the person to make informed decisions about their future care and helps to avoid potentially burdensome interventions as their condition progresses (23–29). Dementia palliative care reflects the qualities of person-centred dementia care and the holistic focus of palliative care. Both models share a person centred philosophy and a set of underlying principles that focus on quality of life, whole person care, a respect for autonomy and care of the person and their family (8). Person centred care seeks to support and maintain personhood through relationships and recognises the need for attachment, comfort, identity, occupation and inclusion (30). This document is underpinned by these core values. Having discussions about future and end-of-life care is a challenge which requires all staff supporting a person with dementia to be able to acknowledge and respond appropriately when that person gives a cue, asks a question, or talks about their wishes in relation to their end-of-life care (31). Research indicates that while healthcare staff recognise the need to have discussions on future and end-of-life care with people with dementia, they may feel unprepared and lack confidence in doing so. This may be due to a lack of training, a fear of upsetting the person, time constraints, lack of role clarity and death anxiety (1). These anxieties can be particularly heightened when speaking about these issues with a person who has dementia (15,32–36). The aim of this guidance document is to inform and guide healthcare staff in initiating and facilitating discussions relating to future and end-of-life care with people who have dementia.
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Facilitating discussions on future and end-of-life care with a person with dementia
2.1 Scope of this guidance document
This guidance document will: • List five key considerations to inform good practice in communicating with a person with dementia. • Provide guidance on four areas which were identified during the development of this document (see Appendix 2 for methodology). A separate guidance document will be developed later in 2015 on completion of advance care planning and advance healthcare directives and this will be guided by the forthcoming Assisted Decision Making (Capacity) Act (37).
2.2 Who is this document for?
This document has been written for all health and social care staff who work with and support people with dementia across all settings (e.g. in the home, in residential care settings, in hospitals, etc). A whole person approach needs a whole team approach: all staff supporting people with dementia will interact and engage with the person with dementia and their families in different ways depending on their roles. Each of those roles are interconnected and are key to delivering good quality person-centred care. Therefore, all staff need to develop competence and confidence in supporting people to have these discussions within their own scope of practice.
2.3 How to use the document
End-of-life care reflects the whole continuum of care and the skills required to facilitate discussions on future and end-of-life care needs to complement existing practices within services. Therefore, this document needs to be used by healthcare staff within their own scope of practice, professional guidelines and standards. This guidance document should be considered as an adjunct to: existing best practice guidelines in dementia care, best practice guidelines in end-of-life care, and national and local policies, standards and procedures which relate to working with people with dementia and older people. It is recommended that if a person is not familiar with the document that they take the time to read it in its entirety as each section builds on the knowledge and information shared in the previous section. The factsheet which accompanies the document should serve as a visual reminder to people who have read the whole document. It is not recommended as a standalone item. Changing attitudes, cultures and care practices takes time. How you choose to use this guidance document will depend on your setting. You may choose to adapt it into policies, deliver it as part of an education programme, hold information sessions on it or discuss it within individual teams to effect changes within services for people with dementia.
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Section 2
2.4 Structure of guidance document
This guidance document is based on key themes which emerged from three literature reviews and a process of consensus building by the Expert Advisory Group (see Appendix 2 for methodology).
The document is divided into 4 sections:
Section 1: Background and Context Section 2: Introduction Section 3: Five Key Considerations to Inform Good Practice The five key considerations should be applied as foundation knowledge for staff supporting a person with dementia to ensure good practice in working with people with dementia. Section 4: Guidance and Resources There are four areas where guidance is provided to the reader on aspects of communication relating to end-of-life care with a person with dementia and their families. Each guidance area is followed by resources and signposting to further information. Section 5: Additional resources which can serve as supplementary information for staff.
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Section 3
FIVE KEY CONSIDERATIONS TO INFORM GOOD PRACTICE
This section explores five key considerations which inform good practice in communicating with a person with dementia. They should be applied as foundation knowledge for all staff supporting the person with dementia. They are as follows:
1. Recognise that communication with a person with dementia is always possible. 2. Develop knowledge about the progression of dementia and key
triggers for end-of-life care discussions. 3. Plan future care to optimise comfort. 4. Promote personhood throughout the person’s journey. 5. Record future wishes when they are expressed.
3.1 Recognise that communication is always possible with a person with dementia
“Relationships cannot develop without communication and quality care is impossible without relationships” (38) As outlined in the statement above, communication is core to forming meaningful relationships and underpins all elements of quality care (39). A person centred approach to communication and to care involves taking the time to get to know each person, their fears and anxieties, listening to their wishes and dreams, and finding out about the things that bring them comfort and joy which enables staff to care for each person in a way that is right for them. This relationship will support staff to talk to people about their wishes for their future care, finding out how much they would like to know if their health begins to decline, or asking them what arrangements they would like to make for after their death (31). Dementia is accompanied by a decline in the ability to communicate using speech. This reduced ability to talk is often misinterpreted as signifying that a person with dementia has nothing to say or, more significantly that they have lost the ability to communicate altogether. As dementia progresses and speech becomes less and less useful as a way of engaging or making contact, staff can easily give up because their attempts at communication are unsuccessful (40). It is always possible to communicate with a person with dementia but the manner in which the person can express themselves will change as their condition progresses, demanding increasingly sensitive communication from those supporting the person (17). Staff need to be creative and open to trying out different approaches to interact, connect with and support the person with dementia to communicate. This belief and willingness to be creative is key to delivering good person-centred end- of-life care. Further guidance on communication skills is provided in section 4.
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Section 3
3.2 Develop knowledge about the progression of dementia and key triggers for end-of-life care discussion “One of the key challenges for managers and staff is knowing when and how to open a discussion with individuals about what they would wish for as they near the end of their life” (41) Before healthcare staff enter into discussions relating to end-of-life care, it is important that they have a good understanding of the clinical progression of dementia as well as being informed of the events or transitions that can prompt or trigger end-of-life discussions (42). Having this knowledge will enable staff to anticipate and be prepared for end-of-life care discussions as part of their routine care planning and to manage informal discussions appropriately and sensitively. Sensitive communication is needed to guide the person and family carers through the potential scenarios which can arise as dementia progresses and where particular decisions may need to be made to ensure the optimum comfort for the person (17) (also see resources section 6.1 for information on the progression of dementia). Some of the milestones which may act as triggers or prompts to facilitate discussions about future and end-of-life care with a person with dementia are as follows:
TRANSITION POINTS
HEALTHCARE EVENTS • Deterioration or decline in a person’s condition • Person presenting with complex symptoms • Person presenting with difficulty with nutrition and hydration • Decreasing response to antibiotics • Consideration of the need for further medical investigations or treatments • Discussion about attempting cardiopulmonary resuscitation (5,8,42,43)
• Time of diagnosis • When the person is doing their Enduring Power of Attorney • Change of care setting: transfer to an acute hospital/ residential care setting etc • Care plan review or referral for homecare package
3.3 Plan future care to optimise comfort
“People with early dementia are interested in participating in advance care planning discussions.....so we should not be scared of asking people with dementia their views” (44) Having early and repeated discussions allows the person with dementia, their family and the team to plan their future care and to ensure that comfort is prioritised throughout the persons journey with dementia. Medical and clinical interventions can help manage many of the symptoms which commonly arise with dementia such as pain, agitation and swallowing difficulties. As the person’s dementia progresses, it is important that the healthcare team discuss the changing needs of the person and explain to the person and their family that interventions should primarily focus on maximizing the person’s comfort (17,42). Overly burdensome treatments such as transfer to hospital, the use of
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Facilitating discussions on future and end-of-life care with a person with dementia
Five key considerations to inform good practice
some medications, use of restraints, artificial nutrition or hydration and attempting cardiopulmonary resuscitation need to be considered in light of each person’s unique needs and set of circumstances (28,30). Such complex clinical decisions will be made by senior clinicians who should consider the will and preferences of the person when determining the most appropriate treatment and future care provided to the individual. It is important that the language used by senior clinicians does not transfer responsibility onto the person with dementia or their family member for the consequences of the decision that has been made. Pain management, advance care planning and advance healthcare directives, nutrition and hydration and ethical decision making will be covered in detail in separate guidance documents in this series.
3.4 Promote personhood throughout the person’s journey
“We must never lose sight of the individual who must be afforded sufficient choice and the opportunity to live well with dementia and to be treated with dignity, kindness and respect” (10) Being treated with compassion, kindness, care and respect is core to our humanity and the delivery of good end-of-life care (40). Good end-of-life care involves responding to and meeting a person’s physical, social, spiritual and psychological needs. The person with dementia’s values, will and preferences should be honoured and respected by staff throughout their journey with dementia. It is never too late to find out about a person’s wishes in relation to their end-of-life care. People with advanced dementia can and do communicate their preferences about what is important to them (45). It is up to staff to recognise a person’s communication attempts, validate and respond to them and share that information with the healthcare team. Relatives are often well placed to provide valuable information in aiding healthcare staff understand what is most important to their family member who has dementia. However, it is important to note that in terms of making medical or legal decisions, no adult has a legal right to give or withhold consent for another adult unless they have specific legal authority to do so (46). In conclusion, staff need to value people with dementia as people who have a unique history, values and preferences and support the person to maintain the essence of their personhood at all stages of their journey with dementia.
3.5 Record future wishes when they are expressed
“Discussions about end-of-life issues can be conceptualised as a process of ongoing conversations over time, rather than a single discussion.” (47) In the instance that a person has clearly expressed their future wishes in any situation or context, it is important that there is a formal record of these wishes kept (42), and that relevant health care staff are made aware of this formal record. The person should receive regular prompts to review and update their record and it should be easily accessible to all staff who are involved in the person’s care (48). While additional details may need to be recorded in the person’s medical and nursing notes, it is beneficial for there to be a single document which can summarise what is important to the person when planning their future and end-of-life care. If this document relates to decisions regarding certain treatments (e.g. attempting cardiopulmonary resuscitation), this form should be signed and completed by a doctor and reviewed on a regular basis. Guidance on hosting formal family meetings and examples of documents used in Ireland for this purpose are given in section 4. Advance care planning and advance healthcare directives will be covered in a subsequent guidance document and this will be developed following publication of the Assisted Decision Making (Capacity) Bill (37).
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Section 4
GUIDANCE AND RESOURCES The four areas which were identified as areas in which staff would benefit from guidance on facilitating discussions on future and end-of-life care are introduced below and are outlined in further detail in the subsequent four sections of this document. These are as follows:
1. Communication skills. 2. Capitalising on informal opportunities. 3. Facilitating discussions. 4. Hosting formal family meetings.
What follows in each section is guidance for staff on how best to approach each of these areas. Each guidance is followed by relevant resources to support learning, development and practice in that area.
4. 1 Communication skills
Getting communication right is essential when discussing and delivering quality end-of-life care. Successful communication is dependent on two people sharing a common language or system of communication, an understanding and ability to interact using that system by both partners and a motivation, reason and opportunity to communicate. As illustrated in section 3, communication is about much more than words. People with dementia may communicate in lots of different ways using facial expression, eye contact, body language, vocalisations, responsive behaviours, writing and speech. The person with dementia may need additional time to process information and find the correct words to formulate a response. They may benefit from additional communication supports such as a pen and paper (writing down key words) / pictures and/or photographs. Some people with advanced dementia may communicate through responsive behaviours and subtle nonverbal cues. Staff should be attentive to the person’s verbal and nonverbal communication in addition to the communication environment they are in in order to understand what the person is communicating and formulate an appropriate response. Communication with people with dementia should take a person-centred approach. Knowing someone’s life history is essential in helping staff to get to know a person, their family, their values and their wishes in order to build relationships with them. It is within this context that purposeful discussions about future and end-of-life care take place. Conversations about end of life often arise in informal everyday situations such as on the corridor, on the phone or by the bedside and are often directed at staff who have the most contact with the person with dementia and their family. All staff including healthcare assistants, catering and housekeeping staff need to be able to acknowledge and respond appropriately when a person makes a comment, asks a question or gives a cue to open a discussion relating to their wishes (8, 40, 48–50).
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Facilitating discussions on future and end-of-life care with a person with dementia
Staff should know when to refer to a more senior staff member if the conversation extends beyond the scope of their role or knowledge (21,22). Formal discussions on a person’s future care are the responsibility of senior staff who have the expertise to answer the clinical questions which commonly arise in discussing end-of-life care for people with dementia. Hosting formal family meetings are discussed later in this section. Finally, people with dementia may have a moment of clarity which are fleeting or ‘special moments’. During these moments the person with dementia may spontaneously express their wishes, including their wishes and preferences relating to the end of their life. Information from an Irish study entitled ‘Planning for the Future’(16) illustrated how people at an advanced stage of their dementia could express their wishes with clarity. The project illustrated how people with dementia often brought up issues regarding pain, their wish to stay in the centre and their readiness for death in these ‘special moments’. This guidance document recommends that these spontaneous interactions from residents with dementia should be captured and documented as they happen. The figure below has been taken from this project and illustrates some of the key aspects of end-of-life care discussions.
It’s really important to us that you are happy here. We want to get to know you and want you to feel comfortable talking to us about your wishes or any worries you might have...
Ask me what I want or what I would not want.
Have you ever thought about what you might want if you became very unwell?
Do you have any worries or wishes about your future care?
We always want to know that we’re doing what you want in relation to your care... We want you to be able to tell us what matters to you.
Is there anything that you’d like to tell us about looking after your future?
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Section 4
We have learned that communication with a person with dementia demands time, skill and creativity. It is essential that organisations place value on staff developing skills to allow them to create an atmosphere that enhances and supports communication. This requires a commitment to allocate time and resources to support staff in learning and developing skills in person-centred communication with persons with dementia. Below are four recommendations or guidance in the area of communication skills. This is followed by a resources section which goes into more detail on these areas and signposts the reader to additional related resources.
GUIDANCE – COMMUNICATION SKILLS
1. Communicating with a person with dementia requires time, skill, creativity and an openness to trying out new approaches. Service providers and staff need to factor in additional time and resources when organising and managing services in order to facilitate good communication with the person with dementia. 2. It is strongly recommended that all staff develop skills in: - person-centred communication with a person with dementia - using a range of communication tools to facilitate effective communication - responding to and facilitating end-of-life care discussions with people with dementia. 3. When talking to the person with dementia it is recommended that staff use short sentences, familiar language and a calm tone of voice. They should be aware of their own nonverbal communication. 4. The use of active listening techniques can facilitate discussions and conversations with the person with dementia.
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Facilitating discussions on future and end-of-life care with a person with dementia
Areas for guidance
Resources
TIPS FOR COMMUNICATION
These are based on themes arising from the literature review and views of the Expert Advisory Group.
1. Adopt a person centred approach to communication
Staff should adopt a person centred approach which values people as individuals with unique histories, values, likes, beliefs and strengths. A total communication approach is one such approach which values all forms of communication and respects individuals’ right to choose the mode or modes in which they communicate. Staff should: • Find out about how best to support a person to understand information and how to facilitate interactions with them. Understand that the person may interact best at certain times of day. This will have a big impact on the success of your interactions. • The use of communication aids that support the person could include objects, visual supports, communication passports, life story books, story boards, maps, photos, picture boards (16,50), pen and paper, Talking Mats (50) and sign such as Irish Sign Language or Lámh (51) which is commonly used by people with intellectual disabilities. • Be creative! Communicating and interacting with people with dementia requires staff to be creative and open in their approach. • People with advanced dementia can communicate their views and preferences in a way that is subtle and often not obvious to people who do not know them well. This means that you need to document communication behaviours that you have noticed and build up a picture about the person’s preferences and wishes around their care including their end-of-life care. This demands a collaborative approach using key ‘nuggets’ of information from staff observations, family and friends. Life story work could form the basis for this work. This is explained in point two below. 2. Connect with the person In section 3, emphasis was placed on the need to promote personhood throughout the person’s journey with dementia. Good quality interactions have a big impact on how a person with dementia feels; there is a strong link between positive, friendly communication and improved mood in people with dementia (52). • Staff should prioritise connecting with a person and try not to get overly focused on exchanging information and facts. Enjoy the contact and the connection and promote success in the interaction. • Life story work can be a very effective way of developing meaningful relationships with the person with dementia (53). This involves taking time to get to know a person and their life history in order to understand and connect with them on a personal level. By knowing who the person is and what is important to them, you can build a meaningful relationship and foster successful interactions. • It can often be useful to focus on the feelings or the intent behind the words instead of facts in order to foster successful interactions.
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Section 4
• Talking a lot about the past can foster success. Everything has potential to lead to a conversation about the past. Using this can be a way of engaging the person about their own wishes and preferences. • Be cautious of correcting a person with dementia – this can have a negative effect on a person’s self-esteem and be counterproductive. Do not argue over facts which the person presents to you which may be inaccurate. Accept this as their reality.
3. Consider the communication environment
The communication environment in which an interaction takes place can have a positive or negative impact on the person with dementia's ability to engage (54). Consider the following aspects of the communication environments you support people in: • Lighting: Good lighting in buildings can help people to see what is around them, to navigate, identify signs and spaces, see others’ faces and participate in activities. However, strong lighting can have a negative effect on people with dementia’s energy levels (55,56). • Noise: It is important to be aware of the level of noise in the environment. Background noises such as TV, music, people moving around, activities in the unit, chatting etc can make it very difficult for a person with dementia to concentrate. Try to reduce noise levels or move away from noise during an interaction as much as possible. • Seating: Ensure that where the person is seated maximizes their ability to engage in interactions (e.g. can they see and hear well in that position? Are they comfortable? Do they have a pen and paper/ photos or other supports they need for communication within reach?). • Resources: Ensure that there are resources to support communication available in the environment such as pens and paper/photos of relevant items for choice making etc. You could set up communication stations within units to have communication supports readily available as they are needed.
4. Be aware of your own communication style and approach
The importance placed upon nonverbal communication increases for people with dementia as they lose their ability to follow conversations. The person with dementia may struggle to find meaning in your words but take meaning from your tone of voice, your body language and your eye contact. Body language, posture, facial expression and eye contact are powerful in supporting a person to engage/disengage. The following tips should help you to engage with the person with dementia: • Approach the person from the front and make eye contact. 3 Sit at the person’s level – eye level is best. 3 Introduce yourself by name – do not expect the person to remember your name: asking them if they remember may be distressing. 3 Call the person by name and tell them what you are there for. • Be attentive to the person’s non-verbal communication. Use your observations of the person’s nonverbal signals to open up a conversation– if a person’s facial expression displays a particular emotion, label it (e.g. say " I see you look a bit happy/sad today").
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Areas for guidance
• Responsive behaviours may be the person’s only way of communicating – it is important that you always view behaviour as a form of communication. • Be aware of your own non-verbal communication. Think about your body language, your eye contact, your tone of voice etc and how this may affect the person's ability to engage with you. • Speak slowly and clearly using a calm tone. • Avoid extremes, by not talking too loudly or too slowly and avoiding childish vocabulary (40, 46,48,49).
5. Active Listening
The use of active listening is particularly important when talking to a person with dementia. It involves fully attending to the person and allowing them to lead the conversation without disruptions. Active listening also involves the use of silence, and although this can be unnerving for staff, sensitive discussions often require these silences to allow the person to assemble their thoughts and questions. These tips might help: • Show you are listening by employing conversational cues such as “mmm”, “I see”, and “really” (15,59) along with an open posture, eye contact and nodding. • Try not to jump in and fill silences with more language. • The person with dementia may struggle to make meaning of what they are hearing and finding the words they wish to say. Give the person extra time to process information and find the words they want. Don’t continue to speak as this may overwhelm the person with dementia. • How long a person with dementia needs to allow them to process information will vary from person to person so find out what works best for the person you are supporting (33,58,60,61).
6. Use simple language
Supporting a person with dementia in conversation means that you may need to think in advance about the words you are going to use. Keep it simple and easy to understand. These tips should help:
• Use the person’s name in conversation. • Keep your language clear and concise. • Focus on one topic at a time. • Avoid medical jargon and terminology.
• Point or demonstrate to help a person understand what you are saying. • Use visual supports such as photos and/or write down key words. • Use different words to get the same point across if the person does not understand the first time. • Provide support and affirmation when a person gets stuck in a story/idea e.g. “you were telling me all about your family and how you felt about your day today” (5,22,44,46,47,49–51).
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Section 4
7. Focus on one question at a time.
Be aware that reasoning, logic and time requires complex thought processes that a person with dementia may struggle with (33,58,60,61,64). Open ended questions (e.g. what do you feel about?) or choice based questions (would you like tea or coffee?) can be very difficult to retain and to process for some people with dementia. These tips may help: • Reframe open-ended questions. If the person is struggling to answer a question, it may be beneficial to rephrase it as a closed question which involves a yes/no answer (e.g. would you like a cup of tea?). • Asking a series of short closed questions which focus on one key idea at a time can be of benefit. • Try not to ask the person to give you lots of facts as this information is difficult for a person with dementia to access and can make conversations feel like a test rather than a two way interaction. It can be useful to ask questions related to feelings rather than facts (e.g. say “Do you like children?” or “Tell me about your children” rather than “How many children do you have?”.) • If the person does not appear to understand what you have said, repeating and/or rephrasing the question can help.
8. Clarify information and check for understanding
• If you have difficulty understanding what the person is saying, ask some questions to help clarify what the person wishes to communicate. • Do not pretend to understand if you do not. Share responsibility (e.g. say “I’m sorry we are getting a bit stuck” or “I didn't get that”.) • Check the person has understood what you are saying. The person may demonstrate this through nonverbal means. • Ensure you have heard and understood the person correctly by repeating back the information to them to allow them to clarify their meaning (e.g. “you’ve told me that you wish to get more help with getting dressed, is that right”).
Additional Resources
1. The National Dementia Training Programme (65) has a session on communicating with the person with dementia which enables staff to develop skills and knowledge in this area. 2. The Social Care Institute for Excellence has a module on positive communication as part of its e-learning “Dementia Gateway” (66). This is available free of charge to the public. 3. The Alzheimers Soceity of Ireland have produced two factsheets relating to communication. These are as follows:
• Communication: Understanding changes in behaviour (67) • Understanding and respecting the person with dementia (68).
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Facilitating discussions on future and end-of-life care with a person with dementia
Areas for guidance
4.2 Capitalising on informal opportunities
Throughout the course of the person’s journey with dementia relationships develop between staff members, the person with dementia and their families as a natural component of care. As discussed in section 4.1, it is within the context of these relationships that discussions regarding a person’s feelings, wishes and preferences for future will take place. Opportunities to address concerns and queries relating to a person’s health and future care will often arise as part of an informal chat or during casual conversations with health care staff (42). At such moments it is vital that staff recognise this as an opportunity to give clear information, explore people’s wishes, thoughts and fears and respond to this in an appropriate way. In order to do this, staff need to ensure they are informed and prepared for the changes that come about during the course of a person’s dementia (9,15,17). See section 5.1 for additional information on understanding the progression of dementia. Informal conversations can be guided by the AFIRM approach (69). AFIRM is an acronym which gives staff a suggested framework to deal with informal conversations. AFIRM has been devised to support staff to be ready to use these occasions as opportunities to pick up on underlying apprehensions or queries that the person with dementia or their family has.The AFIRM acronym is described below and the subsequent case studies (adapted from (69)) illustrate how the AFIRM approach can be used to structure spontaneous and informal conversations.
CKNOWLEDGE the person’s concern or questions.
A
IND out what the person knows about the condition.
F
I
MMEDIATE concern addressed by providing adequate information within the scope of your work.
R
ESPOND to subsequent questions by providing accurate information within the scope of your work role.
M
EETING suggested to discuss their concerns with a senior clinician.
When casual or unplanned conversations about end-of-life care occur, it is important that staff are aware of the steps to take and who they can inform, so that the information shared can inform formal care planning process (69).
Facilitating discussions on future and end-of-life care with a person with dementia
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Section 4
GUIDANCE ON CAPITALISING ON INFORMAL OPPORTUNITIES 1. Staff can use the AFIRM approach as a process to help them to manage informal conversations effectively. 2. Staff need to be clear about the scope of their role when unexpected conversations about future planning and end-of-life care present themselves, so the opportunity for discussion can be optimised. 3. Staff need to ensure that information shared in informal conversations that address matters relating to future and end-of-life care preferences are shared with all people involved in the person’s care and documented. 4. Staff should familiarise themselves with case studies presented below to learn how to capitalise on casual conversations in order to address underlying concerns expressed by the person with dementia or their families.
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Facilitating discussions on future and end-of-life care with a person with dementia
Areas for guidance
CASE STUDY 1 | TOM Tom has been a resident in a nursing home for the past six months and has become increasingly frail. He is currently unable to walk and has a very poor appetite which has caused him to lose a noticeable amount of weight in recent months. His wife regularly visits and has become anxious about her husband’s deteriorating health. His wife, who is distressed, approaches a healthcare assistant asking “Could my husband die from not eating enough?”. As a healthcare assistant, you know that his wife visits regularly but you aren’t sure what she knows about her husband’s diagnosis and care plan.
Possible responses using the AFIRM response may include:
cknowledge concerns “Your husband is certainly eating less now.” ind out what is known “How do you feel your husband is doing?” “What’s your biggest concern right now?”
A
F
mmediate concern addressed “We know that your husband has dementia and reduced appetite is a common problem as dementia progresses.” “There are many ways to help people in this situation to eat, but we know that it may be more comfortable for your husband to eat only when he feels like it.” espond to further questions “Yes, your husband is walking much less and that has gradually reduced over the past year which can be another sign that his dementia progressing.” eeting suggested “Given that your husband’s condition is changing, this could be a good time to arrange to meet the nurse manager to discuss his current health and future care needs.” “This meeting would also be a good time to answer any other questions you may have.” “Would you like a meeting to be organised?”
I
R
M
Facilitating discussions on future and end-of-life care with a person with dementia
19
Section 4
CASE STUDY 2 | KATHLEEN Two years ago, Kathleen was diagnosed with dementia and remains living alone in her own home. Over the last year, she has needed a lot more help from her daughter and needs help with most personal and domestic activities. One day when Kathleen was attending a day care centre, she became quite tearful when speaking to the nurse and said “I am so frightened of having to move from my home and the thoughts of being cared for and dying in a strange place”.
Possible responses using the AFIRM response may include:
cknowledge concerns “Let’s talk a little bit more about this.” “Would you like to go somewhere quieter so we can have a chat about this?”
A
ind out what is known “Are you worried about not being able to remain at home?” “Is this something that is on your mind a lot?” “Can you tell me more about your fear of dying?” “What worries you about being in a strange place?” “Are their particular concerns you have about your future care?” “What is frightening you the most?”
F
mmediate concern addressed “Yes many people are frightened of what will happen as their health deteriorates.” I
espond to further questions “Yes, most people prefer to remain in their homes for as long as possible but as they become increasing frail, some people need to move into more supportive accommodation such as a nursing home.” eeting suggested “As you have being thinking about your future needs, this could be a good time to arrange a meeting with the doctor and/or PHN so we can explain your options if you become increasingly unwell. Would you like a meeting to be organised?”
R
M
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Facilitating discussions on future and end-of-life care with a person with dementia
Areas for guidance
CASE STUDY 3 | MICHAEL Michael is 43-year-old man who has Down Syndrome and a mild Intellectual Disability. He lives in supported accommodation. Michael had until lately travelled either by bus or train to visit his family or to attend matches as he is a passionate supporter of his local and county GAA teams. Monday to Friday he attends a day service where staff have observed that he was “not himself” and that he was not engaging with either them or his colleagues. He has appeared to be withdrawn at times. He has also become more reliant on others and less likely to initiate activities. Reports from the staff in his home have concurred that Michael has lost interest in doing everyday things for himself. Michael recognises that he is struggling more now, his coping skills are diminishing, and he is finding it increasingly difficult to make sense of the world around him. There is evidence of reduced emotional control, irritability and loss of self direction. He is less tolerant of his peers, and with decline in social behaviours becoming more evident, he has begun shouting at staff and other residents, for no obvious reason. Michael attended the memory clinic. A full physical work-up was carried out to out rule out pseudo dementia and to inform differential diagnosis. He had a full cognitive work up and following comprehensive interviews with family members, key staff from his home setting and his workplace a consensus diagnosis agreed that he met ICD-10 criteria for Alzheimer’s type dementia. It was agreed that Michael is presenting with a very compressed decline and that the level of support that he will require in the future will be significant. The psychiatrist has told Michael that he is presenting with memory problems and has explored with him what that means for him. Prior to engaging with a person with an Intellectual Disability and using the AFIRM response, it is important to acknowledge that the person may find it hard to express how they are feeling. Consequently, it is important that staff who know the person very well, and who understand the person’s usual methods of communication are involved when a diagnosis is being explored – particularly where the person involved does not use words to communicate.
Continued Overleaf
Facilitating discussions on future and end-of-life care with a person with dementia
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