Lecture Note PowerPoint Presentation

11

Care at the End of Life

LEARNING OUTCOME 1
Describe the role of the nurse in providing quality end-oflife care for older persons and their families.

NURSES UNIQUE QUALIFICATIONS TO PROVIDE END-OF-LIFE CARE

Holistic view

Comprehensive Effective Compassionate Cost effective

NURSES INVOLVEMENT IN END-OF-LIFE CARE

Spend the most time with patients and their family members at the end-of- life than any other member of the healthcare team Provide education, support, and guidance throughout the dying process

NURSES INVOLVEMENT IN END-OF-LIFE CARE

Advocate for improved quality of life for the person with serious illness Attend to physical, emotional, psychosocial, and spiritual needs of the patient

NURSES WHO HELP THE PATIENT DIE COMFORTABLY AND WITH DIGNITY PROVIDE THE FOLLOWING BENEFITS OF GOOD NURSING CARE:
Attend to pain and symptom control Relieve psychosocial distress Coordinate care across settings with high-quality communication between healthcare providers Prepare the patient and family for death

NURSES WHO HELP THE PATIENT DIE COMFORTABLY AND WITH DIGNITY PROVIDE THE FOLLOWING BENEFITS OF GOOD NURSING CARE:
Clarify and communicate goals of treatment and values Provide support and education during the decisionmaking process, including the benefits and burdens of treatment

NURSES WHO CARE FOR THE DYING

Are well educated Have appropriate supports in the clinical setting Develop close collaborative partnerships with hospice and palliative care service providers

NURSES WHO CARE FOR THE DYING

Must be confident in their clinical skills Are aware of the ethical, spiritual, and legal issues they may confront while providing end-of-life care

NURSES NEED TO BE AWARE OF PERSONAL FEELINGS ABOUT DEATH

Improves ability to meet holistic needs of the patient and family Clarifies ones own beliefs and values

MEANING OF HOPE SHIFTS

From striving for cure to achieving relief from pain and suffering No right or correct way to die: It's everybody's right to live independent and die with dignity

TABLE 11-1 QUESTIONS AND CRITICAL THINKING IN PREPARATION TO CARE FOR DYING PATIENTS

LEARNING OUTCOME 2
Recognize changes in demographics, economics, and service delivery that require improved nursing interventions at the end of life.

CHANGING STATISTICS

Primary cause of death

10 leading causes of death account for 80% of all deaths in the United States
Heart disease Malignant neoplasms Cerebrovascular disease Chronic lower respiratory disease Accidents Diabetes mellitus

CHANGING STATISTICS

Primary cause of death

10 leading causes of death account for 80% of all deaths in the United States
Influenza Pneumonia Alzheimers disease Renal disease Septicemia

CHANGING STATISTICS

Demographic trends

Today, more deaths occur at home The average life span is 77.9 years compared to only 50 in 1900 the average life expectancy in Jordan is 73.1
Today, caregivers are more likely to be professionals rather than family members

Social trends

EXACT CAUSE OF DEATH DIFFICULT TO DETERMINE IN THE OLDER PERSON

Multiple comorbid conditions (is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder) Acute injury added Unexpected pathology

MOST AMERICANS PREFER TO DIE AT HOME

50% die in hospitals 25% die in long-term-care facilities 20% die at home or the home of a loved one 5% die in other settings

SURVEY RESULTS OF HEALTHCARE SYSTEM CARE OF DYING PEOPLE

Excellent: 3% Very good: 8% Good: 31% Fair: 33% Poor: 25%

BARRIERS TO QUALITY END-OF-LIFE CARE

Failure of healthcare providers to acknowledge the limits of medical technology Lack of communication among decision makers Disagreement regarding the goals of care Failure to implement a timely advance care plan

BARRIERS TO QUALITY END-OF-LIFE CARE

Lack of training about effective means of controlling pain and symptoms Unwillingness to be honest about a poor prognosis Discomfort telling bad news Lack of understanding about the valuable contributions to be made by referral and collaboration with comprehensive hospice or palliative care services

LEARNING OUTCOME 3
Describe how pain and presence of adverse symptoms affect the dying process.

NURSES ROLE IN PAIN TREATMENT

Initial and ongoing assessment of levels of pain Administration of pain medication Evaluation of effectiveness of pain medication

HOW NURSES CAN ALLEVIATE THE DISTRESS ASSOCIATED WITH UNTREATED PAIN
Ongoing assessment of levels of pain Administration of pain medication Evaluation of the effectiveness of the pain management plan

NEGATIVE OUTCOMES OF PAIN

Potential to hasten death Associated with needless suffering at the end of life People in pain do not eat or drink well Inability to engage in meaningful conversations with others Isolation in order to save energy and cope with the pain sensation

REASONS FOR UNDERTREATMENT OF PAIN

Patients inability to communicate due to Delirium Dementia Aphasia (speechless) Motor weakness Language barriers

CAUSES OF INADEQUATE CARE AT END OF LIFE

Disparity in access to treatment Insensitivity to cultural differences

Attitudes about death Attitudes about end-of-life care African-Americans prefer aggressive life-sustaining treatments Mexican-Americans, Korean-Americans, and EuroAmericans prefer less aggressive treatment

CAUSES OF INADEQUATE CARE AT END OF LIFE

Mistrust of the healthcare system Pain is subjective and self-report is considered accurate

PAIN CHARACTERISTICS IN COGNITIVELYIMPAIRED OLDER PERSONS

Moaning or groaning at rest or with movement Failure to eat, drink, or respond to presence of others Grimacing or strained facial expressions

PAIN MANNERISMS IN COGNITIVELY-IMPAIRED OLDER PERSONS

Guarding or not moving body parts Resisting care or noncooperation with therapeutic interventions Rapid heartbeat, diaphoresis, change in vital signs

PAIN TREATMENT BASED ON ACCURATE PAIN ASSESSMENT

Systematic Ongoing

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN

Do you usually seek medical help when you believe something is wrong with you? Where does it hurt the most? How bad is the pain (may use the facility pain indicator such as smiley face or rate the pain on a scale of 1 to 10) How would you describe the pain (sharp, dull, shooting)?

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN

Is the pain accompanied by other troublesome symptoms such as nausea, diarrhea, and so on? What makes the pain go away? Are you able to sleep when you are having the pain?

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN

Does the pain interfere with your other activities? What do you think is causing the pain? What have you done to alleviate the pain in the past?

PAIN DURING THE DYING PROCESS

Acute

Sudden onset Usually associated with single cause or event

PAIN DURING THE DYING PROCESS

Chronic
Associated with long-term illness Always present Varies in intensity Tolerance to pain develops Associated factors

Depression Poor self-care Decreased quality of life

PAIN DURING THE DYING PROCESS

Neuropathic pain

Nerves are damaged Burning, electrical, or tingling sensations Deep and severe

Nociceptive pain
Tissue inflammation or damaged tissues Cardiac ischemia

PAIN DURING THE DYING PROCESS

Unrelieved pain during the dying process

Hastens death
Increases physiological stress Diminishes immuno-competency Decreases mobility Increases myocardial oxygen requirements

Causes psychological distress to the patient and family

Suffering Spiritual distress

LEARNING OUTCOME 4
Identify the diverse settings for end-of-life care and the role of the nurse in each setting.

PALLIATIVE CARE
Philosophy of care Highly structured system for care delivery

EMPHASIS OF SUPPORTIVE CARE DURING THE DYING AND BEREAVEMENT PROCESS

Quality of life Living a full life up until moment of death

PALLIATIVE CARE SETTINGS

Hospitals Outpatient clinics Long-term-care facilities Home

HOSPICE CARE

Focuses on the whole person

Mind Body Spirit

Support and care

Patients Family and caregivers

Continues after death of a loved one

HOSPICE CARE

Multidisciplinary team of professional caregivers

Nurse
Manages pain and controls symptoms Assesses patient and family abilities to cope Identifies available resources for patient care Recognizes patient wishes Assures that support systems are in place

HOSPICE CARE

Multidisciplinary team of professional caregivers

Physician Pharmacist Social workers Others

Last phase (6 months) of incurable disease Live as fully and comfortably as possible

HOSPICE SETTINGS
Freestanding Hospital Home health agencies with home care hospice Home Nursing home or other long-term-care settings

LEARNING OUTCOME 5
Explore pharmacological and alternative methods of treating pain.

ADMINISTER PAIN MEDICATION ROUTINELY

Prevent breakthrough pain and suffering

Long-acting drugs provide consistent relief

Chronic pain Acute pain

Short-acting or immediate release agents for prn use

ANTICIPATE AND TREAT ADVERSE EFFECTS OF PAIN MEDICATION

Nausea Constipation

PAIN CONTROL AT THE END OF LIFE

Non-opioids for mild to moderate pain

Acetaminophen NSAIDs

PAIN CONTROL AT THE END OF LIFE

Opioids
Codeine Morphine is gold standard Hydromorphine Fentanyl Methadone Oxycodone

NOTE: DO NOT USE MEPERIDINE OR

PROPOXYPHENE WITH OLDER PERSONS

Adjuvant analgesics

Enhance effectiveness of other drug classes

Muscle relaxants Corticosteroids Anticonvulsants Antidepressants Topical Useful for treatment with lower doses and less side effects

ROUTES OF ADMINISTRATION

Oral

For patient who can swallow Requires higher dosage

Oral mucosa or sublingual

For patients with difficulty swallowing May require more frequent administration

Rectal
For patients with difficulty swallowing or problems with nausea and vomiting Patient needs to be able to reposition easily

ROUTES OF ADMINISTRATION

Transdermal

Delivers 72 hours of pain medication For pain as a result of herpes, arthritis, or local invasive procedures For patients who cannot swallow Use if unable to achieve pain control by other methods

Topical

Parenteral

Epidural or intrathecal

MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATION

Identify when pain is most severe Initiate constipation treatment at time opioids are started Keep patient warm Encourage music listening Visit with spiritual advisor

MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATION

Provide comfort measures

Back rub Position change Warm milk

ALTERNATIVE PAIN MANAGEMENT APPROACHES

Acupuncture Massage therapy Reiki therapy: a combination of all other alternative therapeutic methods Chiropractors: is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine Herbal medications

ADVERSE EFFECTS OF ANALGESIC MEDICATIONS

Constipation Respiratory depression Nausea and vomiting Myoclonus: is brief, involuntary twitching of a muscle or a group of muscles Pruritis

LEARNING OUTCOME 6
Identify the signs of approaching death.

BODY CHANGES INDICATING IMPENDING DEATH

Circulation
Mottling of lower extremities Mottling is sometimes used to describe uneven discolored patches on the skin of humans as a result of cutaneous ischemia (lowered blood flow to the surfaces of the skin).

Pulmonary

Death rattle: s a medical term that describes the sound produced by someone who is near death when saliva accumulates in the throat Cheyne-Stokes respirations: is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea

BODY CHANGES INDICATING IMPENDING DEATH

Skin

Clammy Dusky, gray coloration

Eyes
Discolored Deeper set Bruised appearance

DISCUSS THE DEATH PROCESS AND REASSURE THOSE PRESENT

Support family decisions to be present or to leave Reinforce that the dying process is as individualized as process of living

LEARNING OUTCOME 7
Describe appropriate nursing interventions when caring for the dying.

CORE PRINCIPLES FOR END-OF-LIFE CARE

Respect the dignity of patients, families, and caregivers Display sensitivity and respect for patient and family wishes Use appropriate interventions to accomplish patient goals Alleviate pain and symptoms Assess, manage, and refer psychological, social, and spiritual problems

CORE PRINCIPLES FOR END-OF-LIFE CARE

Offer continuity and collaboration with others Provide access to palliative care and hospice services Respect the rights of patients and families to refuse treatments Promote and support evidence-based clinical practice research

MUCOSAL AND CONJUNCTIVAL CARE

Provide oral hygiene several times a day Ice chips to relieve the feeling of dry mouth can be used as long as the swallowing reflex is present Soothing ointments or petroleum jelly may be used on the lips Lack of dentures makes speech and swallowing difficult

MUCOSAL AND CONJUNCTIVAL CARE

Disease processes contribute to halitosis and thrush Artificial tears: are lubricant eye drops used to treat the dryness and irritation associated with deficient tear production Ophthalmic saline solutions Opened eyes become easily irritated

Halitosis: is a term used to describe noticeably unpleasant odors exhaled in breathing

ANOREXIA AND DEHYDRATION

Patients may choose to stop eating and drinking Anorexia may result in ketosis, leading to a peaceful state of mind and decreased pain Initiation of parenteral or enteral nutrition neither improves symptom control nor lengthens life

SKIN CARE

Monitor skin changes

Edema Bruising Dryness Venous pooling

Avoid shearing forces Reposition frequently Gentle massage or lotion application may be provided by the family

INCONTINENCE CARE
Bowel and bladder incontinence frequently occurs at the end of life Provide protective pads Apply barrier cream Encourage change of position Discourage the use of indwelling catheters

TERMINAL DELIRIUM
Can be distressing to family or caregivers Presents as confusion, restlessness, and/or agitation, with or without day-night reversal Visual, auditory, and olfactory hallucinations may occur during this time Is often irreversible and may vary from patient to patient

TERMINAL DELIRIUM

Management techniques include identifying underlying cause, reducing stimuli and anxiety, and discontinuing all nonessential medications

NEUROLOGIC CHANGES

Distressing for the family

Remind them that the patient may still be able to hear Encourage the family to let go Give the patient permission to die

TYPE AND LEVEL OF CARE AT THE END OF LIFE

Comfort measure only (CMO) Advance directives Use of feeding tubes Euthanasia is illegal

Euthanasia refers to the practice of ending a life in a manner which relieves pain and suffering

LEARNING OUTCOME 8
Describe postmortem care.

PRONOUNCEMENT OF DEATH
Absence of carotid pulses Pupils are fixed and dilated Absent heart sounds Absent breath sounds

POSTMORTEM CARE
Needs to be done promptly, quietly, efficiently, and with dignity Straighten limbs before death, if possible Place head on pillow After pronouncement

Glove Remove tubes Replace soiled dressings Pad anal area

POSTMORTEM CARE

After pronouncement
Gently wash body to remove discharge, if appropriate Place body on back with head and shoulders elevated Grasp eyelashes and gently pull lids down Insert dentures Place clean gown on body and cover with clean sheet

FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION

Note time of death and chart Notify attending physician

Chart any special directions Allow time with loved one

Notify family members

Gather eyeglasses and other belongings Prepare necessary paperwork for body removal

FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION

Call funeral home (or other appropriate personnel) for body transport Note on chart

What personal artifacts were released with the body What belonging were released Who received the belongings

Tag or provide body identification as per policy

LEARNING OUTCOME 9
Discuss family support during the grief and bereavement period.

ALLEVIATE PATIENT AND FAMILY FEARS AND ANXIETIES

Prior to death

Maintain hope for the patient and family

After death
Relief statements Rationalizations Educate about mourning and bereavement

EXPRESSIONS OF GRIEF
First phase: numb shock: the feeling of distress and disbelief that you have when something bad happens accidentally; "his mother's death left him in a daze"; "he was numb with shock" Second phase: emotional turmoil or depression Third phase: reorganization or resolution

CARING FOR THE CAREGIVER

What have I done to meet my own needs today? Have I laughed today? Did I eat properly, rest enough, exercise, and play today? How have I felt today? Do I have something to look forward to?