End-of-Life

Introduction to Palliative Care

Conferences, workshops, and lectures are all important to attend either as a professional or as a student.

This past Thursday, I attended an Introduction to Palliative Care conference through a local government health clinic. As a professional who works with older adults, and is witnessing the aging of clients, it is important to know what is available within the community for healthcare access. Palliative Care or hospice as it is called elsewhere, is an important part of healthcare for those with chronic health conditions whether it be cancer, respiratory issues, infection, dementia, heart disease, diabetes, other conditions, or a combination thereof.

Palliative means a person has a life-threatening illness and is dying. The services they receive in-home or within a medical setting focuses on or should focus on physical, psychological, social, and spiritual needs. The objective is to make the person comfortable whether it be pain management or symptom management for their last few months, weeks or days.

Part of the presentation focused on where a person would like to die, most said at home, but is this really feasible? Can the family provide the necessary caregiving, the necessary medical equipment, the cost of the medications? Once a person is in a hospital or long-term care facility all of that is provided, although the family may choose to hire additional private care or be the additional caregiver(s) themselves. Whether the patient is at home or in a medical setting they have access to a team of professionals which includes physicians, nurses, occupational therapists or other rehabilitation staff, social workers, nutritionists and others. Optimally, this care is 24/7, but that will depend on the facility, community organizations and resources that the family is providing.

Palliative Care also has, or should have, a bereavement component for both the patient and the family. Dying is a natural phenomenon, the approaches used are not to postpone death. If at all possible the patient and family needs to accept death, speak openly about death and have come up with a plan regarding what happens after. Professional staff can assist with this process.

Not all communities offer Palliative Care and even if they do, quite often there is a lack of resources and services, budget constraints, and a conflict between what the patient may want/need versus what the family wants/needs. Training is an issue as well for the community itself and for professional staff working in palliative care. This can be a very uncomfortable area for many and an area that many choose not to work in.

I am hoping with time this will change considering all the Baby-Boomers who are going to enter the 65+ demographic within the next 10-15 years.

Written by Victoria Brewster, MSW

*First published at: http://www.socialjusticesolutions.org/2013/02/24/introduction-to-palliative/

Healthcare, News, Social Work/Helping Profession/Mental Health

Seeking Action for Safety in Long Term Care Facilities

Advocacy, one of the core competencies in the profession of social work. It is one skill that I was taught both in graduate school and as a professional over the past 15 years, it is a skill I take to heart.

On February 9, 2013 a documentary W5, Crisis in Care, reported by Sandi Rinaldo and the CTV team of investigators, was released. This investigation uncovered horrific statistics and stories of abuse taking place in Long Term Care facilities in Canada. The focus was on residents with dementia assaulting and killing other residents.

http://watch.ctv.ca/w5/latest-episodes/w5—crisis-in-care—february-9-2013/#clip862011

After viewing it, the natural human response is to wonder how something this horrendous could happen. Further questions of who is at fault and what solutions will facilitate the needed changes, come to mind as well. Finger pointing and blaming will not provide solutions or changes. Staff that work in residences and Long Term Care (LTC) facilities, for the most part, are very good at their job and demonstrate the skills of empathy, compassion, and hard work.

A team of three dedicated professionals who all belong to the professional LinkedIn group, Gerontology Professionals of Canada, decided to team up to formulate a response to the W5 documentary, Crisis in Care. Eleanor Silverberg, BA, Psych, MSW, RSW drew up the initial draft and is the main author, asked Angela Gentile, BSW, RSW and  Victoria Brewster, MSW for their contributions. Seeking Action for Safety in Long Term Care Facilities was completed on February 20, 2013, and was forwarded to the following individuals/organizations as of February 23, 2013:

•W5, Sandi Rinaldo, the investigative team and the producers
•Federal Health Minister, the Honourable Leona Aglukkaq
•Alzheimer Society of Canada, CEO, Mimi Lowi-Young
•Alzheimer Society of Ontario, CEO, Gale Carey
•Alzheimer Society of Manitoba, CEO, Sylvia Rothney
•Federation of Quebec’s Alzheimer Society, CEO, Sandro di Cori
•Ontario Minister of Health and Long Term Care, Deb Matthews
•Quebec Minister of Health and Social Services, Dr. Réjean Hébert
•Manitoba Minister of Health, Hon. Theresa Oswald
•Canadian Alliance for Long Term Care
•Healthy Living, Seniors and Consumer Affairs Minister of Manitoba, Hon. Jim Rondeau
•Misitere de la santé des Services sociaux- Services Quebec

The site, Action for Safety, created by social worker, Angela Gentile will continue to be a place where updates will be provided, as well as a place where other professionals, families and concerned individuals can express their views, working together on behalf of the vulnerable residents in Long Term Care facilities.

It is worthwhile to read the full response which describes the issues, provides some examples of assaults and deaths that have occurred in Canada while making suggestions for solutions. It is not possible that these horrible tragedies have only occurred here in Canada. It is not possible that budget cuts, reduced staff, lack of education, and a lack of awareness only effect Canada when it comes to LTC facilities and the disease of Dementia.

The link to Action for Safety has been shared with friends, family, colleagues, on social media through LinkedIn, Twitter, and Facebook with an end goal of obtaining solutions to a very serious issue. This will continue along with contacting media to further bring the issue to light and raise awareness.

It is necessary for professionals to unite over a cause while advocating for needed change and I consider myself fortunate to have been a part of this project. A special thank you to Eleanor Silverberg and Angela Gentile!

Written by Victoria Brewster, MSW

Social Work/Helping Profession/Mental Health

Dreams

Dreams are real
and without them life is a sad existence.

Dreams hold us together and give us a vision,
something to aim for,
the road leading to our destination.

Dreams are the magic,
the magician making us laugh,
or the sun which makes us warm.

Dreams are like the rain,
when it ends there is a rainbow,
that streaks across the sky in shimmering colors
and where it ends,
is a new beginning.

Dreams are our imagination
and they are what we make of them.

Without dreams, we are nothing,
for dreams are the child, the joy, the sadness the imagination,
the goals in all of us.

I wrote this poem quite awhile ago, but the poem signifies our journey in life, both personal and professional. Dreams, imagination, goals and inspiration are part of our creative drive. I cannot picture my life without creativity. We all have it in us; we just need to listen. Do not be afraid to try something new, something different. Take a chance and see what happens.

To start the process, picture in your mind ‘you’ doing something different, whether it is a new career, starting a new hobby or sport, making new friends or going on an adventure. How do you feel after imagining this new you? Do you feel better? Do you feel relaxed? Has your stress levels lessened or increased? Are you happy?

By doing activities like this in your mind, you are trying something new without taking a risk. It is a good way to begin and perhaps after doing this ‘mind exercise’ a few times and noting a positive reaction after both physically and mentally, you may be willing to take action and implement change in your life.

Written by Victoria Brewster, MSW

*First posted at: http://www.socialjusticesolutions.org/2013/02/18/dreams/

News, Social Work/Helping Profession/Mental Health

DSM-5 Changes: A Continuation

I continue to come across articles and information regarding the soon to be released DSM-5. Reading this link will provide quite a bit of information on the upcoming changes to the DSM. I have to wonder if our society is becoming too focused on a diagnosis and pharmacare.

“After the American Psychiatric Association (APA) approved the latest version of its diagnostic bible, the DSM-5, psychiatrist Allen Frances, the former chair of the DSM-IV task force and current professor emeritus at Duke, announced, “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry.”

That statement alone says it all especially coming from a psychiatrist.

Get ready to hear about a new mental illness diagnosis for kids: ‘disruptive mood dysregulation disorder‘ (DMDD)… Frances concludes DMDD “will turn temper tantrums into a mental disorder.”…

“What constitutes binge eating disorder? Frances reports, “Excessive eating 12 times in three months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM-5 has instead turned it into a psychiatric illness called binge eating disorder.”

The DSM-5 also brings us “minor neurocognitive disorder” — the everyday forgetting characteristic of old age. Francis states, ”Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia.”

“First time substance abusers will be lumped in definitionally with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.” DSM-5 also introduces us to the concept of “behavioral addictions,” which Frances points out “eventually can spread to make a mental disorder of everything we like to do a lot.”  And Frances adds that “DSM-5 obscures the already fuzzy boundary between generalized anxiety disorder and the worries of everyday.”

What about grief and bereavement which are also re-categorized in the upcoming DSM? Normal human grief, which I covered in another write-up here on SJS becomes yet another diagnosis: “In removing the ‘bereavement exclusion’, the DSM-5 encourages clinicians to diagnose major depression in persons with normal symptoms of bereavement after only 2 weeks of mild depressive symptoms.” Grief usually runs its course within 2-6 months and typically does not require treatment with medications. In addition:

The proposal by the DSM-5 Neurodevelopmental Work Group recommends a new category called autism spectrum disorder which would incorporate several previously separate diagnoses, including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified. The proposal asserts that symptoms of these four disorders represent a continuum from mild to severe, rather than a simple yes or no diagnosis to a specific disorder. The proposed diagnostic criteria for autism spectrum disorder specify a range of severity as well as describe the individual’s overall developmental status–in social communication and other relevant cognitive and motor behaviors.

Much of what I have read from parents and professionals is concern that the new definition of autism in the DSM-5 will exclude many people from both a diagnosis and state/provincial services that depend on a diagnosis.

The DSM has been looked at over the years, changes made by dropping diagnoses and creating new ones, but to what benefit? Studies that have been done over the years have caused some embarrassment regarding the DSM. For example, Read further about the 1973 study. In the study Eight pseudopatients were sent to 12 hospitals, all pretending to have this complaint of hearing empty and hollow voices with no clear content. All were able to fool staff and get hospitalized.

The 1980 DSM-III was dramatically changed to include concrete behavioral checklists and formal rules to solve the diagnostic reliability problem, hmmm…did it work?

I have the DSM-IV at a cost of $95 in 1995, and used it in graduate school and then professionally for 1 1/2 years with children. I had to choose a diagnosis for the insurance companies to pay for the therapy and treatment that was being provided and it had to be a diagnosis that the insurance company agreed with. I am not a fan of labeling people, especially children, as the diagnosis follows them around for many years if not their entire life. A label does not define a person, but unfortunately many become their label.

Should we focus more on treating the symptoms and less on the diagnosis? Are there alternatives to pharmacare? What changes can be made in the classroom or work setting to assist the person best? Have many of these diagnoses been created for insurance reimbursement purposes, especially when considering the new ones? Are everyday life choices and events being turned into a diagnosis?

The suggested price for the new DSM-5 is $199.00 U.S.! That is one expensive book.

Written by Victoria Brewster, MSW

*First published at: http://www.socialjusticesolutions.org/2013/02/17/dsm-5-changes-a-continuation/

Social Work/Helping Profession/Mental Health

System Malfunction: Mental Health Issues

Mental Health is an area that certainly needs improvements along with properly trained professionals. These professionals whether nurses, social workers, physicians or administrative staff  need regular skill upgrades provided by their employer, of their own choice/initiative or as required through the state, province or the profession itself.

Below is an example of what should not happen when an individual who has a history of depression goes off their medications of their own doing, exhibits behavior that causes one to pause and asks for help to make changes to this downward spiral.

A patient goes to his physician and shares that he has stopped taking his lithium and Paxil, admits to having returned to the habit of drinking one or two six-packs daily and more on weekends, stopped going to work and was fired. This man has no energy or ambition, is not sleeping well and recently had gotten angry with a neighbor and tried choking him. When asked him if he had other times when he considered doing things that might harm others, he said he had been driving around with his loaded gun, feeling very angry and wondering if he would feel better if he shot somebody, and whether it would be better to shoot somebody he knew or a stranger. Are these not warning signs that something serious is going on here! That little red flag should be in each of our minds with this information.

The man and the physician talk briefly about the fact that the medicines might have stopped working because of the alcohol, but that he was now dangerously depressed, and that the options were to go directly to the crisis unit for admission or, if he refused, I would call the police. He readily agreed to admission. “That’s why I’m here doc. I need help before it’s too late.”

His wife drove him straight to Crisis in the hospital across town, where he was evaluated. They called and told me the decision had been made to admit him.

Now, without relaying more information-what are your thoughts? What do you think will happen once he is at the hospital? Will he be admitted, sent way with a prescription or kept for observation until the morning? Which professional will make this decision and what is the reaction  of the physician who convinced the patient to go to the hospital?

Below are excerpts

He had been seen and evaluated by the nurse practitioner on call, was felt to be seriously depressed and “at major risk for harming himself or others.” It was late in the day, there was no bed available on the psych floor, and the psychiatrist had left for the day. The man was kept overnight in the emergency room for admission in the morning. During that time, he underwent the standard and metabolic screening and physical exam by the emergency room physician whose note confirmed the patient’s description of events.

Early Saturday morning he was visited in the ER by an intake worker. She reviewed the chart and spoke to someone on the psych floor, after explaining he did not need inpatient care. The man was discharged home with (written) instructions to see his primary physician to restart his medications. He was also told to call for an outpatient counseling appointment.

The phone call was made and he was told that the counseling sessions were booking into the fall and he would be put on a waiting list. If services were needed sooner, he should contact his primary physician or return to the Crisis Unit in the ER.

This is the unfortunate reality today. Not enough Mental Health workers to provide needed services, untrained staff, wait lists, budget cuts and it is the individuals suffering from mental health issues that are left to their own devices and every country has been witness to the types of tragedies that occur because of the above.

It took another 5 days before this man was admitted to the psychiatry floor of a local hospital, friends and family stepping in to provide assistance and a caring physician. What about those without friends or family? Those without a family or primary physician?  What about those individuals who do not seek help and do not recognize that their life is taking a downward spiral?

No country can afford to continue along its current path of reducing services or having untrained professionals. Mental Health issues are increasing not decreasing!  Has the world not learned from all the recent shootings?

Any individual who tells a professional or goes to a hospital or clinic seeking help because there is admitted risk of hurting/harming self or someone else, needs to be admitted for observation and placed in a safe environment. No bed in psychiatry? Place them in another bed, keep them in the ER, contact the physician who helped with the original admittance. DO NOT send the person home.

Written by Victoria Brewster, MSW

*First posted at: http://www.socialjusticesolutions.org/2013/02/15/mistakes-that-are-occurring-for-those-with-mental-health-issues-by-the-system/#comments

Healthcare

Globe and Mail & CBC-Canadian Healthcare and Economics

This link is worth taking a look at. We may not want to think about economics, but as healthcare is a huge topic of discussion here in Canada, we need to.

The health sector, public and private (and let’s not forget we have plenty of both), is an economic driver, a generator of wealth, a source of good-paying jobs and a stabilizer in times of economic upheaval.

Of course, none of this suggests we cannot deliver health care more efficiently and cost effectively. On the contrary. We shouldn’t advocate spending for the sake of spending.

The issues should focus on how to improve Canadian healthcare, how to streamline the process, offer better services and care, reduce wait lists, increase access to clinics in the evenings, weekends and holidays to reduce or redirect non-emergency cases from the ER. With this discussion comes the financial aspect-how much will it cost individual provinces/territories, the federal government, individuals with regards to taxes, paying out-of-pocket or user fees. What are the most efficient ways to improve the system without it costing a fortune while at the same time improving the patient experience?

Why is it that Canadians cannot find or do not have access to a family doctor or general physician? How is it that doctors are unemployed or cannot find work? More than four million Canadians can’t find a family doctor. That’s more than one in every ten people in the country. And yet, Canadian medical schools are turning out more physicians than ever before … and a growing number of those doctors can’t find jobs.

This does not make sense and requires change. Canadians pay for their socialized medicine through tax dollars, high taxes on all merchandise and on their individual income tax returns, so every Canadian should have access to needed medical attention without having to wait hours at a clinic to be seen or days/weeks to access their own GP.

Victoria Brewster, MSW

 

News, Social Work/Helping Profession/Mental Health

Presence- Part 1

“Presence must be balanced with a strong sense of who you are at your core.”

“Treat everyone, no matter the person’s position or level of power as a respected colleague.”

“Pay attention, the simple act of noticing your own behavior and that of others, in a deeper way, will create an ongoing focal point on presence.”

(Taken from Kristi Hedges- The Power of Presence)

The definition of presence I would use in the above is: a noteworthy quality of poise and effectiveness, the actor’s commanding presence. This definition best describes the book above which is a fantastic book on leadership or management with a strong presence.

The focus is on a sense of worth, walk tall, hold your head up, look people in the eye, talk to everyone as an equal, display confidence with excitement and passion, and your body language must match the spoken message. This aspect will be discussed in more depth in a future post.

Further questions to consider focus on-What is it about some people that they can get others to follow them? What qualities do they have that state or show ‘trust me?’

First and foremost, be yourself, be authentic, be intentional and most importantly…. be present.

Written by Victoria Brewster, MSW