Chapter 17: Chapter 17: Ethical/Legal Principles Ethical/Legal Principles

and Issuesand Issues

Ethics of CareEthics of Care

CompassionCompassion EquityEquity FairnessFairness DignityDignity ConfidentialityConfidentiality Mindfulness of a person’s autonomy Mindfulness of a person’s autonomy

within the realm of a person’s within the realm of a person’s abilities and mental capacityabilities and mental capacity

Ethical ConceptsEthical Concepts Principles that facilitate decision making and Principles that facilitate decision making and

guide our professional behaviorguide our professional behavior Evolve from our beliefs and valuesEvolve from our beliefs and values Ethical decision making is driven by moral Ethical decision making is driven by moral

reasoning – our determination of what is right and reasoning – our determination of what is right and wrongwrong

Define our character and are expressed in our Define our character and are expressed in our conduct and actionsconduct and actions

Code of Ethics: ANA Code for NursesCode of Ethics: ANA Code for Nurses– A set of moral principles accepted by all members of the A set of moral principles accepted by all members of the

professionprofession– Provides tools for identifying ethical responsibilities and Provides tools for identifying ethical responsibilities and

to guide decision makingto guide decision making

Conflict and DilemmaConflict and Dilemma

Moral distress: occurs when someone Moral distress: occurs when someone wants to do the right thing but is wants to do the right thing but is limited by the constraints of the limited by the constraints of the organization or societyorganization or society

Moral uncertainty: defines the Moral uncertainty: defines the confusion surrounding situations in confusion surrounding situations in which a person is uncertain what the which a person is uncertain what the moral problem is or which moral moral problem is or which moral principles or values applyprinciples or values apply

Conflict and Dilemma (cont’d)Conflict and Dilemma (cont’d)

Moral dilemma: arises when two or Moral dilemma: arises when two or more moral principles apply that more moral principles apply that support mutually inconsistent actionssupport mutually inconsistent actions

True dilemma: occurs when it True dilemma: occurs when it appears there are no acceptable appears there are no acceptable choices choices

Ethical/Moral PrinciplesEthical/Moral Principles AdvocacyAdvocacy

– Championing of the needs and interests of Championing of the needs and interests of others others

AutonomyAutonomy– Person’s right to make independent Person’s right to make independent

choices/decisionschoices/decisions– Respect for personal lifestyle, values, beliefs, Respect for personal lifestyle, values, beliefs,

and choicesand choices– Educate, provide support and resources but Educate, provide support and resources but

cannot force compliance with recommended cannot force compliance with recommended treatmenttreatment

Informed consentInformed consent Advance directivesAdvance directives

– Avoid paternalismAvoid paternalism

Beneficence/NonmaleficenceBeneficence/Nonmaleficence

To do good and do no harmTo do good and do no harm To prevent or remove harmTo prevent or remove harm Failure to rescueFailure to rescue

– Effectiveness in rescuing a patient from Effectiveness in rescuing a patient from a complication vs. preventing a a complication vs. preventing a complicationcomplication

DefinitionsDefinitions

Confidentiality Confidentiality – The right to privacyThe right to privacy– HIPPA (need to know)HIPPA (need to know)

FidelityFidelity– Keeping promises or being true to Keeping promises or being true to

anotheranother– Being faithful to commitments and Being faithful to commitments and

responsibilitiesresponsibilities Fiduciary ResponsibilityFiduciary Responsibility

– Good stewardshipGood stewardship

Definitions (cont’d)Definitions (cont’d)

JusticeJustice– Fairness of an act or situationFairness of an act or situation– Treat equals equally and treat those Treat equals equally and treat those

who are unequal according to their who are unequal according to their needsneeds

– QOLQOL– Sanctity of life (right to live)Sanctity of life (right to live)

ANA Code of Ethics for NursesANA Code of Ethics for Nurses ““Nurses may not act with the intent Nurses may not act with the intent

to end life but may support and act to end life but may support and act on well-thought-out decisions on well-thought-out decisions regarding resuscitation status, regarding resuscitation status, withholding and withdrawing of life-withholding and withdrawing of life-sustaining care including nutrition sustaining care including nutrition and hydration, and aggressively and hydration, and aggressively managing pain and other symptoms managing pain and other symptoms at the end of life even if such care at the end of life even if such care hastens death.” (Mauk, page 592)hastens death.” (Mauk, page 592)

More DefinitionsMore Definitions

ReciprocityReciprocity– Ability to be true to one’s self while Ability to be true to one’s self while

respecting and supporting the values respecting and supporting the values and views of anotherand views of another

VeracityVeracity– Accuracy, truthAccuracy, truth– Not misleading or deceivingNot misleading or deceiving

Patient RightsPatient Rights

Advance Directives and Living WillsAdvance Directives and Living Wills Durable Power of AttorneyDurable Power of Attorney CompetenceCompetence

– May be transientMay be transient– Legal competence is determined by the courtsLegal competence is determined by the courts

Assisted SuicideAssisted Suicide– ANA does not support it in any formANA does not support it in any form– ANA suggests that nurses focus on providing ANA suggests that nurses focus on providing

competent, comprehensive, and competent, comprehensive, and compassionate EOL carecompassionate EOL care

Ethics in PracticeEthics in Practice Mistakes happenMistakes happen

– Admit the errorAdmit the error– Take steps to correct the situationTake steps to correct the situation– ApologizeApologize– Make amends if possibleMake amends if possible– Evaluate how to prevent in the futureEvaluate how to prevent in the future

MalpracticeMalpractice– deviation from standard of care than results in deviation from standard of care than results in

injury or damageinjury or damage Conflict of InterestConflict of Interest

– Competing loyalties and opportunitiesCompeting loyalties and opportunities

Chapter 21: Alternative Chapter 21: Alternative Health ModalitiesHealth Modalities

What is Complementary and What is Complementary and Alternative Medicine?Alternative Medicine?

NCCAM: “A group of diverse medical and NCCAM: “A group of diverse medical and health care systems, practices, and health care systems, practices, and products that are not presently considered products that are not presently considered part of conventional medicine”part of conventional medicine”

5 domains or classifications5 domains or classifications– Whole medical systemsWhole medical systems– Mind-body medicineMind-body medicine– Biologically based practicesBiologically based practices– Manipulative and body-based practicesManipulative and body-based practices– Energy medicineEnergy medicine

Whole Medical SystemsWhole Medical Systems HomeopathyHomeopathy

– Goal: Stimulate the body’s own healing Goal: Stimulate the body’s own healing responses to prevent or treat illnessesresponses to prevent or treat illnesses

– Dilution processDilution process Naturopathic medicineNaturopathic medicine

– Body is supported and barriers to cure are Body is supported and barriers to cure are removedremoved

– Diet and nutritionDiet and nutrition– HydrotherapyHydrotherapy– Spine and soft tissue manipulationSpine and soft tissue manipulation– Acupuncture and acupressureAcupuncture and acupressure– Herbs, Exercise, Counseling, Light TherapyHerbs, Exercise, Counseling, Light Therapy

Whole Medical Systems (cont’d)Whole Medical Systems (cont’d) AyurvedaAyurveda

– Comprehensive system that encompasses the Comprehensive system that encompasses the body, mind, and consciousness connectionbody, mind, and consciousness connection

– Seeks to restore a person’s harmony or Seeks to restore a person’s harmony or balancebalance

– Includes diet, exercise, meditation, herbs, Includes diet, exercise, meditation, herbs, massage, exposure to sunlight, controlled massage, exposure to sunlight, controlled breathing, and detoxificationbreathing, and detoxification

– 5 elements and 3 types of energy5 elements and 3 types of energy Traditional Chinese medicineTraditional Chinese medicine

– Includes acupuncture, herbal medicine, Includes acupuncture, herbal medicine, massage, and meditationmassage, and meditation

– Two apposing forces: Yin and yangTwo apposing forces: Yin and yang

AcupunctureAcupuncture Promotes the flow of qi through pathways in the Promotes the flow of qi through pathways in the

body called meridiansbody called meridians According to WHO, there is support for the use in According to WHO, there is support for the use in

the following:the following:– Post-op painPost-op pain– Chemotherapy induced n/vChemotherapy induced n/v– Pregnancy induced nauseaPregnancy induced nausea– Dental painDental pain

It is believed that it releases endogenous opioids It is believed that it releases endogenous opioids similar to TENSsimilar to TENS

Promising in the treatment of Promising in the treatment of – Headache, CVA rehab, OA, LBP, carpel tunnel, and Headache, CVA rehab, OA, LBP, carpel tunnel, and

asthmaasthma

Mind-Body InterventionsMind-Body Interventions Acknowledge that emotional, mental, Acknowledge that emotional, mental,

social, spiritual, and behavioral factors can social, spiritual, and behavioral factors can directly affect healthdirectly affect health

Includes:Includes:– PrayerPrayer– Deep breathingDeep breathing– MeditationMeditation– YogaYoga– BiofeedbackBiofeedback– Tai chiTai chi– Guided imagery Guided imagery – Pet Therapy and Music TherapyPet Therapy and Music Therapy

Biologically Based TherapiesBiologically Based Therapies

BotanicalsBotanicals Animal-derived extractsAnimal-derived extracts Vitamins/MineralsVitamins/Minerals Fatty acidsFatty acids ProteinsProteins Prebiotics and probioticsPrebiotics and probiotics Whole diets: vegetarian, macrobiotic, Whole diets: vegetarian, macrobiotic,

Atkins, Zone (see page 674 of text)Atkins, Zone (see page 674 of text) Myth: “If a little is good, more must be Myth: “If a little is good, more must be

better.”better.”

Manipulation and Body-Based Manipulation and Body-Based PracticesPractices

Believe that parts of the body are Believe that parts of the body are interdependent and the body has the interdependent and the body has the ability to heal itselfability to heal itself

Includes:Includes:– Chiropractic and osteopathic medicineChiropractic and osteopathic medicine– Massage therapyMassage therapy– ReflexologyReflexology– RolfingRolfing

Energy MedicineEnergy Medicine

Veritable energy fieldsVeritable energy fields– Mechanical vibrationMechanical vibration– Electromagnetic forcesElectromagnetic forces

Putative energy fieldsPutative energy fields– ReikiReiki– qi gongqi gong– Healing (or therapeutic) touchHealing (or therapeutic) touch– Prayer for the health of others (intercessory Prayer for the health of others (intercessory

prayer)prayer) Most controversial because they can’t be Most controversial because they can’t be

measuredmeasured

Reasons for CAM UseReasons for CAM Use

Pain reliefPain relief Increased quality of lifeIncreased quality of life Maintain health and fitnessMaintain health and fitness Sense of well beingSense of well being Dissatisfaction with traditional Western Dissatisfaction with traditional Western

medicinemedicine Supplement to traditional medicineSupplement to traditional medicine Kinder and gentler medicineKinder and gentler medicine Difficulty with accessing health systemDifficulty with accessing health system

Nursing Interventions Nursing Interventions

Ask about use of CAMAsk about use of CAM Ask specifically about use of vitamins Ask specifically about use of vitamins

and herbsand herbs Some herbs/vitamins may interfere Some herbs/vitamins may interfere

with prescribed medicationswith prescribed medications Integrated care may be best for the Integrated care may be best for the

older adultolder adult

Chapter 24: End-of-Life Chapter 24: End-of-Life CareCare

EOL InitiativesEOL Initiatives

EPEC: Education in Palliative and EOL EPEC: Education in Palliative and EOL CareCare

ELNEC: EOL Nursing Education ELNEC: EOL Nursing Education ConsortiumConsortium

CAPC: Center to Advance Palliative CAPC: Center to Advance Palliative CareCare

Historical AttitudesHistorical Attitudes

““In the Orient, dying is a In the Orient, dying is a requirement. In Europe, dying is requirement. In Europe, dying is inevitable. In America, dying appears inevitable. In America, dying appears to be an option.”to be an option.”

Results in expensive medical careResults in expensive medical care– Medicare pays out 5-6 times more for Medicare pays out 5-6 times more for

care within the last 12 months of life care within the last 12 months of life than any other timethan any other time

Background informationBackground information Every person has the right to a peaceful Every person has the right to a peaceful

death and some control at the end of death and some control at the end of life.life.

80% of Americans say their wish is to 80% of Americans say their wish is to die at home but less than 25% get to do die at home but less than 25% get to do so.so.

Nurses have the opportunity to Nurses have the opportunity to influence the processinfluence the process– Nurses spend more time with patients and Nurses spend more time with patients and

familiesfamilies– Can provide support, education, and Can provide support, education, and

guidanceguidance

CommunicationCommunication Talk about the elephant in the roomTalk about the elephant in the room EPEC 6 stepsEPEC 6 steps

– Get started: plan what to sayGet started: plan what to say– Find out what the patient knowsFind out what the patient knows– Find out how much the patient wants to Find out how much the patient wants to

knowknow– Share informationShare information– Respond to feelingsRespond to feelings– Plan/follow upPlan/follow up

Advance DirectivesAdvance Directives

Durable Medical Power of AttorneyDurable Medical Power of Attorney Living WillLiving Will

– 5 Wishes (legal in 40 states)5 Wishes (legal in 40 states) CPR DirectiveCPR Directive

– Colorado specificColorado specific– MD orderMD order– Allow natural death (AND)Allow natural death (AND)

Curative CareCurative Care

There are patients, families, and There are patients, families, and cultures who choose the life-cultures who choose the life-prolonging focus of care of a hospital prolonging focus of care of a hospital deathdeath

Usually an ICU settingUsually an ICU setting Promotes doing everything possiblePromotes doing everything possible Don’t make judgmentsDon’t make judgments

Hospice Hospice Dying is a normal part of the life cycleDying is a normal part of the life cycle Promotes the idea of “living until you die”Promotes the idea of “living until you die” Provides comfort and dignity at EOLProvides comfort and dignity at EOL Care is provided in multiple settings and Care is provided in multiple settings and

supports the patient/family through the supports the patient/family through the dying process as well as providing later dying process as well as providing later bereavement support to surviving familybereavement support to surviving family

Eligibility is based on life expectancy of 6 Eligibility is based on life expectancy of 6 months or lessmonths or less

Palliative CarePalliative Care ““Seeks to prevent, relieve, reduce, or Seeks to prevent, relieve, reduce, or

soothe the symptoms of disease or disorder soothe the symptoms of disease or disorder without effecting a cure” (Field & Cassel, without effecting a cure” (Field & Cassel, 1997).1997).

Whole-person care for those with life-Whole-person care for those with life-limiting illnesses who are not yet eligible for limiting illnesses who are not yet eligible for hospicehospice

Care, not cure, orientedCare, not cure, oriented Goal is highest quality of life possible for Goal is highest quality of life possible for

patients and their families in their given patients and their families in their given situationsituation

Control pain and other symptomsControl pain and other symptoms

Symptom Management: Symptom Management: RespiratoryRespiratory

DyspneaDyspnea– Morphine po or scMorphine po or sc– Relaxation techniquesRelaxation techniques– Use fans and/or cool, humidified airUse fans and/or cool, humidified air– Elevate the head of the bedElevate the head of the bed– OxygenOxygen

Anxiety r/t fear of suffocatingAnxiety r/t fear of suffocating – LorazepamLorazepam

Excessive secretions results from fluid Excessive secretions results from fluid overloadoverload– ScopolamineScopolamine– AtropineAtropine

Symptom Management: Symptom Management: Gastrointestinal/NutritionalGastrointestinal/Nutritional

ConstipationConstipation– Combination softner/stimulantCombination softner/stimulant– RelistorRelistor (methylnaltrexone bromide): an injectable (methylnaltrexone bromide): an injectable

medication, approved for patients with later-stage medication, approved for patients with later-stage advanced illness who use a continual regimen advanced illness who use a continual regimen of opioids of opioids

Nausea/vomitingNausea/vomiting– DexamethasoneDexamethasone– MeclizineMeclizine– ScopolamineScopolamine– Compazine pr or poCompazine pr or po– MetoclopramideMetoclopramide– Zofran, KytrilZofran, Kytril

Symptom Management: Symptom Management: Gastrointestinal/NutritionalGastrointestinal/Nutritional

Decreased appetiteDecreased appetite– Eating for pleasure is the goal - provide favorite Eating for pleasure is the goal - provide favorite

foodsfoods– No dietary restrictions - high calorie, small No dietary restrictions - high calorie, small

frequent mealsfrequent meals– PEG tubes and TPN have limited rolePEG tubes and TPN have limited role– Less nourishment requiredLess nourishment required

HydrationHydration– May be detrimental to comfortMay be detrimental to comfort– Contributes to fluid overloadContributes to fluid overload– Popsicles, ice chipsPopsicles, ice chips– Meticulous mouth careMeticulous mouth care

Symptom Management: Symptom Management: Anxiety/DeliriumAnxiety/Delirium

Realize that these often occur together - in Realize that these often occur together - in the elderly especiallythe elderly especially

DeliriumDelirium– Occurs in last hours to days of lifeOccurs in last hours to days of life– Causes: pain, dyspnea, constipation, urinary Causes: pain, dyspnea, constipation, urinary

retentionretention– Reduce stimuliReduce stimuli– Family/loved one at bedsideFamily/loved one at bedside– Re-orient if possibleRe-orient if possible– Provide emotional supportProvide emotional support– Music therapyMusic therapy– Anti-anxiety meds may be helpfulAnti-anxiety meds may be helpful

Symptom Management: Symptom Management: Anxiety/Delirium/DepressionAnxiety/Delirium/Depression

AnxietyAnxiety– Relieve physical symptoms, i.e. pain, SOBRelieve physical symptoms, i.e. pain, SOB– Family/loved one at bedsideFamily/loved one at bedside– Anti-anxiety medicationAnti-anxiety medication

Maximize symptom managementMaximize symptom management Assist persons to draw on sources of Assist persons to draw on sources of

strengthstrength Encourage verbalization/Acknowledge fearsEncourage verbalization/Acknowledge fears Educate (help sort real fears from Educate (help sort real fears from

imagined)imagined) ListenListen

Symptom Management: PainSymptom Management: Pain

Unrelieved pain can contribute to Unrelieved pain can contribute to unnecessary sufferingunnecessary suffering

Pain may actually hasten death by Pain may actually hasten death by increasing physiological stressincreasing physiological stress

Under-appreciated, under-reported, Under-appreciated, under-reported, and under-treatedand under-treated

Misconceptions About Pain Misconceptions About Pain in the Elderlyin the Elderly

Pain is a natural outcome of growing old.Pain is a natural outcome of growing old. Pain perception or sensitivity decreases with age.Pain perception or sensitivity decreases with age. If an elderly person does not report pain, he or If an elderly person does not report pain, he or

she doesn’t have pain.she doesn’t have pain. If an elderly patient appears to be asleep or If an elderly patient appears to be asleep or

otherwise distracted, he or she doesn’t have pain.otherwise distracted, he or she doesn’t have pain. Potential side effects of opioids make them too Potential side effects of opioids make them too

dangerous to use to relieve pain in the elderly.dangerous to use to relieve pain in the elderly. Alzheimer patients and others with cognitive Alzheimer patients and others with cognitive

impairments do not have pain, and their reports impairments do not have pain, and their reports of pain are most likely invalid.of pain are most likely invalid.

PainPain Pain is subjectivePain is subjective Pain is whatever the experiencing person Pain is whatever the experiencing person

says it is, existing whenever he says it says it is, existing whenever he says it does.” (McCaffery, 1968)does.” (McCaffery, 1968)

There are many different descriptions of There are many different descriptions of pain: sharp, dull, nagging, burning, pain: sharp, dull, nagging, burning, tingling, electrical, shooting, aching, tingling, electrical, shooting, aching, throbbing, squeezing, cramping.throbbing, squeezing, cramping.

Fear of addiction should not be a factor in Fear of addiction should not be a factor in pain control.pain control.

Types of PainTypes of Pain NociceptiveNociceptive

– SomaticSomatic Tissue, bone, joint, connective tissue injuryTissue, bone, joint, connective tissue injury Can localizeCan localize NSAIDS, steroids, opioids, may require comboNSAIDS, steroids, opioids, may require combo Ex: fracture, bone mets, muscle strainEx: fracture, bone mets, muscle strain

– VisceralVisceral Internal organsInternal organs Unable to localizeUnable to localize OpioidsOpioids Ex: shoulder pain, lung or liver metsEx: shoulder pain, lung or liver mets

NeuropathicNeuropathic– Injury to peripheral or central nervesInjury to peripheral or central nerves– Anticonvulsants or tricyclic antidepressantsAnticonvulsants or tricyclic antidepressants– Ex: shingles, diabetic neuropathyEx: shingles, diabetic neuropathy

Pain ManagementPain Management

Good assessment of pain is the first Good assessment of pain is the first step in treatmentstep in treatment

Suffering can increase painSuffering can increase pain Excellent and safe medications are Excellent and safe medications are

available so that persons should not available so that persons should not have to die in uncontrolled pain. have to die in uncontrolled pain. Other therapeutic modalities can also Other therapeutic modalities can also help relieve pain and sufferinghelp relieve pain and suffering

Pain ManagementPain Management Step 1:Step 1: Mild pain (1–3 on 0–10 scale) Mild pain (1–3 on 0–10 scale)

– Acetaminophen and NSAIDs Acetaminophen and NSAIDs – Acetaminophen should be dosed at 4,000 Acetaminophen should be dosed at 4,000

mg/day or less. An adjuvant may also be usedmg/day or less. An adjuvant may also be used Step 2:Step 2: Moderate pain (4–6 on a 0–10 scale) Moderate pain (4–6 on a 0–10 scale)

– Low-dose, short-acting opioids, in combination Low-dose, short-acting opioids, in combination with acetaminophen and NSAIDswith acetaminophen and NSAIDs

– Combination medications have a ceiling dose Combination medications have a ceiling dose – Adjuvants may also be usedAdjuvants may also be used

Step 3:Step 3: Severe pain (7–10 on a 0–10 scale) Severe pain (7–10 on a 0–10 scale)– Opioids; not used in combination with Tylenol Opioids; not used in combination with Tylenol

or NSAIDs so there is no ceiling for dosingor NSAIDs so there is no ceiling for dosing– Allows for the use of higher doses of these Allows for the use of higher doses of these

opioids opioids – Nonopioids and adjuvants may also be usedNonopioids and adjuvants may also be used

Grief, Loss, BereavementGrief, Loss, Bereavement The dying process involves loss.The dying process involves loss. Most losses trigger mourning and grief Most losses trigger mourning and grief

reactions.reactions. Grief is an emotional response to a loss. It Grief is an emotional response to a loss. It

is an individual process, not an event.is an individual process, not an event. Mourning is the outward expression of a Mourning is the outward expression of a

loss. How one mourns is often influenced loss. How one mourns is often influenced by culture and religion.by culture and religion.

Bereavement includes grief and mourning. Bereavement includes grief and mourning. This includes inner feelings and outward This includes inner feelings and outward behavior. behavior.

CommunicationCommunication 80% of communication is nonverbal80% of communication is nonverbal We should communicate respect, We should communicate respect,

acceptance, a value of human life, an acceptance, a value of human life, an understanding of suffering, a compassion understanding of suffering, a compassion for the dying as well as the livingfor the dying as well as the living

We should advocate for the patient’s best We should advocate for the patient’s best interestinterest

Patients and families want to know that we Patients and families want to know that we will not abandon them, but will listen, tell will not abandon them, but will listen, tell the truth, and be there for themthe truth, and be there for them

HopeHope

A patient can hear a terminal diagnosis A patient can hear a terminal diagnosis and still have hopes for the type of life and still have hopes for the type of life remainingremaining

Hope for appropriate help and supportHope for appropriate help and support A good death is possibleA good death is possible

– Instilling good memoriesInstilling good memories– Uniting familyUniting family– Avoiding suffering and painAvoiding suffering and pain– Becoming spiritually readyBecoming spiritually ready– Saying good-byeSaying good-bye

DeathDeath

Death is a universal processDeath is a universal process 10% sudden10% sudden 90% from chronic illness90% from chronic illness Advocacy, communication, education Advocacy, communication, education

and support are keyand support are key Be ready and prepared to assist Be ready and prepared to assist

families with the death vigilfamilies with the death vigil

The Dying ProcessThe Dying Process

No one can predict the exact time of No one can predict the exact time of death. It is determined by a number death. It is determined by a number of variables.of variables.

The dying process is a natural The dying process is a natural slowing down of all biological and slowing down of all biological and mental functions.mental functions.

The Dying ProcessThe Dying Process

Some patients seem to know when Some patients seem to know when death will occur. Listen to what they death will occur. Listen to what they tell you and believe them.tell you and believe them.

When hydration and nutrition are When hydration and nutrition are removed, death often does not occur removed, death often does not occur “quickly”, as family members might “quickly”, as family members might expect. Help them be prepared.expect. Help them be prepared.

Physical Signs and Symptoms of Physical Signs and Symptoms of End of LifeEnd of Life

Confusion, disorientation, deliriumConfusion, disorientation, delirium Weakness and fatigue with surges of Weakness and fatigue with surges of

energy at timesenergy at times Change in sleeping patternsChange in sleeping patterns Decreased oral intakeDecreased oral intake Decreased swallow reflexDecreased swallow reflex Restlessness, agitation, picking at Restlessness, agitation, picking at

thingsthings Change in bowel and bladder patternsChange in bowel and bladder patterns

Signs and Symptoms of Signs and Symptoms of Impending Death Impending Death

Decreased urine outputDecreased urine output Cold and mottled extremities Cold and mottled extremities

(earlobes may mottle first)(earlobes may mottle first) Vital sign changesVital sign changes Respiratory congestion Respiratory congestion Breathing pattern changesBreathing pattern changes

Signs and Symptoms of DeathSigns and Symptoms of Death Non-responsiveNon-responsive No heart beat and respirationsNo heart beat and respirations Incontinence of stool and urine possibleIncontinence of stool and urine possible Pupils fixed and dilatedPupils fixed and dilated Skin is pale, waxen, and cool to the Skin is pale, waxen, and cool to the

touchtouch Eyes may remain openEyes may remain open Jaw may fall openJaw may fall open

Nursing InterventionsNursing Interventions

Be there. Remember that you may Be there. Remember that you may be there as much for the family as be there as much for the family as for the patient.for the patient.

ListenListen TouchTouch PrayPray Make accommodations for any Make accommodations for any

cultural issues/beliefscultural issues/beliefs

Nursing InterventionsNursing Interventions

Give the family something to do. For Give the family something to do. For example, keeping the cool wash example, keeping the cool wash cloth on the forehead. Some family cloth on the forehead. Some family members will need a “job”.members will need a “job”.

Give the family time to rest. Give the family time to rest. Remember that the death vigil may Remember that the death vigil may be long.be long.

Promote family involvement. Promote family involvement.

Nursing InterventionsNursing Interventions Educate the family as to what to expect. Educate the family as to what to expect.

Remember that they may not only feel Remember that they may not only feel grief, but also guilt, uncertainty, grief, but also guilt, uncertainty, frustration and other emotions.frustration and other emotions.

Encourage family members to talk to Encourage family members to talk to the dying person.the dying person.

Provide a peaceful environment.Provide a peaceful environment. Allow the person to die the way they Allow the person to die the way they

wish.wish.

QuestionsQuestions

How do I feel about palliative How do I feel about palliative (comfort-based) care?(comfort-based) care?

How would I feel if I knew that I was How would I feel if I knew that I was going to die?going to die?