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VN057 gerontology 8
Chapter 15
End-of-Life Care
2
The American Way of Dying
• Not seen as a natural progression
• Uncomfortable with death
• people are faced with fragmented, disorganized &
inadequate guidance
• forced to attempt to make sense of changing rules
and regulations set up by various bureaucracies
– Gvt
– insurance
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Attitudes Toward Death and
End-of-Life Planning
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Attitudes
• variety of options makes end-of-life decision
making difficult
• Personal values, cultural & spiritual beliefs, &
life experiences all affect choices
• Many older people say that they do not fear
death as much as they fear how they will die
• Ideally, discussions regarding end-of-life care
and death planning will occur before a health
crisis arises
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Advance Directives
• Specific end-of-life decisions can be expressed
in advance directive documents, such as a
living will or durable power of attorney for
health care
• Specify the type and amount of intervention
desired by an individual
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Advance Directives (cont.)
• Copies to the physician, hospital of choice,
extended-care facility, power of attorney for
health care, and anyone else deemed appropriate
• A competent person retains the right to change
his or her mind about treatment at any time
–
–
–
–
Intubation or feeding
Full code to DNR
DNR to full or chem code
Comfort care to any of the above
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Caregiver Attitudes Toward
End-of-Life Care
• Many health providers see death as a professional
failure rather than as the inevitable end to the
human experience
• Caregivers need to be able to communicate effectively –
deal with grief, loss & bereavement at the end of life
– patient,
– family
– significant others
9
Death among older adults is typically caused by
a(n):
A. acute illness.
B. accident.
C. chronic and debilitating conditions.
D. sudden, unexpected condition.
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Values Clarification Related to
Death and End-of-Life Care
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Ethical Dilemmas
• value systems of the patient & caregiver differ
significantly
• Individuals would benefit from spending some
time identifying their personal values related
to the end of life
• Understanding the value systems of others can
help the nurse provide quality end-of-life care,
even when his or her values are not the same
13
Values Clarification
• Death, dying, and the end of life have different
meanings for every person
• Each individual must examine his or her own
values
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What Is a “Good Death”?
• Many groups have conducted research to
identify the specific end-of-life outcomes that
are most valued and desired by those nearing
the end of life and by their families
• Themes throughout all studies indicate that
given their choice, most people wish to be
treated with respect and dignity and to die
quietly and peacefully, with loved ones nearby
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Patients’ Wishes Related to
End of Life
• Most dying patients have similar desires
17
Where People Die
• 90% of people surveyed indicated a wish to
die at home, less than one-fourth of deaths
actually occur there
• half occur in hospitals; another quarter in
extended-care facilities
• Hospice care
– The focus of hospice care is palliative, providing
comfort and meeting the needs of patients and
their families
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Hospice care is usually available for the last
__________ of life.
A. month.
B. 6 months.
C. 1 year.
D. 2 years.
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• Medicare will cover hospice when death is
expected to occur within 6 months
– Not always exact timing
– Not always cancer
•
•
•
•
CHF
Dementia
COPD
etc
Hospice Care
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Palliative Care
• Focus-reducing or relieving symptoms
without attempting a cure; it neither hastens
nor postpones death
• Interventions designed to optimize ability to
live as active and complete a life as possible
until death comes
• “Comfort Care”
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Palliative Care (cont.)
• Individuals chosing palliative care typically
choose to decline procedures
– Invasive diagnostic tests
– cardiopulmonary resuscitation (CPR)
– artificial ventilation
– artificial feeding,
• prolong the dying process
23
Collaborative Assessments and
Interventions for End-of-Life Care
• requires commitment and collaboration of all
caregivers
• Everyone must work together cooperatively &
creatively & with a positive attitude to solve
any problems
• Problem solving requires mutual respect and
prompt effective communication among all
team members
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Communication at the End of Life
• The responsibility for providing and
maintaining effective communication
– nurses and assistive caregivers, who spend the
most time with dying patients
• Nurses need to work to develop a climate that
encourages open communication
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Communication at the End of Life
(cont.)
• demonstrate verbally and nonverbally you are
approachable and not detached or indifferent
• need to demonstrate willingness to listen to
suggestions, requests, or criticisms made by
the dying person or, more likely, by his or her
family
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Audience Response System
Question 3
One of the most important things caregivers can
do for a dying person is to:
A. not talk about when they will die.
B. allow them to be alone as much as possible.
C. talk to them about a “do not resuscitate”
status.
D. spend more time with them.
Copyright © 2012, 2008 by Mosby,
Inc., an affiliate of Elsevier Inc. All
rights reserved.
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Psychosocial Perspectives,
Assessments, and Interventions
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Cultural Perspectives
• A person’s cultural beliefs influence how he or
she thinks, lives, and interacts with other
people; the beliefs also affect how a person
will approach death
• A part of the nurse’s responsibility is to assess
each individual to determine his or her unique
preferences and viewpoints so that trust can
be developed and culturally sensitive care can
be planned
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Communication About Death
• The Western or European and American
perspective tends to emphasize the patient’s
“right to know” his or her diagnosis and
prognosis so that the patient can make
informed decisions
• Asians and Native Americans often believe
that speaking about death or other bad things
will decrease hope and produce bad outcomes
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Decision-Making Process
• Amount and type of intervention that will be
accepted
– Some focus on helping people cope with death
– Other cultures more likely to focus on living and
prolonging life
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Decision-Making Process (cont.)
• Significance of pain and suffering
– The Western perspective focuses on achieving
freedom from pain and suffering
– Non-Western cultures are more likely to view pain
as a test of faith or a preparation for the afterlife;
it is something that is to be endured rather than
avoided
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Spiritual Considerations
• Determine whether any specific religious
beliefs or practices are important to the
patient or his or her family members
• Assess whether the patient has a preferred
spiritual counselor
• Offer choices when available
• Determine whether the person wishes any
spiritual counselor to be notified
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Spiritual Considerations (cont.)
• Demonstrate respect for the patient’s religious
and spiritual views
• Avoid imposing your own beliefs on the
patient
• Be present, be available, and listen
• Avoid moving beyond your role and level of
expertise unless you have specific ministerial
or pastoral training in death and dying
34
Depression, Anxiety, and Fear
• It is one thing to know that you will die
eventually; it is another to realize that you
have lived most of your life and that death is
likely to be a reality soon
• Individuals must decide whether they will give
up and let fear, anxiety, or depression
overwhelm them or whether they will do
something to remain in control of whatever
time they have remaining
35
Physiologic Changes, Assessments,
and Interventions
36
Pain
• Often the most significant concern of the
dying person and his or her significant others
• Can interfere with the dying person’s ability to
maintain control, cope, and complete end-oflife tasks
• Increases the likelihood of fatigue, depression,
and loss of appetite
37
Pain (cont.)
• Interferes with the ability of the dying person
to make thoughtful decisions and to
communicate effectively with loved ones at a
critical time
• Relief of pain begins with careful assessment
• Assessment needs to be performed early and
often, because the patient’s status can change
dramatically in a relatively short period
38
Pain (cont.)
• Pain is what the patient says it is, but many older
patients who have lived with multiple discomforts
often underreport the amount of pain they are
experiencing
– Don’t want to be a bother
– Afraid of addiction to medication
• Medical personnel
• Family
• patient
• Self-reported logs or journals are helpful because
the patient and significant others are more
focused and attuned to subtle changes in the
individual
39
Fatigue and Sleepiness
• May be caused by underlying disease
processes, stress, anxiety, or medications
• Fatigue can interfere with the dying person’s
ability to carry out necessary end-of-life tasks,
including communicating with loved ones
• Because of metabolic changes [& depression]
patient may begin to sleep more and may be
difficult to awaken as the end of life nears
40
Cardiovascular Changes
• Diminished peripheral circulation already is
likely to worsen as death nears, resulting in
dry, pale, or cyanotic extremities
• Peripheral pulses are often weak
• Blood pressure typically is decreased by 20 or
more points from the normal range and may
be difficult to auscultate
• Body temperature may elevate significantly as
death nears
41
Respiratory Changes
• Shortness of breath, difficulty breathing
(dyspnea), and Cheyne-Stokes respirations
during sleep are commonly observed in older
adults as death nears
• Mild respiratory difficulty usually can be
relieved by changing positioning, elevating the
upper body, opening windows or using a fan
to increase ventilation, or administering
oxygen by nasal cannula
– Narcotics often given for air hunger
42
Gastrointestinal Changes
• Loss of appetite (anorexia) and muscle
wasting (cachexia) are commonly observed
with advanced terminal conditions,
particularly some forms of cancer
• Dry mouth (xerostomia) and ulcerations of the
mouth
• Nausea and vomiting are not signs of
impending death; rather, they are distressing
symptoms of underlying problems
43
Gastrointestinal Changes (cont.)
• Constipation is a common and distressing
problem for the terminal patient
• Diarrhea is a less common problem at the end
of life, but one that can have a profound effect
on the quality of life
44
Urinary Changes
• Oliguria common-decreases in fluid intake,
blood pressure, and kidney perfusion
• Urinary incontinence common
• Absorbent pads or indwelling catheter
– used to reduce need for bed changes that may
disturb the dying person
45
Integumentary Changes
• Skin breakdown is a problem
– malnourished
– Lack of mobility
– incontinence
• Interventions to prevent skin tears or pressure sores
proper skin cleansing
– careful handling of skin
– frequent turning and positioning
– measures to reduce pressure
• soft, nonconstricting, nonirritating clothing helps promote
comfort and minimizes risk for skin dryness and rash
46
Sensory Changes with end of life
• Vision- diminishes and the visual field narrows
• Hearing-acute until death
– even if the person does not respond
– Calm, supportive, loving messages should be
delivered, even when unresponsive
– Negative or disturbing conversations should be
avoided
,
47
Changes in Cognition
• Delirium-present in over 80% @ end of life
– Causes
• Hypotension
• oxygen deprivation
– Apnea
– hypoventilation,
• Fever
• neurologic changes
• metabolic abnormalities
– Hyperglycemia
-uremia
-dehydration
• other physiologic or emotional disturbances
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Death
49
Family Members and
Significant Others
• Often wish to be present at the time of death
• Some can spend only limited time
– wish to be called only when there is a significant
change in the person’s status
– Others would rather be notified only after death
has occurred
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Indicators of Imminent Death
•
•
•
•
Increased sleepiness
Decreased responsiveness
Confusion in a person who has been oriented
Hallucinations about people (sometimes
deceased family members)
• Increased withdrawal from visitors or other
social interaction
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Indicators of Imminent Death (cont.)
• Loss of interest in food and fluids
• Loss of control of bowel and bladder
• Altered breathing patterns
– shallow breathing
– Cheyne-Stokes respirations
– rattling or gurgling
• Involuntary muscle movements and
diminished reflexes
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After Death
• family members should be allowed to sit at
the bedside and say farewells or grieve as long
as they need
• It is appropriate for the nurse to discreetly
remove oxygen, IV lines, or other medical
devices
• Cultural practices regarding grieving and
preparation of the body should be respected
and accommodated whenever possible
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Postmortem Care
• Removal of soiling and application of a clean
sheet or shroud according to agency policies
• In most cases, the head is elevated slightly to
prevent discoloration
• Eyes are gently closed, dentures are inserted,
and a small towel is rolled and tucked under
the jaw to close the mouth
• Personal belongings should be identified,
listed, and bagged for return to the family
55
Funeral Arrangements
• Most older people have given some thought
to their final resting place, and many have
made specific plans, issued specific directions
regarding their wishes and, in some cases,
even paid for their funeral
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Bereavement
• Survivors often express having ambivalent
feelings regarding the death
– On one hand, they feel a sense of relief that the
struggle is over and that the loved one is at rest
– On the other hand, they seriously grieve and miss
the loved one’s presence
• Even when death is anticipated, the initial
feeling of shock and numbness typically occurs
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Bereavement (cont.)
• reality of the loss strikes
• survivors often experience s/s of depression
– loss of appetite
– inability to sleep
– avoidance of social interaction
– uncontrolled bouts of crying
• In normal grieving, the frequency and severity of
these signs of grieving gradually decrease over
time, but the loss of a loved one never goes away
completely
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Chapter 16
Sexuality and Aging
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Factors that Affect Sexuality of
Older Adults
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Normal Changes in Women
• changes in the reproductive system related to
decreased levels of progesterone and estrogen
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Changes in Women
• The good
– More relaxed about sexuality
• Experience/assertiveness
• No pregnancy worries
• Less life stress
Changes in Women (cont.)
• The not so good
• Increased STD risk
– Tissue thinning
– No pregnancy worry=no condom
• discomfort or pain during intercourse
– Irritation of the external genitals
– Thinning and dryness of the vaginal walls
– Alteration in vaginal flora
• increased risk for vaginal yeast infections
65
Erectile Dysfunction in Men
• orgasm takes longer to achieve and has a
shorter duration than at a younger age
• Ejaculation less forceful-smaller volume of
seminal fluid is released
• Loss of erection occurs quickly after orgasm
• The time between orgasms increases, and
orgasm may not occur with every episode of
sexual intercourse
66
Illness and Decreased Sexual Function
• Many disease processes & medications
interfere with normal sexual function 
– Some medications enhance sexual function, even
some that aren’t designed to do so 
• Incontinence does not interfere with sexual
relations but may cause some people to avoid
sex because of the risk of embarrassment
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Illness and Decreased Sexual Function
(cont.)
• Joint pain resulting from arthritis can interfere
with sexual activity
• Cardiac problems can interfere with normal
sexual activity-more from fear than from
actual danger
– Circulation problems affect ALL organs…..
68
Illness and Decreased Sexual Function
(cont.)
• Stroke need not prevent sexual activity
• Neither hysterectomy nor mastectomy
changes sexual functioning
– BUT.. They often cause body image problems
• Depression- can decrease sexual interest &
lead to decreased response to intimacy
– Many antidepressants cause sexual side effects
69
Alcohol and Medications
• Excessive alcohol intake
– delayed orgasm in women
– loss of the ability to achieve or maintain erection in
men
• Digitalis, tranquilizers, diuretics, antihypertensives,
antihistamines, antidepressants, and even some
medications used to treat GERD are likely to cause
sexual problems for men and women
70
Loss of Partner
• Single older women experience more of a
problem than single older men
• By age 85, there are 100 single women for
every 39 single men
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Loss of Partner (cont.)
72
Marriage and Older Adults
73
Marriage
• many different responses- particularly from families
• Pensions, insurance benefits, and other financial
concerns may be contingent on the person’s
remaining single
• Some choose to live together without marrying
– can be a difficult decision for them and their families
74
Caregivers and the Sexuality of
Older Adults
75
Caregivers
• Young people often uncomfortable with the
thought of sexual activity
• health care professionals may be unaware of
or uncomfortable about addressing the sexual
needs of older adults
• Fear, shame, or embarrassment causes many
older people to hide their sexual interests and
activity, even from health care professionals
77
Sexual Health and
Sexual Orientation
78
Sexual Health
• Older adults often are not considered when
sexually transmitted diseases are discussed,
yet 10% of acquired immunodeficiency
syndrome (AIDS) cases occur in people older
than 50 years
• All sexually active individuals, no matter what
their age, should use safe sex practices
• The risk for sexually transmitted disease does
not disappear with age
79
Sexual Orientation
• People may be more comfortable expressing
sexual orientation as they age
• Health care providers must be careful to
recognize the sexual needs and concerns of
older lesbian, gay, and transgendered people
81
Privacy and Personal Rights of Older
Adults
• Obtaining adequate privacy may be difficult
even for married couples who reside in the
same institution, particularly if regular
medical or nursing care is necessary
• Touching, hand-holding, and cuddling are
encouraged
• A closed door must be respected when privacy
for intimacy is desired
82
Touch and Affection
83
• Touch and affection are human needs, even
when sexual expression isn’t possible