Download 401-Death-and-Dying

Caring for the Dying Patient
Keith Rischer RN, MA, CEN
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Today’s Objectives…
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Discuss the current ethical issues surrounding
end of life care.
Identify goals of end of life care.
Compare & contrast the emotional & spiritual
needs of the family and client who is dying.
Contrast early vs. late physical changes in the
client who is dying.
Describe nursing goals and priorities for
managing the client who is dying.
Contrast the needs of the family with the nurse
in the client who has died.
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End of Life Ethics
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Assisted Suicide
Withdrawal food/fluids
Passive vs. Active
Euthanasia
Legalized active
euthanasia in US
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Oregon “Death
w/Dignity Act”
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Advance Directives
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Living will
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Legal document instructs measure of care
desired if incapable
Shortcomings
 Life
& death choices over unknown set of
circumstances
 Some ethicists believe document is “worthless”
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Durable power of attorney
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The Cure/Care Model
D
Life
Prolonging
Care
Palliative/ E
Hospice
Care
Disease Progression
A
T
H
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Concerns of Dying Patient
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Fear of physical pain and suffering
Symptom burden
Fear of unknown
Fear of loneliness
Anonymity
Loss of choice over destiny
Loss of dignity
Loss of consortium
Separation and lack of connection
Spiritual
Financial
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Palliative Care’s Place in Course of Illness
Life Prolonging Therapy
Death
Diagnosis
of serious
Palliative Care
illness
Medicare
Hospice
Benefit
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Early Physical Changes
↓ Appetite ↑Weight loss
 Assistance with ADLs
 Pain (> or < )
 Increased HR; Potential O2 deficiency
 Drowsiness
 Fatigue
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Early Emotional Changes
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Months to Weeks
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Hope
 Desirable
 Expectational
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Withdrawal
Changes in mood
 Anger,
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irritable, hope, denial, ect
World view changes; gets smaller
Attending to business
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Spiritual Distress
Signs of Spiritual Distress
 Doubt
 Despair
 Guilt
 Anger
 Boredom
 Isolation
 Statements of regret
 Statements of unresolved
hurt
Nursing Interventions
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Ask about their source
of strength
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Discuss sources of
spiritual strength
throughout their lives
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Assess support system
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Assess coping
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Refer to clergy/chaplain
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Ministry: ex. Stephens
Ministry at churches
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Family Needs
Focus on dying patient without losing the
present and future
 The work of daily life goes on
 Anticipatory grief
 Increase in responsibilities (house,
finances, work, children, and acting as a
caregiver).
 Need for support from family, community,
spiritual faith.
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Goals of Nursing Care for the Dying
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Hospice
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Control symptoms
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Improve quality of life w/terminal illness
Pain
N&V
Fatigue
SOB
Identify-prioritize needs
Promote meaningful interactions w/family and
others
Facilitate peaceful death
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Nursing Care:Holistic
Chaplain/ Clergy visit
 Hospice/ respite care
 Hospice/Home Care
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Provide CNA daily for ADL hygiene and care
More frequent RN visits
More frequent Social Worker visits
Talk candidly about end of life= how it will
likely be for that specific patient
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Nursing Care:Physical Priorities
Pain management
 N&V management
 Fatigue management
 Skin care
 Mouth care
 Urinary care
 Respiratory care
 Comfort
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Nursing Care: Physical Priorities
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Attend to any needs of patient
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Pain
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Nausea
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Long acting analgesics with medication for breakthrough pain
May need to increase doses of medication
Counsel pt./family on pain cycle and breakthrough pain
Antiemetics…Zofran
Foods that taste good with increased protein and fat
Ensure or supplements
Comfort
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Comfortable bed
Chair
pillows
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Why Pain?
• Practitioners are not trained in state-of-the art
pain management
• Myths about addiction, dependence, and
tolerance abound
• The toll that unrelieved pain takes on the body
and mind is not understood or acknowledged
• Fear that pain intervention might cause the
patient to die
• Flawed assessments
• Disconnect
• Failure to look at non-physical sources
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Nursing Care: Physical Priorities
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Mobility
 Cane,
walker,
 Prevent falls
 Falls often indicate change in status
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Sleep
 Sleeping
more? Less? Look at medications and
physical status. Normal to increase in sleeping.
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Fatigue
 Do
what only matters, find what is important to
patient
 Hospice volunteer for family for relief
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Nursing Care: Physical Priorities
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Neuro
• Changes due to disease (brain mets, lack of oxygen?)
CV
• May need fan for cool or light weight blankets for warmth
Lungs
• Teach use of several pillows, O2 may be needed
Skin
• Teach positioning, turning, and prevention of breakdown
GI
• Use of stool softeners is a must; may need laxatives later on
Urinary
• May have incontinence (pads, diapers, last resort is foley)
Medications
• Order what is needed for comfort
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Changes with Weeks Remaining:
Physical Changes
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Profound weakness
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Bedbound
Falling if ambulating
Muscle weakness
Potential skin breakdown
 Increased care needed
 VS
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↑ HR ↓ Pulse
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Dyspnea Managment
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Morphine sulfate
Diuretics
Bronchodilators
Antibiotics
Anticholinergics
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Atropine
Sedatives
Oxygen
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Changes with Weeks Remaining:
Emotional Changes
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↑ Fear, apprehension or peacefulness
↑ withdrawal into self
Often sees “spiritual beings”
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God; previous family members who have died
speaking out to them
Only allows family and loved ones in their world
Starts to say goodbye to loved ones
A sense of peace and finished business may be
felt OR a sense that there is not enough time left
to finish life
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Changes with Weeks Remaining: Family
Needs
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How to care for their love one
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Focus is home care management
May not be able to get to PCP’s office
May involve equipment and teaching nursing care for ADLs
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Pain relief
Symptom management
Medication management increases
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O2, transfer techniques, shower chair, turning techniques, decubitus
care, mouth care, foley care, ect
Subq meds, rectal suppositories
Psychological support increases
Focus on quality of life vs. quantity
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Imminent Death:Nursing Care
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Medication management
• If unable to swallow (subq,
rectal suppositories)
• For death rattle “Scopolamine
patch” works
• Pain management
• Comfort measures increase
 Turning, mouth care,
positioning of limbs,
warm/cool measures, eye
drops, ect
• Assistance respiratory with
positioning
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Imminent Death:Physical Changes
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Actively Dying: 48-72 hours remain
Confusion and disorientation
• Metabolic changes
Withdraws from family “going” somewhere
• Decreased consciousness
May refuse all fluid and food
• Body conservation of energy for function
Total care ↓ alertness ↑ drowsiness
• Metabolic changes and decreased oxygen to brain
↑ Restlessness
↓ BP ↑HR (120-150)
• Peripheral circulation diminishing to vital organs
• Mottling of extremities
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Imminent Death:Physical Changes
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Incontinence of urine and bowel
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Dependent areas become cyanotic & cold
Skin color is pale and mottling of skin occurs (knees,
legs, nose)
Slower pupil response to light, & eyes fixed stare-even in
sleep
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Muscle becomes slack, decreased oxygen
Speech may be difficult and soft
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Increased muscle relaxation and decreased consciousness
May be incontinent around the foley catheter
Muscle becomes slack
Hearing is thought to remain present
Vision may be lost
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Imminent Death:Physical Changes
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Cheyne-Stoke respirations
• Metabolic and oxygen changes
• Decreased RR
• Death rattle
Profuse perspiration
• Decreased circulation to all organs as they are
shutting down
↓ urinary output
• Decreased vital organ/ kidneys shutting down
Body temp varies
• May decrease or rise
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Imminent Death:Emotional Needs
Sense of peacefulness in the room
 Family and loved ones present
 Caring feeling by loved ones
 Its going to be OK
 Its OK to go now
 Your work is done
 I love you/ I forgive you
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Imminent Death: Family Needs
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Presence of Nurse
Care for patient
Support for patient and family
Educate family throughout the process to avoid
the feeling of not knowing what next
Be the detail person
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Be prepared for how family will handle death
Know emergency numbers for family/hospice
Make final arrangements
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Mortuary; pick up equipment, clean up room.
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Imminent Death: Family Needs
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Encourage them to stay with patient
Touch and talk with patient
Be vigilant about what the patient hears, even
though he/she cannot respond
Encourage active comfort measures
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Light massage, mouth care,
Allow them time to privately grieve with family
Acknowledge the process of dying
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Skin cooling, cyanosis, Cheyne-Stokes, urinary
incontinence (all this is normal)
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Pronouncement of Death
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Cessation of blood
pressure, pulse and
respirations.
In hospice is pronounced
by RN (or Social Worker
in some states)
• Blood pressure may
be not be able to be
palpated for hours
before death
• Final respirations may
be gasping
• Eyes are fixed (pupils
fixed and dilated)
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• No apical pulse
Needs of the Family After Patient’s Death
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Presence of a support system
• Family, chaplain, nurse,
social worker
Make sure someone is with
them
• Don’t leave them alone to
go home
• No One Dies Alone at ANW
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Vounteers who stay during
last hours
Call family members if needed
(when unexpected)
Allow time for the family to
spend with the patient who
died
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Needs of the Nurse After the Patient’s
Death
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Support system
• Other staff, friends,
family (who can listen to
you)
Physical and emotional
rest
Attend memorial or burial
service for closure
Final separation from
family
Remind yourself that you
made a difference
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Near Death Experiences
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Altered state of consciousness during brief cessation of
VS (cardiac arrest)
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Afterwards for patient
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Tunnel of light
Sense of being separated from body
Fear & anxiety-torment
More spiritual minded-less material focused
Less fearful of death
Nurse’s role
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“What do you remember about being unconscious?”
“Did you have a sense of being separate from your body while
we were reviving you?”
Avoid negative statements during code
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