End-of-life careBySheila Marie P. Oconer, RN, MAN

REALITY TELLS US THAT EVERY PERSON WILL DIE

LESS THAN 10% WILL DIE SUDDENLY AND 90% WILL DIE AFTER PROLONGED ILLNESS

Experiences throughout lifetime defines the way he or she wishes the end of own life

Family, culture, life events influences a person choices facing life and death come sooner rather than later

Anthropologist Margaret Mead says, “When a person is born we rejoice, and when they get married we jubilate, but when they die we pretend nothing happens”.

Talking about death and dying is often difficult for nurses and patients, if nurses does not want to talk about it there is no discussion, and death become the "elephant in the room”---something unavoidable and taboo.

Communicating bad news is an essential skills for the physician, nurses and interdisciplinary team members who interacts with the patient and families

6 Steps to communicating Bad News

1. Get started

-plan what to say based on medical facts, create conducive environment, determine who are others persons present, and allocate ample time.

2. Find out what the patient knows

-assess his or her ability to comprehend bad news

3. Find out what the patient wants to know

-recognize and support patient’s preference to decline information and designate someone else to communicate in his/her behalf, consider cultural, religious, and socioeconomic influences

4. Share information

-say it then stop. Pause frequently, check for understanding and use silence and body language, avoid vagueness, jargon and euphemism

5. Respond to feelings

- expect affective, cognitive and fight-flight responses., be prepared for strong emotions and a broad range of reactions. Give time to react, listen and encourage description of feelings. Use nonverbal communication of touch and eye contact

6. Plan/follow up

-provide additional test, symptom treatment, and referrals as needed, discuss potential sources of support, assess safety of the patient and home supports before he/she leaves . Repeat the news at future visits.

Advance directives Help individual identify their personal wishes in a legal manner and to share that information with the people around them, including medical personnel.

Durable power of attorney, living will declaration, appointment of health care representative, DNR and life prolonging procedures declaration are all legally recognized documents for indicating one’s health care wishes

Five Wishes (towey,2005) and Allow Natural Death (AND) are 2 more recent options for stating end-of-life care wishes.

OPTIONS FOR END-OF-LIFE CARE

CURATIVE/ACUTE CURE

Life-prolonging and acute care options focus on cure

HOSPICE CARE

Nonlife prolonging care, provide comfort and dignity at end of life.

PALLIATIVE CARE

Refers to comprehensive management of physical, psychological, social, spiritual and existential needs of the patient.

Care of people with incurable and progressive illnesses

Achieve the best quality of life, control of pain, and other symptoms

 

Nurse’s primary responsibilities is to coordinate patient’s care and to assist with Symptom Management or Focus on treating Symptom

Physical Non pain symptoms

Respiratory – difficulty of breathing, excess secretions, anxietyGastrointestinal – constipation, nausea/vomiting

Anxiety and DeliriumAnxiety at end of life – loss of control, loss of self esteem, loss of independence treating physical symptoms of pain and

SOB, anti-anxiety meds

Delirium – fluctuating cognitive disturbance, changes in mental status, occurs in the last hours to days of most dying patients environmental comfort by reducing stimuli,

reorientation, familiar person at bedside, health team members providing emotional, social and spiritual support, music therapy, therapeutic/healing touch, nonmedical nursing interventions, anti-anxiety meds given cautiously

NUTRITION AND HYDRATIONDeclining appetite for Dying persons, less active body requires less nourishmentHydration is detrimental to fluid overload

Give bites rather than regular portions, foods in variety

Provide small amounts of fluid like popsicles or ice chips, meticulous

mouth care for dry mouth

PHYSICAL, PAIN SYMPTOMS

“We all must die. But if I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is more terrible Lord of mankind than even death itself”

Albert Schweitzer

Unrelieved pain can contribute to unnecessary suffering, evidenced by sleep disturbance, hopelessness, loss of control and impaired social interactions

Pain may hasten death by increasing physiological stress, decreasing mobility, contributing to pneumonia and thromboemboli

Nurse must be able to assess pain, assist patient in describing their pain, use Wong-Baker Pain Rating scale

Treatment of pain based on origins and systematic approach (pain meds and adjuvant)

Pain meds remain the 1st line of tx Opiods are used if nonopiods ineffective Understanding between addiction and tolerance,

physical dependence

Physiological Type of Pain

Nociceptive- Somatic

Tissue injury Skeletal system, soft tissue, joints, skin or connective tissueLocalized pain can be point by fingerDescribe as throbbing, dull, aching, gnawing in natureTreated with NSAIDs, steroids partially responsive to opiod therapy or combinations 

- VisceralActivation of nociceptorsInternal organsUnable to localize, may use open hand to show affected area,pain is diffuseDeep, aching, cramping or sensation of pressureVery responsive to opiod therapyExample is shoulder pain secondary to lung or liver metatases

Neuropathic

-injury to peripheral nerve or CNSShooting, stabbing, burning, shock-likeConstant or intermittentLess responsive to opiods, responds best to anticonvulsants, tricyclic antidepressantsEx. Herpes zoster or diabetic neuropathy

LOSS AND GRIEF

Primary LossesLoss of people close to them – spouses, children, parents, siblings

Secondary LossesAre those resulting from the primary Loss-companionship, roles the deceased assume in relationship and independence 

Grief – is the natural and normal loss of any kind and is experienced psychologically, behaviorally, socially and physically. It involves changes over time

Mourning- is the cultural and/or public display of grief through one’s behaviors. These include accepting the reality of loss, reacting to separation, and finding ways to channel reactions, handling the unfinished business, and transferring the attachment to the deceased from physical presence to symbolic interaction.

COMPONENTS OF PEACEFUL DYING

“The key to peaceful dying is achieving the components of peaceful living during the time you have left” (Preston, 2000)

Instilling good memories Uniting with family and medical staff Avoiding suffering, with relief of pain and other

symptoms Maintaining alertness, control, privacy, dignity and

support Becoming spiritually ready Saying goodbye Dying quietly

 

GOOD DEATH

Is possible and can be facilitated by the nurse who advocates for and works to ensure that the patients, families, and caregivers are free from avoidable distress and suffering, that the process is in accord with the wishes of the patient, family, and that is consistent with clinical, cultural, and ethical standards.

POSTMORTEM CARE

Pronouncing Death

Pronouncing the death of the person varies from state to state and institution to institution, nurses may pronounce the death, in some may not be allowed

Policies differ and individual institutional polices are followed

In pronouncing death, it is customary to identify the patient and note the following;

General appearance of the body Lack of reaction to verbal or tactile stimulation Lack of pupillary light reflex (pupils fixed and dilated) Absent breathing and lung sounds Absent carotid and apical pulses (listening for apical

pulse is full minute)

PHYSICAL CARE OF THE BODY

IS AN IMPORTANT NURSING FUNCTION Careful and gentle handling of the body

communicates care and concern on the part of the nurse

Rituals and customs should have been identified before the death, to be incorporated into the care, reflecting the patient/family wishes

Nursing care also includes removal of drains, tubes, IVs and other devices

 

The Nurse’s gratification does not come from caring, but rather from supporting the patient in a peaceful and dignified “ good death”.