Instructional Material for Online Teaching and Learning

Care of the Older Client (NCM 114a)

Department of Nursing
BSN Level III, 2020

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 CHAPTER 4: CORE ELEMENTS OF EVIDENCE-BASED GERONTOLOGICAL NURSING PRACTICE

Clinical decision making that is grounded in the best available evidence is essential to
promote patient safety and quality health care outcomes. With the knowledge base for geriatric
nursing rapidly expanding, assessing geriatric clinical practice guidelines for their validity and
incorporation of the best available evidence is critical to the safety and outcomes of care.

Evidence-based practice (EBP) is a framework for clinical practice that integrates the best
available scientific evidence with the expertise of the clinician and with patients’ preferences and
values to make decisions about health care (Boltz, M. et al, 2016). The role of the gerontological
nurse is influenced by a number of factors (e.g., legal dimensions, legislative authority, human
rights, current social and political trends, growth of specialization and professional organizations
that require inter-sectoral collaborations).
Gerontological nurses work in a variety of roles and in their practice apply theoretical knowledge of
aging across the continuum of aging, and promote wellness to enhance quality of life in chronic
illness.

This chapter is divided into two (2) lessons. Overall, this chapter will consume four (8) hours
for lecture.

Lesson 1: Standards, Competencies, and Principles of Gerontological Nursing Practice

Lesson 2: Issues and Concerns on Gerontological Nursing Practice
• Ethico-Legal Considerations in the Care of Older Adult
• Communicating with Older Persons
• Guidelines for Effective Documentation
• Geriatric Health Care Team

LESSON 1: STANDARDS, COMPETENCIES AND PRINCIPLES OF GERONTOLOGICAL NURSING

PRACTICE
Practice standards describe the appropriate therapeutic health and wellbeing of
gerontological nurses to facilitate the older person’s health, recovery and/or wellbeing and comfort.
“The primary purpose of having standards is to provide direction for professional practice in order
to promote competent, safe and ethical service for clients”.

After completing this lesson, you must have:

1. Enumerated the purpose of standards of gerontological nursing practice.
2. Applied the standards, competencies and principles in the care of older client.

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Warm-up Activity:

Answer the following questions:

1. Have you ever cared for an elderly person before? If so, what was that experience
like?
2. How do you feel about caring for older adults in your nursing practice?

Learning Inputs:

A. Standards of Gerontological Nursing Practice

The standards for clinical gerontological nursing include assessment, diagnosis, outcome
identification, planning, implementation, and evaluation (ANA, 2001). The standards of professional
gerontological nursing performance include quality of care, performance appraisals, education,
collegiality, ethics, collaboration, research, and research utilization.

Purpose of Standards of Practice

• Define the scope and depth of gerontological nursing practice
• Establish criteria and expectations for high quality nursing practice and safe, ethical
care
• Provide criteria for measuring actual and desired performance
• Support ongoing development of gerontological nursing
• Promote gerontological nursing as a specialty, providing the foundation for certification
of gerontological nursing by the Canadian Nurses Association
• Promote components of gerontological nursing knowledge as entry-to-practice
competencies, setting a benchmark for new graduates
• Inspire excellence in and commitment to gerontological nursing practice

Standards of Gerontological Nursing Practice

(Adapated from Canadian Gerontological Nursing Association (2019). Gerontological Nursing
Standards of Practice and Competencies 2019 (4th ed.). Toronto, Canada: CGNA)

STANDARD I: HUMANISTIC AND RELATIONAL CARE

Definition: Gerontological nurses develop and preserve relationship care.

Gerontological nurses understand that reciprocal communication and respectful
interactions are central to the central human enterprise of nursing (Sakamoto, et al.,
2017).

Gerontological Nurses address:

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 ▪ Humanistic nurse, older person and care partner relationships to optimize
health and wellbeing of older people and their care partners
▪ Personal, older person and care partner preferences, reflecting one’s unique
experiences, cultural context, and social determinants of health.
▪ Relational care approaches to value the person-centred and ethical issues that
affect person-centred care
▪ Gerontological nurses recognize their role as part of an inter-professional
collaboration

STANDARD II: ETHICAL CARE

Definition: Gerontological nurses understand the importance of the ethical
underpinnings of nursing. Gerontological nurses are consciously aware of and think
critically about what ought to happen, what should be done and what is fair and just.
Gerontological nurses are respectful of the person’s right to self-determination,
choice and collaborative decision-making.

Gerontological Nurses address:

▪ Older people and care partners as advocates
▪ Human right for autonomy, diversity, inclusion
▪ Self-determination and freedom of expression
▪ Ethical, moral and legal contexts of nursing practice
▪ Collaborative decision-making (e.g. beginning and ending treatments, end-of-life
care, medical assistance in dying)
▪ Access to and provision of care reflecting the person’s preferences and cultural
requirements
▪ Promotion and support of autonomy and independence

STANDARD III: EVIDENCE-INFORMED CARE

Definition: Gerontological nurses recognize that nursing care for older people and
their care partners is based on evidence-informed knowledge, which is
comprehensive and complex. Gerontological nurses have inquiring minds, question
the status quo, and seek new evidence-informed knowledge to answer questions
when faced with nursing care challenges.

Gerontological Nurses address:

▪ All aspects of health and well-being
▪ Information and educational needs
▪ Assessment of health, functional and cognitive capacities
▪ Geriatric syndromes
▪ Pain and symptom management

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 ▪ Acute illness and chronic health conditions management
▪ Medication management,
▪ Behavior and cognitive therapy
▪ Adaptive communication needs
▪ Advance care planning
▪ Coping and grieving
▪ End-of-life care (EoLC) and Medical Assistance in Dying (MAiD)

STANDARD IV: AESTHETIC/ARTFUL CARE

Definition: Gerontological nurses recognize that nursing care of older people and
their care partners must reflect aesthetic practices, the art of nursing. Gerontological
nurses recognize the importance of searching for the deeper meaning of the older
person’s health/illness/dying experience. Consequently, gerontological nurses seek
to connect to the human experience of sickness, suffering, recovery, transitioning
and death through provision of care that is artful, person-centred, and grounded in
evidence-informed, ecopsychosocial practices.

Gerontological Nurses address:

▪ Need for older people to share experiences and their meaning
▪ Aesthetics of living/caring spaces (e.g. acute, convalescent and long-term care
spaces, bedrooms, common rooms, bathrooms, bathing environments and
mealtime environments)
▪ Environmental design (wall colour, pictures, plants, photographs, drawings,
where appropriate)
▪ Need for music, warmth, comfort, food, artistic elements, presence of familiar
people or objects
▪ Access to activities that spring from need for creative expression through
interpersonal health resources such as mindfulness, yoga, dance, massage,
movement, art therapy, interaction with living organisms such as plants,
animals, pets, nature
▪ Appropriate skill mix, shared decision-making, shared power, effective staff
relationships and supportive organizational systems

STANDARD V: SAFE CARE

Definition: Gerontological nurses are responsible for assessing the older person and
the environment for hazards that threaten safety, as well as planning and
intervening appropriately to maintain a safe environment.

Gerontological Nurses address:

▪ Health literacy (e.g. accessible access to accurate, relevant and safe health
information resources, including technology)

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 ▪ Culturally competent and safe care
▪ Equipment requirements for maintaining safety (e.g. transfers, mobility, stairs)
▪ Risk reduction and monitoring of risk over time Assessment, prevention and
mitigation of all forms of abuse
▪ Safe interpersonal relationships, including relationships of intimacy
▪ Assessment of risk; reduction, mitigation, and monitoring of risk over time (e.g.
falls, depression, disaster planning, suicide, self-harm, self-neglect, access to
required medication, review of medication or substances abuse or misuse,
polypharmacy, STIs)
▪ Food security
▪ Access to safe and affordable housing

STANDARD VI: SOCIO-POLITICALLY ENGAGED CARE

Definition: Gerontological nurses are aware of the socio-economic-political contexts
that influence all aspects of care. As such, Gerontological nurses collaborate with
older people and their care partners to advocate for equitable access to health
system resources that address their care needs.

Gerontological Nurses address:

▪ Ageism that limits health care delivery and stigmatizes older people within
society
▪ Care inequities across all sectors of health care delivery
▪ Inadequate health policy at the local, provincial and national levels
▪ Advocacy needs of the older person within the healthcare system

B. Gerontological Nursing Competencies

1. Incorporate professional attitudes, values, and expectations about physical and
mental aging in the provision of patient-centered care for older adults and their
families.
2. Assess barriers for older adults in receiving, understanding, and giving of
information.
3. Use valid and reliable assessment tools to guide nursing practice for older adults.
4. Assess the living environment as it relates to functional, physical, cognitive,
psychological, and social needs of older adults.
5. Intervene to assist older adults and their support network to achieve personal
goals, based on the analysis of the living environment and availability of
community resources.
6. Identify actual or potential mistreatment (physical, mental, or financial abuse,
and/or self-neglect) in older adults and refer appropriately.
7. Implement strategies and use online guidelines to prevent and/or identify and
manage geriatric syndromes.

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 8. Recognize and respect the variations of care, the increased complexity, and the
increased use of healthcare resources inherent in caring for older adults.
9. Recognize the complex interaction of acute and chronic comorbid physical and
mental conditions and associated treatments common to older adults.
10. Compare models of care that promote safe, quality physical and mental health
care for older adults such as PACE, NICHE, Guided Care, Culture Change, and
Transitional Care Models.
11. Facilitate ethical, noncoercive decision making by older adults and/or
families/caregivers for maintaining everyday living, receiving treatment, initiating
advance directives, and implementing end-of-life care.
12. Promote adherence to the EBP of providing restraint-free care both physical and
chemical restraints).
13. Integrate leadership and communication techniques that foster discussion and
reflection on the extent to which diversity among nurses, nurse assistive
personnel, therapists, physicians, and patients has the potential to impact the
care of older adults.
14. Facilitate safe and effective transitions across levels of care, including acute,
community-based, and long-term care le g., home, assisted living, hospice,
nursing homes for older adults and their families.
15. Plan patient-centered care with consideration for mental and physical health and
well-being of informal and formal caregivers of older adults.
16. Advocate for timely and appropriate palliative and hospice care for older adults
with physical and cognitive impairments.
17. Implement and monitor strategies to prevent risk and promote quality and safety
e.g., falls, medication mismanagement, pressure ulcers) in the nursing care of
older adults with physical and cognitive needs.
18. Utilize resources/programs to promote functional, physical, and mental wellness
in older adults.
19. Integrate relevant theories and concepts included in a liberal education into the
delivery of patient- centered care for older adults.

C. Principles of Gerontological Nursing

1. Aging is a natural process.
2. Various factors influence the aging process.
3. Nursing of the elderly requires unique information and skills.
4. There are common needs shared by the elderly and all age.
5. Gerontological Nursing’s goal is to promote optimum levels ofphysical, psychological,
social and spiritual health.

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Activity 1. Look at the list of competencies for gerontological nurses. How many of these
competencies do you feel you meet at this point? Make a conscious effort to develop these skills as
you go through your career.

Wrap-up Activity
In conclusion, our attitudes about aging and caring for the elderly are influenced by many
factors. Because of the changing population, all nurses need to have basic competence in the care
of older adults. Gerontological nursing practice is guided by standards and core competencies. The
scope of practice may be expanded with formal advanced education, and certification at any level is
a way to demonstrate expertise.

Post-assessment:
A quiz will be uploaded in the mVLE after the discussion.

References:
Boltz, M., Capezuti, L., Fulmer, T. T., & Zwicker, D. (2016). Evidence-based geriatric nursing
protocols for best practice. 5th edition. New York, NY: Springer Publishing Company, LLC.
Canadian Gerontological Nursing Association (2019). Gerontological Nursing Standards of
Practice and Competencies 2019 (4th ed.). Toronto, Canada: CGNA

Mauk, K. L. (2014). Gerontological Nursing: Competencies for Care (3rd edition). Burlington,
MA: Jones & Bartlett.

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LESSON 2: ISSUES AND CONCERNS ON GERONTOLOGICAL NURSING PRACTICE
The health of older client is a critical issue during this century. The health care providers
may have to rethink fundamental cultural values about the meaning of providing health care to
older adults with chronic conditions. Simply treating disease is no longer sufficient. The growing
number of older adults, and the families who care for them, will need emotional, educational, and
financial resources that are not currently available. This growing elderly population will have an
increasing need for health care and related services, an effect that will ripple through society as we
grapple with the implications of caring for our elders. The increased proportion of older adults in
the population need not present major problems if we can provide appropriate resources for
adequate quality of life for older adults, such as specialized health care that includes attention to
the management of chronic illness, support for family caregivers, and the financial constraints of
older adults.

After completing this lesson, you must have:

1. Identified the different laws affecting older clients/ senior citizens.
2. Identified the privileges of older clients/ senior citizens in the acquire healthcare services.
3. Discuss demographics related to aging and medication use.
4. Explain age-related pharmacokinetic changes.
5. Determined what is the effect of polypharmacy to older clients.
6. Review the nurse’s role in the older adult’s adherence to a medication regimen.
7. Critically evaluated selected case studies related to older adults and medication.
8. Define key ethical constructs as they relate to the care of geriatric patients.
9. Discuss concepts of ethics and the implications in the care of geriatric patients.
10. Identified attitudes towards death and dying.
11. Recognized the choices of the elderly and their families in directing their end-of-life care as
well as the nurse’s role in support/implementation of the patient’s choice.
12. Recognized the important of spirituality in older clients.
13. Discussed the nurse’s role at end of life using the above concepts of care.
14. Communicated effectively, respectfully, and compassionately with older adults and their
families.
15. Identified physiological and psychosocial barriers to communication among older adults.
16. Recognized the nurse’s role and responsibility in the process of communication.
17. Utilized basic principles when communicating with older adults.
18. Identified and used strategies to overcome communication barriers.
19. Described the reasons for accurate and thorough documentation in gerontological nursing.
20. Compare the major documentation methods used in acute, long-term, and home care.
21. Appreciate the unique contributions that the interdisciplinary geriatric team can make
towards helping older adults achieve their maximal levels of independence.

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Warm-up Activity:
Before you proceed to learning inputs,
1. What are the age-related changes that occur in pharmacokinetics of the older
adults?
2. As you prepare to care for older adults, what values, conflicts, or ethical dilemmas
do you anticipate you will face?
3. Explain the reasons why documentation is critical to patient care.

Learning inputs:
A. Ethico-Legal Considerations in the Care of Older Adult
Ethics is a fundamental part of geriatrics. Ethics, or the provision of ethical care, refers to
a framework or guideline for determining what is morally good or bad. Ethical problems
arise when there is conflict about what is the “right” thing to do. This dilemma generally
occurs when decisions need to be made whether or not a medical intervention should be
implemented and whether or not the intervention is futile. The answers to ethical questions
are not straightforward; they involve a complex integration of thoughts, feelings, beliefs,
and evidence-based data. Ageism can play a strong role in these decisions. Acknowledging
and acting on the wishes of the older individual are a critical component of ethical care
(Kane, 2013).

1. Laws Affecting Senior Citizens/Older Persons

a. Republic Act 7432
- An act to maximize the contribution of senior citizens to nation building, grant
benefits and special privileges and for other purposes.

b. Republic Act 9257

- An act granting additional benefits and privileges to senior citizens amending for
the purpose Republic Act 7432.

c. Republic Act 9994

- An act granting additional benefits and privileges to senior citizens amending for
the purpose Republic Act 9257.

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 -

RA 7432 RA 9257 RA 9994

Exemption from ITR Exemption from ITR a. Exemption from Income Tax who are considered to be minimum
- Annual TaxabIe does - Annual TaxabIe does not exceed the wage earners under RA 9504.
not exceed P60k or such poverty level as determined by NEDA
amount determined by b. 20% discount and exemption from VAT:
NEDA 20% discount from all establishments on 1. Purchase of medicines, influenza and pnuemococcal vaccines,
services of hotels and similar lodging and other essential medical supplies, accessories and
20% discount on establishments, purchase of medicines for the equipments
transportation services, exclusive use and enjoyment of SC, and 2. PF of attending physicians
hotels and similar lodging funeral and burial services 3. PF of licensed professional health providing home health care
establishments, services
restaurant, recreation 20% discount on admission fees on theaters, 4. On medical/dental services, diagnostic and laboratory fees
centers, and purchases of cinema houses, concert halls, circuses, 5. In actual fare for land transportation travel in PUBs, PUJs,
medicine anywhere in the carnivals etc. taxis,AUVs, shuttle services and public railways, including LRT,
country MRT, and PNR
20% discount on medical dental services, PF of 6. Actual transportation fare for domestic air transport services
Min. of 20% discount on attending doctors and diagnostic and and sea shipping vessels, based on the actual fare & advanced
admission fees on laboratory fees booking
theaters etc. 7. On the utilization of services in hotels and similar lodging
20% discount in fare for domestic air and sea establishments, restaurants and recreation centers
travel 8. On admission fees charged by theaters, cinema houses and
concert halls, circuses, leisure and amusement; and
20% discount in public railways, skyways and 9. On funeral and burial services for the death of senior citizen
bus fare c. Grant of a minimum of 5% discount on the monthly utilization of
water and electricity supplied by public utilities

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 Privileges for Senior Citizens
(a) The grant of twenty percent (20%) discount and exemption from the
value added tax (VAT) on the sale of the following goods and services:
1. on the purchase of medicines
2. on the professional fees of attending physician/s
3. on the professional fees of licensed professional health
providing home health care services
4. on medical and dental services, diagnostic and laboratory fees
5. in actual fare for land transportation travel
6. in actual transportation fare for domestic air transport services
and sea shipping vessels and the like
7. on the utilization of services in hotels and similar lodging
establishments, restaurants and recreation centers
8. on admission fees charged by theaters, cinema houses and
concert halls, leisure and amusement
9. on funeral and burial services for the death of senior citizens
(b) exemption from the payment of individual income taxes of senior citizens
who are considered to be minimum wage earners in accordance with
Republic Act No. 9504
(c) the grant of a minimum of five percent (5%) discount relative to the
monthly utilization of water and electricity supplied by the public utilities
(d) Exemption from training fees for socioeconomic programs
(e) Free medical and dental services diagnostic and laboratory fees in all
government facilities
(f) Free vaccination against the influenza virus and pneumococcal disease for
indigent senior citizen patients
(g) Educational assistance to senior citizens
(h) The continuance of the same benefits and privileges given by the GSIS,
the SSS and the PAG-IBIG as the case maybe, as are enjoyed by those in
actual service
(i) The retirement benefits of retirees shall be regularly reviewed to ensure
their continuing responsiveness and sustainability
(j) The government may grant special discounts for senior citizens on
purchase of basic commodities
(k) Provision of express lanes for senior citizens
(l) Death benefit assistance of a minimum of P 2,000.00

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 2. Medications of Older Adults (Polypharmacy)

Figure 1.Physiological changes of aging and the pharmacokinetics and pharmacodynamics of drug
use.Adapted from Touhy, T. A., Jett, K. F., & Ebersole, P. (2014). Ebersole and Hess' gerontological nursing
& healthy aging. 4th ed. St. Louis, Mo.: Elsevier/Mosby.

Older adults have a high prevalence of multiple chronic health conditions for which
multiple medications are typically recommended as treatment. Thus, effective and safe drug
therapy is one of the greatest challenges within the elderly population. Consequently,
multiple medication use, often referred to as polypharmacy, is common in this population.

Effects of polypharmacy:
(a) it may increase the risk of using potentially inappropriate medications
(b) results in medication nonadherence
(c) increased risk of drug duplication, drug–drug interactions and adverse drug
reactions
(d) higher health care costs

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 The nurse plays a key role in screening for polypharmacy. When determining if
a medication is appropriate for a patient, the nurse should ask the following
questions:
• Is the treatment necessary?
• Is this the safest drug available?
• Is this the most appropriate dose, route of administration, and dosage form?
• Is the frequency appropriate?
• Do the benefits outweigh this risk?

INDICATOR DESCRIPTION
INDICATION When prescribing a new drug, the therapy should have a clearly
defined indication documented in
the medical record.
PATIENT EDUCATION When prescribing a new drug, the patient or caregiver should be
educated about the optimal use of the therapy and the
anticipated adverse events.
MEDICATION LIST Medical records (outpatient or hospital) should contain a current
medication list.
RESPONSE TO THERAPY Every new drug prescribed on an ongoing basis (e.g., for a
chronic condition) should have documentation of response of
therapy within 6 months.
PERIODIC DRUG REVIEW Annual drug regimen review.
MONITORING WARFARIN When warfarin is prescribed, international normalized ratio (INR)
THERAPY should be evaluated within 4 days and at least every 6 weeks.
MONITORING DIURETIC When a thiazide or loop diuretic therapy is prescribed,
THERAPY electrolytes should be checked within 1 week after initiation and
at least annually.
AVOID USE OF When prescribing an oral hypoglycemic agent, chlorpropamide
CHLORPROPAMIDE AS A should not be used.
HYPOGLYCEMIC
AGENT
AVOID DRUGS WITH Do not prescribe drug therapies with a strong anticholinergic
STRONG ANTICHOLINERGIC effect if alternative therapies are
PROPERTIES available.
AVOID BARBITURATES If older adult does require the therapy for control of seizures, do
not use barbiturates.
AVOID MEPERIDINE AS AN When analgesia is required, avoid use of meperidine.
OPIOID ANALGESIC
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MONITOR RENAL If angiotensin-converting enzyme inhibitor therapy is initiated,
FUNCTION AND potassium and creatinine levels
POTASSIUM IN PATIENTS should be monitored with 1 week of initiation of therapy.
PRESCRIBED
ANGIOTENSIN-CONVERTING
ENZYME
INHIBITORS

3. Ethical Principles
The ethics of care in the geriatric population, as in others, include compassion,
equity, fairness, dignity, confidentiality, and mindfulness of a person’s autonomy within the
realm of the person’s abilities and mental capacity. It is not possible to care for this
population without being faced with difficult choices surrounding issues relating to the
ability to live independently.

(a) Advocacy
- refers to loyalty and a championing of the needs and interests of others requiring
the nurse to educate patients and their families so that they know their rights,
are fully informed, and are able to access all the benefits they are entitled to

(b) Autonomy
- is the concept that each person has a right to make independent choices and
decisions. It is reflected in guidelines and laws regarding patient rights and
self-determination.

(1) Advance directive is a set of instructions indicating a competent person’s preferences

for future medical care should the person become incompetent or unable to
communicate. Advance directives typically focus on the conditions of being terminal,
comatose, or in a state of irreversible suffering. However

i. Living will
• A document describing a patient’s preferences for the initiation, continuation,
or discontinuation of particular forms of treatment.
ii. Durable power of attorney (DPA)
• a.k.a., health care proxy
• A document that designates a surrogate (also called an “agent,” “proxy,” or
“attorney-in-fact”) to make medical decisions on a person’s behalf should
that person become unable to make a decision.

(c) Beneficence/Nonmaleficence

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 - These concepts of beneficence and nonmaleficence are integral to healthcare.
Nurses intend to do good for their patients.Nurses are also concerned about
situations thatcan result in harm to patients

(d) Confidentiality
- requiring that only persons with a need to know access the patient’s record or
receive information about the patient.

(e) Fidelity
- refers to keeping promises or being true to another; being faithful to
commitments and responsibilities

(f) Fiduciary Responsibility

- Health care professionals have an ethical obligation to good stewardship of both
the patient’s and the organization’s funds—fiduciary responsibility

(g) Justice
- refers to the fairness of an act or situation.

(h) Quality & Sanctity of Life

- Quality of life is one’s personal perception of the conditions of life, and sanctity of
life, referring to the value of life and the right to live.

(i) Reciprocity
- is a feature of integrity concerned with the ability to be true to one’s self while
respecting and supporting the values and views of another.

(j) Veracity
- means truthfulness and refers to telling the truth, or, at the very least, not
misleading or deceiving patients or their families.

Long Term Care, Palliative Care, and End-of life Care

Anthropologist Margaret Mead was quoted as saying, “When a person is born we rejoice,
and when they’re married we jubilate, but when they die we try to pretend nothing happened.”

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This part deals with the nurse’s role in assisting a patient and family to identify the options for
meeting end-of-life needs.
(a) Long-term care
- refers to myriad services designed to provide assistance over prolonged periods to
compensate for loss of function due to chronic illness or physical or mental
disability.
- supports older adults in two distinct realms:
o Activities of daily living (ADLs).
o Instrumental activities of daily living (IADLs)..

(b) Palliative Care

- Palliative care is interdisciplinary care focused on the relief of suffering and
achieving the best possible quality of life for patients and their loved ones.
- It is offered simultaneously with life-prolonging and curative therapies for persons
living with serious, complex, and eventually terminal illness.

▪ focuses on comfort rather than cure

▪ focuses on the treatment of symptoms rather than disease
▪ focuses on quality of life left rather than quantity of life lived.

(c) End-of life Care

- The focus of care at end of life should center on living with terminal illness—with
medical care, support, and interventions geared toward quality of life and
comfort, rather than on prolonging suffering or the dying process—if that is what
patient wants.

12 principles:
1. Pairing profile on death and dying
2. Strategically commissioning services to provide the best quality care
3. Identifying people approaching end of life
4. Care planning
5. Coordination of care
6. Rapid access to care
7. Delivery of high quality services in all locations
8. Last day of life and care after death
9. Involving and supporting for care
10. Education and training and continuity professional development
11. Measurement and research
12. Funding to support the principles

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The End-of-Life Strategy
1. Step 1 – Discussion as the end of life approaches

i. Closed awareness
ii. Suspicion
iii. Mutual preference
iv. Open awareness

Factors to consider Guidelines

The environment Privacy, no interruptions
Body language Understand how posture/body language may reflect barriers
in communication
Non-verbal communication Personal space, posture, gesture
Verbal communication Use of simple language and open-ended questions
Listening Use of silence, body language, what is being said
Demonstrating empathy Acknowledge feelings
Reflection Assess level of understanding and document/share with MDT
Barriers Address

2. Step 2 – Assessment, care planning, and review

Five Domains of Assessment: These form an essential part of the Gold

Standard Framework

i. Background information and assessment preferences

ii. physical needs
iii. social and occupational needs
iv. Physical well-being
v. spiritual well being and life goals

The Gold Standard Framework

▪ is a system-focused approach formalizing best practice for
individuals in their last year of life.
- Based from the GSF, patients are identified based on this premise
that they have at most 6 months to live

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 Key aspect of Gold Standard Framework – enable the MDT to plan ahead,
anticipate possible crises, assess carers’ needs and manage bereavement
concerns of the family.

The GSF comprises:

One aim – to deliver a “gold” standard of care for all patients nearing
the end of life

Three steps: identify, assess, plan

a) Identify- the last year of life (6-12 months) and list those
identified patients for the MDT to proactively plan care.
The care plan is based on the stage of the disease that is
predicted using the needs Based Coding:

✓ All from diagnosis; stable; years plus prognosis

✓ benefits; unstable/advanced disease; months
prognosis
✓ continuous care; deterioration; needs prognosis
✓ days/final days; terminal care; days prognosis “After
Care”

b) Assess – through holistic common assessment

✓ Assess needs for anticipatory care
✓ Assess for carers’ needs
✓ Assess if patient is entitled to some benefits

c) Plan – general care generated from assessment, ACP

discussions and any recorded wishes/choices

3. Step 3. Coordination of Care

▪ It should be ensured that MDT is communicating and coordinating care.

4. Step 4. Delivery of high quality services

▪ High-Quality Care provisions in all settings

5. Step 5. Care in the last days of life

▪ Identify the dying phase

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 Liverpool Care Pathway
- The LCP is a tool encompassing assessment and care plan for patients
identified as dying

Key features of the LCP”

1. Symptom control
2. Comfort measures
3. Discontinuation of inappropriate measures
4. Communication and coordination
5. Care of the family

6. Step 6. Care after Death

▪ MDT should recognize that EoLC does not stop at the point of death
▪ Care and support to family member
▪ Provide an aide – based on the policy of the institute or local.

5.Spirituality Among Older Persons

Spirituality
- the personal quest for understanding answers to ultimate questions about life, about
meaning, and about relationships that are sacred or transcendent (Koenig, McCullogh,
and Larson , 2001)

In conducting spiritual assessments, the nurse may ask about many topics:
(1) the individual’s beliefs and practices;
(2) what spirituality means to the client;
(3) whether the client is affiliated with specific religions and is actively involved;
(4) whether spirituality is a source of support and strength; and (5) whether the client has
any special religious traditions, rituals, or practices they like to follow.

B. Communicating with Older Persons

“There may be no single thing more important in our efforts to achieve

meaningfulwork and fulfilling relationships than to learn to practice the art of
communication.”
—Max DePree

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 1. Information Sharing
Elderly patients often share control of their personal health information and decision
making with family and friends when needed. Patient portals can help with information
sharing

Consequences on information sharing:

(1) elders and caregivers have different perspectives on what is seen as the "burden" of
information
(2) access to medical information by families can have unintended consequences, and
(3) elders do not want to feel "spied on" by family. Second, control of information sharing
is dynamic
(4) elders wish to retain control of decision making as long as possible
(5) transfer of control occurs gradually depending on elders' health and functional status
(6) control of information sharing and decision making should be fluid to maximize elders'
autonomy
(7) no "one-size-fits-all" approach can satisfy individuals' different preferences

2. Non-verbal Communication
(a) Vocal nonverbal communication
(b) Nonvocal nonverbal communication

3. Communicating with Older Adults

The basic principles are invite, arrange environment, maximize communication, maximize
understanding and follow through.

(1) Invite
(2) Arrange the environment
(3) Maximize communication
(4) Maximize understanding
(5) Follow up and follow through

4. Barriers to Communication
• hearing impairment;
• declining sight or vision;
• declining memory and,
• inability to read or understand.

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 Other issues include:
• the type of information being shared,
• understanding of an issue or topic,
• the environment, and
• personal style, such as use of body language, tone of voice, choice of words,
speaking pace and more.

5. Skills and Techniques

SAGE ADVICE
(Adapted from Look Close See Me, Aging & Communications: Engaging Older People. 2011.
University of Cincinnati College of Nursing)
S is for SIMPLIFY.
A is for ASSURE.
G is for GIVE information.
E is for EASE into it.
A is for ACKNOWLEDGE
D is for DISCOVERY.
V is for VALUE.
I is for INDIVIDUALIZE.
C is for COMMUNICATE.
E is for EMPATHIZE:

KEY POINTS TO REMEMBER

Consider the following as you interact with older people:
1. Older people need and are entitled to be recognized when matters involve them.
Even if a person has dementia or memory loss, direct your comments and
attention to him or her.
2. You can interact more effectively by understanding how aging changes can impact
communication.
3. We must communicate respectfully with older people and provide the right
information the right way to help them make informed decisions.

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 Communicating with Individuals with Memory or Cognitive Deficits
Invite, Respect • Approach persons in a nonthreatening manner within their visual field.
• Sit quietly with the person and gently touch her hand.
• Be respectful of the patient’s belongings.
• Show concern; stop and have a conversation
Environment • Post a few pictures, a calendar, or a daily schedule in the patient’s
room and use it to enhance conversation or promote recall.
• Sit so you are facing the person when speaking.
• Avoid a setting with a lot of sensory stimulation
• Maintain eye contact; it will help keep the patient focused on you and
the topic.
• Be respectful of space.
Understanding • Speak in normal tones.
• Use age-appropriate language.
• Start with a familiar topic.
• Talk about people or events known to the person.
• For many individuals, pleasant memories from the past are a source of
comfort.
• Orientation questions can be confusing and frustrating for the person,
• Ask one question at a time.
•
Communication • Show interest in the person.
• If it is difficult to hear the person, gently ask his or her to speak louder.
• Provide time for conversation
• Don’t laugh at responses, no matter how bizarre.

Communicating with Individuals with Aphasia

Invite, Respect • Include the individual in conversations. Look at the person as well as
others during conversation.
• Treat the person as an adult.
• Provide time for the individual to speak.
• If you don’t understand the person, politely say so
• Remember, frustration works both ways
Environment • Position yourself across from the person so they can see your face and
you can see theirs.
Understanding • Speak naturally. Don’t raise your voice
• Speak slowly using simple words and sentences.
• Use simple gestures to supplement your message.

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 • Tell the patient one thing at a time.
Communication • Provide time for the individual to speak.
• Look at the person and listen as they speak.
• If you don’t understand, ask them to describe the word
• If the individual is able to write, ask them to write the word or use a
word board to spell the word.
•

Communicating with Individuals with Visual Impairments

Invite, Respect • Gently call out to the individual when entering the room and identify
yourself and anyone with you in the room.
• If the individual can see shapes or outlines, stand where he or she can
see you.
•
Environment • Minimize distractions. Describe the environment and where you are
located in relation to the person.
• Explain what you are doing, especially when you are moving and
creating sounds in the room
• Make certain not to move frequently used objects.
Understanding • Alert the person when you will be touching them
Communication • Oral communication with touch is more important than nonverbal
gestures that they cannot see; use an appropriate tone of voice.

Communicating with Individuals with Hearing Impairment

Invite, Respect • To get the attention of the person, touch the person gently, wave, or
use another physical sign.
• Store assistive devices—hearing aid, notepad, and pen—within reach of
the individual.
•
Environment • If the individual uses a hearing aid, check to see whether he or she is
wearing it and that it is turned on.
• Minimize background noise
• When speaking, face the person directly so he or she can see you
Understanding • Speak clearly in a low-pitched voice; avoid yelling or exaggerating

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 speaking movements—it won’t help.
• Use short sentences.
• Don’t hesitate to use written notes to maximize understanding and
involve the person in the conversation.

Communication • Allow the individual to be involved in making decisions—don’t assume

it takes too much time to ask.
• Provide time for the individual to speak.
•

Communicating with Individuals Who Are Deaf

Invite, Respect • Note on the patient’s record that the individual is deaf and may need
an interpreter.
• Document if the individual uses American Sign Language or other
assistive communication.
• Use a TDD phone or relay service to communicate with the person.
• Use an interpreter for conversations regarding health care decision
making.
Environment • When speaking, face the person directly so that he or she can see your
lips and facial expressions. The preferred distance is 3–6 feet from the
person.
Understanding • Don’t hesitate to use written notes to maximize understanding and
involve the person in the conversation.
• Avoid chewing, eating, or smoking as you speak
• When using an interpreter, face the individual not the interpreter
• Be mindful of your nonverbal expressions during conversations
Communication • Allow the individual to be involved in making decisions—don’t assume
it takes too much time to ask.
• Provide time for the individual to return communication and keep your
focus on the person.

C. Guidelines for Effective Documentation

Purposes in the Care of Older Client

(1) The recorded assessment provides the data needed for the careful development of the
individualized plan of care and the evaluation of patient outcomes.
(2) Documentation also provides the communication needed to ensure that a person
continues to receive continuity of care

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 (3) Documentation is the major means for the nurse to demonstrate the quality of care he
or she provides.
(4) Documentation also serves as the basis for the determination of reimbursement in most
settings.
(5) The nursing records supplements documentation with more details regarding a person’s
wishes and include who they want involved in their care

Documentation in Acute Care and Acute &Rehabilitation Care Settings

1. Electronic Medical Record
- Computers can be found at the bedside, in nurses’ pockets, and in strategic
locations around the unit. Nurses are given passwords that may be more
important than their name tags.

2. Care maps
- used to predict and document the care provided within a preestablished
trajectory and to anticipate the day of discharge.

3. Problem-oriented notes
- The patient is assessed (usually with a checklist); problems are identified and
care plans of interventions are developed.

Documentation in Long-Term Care Facilities

1. In family care homes and assisted living facilities, documentation generally occurs only if a
nurse has been hired or is under contract with the facility.
2. Both nursing facilities and skilled nursing facilities nursing observations, documentation in
these facilities encompasses the recording of day-to-day care such as eating and bowel
movement

D. Geriatric Health Care Team

Multidisciplinary teams
- function as a group (multiple) of professionals who work loosely in the same
area or with the same client.

Interdisciplinary teams
- are an interconnected group of professionals who have common and
collective goals.

26 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114

 Disciplines, Education, Roles, and Web Resources in Gerontology
Discipline Role in Gerontology
Audiologist Assesses hearing including audiometric studies, evoked potentials, and
other diagnostic procedures and treatment of hearing loss
Religious workers, Provide support to the client/patient, family, and others as it relates to
Including chaplain, spiritual needs. May assist in identifying resources
priest, rabbi, minister from within congregation for support, visitation, or respite.
Geriatrician Utilizes knowledge of normal aging as part of assessment.
Specializes in the diagnosis and treatment of the elderly.
Dietician Assesses nutritional status and implements nutritional plan.
Advanced Provides primary care including history and physical, and chronic
gerontological disease management.
nurse practitioner
Occupational Assesses and treats functional, sensory, and perceptual deficits
Therapist that impact ADLs. Assesses need for assistive devices. Assesses and
treats cognitive deficits. Provides rehabilitative services in
geropsychiatric services.
Pharmacist Prepares and dispenses medication. Provides clinical consultation and
education for patient and geriatric team.
Physical Assesses mobility and functional capacity of the elderly. Treatment
Therapist includes rehabilitation, strengthening, mobility, and use of assistive
devices.
Psychiatrist Geropsychiatry. Evaluates, treats, and manages mental health issues
faced by the elderly. Includes pharmacotherapy, evaluation of
cognition, and psychotherapy.
Psychologist Geropsychology. Assesses, consults, intervenes in, and manages
conditions related to adaptation, bereavement, counseling, and
treatment for clinical, cognitive, and behavioral needs
Registered nurse Assesses, plans, provides, coordinates, and evaluates care, which
focuses on health, optimal wellness, disease prevention, and advocacy.
Social worker Assists with coping and problem solving as individuals and families
adjust to and face changes with aging and chronic illness.
Provides counseling and psychotherapy.
Speech-language Assesses and treats communication, disorders including speech,
Pathologist language, and hearing, as well as swallowing and cognitive deficits.
Clinical specialist Provides, directs, and influences care of older adults and families in
in gerontological various settings
nursing

27 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114

 Activity 1

Case Study
Ms. Espinoza is a 90-year-old Hispanic female admitted to the hospital from her assisted living facility. She has a history
of hypertension and dementia, and had a stroke and a myocardial infarction 3 years ago. She has also had insomnia
for the past month. Ms. Espinoza is admitted due to an alteration in her mental status. She has had a cold and a cough
for a week, for which she took Coricidin (acetaminophen and chlorpheniramine) and Tylenol PM (acetaminophen and
diphenhydramine). Her home medications include monthly Nascobal (vitamin B12) injections; Toprol-XL (metoprolol
succinate), 100 mg daily; Plendil (felodipine), 10 mg daily; Allegra (fexofenadine), 180 mg daily; Ecotrin (aspirin EC), 325
mg daily; and Colace (docusate sodium), 100 mg daily. She also has a very unsteady gait. Ms. Espinoza’s admitting
diagnosis is mnpneumonia. The physicians order the following medications: Lasix (furosemide), 20 mg IV push, x1;
Pepcid (famotidine), 20 mg bid; Ecotrin (aspirin EC), 325 mg daily; Toprol-XL (metoprolol succinate), 100 mg daily; Colace
(docusate sodium), 100 mg daily; Allegra (fexofenadine), 180 mg daily; Levoquin (levofloxacin), 250 mg daily IVPB;
Plendil (felodipine), 10 mg po daily; and Ambien (zolpidem), 5 mg at bedtime as needed.

Questions
1. Which medication(s) may have contributed to Ms. Espinoza’s altered mental status?
2. In addition to the drug regimen, does Ms. Espinoza have any other risk factors for altered mental status?
3. Would you alter her drug regimen in any way? If so, how?

28 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114

 Activity 2:

Case Study
Mr. Bowen is 64 years old. He has been very healthy by report and very active working as a dairy farmer.
He had a stroke affecting his right side 2 weeks ago and currently has a moderate leg weakness with a
more significant arm weakness, slurred speech, and mild dysphagia (swallowing difficulty). He is predicted
to be ambulatory with a cane, though prognosis of arm function returning is more guarded. It is likely he
will improve speech function and swallowing ability but will require some specialization of diet to prevent
aspiration. Mr. Bowen has chosen to stop eating, stating that he does not want to live as man invalid. His
family is very distressed and wants him to be forced to eat. They cannot imagine why he has made this
choice when his prognosis is so good compared to othersthey have seen in the rehabilitation setting with
much more severe deficits. He has been evaluated for depression and an antidepressant has been
recommended, which he refuses to take along with all other medications recommended for his newly
diagnosed cardiovascular disease. Mr. Bowen is oriented and has not had represent a competence
questioned prior to taking this stand. Some of the staff supports his decision and others do not. Discussion
with the family reveals that Mr. Bowen has frequently made deriding remarks about persons with
disability, including remarks like “If I ever end up that way, just take me out behind the barn and shoot
me.” The psychologist comments that Mr. Bowen is frankly depressed andthat part of this depression is
related to the location of his stroke. He also points out that he feels strongly that should the depression be
resolved, Mr. Bowen would likely change his opinion.
1. How is this situation best handled?
2. Does Mr. Bowen have the right to refuse to eat and take medications when he is clearly not in an end-of-life situation?
3. How does the team resolve the situation when the depression is so prevalent and he refuses treatment for it?
4. Will you be able to care for Mr. Bowen if his wishes are granted?

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Activity 3

Sometimes, referral to hospice is provided at the very end of life. The patient and family are
still able to benefit from the comfort philosophy when the life expectancy is hours or days,
rather than weeks. However, the care may often be provided in a crisis-resolving mode, as
evidenced in this case study. Jose is a 76-year-old man who has advanced prostate cancer,
metastatic to the lungs. He has been treated with hormone injections for the past 4 years and
has had radiation therapy. He has been functioning with the assistance of his wife Maria, has
been able to go to lunch with his retired work buddies, and enjoyed sports and the nightly
news on TV until about 1 month ago. Upon return home from his most recent hospitalization,
Jose continued to have back pain (rated 7 on a 0–10 scale) unrelieved by hydrocodone. He is
now increasingly weak, sleeping much of the day and night, and is short of breath with any
exertion—even talking. He is disinterested in TV, newspapers, or other outside interests, and is
consuming only bites and sips of food and fluids. Jose has voiced concerns about addiction to
pain medications. His wife is unable to get him into the physician’s office for the scheduled
follow-up visit, and calls the physician with concern about managing her husband’s care. Maria
is crying and seems to be in a panic about how to manage her husband’s increasing
needs—Jose seems to have a lot of pain, he is incontinent with increasing frequency, and has
slipped to the ground with transfers to the bathroom overnight. The physician calls the
home/hospice care agency with an order to evaluate Jose and Maria’s situation.Wishing to
evaluate for the possibility of hospice care, the agency sends a nurse and social worker to
evaluate the patient’s condition and caregiver status. Upon physical assessment, the nurse
perceives that the patient’s time is short perhaps hours to a few days, not weeks. The social
worker identifies that the wife, age 75, has a history of arthritis and high blood pressure, and
will need assistance to provide for Jose’s much increased care needs. The couple has no
children of their own, and Maria’s two adult children live on opposite sides of the country and
are unaware of the most recent changes in their stepfather’s condition.Maria appears to be
unaware of Jose’s end-of-life status. She is talking about building his strength, making his
favorite foods so he’ll eat more, and arranging for him to attend the army reunion next month
that he had solooked forward to.

30 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114

 Questions:
1. What are your recommendations after the initial assessment?
2. How can you begin to alleviate Maria’s apparent denial about Jose’s condition?
3. What team members should be a part of Jose’s care plan?
4. How can we determine Jose’s goals for his end of life?
5. Evaluate Jose’s emotional status; how does it affect his daily functioning? How does it affect his
relationship with his wife? How can other team members assist with these issues?
6. What impact do Jose’s spiritual life/beliefs have on his condition and functional ability?
7. How might hospice offer Maria assistance in meeting Jose’s physical care needs?
8. What can be done for Jose’s symptoms? How would you address Jose’s addiction concerns, in
light of the fact you believe he needs a stronger opioid?
9. What support will Maria need in keeping Jose at home?
10. What other care options exist to provide Jose and Maria?

Activity 4

A student nurse on rounds enters a patient’s room and finds an olderwoman sitting
comfortably in a wheelchair in no apparent distress staring outthe window with her
back to the nurse. Is this patient inviting communication from the nurse? Based on the
patient’s position and posture, the nurse may elect to not speak or say anything fearing
she might disturb the patient. Shortly the staff nurse enters the room and comments,
“Mrs. Hale, are you waiting for someone? Can I do anything to help you get ready for a
visit?” Mrs. Hale responds “I am waiting for my son. He is generally on time. I hope
nothing bad has happened. I would like to go the bathroom before he arrives so I don’t
have to worry about that during his visit.” What is the nurse’s most appropriate
response in this situation? Should the nurse have done anything differently during the
first visit to the room on rounds? If so, what? What nonverbal communication would
the nurse expect to see from Mrs. Hale? What nonverbals should the nurse include in
her care of this woman?
31 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114
Activity 5

Mr. J., an 84-year-old man, has Type 2 diabetes and hypertension. He notices some
decrease in his activities of daily living due to unsteadiness on his feet. He is mourning
the loss of his wife, who died 6 months ago. His daughterin- law is concerned about the
number of medications he is on and if he is taking them correctly. Mr. J. has been eating
frozen dinners and spends most of his days sitting in the front room watching
television.

Questions:
1. Who is the correct person for him to see? the physician, the social worker, the registered
pharmacist, the dietician, the physical therapist, or the occupational therapist?
2. Should the physician be an internist, an endocrinologist, a psychiatrist, or a gerontologist?
3. Should Mr. J. see all of these individuals and have multiple evaluations, treatment plans, and
follow-up appointments?
4. Which professional should he see first?
5. Is it possible for the different treatment plans to be duplicative or counterproductive to each
other?

Reflections on the Case Study

The assessment team for Mr. J. in the case study may include a geriatrician,
gerontological nurse practitioner, social worker, dietician, physical and occupational
therapist, pharmacist, and psychologist or psychiatrist. Together they could assess Mr.
J. for diabetes control and the presence of peripheral neuropathy, which may be
affecting his mobility and rule out a minor stroke given his history of hypertension and
diabetes. From that point they could assess his need for physical or occupational
therapy for functional mobility. The dietician could analyze his diet and, based on Mr.
J.’s diabetes, recommend dietary needs. Depending on the assessment for grieving or
depression, recommendations for counseling, medication, or socialization might be
needed. Referrals could be made as needed for Meals on Wheels or for some
socialization activities at a senior center.

32 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114

Wrap-up Activity:
Nurses must respect the worth, dignity, and rights of the elderly and must provide care that
meets their comprehensive needs across the continuum. Their fundamental commitment to the
uniqueness of the patient creates opportunities for participation in planning and directing care.
Their vigilance in advocating for dignified, just, and humane care establishes a standard that can be
appreciated, and potentially needed, by all of us. It is not the rules and regulations that create
ethical care delivery; it is the little actions done by each and every nurse in every day of practice.

In summary, palliative care is an interdisciplinary care that is focused on relieving suffering

and improving quality of life for patients and families living with chronic serious illness. It is neither
end-of-lifecare nor hospice, and it is offered simultaneously with all other appropriate medical
treatments.

As the population of older adults continues to rise, the number of special problems that
affect the quality of life unique to this population will expand. Regardless of the trajectory of these
quality of life issues among older adults, nurses are in a key position to assess older adults for the
risk and existence of these commonly occurring issues and implement strategies to reduce their
negative consequences. In so doing, nurses can promote a high quality of life for older adults in all
care settings.

Post Assessment Activity

A quiz will be uploaded in mVLE after your discussion.

References:

Kane, R. L., Ouslander, J. G., &Abrass, I. B. (2013). Essentials of clinical geriatrics. New York:
McGraw-Hill, Health Professions Division.

https://www.officialgazette.gov.ph/2010/02/15/republic-act-no-9994/

https://www.comelec.gov.ph/?r=References/RelatedLaws/ElectionLaws/PWDandSeniors/RA7432

https://www.officialgazette.gov.ph/2004/02/06/republic-act-no-9257/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573668/

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Touhy, T. A., Jett, K. F., & Ebersole, P. (2014). Ebersole and Hess' gerontological nursing & healthy
aging. 4th ed. St. Louis, Mo.: Elsevier/Mosby.

https://www.researchgate.net/publication/279807586_Information_Sharing_Preferences_of_Olde
r_Patients_and_Their_Families

Fitzwater, C. 2011.Look Close See Me, Aging & Communications: Engaging Older People. University
of Cincinnati College of Nursing

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