Download lecture 7: chapter 11 End of Life Care

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Care at the End of Life
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-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
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 one’s 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
 Alzheimer’s 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-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.
NURSE’S 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
Patient’s 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 COGNITIVELYIMPAIRED 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
Short-acting or immediate release agents for prn use

Acute pain
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


Topical


For pain as a result of herpes, arthritis, or local invasive
procedures
Parenteral


Delivers 72 hours of pain medication
For patients who cannot swallow
Epidural or intrathecal

Use if unable to achieve pain control by other methods
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
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?
