Download VN057_gerontology_8.1

15,
End-of-Life Care
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Not seen as a natural progression
Uncomfortable with death
fragmented, disorganized & inadequate guidance
forced to attempt to follow changing rules &
regulations set up by multi bureaucracies
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Gvt
insurance
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end-of-life care and death planning
Ideally, discussions before a health crisis
variety of options-end of life decisions difficult
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too many choices
values, cultural & spiritual beliefs, & life
experiences all affect choices
Most say that they do not fear death as much
as they fear how they will die
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Specific end-of-life decisions
Written- official documents
Fewer issues-both providers & family
 advance directive
 living will
 durable power of attorney for health care
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Specify the type and amount of intervention
desired by an individual
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Copies to
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PCP, hospital of choice, extended-care facility, power
of attorney for health care, anyone else as
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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Not official or required
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Medic-alert bracelet or necklace with code status
Copy on refrigerator if person lives @ home
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providers see death as a professional failure rather
than 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
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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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value systems of patient & caregiver are often
very different
Caregivers benefit from spending time
identifying their personal end of life values
Understanding the value systems of others
help the nurse provide quality end-of-life care,
even when his or her values are not the same
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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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research to identify specific end-of-life
outcomes most valued & desired by those
nearing the end of life & by their families
Common theme: 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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Most dying patients have similar desires
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90% indicated a wish to die at home
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less than 25% actually occur there
50% occur in hospitals
25%in extended-care facilities
Hospice care
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The focus is palliative
providing comfort
meeting the needs of patients & 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 covers hospice when death is
expected to occur within 6 months
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Not always exact timing-some lee way
Not always cancer
 CHF
 Dementia
 COPD
 etc
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Focus-reduce or relieve symptoms without
cure
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neither hastens nor postpones death
Interventions designed to make the best of the
time left & live as active and complete a life as
possible until death comes
“Comfort Care”
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Individuals choosing palliative care usually
choose to decline procedures
Invasive diagnostic tests
 cardiopulmonary resuscitation (CPR)
 artificial ventilation
 artificial feeding,
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 prolong the dying process
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Commitment & collaboration of all caregivers
Disciplines must work together cooperatively
& creatively
positive attitude to solve any problems
requires mutual respect & communication
between all team members
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responsibility for providing & maintaining
effective communication
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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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demonstrate verbally and nonverbally you are
approachable
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not detached or indifferent
demonstrate willingness to listen
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suggestions, requests, or criticisms made by the
dying person or, more likely, by family
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cultural beliefs influence people think, live &
interact with other people-they also affect how
a person approaches death
nurse’s responsibility to assess each person to
find out their preferences & viewpoints
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Develops trust & can plan culturally sensitive care
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The Western perspective emphasizes patient’s
“right to know” diagnosis and prognosis
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patient can make informed decisions
Asians & Native Americans often believe
speaking about death or other bad things
decreases hope and produces bad outcomes
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Amount and type of intervention that will be
accepted
Individual/cultural
focus on helping people cope with death
 focus on living and prolonging life
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Significance of pain and suffering
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Western perspective focuses on freedom from pain
and suffering
Non-Western cultures often see pain as a test of faith
or a preparation for the afterlife
 something that is to be endured rather than avoided
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Determine if there are specific religious beliefs
or practices important to the patient or their
family members
Assess whether they have a preferred spiritual
counselor
Offer choices when available
Determine whether the person wishes any
spiritual counselor to be notified
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respect for the patient’s religious and spiritual
views
 Avoid imposing your own beliefs
 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
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It is one thing to know that you will die
eventually; it’s 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
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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.
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Biggest concern of the dying person and their
significant others
Can interfere with the ability to maintain
control, cope, and complete end-of-life tasks
Increases the likelihood of fatigue, depression,
and loss of appetite
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Interferes with the ability of the dying person
to make thoughtful decisions & communicate
effectively with loved ones at a critical time
Relief of pain begins with careful assessment
Perform assessment early & often
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patient’s status can change dramatically in a
relatively short period
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Pain is what the patient says it is, but many
older patients who have lived with multiple
discomforts often underreport pain
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Don’t want to be a bother
Afraid of addiction to medication
 Medical personnel
 Family
 patient
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Self-reported logs or journals are helpful
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patient and significant others more focused and
attuned to subtle changes in the individual
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May be caused by underlying disease
processes, stress, anxiety, or medications
can interfere with ability to carry out end-oflife 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
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Diminished peripheral circulation
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likely to worsen as death nears
resulting in dry, pale, or cyanotic extremities
Peripheral pulses are often weak
Blood pressure often decreased by 20 or more
points from normal range and may be difficult
to hear
Body temperature may elevate significantly as
death nears
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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
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Narcotics often given for air hunger
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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
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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
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Oliguria common-decreases in fluid intake,
blood pressure, and kidney perfusion
Urinary incontinence common
Absorbent pads or indwelling catheter
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used to reduce need for bed changes that may
disturb the dying person
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Skin breakdown is a problem
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Interventions to prevent skin tears or pressure sores
proper skin cleansing
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malnourished
Lack of mobility
incontinence
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
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Vision- diminishes and the visual field narrows
Hearing-acute until death
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even if the person does not respond
Calm, supportive, loving messages should be
delivered, even when unresponsive
Negative or disturbing conversations should be
avoided
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Delirium-present in over 80% @ end of life
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Causes
 Hypotension
 oxygen deprivation
 Apnea
 hypoventilation,
 Fever
 neurologic changes
 metabolic abnormalities
 Hyperglycemia -uremia -dehydration
 other physiologic or emotional disturbances
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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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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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Loss of interest in food and fluids
Loss of control of bowel and bladder
Altered breathing patterns
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shallow breathing
Cheyne-Stokes respirations
rattling or gurgling
Involuntary muscle movements and
diminished reflexes
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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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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
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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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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
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Even when death is anticipated, the initial
feeling of shock and numbness typically occurs
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reality of the loss strikes
survivors often experience s/s of depression
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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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Denial — "This can't be happening to me.“
Anger — "Why me? It's not fair!""Who’s to blame?“
Bargaining — "I'll do anything for a few more
years."hope that the individual can delay death.
Depression —"I'm going to die soon so what's the
point?”
Acceptance — "It's going to be okay."