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Chapter 9Chapter 9

End-of-Life CareEnd-of-Life Care

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Overview: Death and DyingOverview: Death and Dying

Concept of “good” death and “bad” deathConcept of “good” death and “bad” death DeathDeath——cessation of integrated tissue and cessation of integrated tissue and

organ function, manifested by cessation of organ function, manifested by cessation of heartbeat, absence of spontaneous heartbeat, absence of spontaneous respirations, or irreversible brain respirations, or irreversible brain dysfunctiondysfunction

Incidence of deathIncidence of death——over 2 million deaths over 2 million deaths in the United States in 2004in the United States in 2004

Most common cause of deathMost common cause of death——diseases diseases of the heart, followed by cancerof the heart, followed by cancer

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Advance DirectivesAdvance Directives

Written document prepared by a competent individual Written document prepared by a competent individual specifying what, if any, extraordinary actions the person specifying what, if any, extraordinary actions the person would want when no longer capable of decisions about would want when no longer capable of decisions about personal health carepersonal health care

DPOA—legal document assigning decision-making power DPOA—legal document assigning decision-making power to another person to make his or her health care decisions to another person to make his or her health care decisions in the event he or she becomes incapable of making in the event he or she becomes incapable of making decisionsdecisions

Living will—legal document that instructs physicians and Living will—legal document that instructs physicians and family members about what life-sustaining treatment a family members about what life-sustaining treatment a person does or does not want at some future time if he or person does or does not want at some future time if he or she becomes unable to make decisionsshe becomes unable to make decisions

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Desired Outcomes for End-of-Life Desired Outcomes for End-of-Life CareCare

Identification of patient needsIdentification of patient needs Control of symptoms of distress Control of symptoms of distress Promotion of meaningful interactions Promotion of meaningful interactions

between the patient and familybetween the patient and family Facilitation of a peaceful deathFacilitation of a peaceful death

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Hospice and Palliative CareHospice and Palliative Care

Hospice care—interdisciplinary approach to Hospice care—interdisciplinary approach to assess and address the holistic needs of patients assess and address the holistic needs of patients and families to facilitate quality of life and a and families to facilitate quality of life and a peaceful deathpeaceful death

Palliative care—a philosophy of care and an Palliative care—a philosophy of care and an organized, structured system for delivering care organized, structured system for delivering care for individuals with a life-threatening illnessfor individuals with a life-threatening illness

Goal of palliative care—to prevent and relieve Goal of palliative care—to prevent and relieve suffering and to support the best possible quality suffering and to support the best possible quality of life for patients and their families, regardless of of life for patients and their families, regardless of the stage of the disease or the need for other the stage of the disease or the need for other therapiestherapies

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Symptoms at End of LifeSymptoms at End of Life

As death nears, patients often have signs As death nears, patients often have signs and symptoms of decline in physical and symptoms of decline in physical function, manifested as:function, manifested as: WeaknessWeakness AnorexiaAnorexia Changes in cardiovascular functionChanges in cardiovascular function Changes in breathing patternsChanges in breathing patterns Changes in gastrointestinal functionChanges in gastrointestinal function Changes in genitourinary functionChanges in genitourinary function

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Patient-Centered Collaborative Patient-Centered Collaborative CareCare

AssessmentAssessment Physical assessment/clinical Physical assessment/clinical

manifestationsmanifestations Coolness of extremitiesCoolness of extremities Increased sleepingIncreased sleeping Fluid and food decreaseFluid and food decrease IncontinenceIncontinence Congestion and gurglingCongestion and gurgling

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Physical Assessment/Clinical Physical Assessment/Clinical ManifestationsManifestations

Breathing pattern changeBreathing pattern change DisorientationDisorientation Restlessness Restlessness

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Psychosocial AssessmentPsychosocial Assessment

FearFear AnxietyAnxiety Cultural considerations and bereavementCultural considerations and bereavement Feelings of patient and significant othersFeelings of patient and significant others

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Interventions: Weakness Interventions: Weakness ManagementManagement

Aspiration precautionsAspiration precautions Mouth care and moisture for lipsMouth care and moisture for lips Altered routes of medication administration Altered routes of medication administration

if needed—choose the least invasive route if needed—choose the least invasive route of medication administration with the most of medication administration with the most effective treatmenteffective treatment

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Pain ManagementPain Management

Pain is the symptom that dying patients Pain is the symptom that dying patients fear most.fear most.

Pain medications should be scheduled to Pain medications should be scheduled to prevent any recurrence of pain.prevent any recurrence of pain.

Consider alternative route of pain Consider alternative route of pain medication administration as needed.medication administration as needed.

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Complementary and Alternative Complementary and Alternative TherapiesTherapies

MassageMassage Music therapyMusic therapy Therapeutic touchTherapeutic touch AromatherapyAromatherapy

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Dyspnea Dyspnea Management/PharmacologicManagement/Pharmacologic

OpioidsOpioids AnticholinergicsAnticholinergics BronchodilatorsBronchodilators SedativesSedatives

CorticosteroidsCorticosteroids Oxygen therapyOxygen therapy DiureticDiuretic AntibioticsAntibiotics

Treat the primary cause, and relieve the psychological distress that accompanies the symptom.

Pharmacologic interventions:

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Dyspnea Dyspnea Management/NonpharmacologicManagement/Nonpharmacologic

Cool airCool air Wet cloths to patient’s faceWet cloths to patient’s face Positioning of the patient to facilitate chest Positioning of the patient to facilitate chest

expansionexpansion Frequent rest periodsFrequent rest periods Encouraging imagery and deep breathingEncouraging imagery and deep breathing

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Nausea and Vomiting Nausea and Vomiting ManagementManagement

Antiemetic agentsAntiemetic agents Remove any source of odorsRemove any source of odors Comfortable room temperatureComfortable room temperature Dietary changesDietary changes Assess for and treat constipationAssess for and treat constipation

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Restlessness and Agitation Restlessness and Agitation ManagementManagement

Assess for pain, urinary retention, Assess for pain, urinary retention, constipation, or another reversible causeconstipation, or another reversible cause

Treat the underlying causeTreat the underlying cause Pharmacologic agentsPharmacologic agents Complementary and alternative therapiesComplementary and alternative therapies Music therapyMusic therapy Aromatherapy Aromatherapy

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Seizure ManagementSeizure Management

Pharmacologic therapyPharmacologic therapy

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Management of the Refractory Management of the Refractory Symptoms of DistressSymptoms of Distress

Drug therapyDrug therapy The ethical responsibility of the nurse in The ethical responsibility of the nurse in

caring for patients near death is to follow caring for patients near death is to follow guidelines for drug use to manage guidelines for drug use to manage symptoms and to facilitate prompt and symptoms and to facilitate prompt and effective symptom management (Guideline effective symptom management (Guideline Panel for Management of Cancer Pain, Panel for Management of Cancer Pain, 1994)1994)

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Psychosocial ManagementPsychosocial Management

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Interventions for Providing Interventions for Providing Psychosocial SupportPsychosocial Support

PresencePresence Life reviewLife review ReminiscenceReminiscence SpiritualitySpirituality ReligionReligion

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Postmortem CarePostmortem Care

Legal considerations, such as death Legal considerations, such as death certificatecertificate

Determination of the need for an autopsy Determination of the need for an autopsy Transfer of the bodyTransfer of the body

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EuthanasiaEuthanasia

Withdrawing or withholding life-sustaining Withdrawing or withholding life-sustaining therapy (WWLST)therapy (WWLST)

Passive euthanasiaPassive euthanasia Active euthanasiaActive euthanasia