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LectureNotePowerPointPresentation

CareattheEndofLife

LEARNING OUTCOME 1

Describe the role of the nurse in providing quality endof-life 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-OFLIFE 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-OFLIFE 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
decision-making 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-oflife 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

Social trends
Today,

caregivers are more likely to be professionals


rather than family members

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-OFLIFE 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-OFLIFE 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
COGNITIVELY-IMPAIRED 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

family

psychological distress to the patient and

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

Chronic pain

Short-acting

drugs provide consistent relief

Acute pain

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

Topical

72 hours of pain medication

For

pain as a result of herpes, arthritis, or local invasive


procedures

Parenteral
For

patients who cannot swallow

Use

if unable to achieve pain control by other methods

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-OFLIFE 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-OFLIFE 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

Notify family members


Allow

time with loved one

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?