(Relates to Chapter 11, “Palliative Care at End of Life,” in the textbook) Copyright © 2011,...

(Relates to Chapter 11, “Palliative Care at End of Life,”in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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•Any form of care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure

• Includes hospice, end-of-life care, and bereavement


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•Overall goals Prevent and relieve suffering Improve quality of life for patients with serious, life-limiting illnesses

•Initiated after a person receives a diagnosis of a life-limiting illness


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•Ideally, involves interdisciplinary team Physicians Social workers Pharmacists Nurses Chaplains Other health care professionals


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• Concept of care that provides compassion, concern, and support for the dying and their families

• Exists to provide support and care for persons in last phases of incurable diseases


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•Approximately 1½ million patients receive hospice services each year.

•Organized under a variety of models Hospital-based, part of existing

home health care agencies, free-standing, or community-based

•Emphasizes palliative rather than curative care


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•Care is provided in a variety of locations.

•Can be part-time, intermittent, on-call, regularly scheduled, or continuous basis

•Services are available 24 hours a day, 7 days a week.


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•Medically supervised interdisciplinary team of professionals and volunteers

•Hospice nurse is an integral part. Pivotal role in coordination of hospice team

Educated in pain control and symptom management


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•To begin hospice is a difficult decision. Lack of information about hospice care

Physician may view decline as personal failure.

Patients or family may see it as giving up.


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•Admission has two criteria: Patient must desire services.

▪ Must agree that curative care can be used to treat the terminal illness

Physicians must certify that patient has 6 months or less to live.


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A patient with advanced cancer is referred for hospice care. The nurse explains to the patient and the family that the goal of hospice care differs from the goal of traditional care in that hospice care1. Provides for more complete pain control.2. Focuses on helping the patient and family prepare for death.3. More readily recognizes advance directives related to “right to die.”4. Is delivered in the home and does not rely on the technology of hospitals.

Audience Response Questions


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The hospice nurse identifies an abnormal grief reaction in the wife of a dying patient who says,1. “I don’t think that I can live without my husband to take care of me.”2. “I wonder if expressing my sadness makes my husband feel worse.”3. “We have shared so much that it is hard to realize that I will be alone.”4. “I don’t feel guilty about leaving him to go to lunch with my friends.”

Audience Response Questions


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•Occurs when all vital organs and body systems cease to function

•Irreversible cessation of cardiovascular, respiratory, and brain function


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• An irreversible loss of all brain functions, including the brainstem

• A clinical diagnosis that can be made in patients whose hearts continue to beat and who are maintained on mechanical ventilation in the ICU

• Cerebral cortex stops functioning or is irreversibly damaged.


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•Controversies have arisen related to an exact definition of death.

•Currently, legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected by the physician.


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•Generally refers to the final phase of a patient’s illness, when death is imminent

•The time from diagnosis of a terminal illness to death varies considerably, depending on the patient’s diagnosis and extent of disease.


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•In some cases, it is obvious to health care providers that the patient is in this phase.

•In other cases, they may be uncertain whether the end is close at hand.


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•Term used for issues related to death and dying, as well as for services provided to address these issues

•Focuses on physical and psychosocial needs of the patient and the patient’s family


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•Goals Provide comfort and supportive care during dying process

Improve quality of remaining life

Help ensure a dignified death Provide emotional support to the family


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•Metabolism is decreased. •Body gradually slows down

until all function ends.•Respiration generally ceases

first. Heart stops beating within a few minutes.


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• Hearing is usually last sense to disappear.

•Decreased sensation•Decreased perception of pain

and touch


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•Blurring of vision•Blink reflex absent•Patient appears to stare.•Decreased sense of taste and

smell


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•Mottling on hands, feet, arms, and legs

•Cold or clammy skin•Cyanosis on nose, nail beds,

or knees•“Waxlike” skin when very

near death


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•Irregular breathing•Cheyne-Stokes respiration •Inability to cough or clear

secretions Grunting, gurgling, or noisy congested breathing (“death rattle”)


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•Gradual decrease in urinary output

•Incontinent of urine•Unable to urinate


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•Slowing of digestive tract and possible cessation of function

•Accumulation of gas•Distention and nausea •Loss of sphincter control•Bowel movement may occur

before imminent death or at the time of death.


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•Gradual loss of ability to move

• Loss of facial muscle tone Sagging of jaw Difficulty speaking Swallowing can become more difficult.


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•Difficulty maintaining body posture and alignment

•Loss of gag reflex •Jerking seen in patients on

large amounts of opioids


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•Decreased heart rate Later slowing and weakening of

pulse • Irregular rhythm•Decreased blood pressure•Delayed absorption of drugs


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•Altered decision making•Anxiety about unfinished

business•Decreased socialization•Fear of loneliness•Fear of meaninglessness•Fear of pain


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•Helplessness•Life review•Peacefulness•Restlessness•Saying goodbyes


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•Unusual communication•Vision-like experiences•Withdrawal


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•Bereavement is the period of time following the death of a loved one during which grief is experienced and mourning occurs.


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•Grief is the normal process of reacting to loss or adapting to change.

•Dynamic process•Includes both psychologic

and physiologic responses following a loss


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•Manifested in a variety of ways Feelings Behaviors Thoughts Physical manifestations


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•Intensity of grief is driven by Individual’s personality Nature of the relationship with the dying person

Concurrent life crises Coping resources Availability of support systems Cultural beliefs


Kübler-Ross (1969) Martocchio (1985) Rando (1993)

DenialDenial Shock and disbelief Shock and disbelief AvoidanceAvoidance

Anger/bargainingAnger/bargaining Yearning and protestYearning and protest ConfrontationConfrontation

DepressionDepression Anguish, Anguish, disorganization, and disorganization, and despairdespair

AcceptanceAcceptance Reorganization and Reorganization and restorationrestoration

Accommodation Accommodation

37Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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•Adaptive grief Healthy response Grief that assists the person in accepting the reality of death


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•Prolonged grief disorder Prolonged and intense mourning

Denial of the loss for longer than 6 months


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•Goals for the grief process Resolving emotions Reflecting on the dying person Expressing feelings of loss and sadness

Valuing what has been shared


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•Patient also experiences grief.•Goals for grief resolution include

Patient expression of feelings related to grief

Acknowledgment of the impending loss

Demonstration of behaviors that reflect progress in grief resolution


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•Spiritual needs do not necessarily equate to religion.

•At the end of life, many patients question their beliefs about a higher power, their own journey through life, religion, and an afterlife.


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•Deep-seated spiritual beliefs may surface for some patients when they deal with their terminal diagnosis and related issues.

•Spiritual distress may occur.


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•Cultural beliefs affect a person’s understanding of and reaction to death or loss.

•In some cultural/ethnic groups, death and dying are private matters shared only with significant others. Often feelings are repressed or internalized.


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•Other cultural groups, such as African Americans and Hispanic/Latinos, may express their feelings and emotions easily.

•In such cultures, family members, both immediate and extended, provide support for one another.


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•Families with non–English-speaking members are at risk for receiving less information about their family member’s critical illness and prognosis.

•Cultural variations in symptom expression (e.g., pain expression) and use of health care services also exist.


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• Nursing assessment of beliefs and preferences should be made on an individual basis.

• Avoids stereotyping individuals with different cultural belief systems


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•Outcomes related to care based on patient’s wishes Organ and tissue donations Advance directives

▪ Medical power of attorney or living wills

Resuscitation


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•Advance directives Written statements of medical care wishes

•Directive to physicians Patient’s desire to accept or deny treatment


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•Do not resuscitate (DNR) Order instructing health care providers not to attempt CPR

Variety of CPR decisions


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•Withholding or withdrawing treatment must be included in an advance directive.

•What is to be done and what is not to be done must be included in clear terms.


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•Euthanasia is the deliberate act of hastening death.

•The ANA statement on active euthanasia states that the nurse should not participate in active euthanasia.


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•Holistic Psychosocial and physical needs

•Focuses on Psychosocial manifestations Grieving process Physical changes associated with dying


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•Varies with Patient condition Proximity of approaching death

•Limited to essential data•Document specific change

that brought patient into health care agency


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•If patient is alert Brief review of body systems to detect signs and symptoms

Assess for discomfort, pain, nausea, or dyspnea.

•Assess coping abilities of patient and family.


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•Functional assessment of activities of daily living Patient’s abilities Food and fluid intake Patterns of sleep and rest Response to the stress of terminal illness


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•Frequency of assessment depends on stability, but it is done at least every 8 hours. As changes occur, assessment and documentation need to be done more frequently.


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•As death approaches, neurologic assessment is important. Level of consciousness Presence of reflexes Pupil responses


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•Evaluate and monitor Circulation changes

▪ Vital signs, skin color, and temperature

Respiratory status▪ Character and pattern of respirations


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•Evaluate and monitor (cont’d) Gastrointestinal/renal functioning▪ Nutritional/fluid intake, urinary output, and bowel function

Skin condition▪ Fragile: Note breakdown


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•Be sensitive.•Assess patient frequently

(but not unnecessarily). Use health history data available in chart.


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•Acute confusion•Chronic confusion•Compromised family coping•Death anxiety•Disturbed thought processes


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•Fear•Grieving•Hopelessness•Impaired religiosity•Impaired social interaction


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•Impaired verbal communication

•Ineffective coping•Ineffective denial•Interrupted family processes•Insomnia


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•Readiness for enhanced spiritual well-being

•Risk for loneliness•Social isolation•Spiritual distress


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•Acute pain•Bowel incontinence•Chronic pain•Constipation•Decreased cardiac output•Diarrhea


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•Fatigue•Imbalanced nutrition: less

than body requirements•Impaired bed mobility•Impaired comfort•Impaired gas exchange•Impaired oral mucous

membrane


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•Impaired physical mobility•Impaired skin integrity•Impaired swallowing•Impaired tissue integrity•Impaired urinary elimination•Ineffective airway clearance


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•Ineffective breathing pattern•Ineffective thermoregulation•Ineffective tissue perfusion•Nausea•Risk for aspiration•Risk for infection


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• Risk for injury• Self-care deficit• Total urinary incontinence


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•Coordination of care focus Patient’s needs Family and significant other’s needs

Education, counseling, advocacy, and support


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•Nursing goals Center on patient’s abilities to express and share feelings with others

Involve comfort measures and physical maintenance care


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•Education Ongoing information about the disease

Dying process Any care provided How to cope

•Denial and grieving may be barriers to patient’s learning.


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•Uneasy feeling caused by a source not easily identified

•Frequently related to fear•Management

Pharmacologic or nonpharmacologic interventions


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•Causes Uncontrolled pain, psychosocial

factors from disease process or impending death, altered physiologic states, drugs used in increasing doses

•Management Encouragement, support, and

education


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•The surviving family members may be angry with the dying loved one who is leaving them.

•Nurses are sometimes the target of the anger and must understand what is happening and not react on a personal level.


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•Common emotions at the end of life

•You need to encourage realistic hope within the limits of the situation.

•Decision making about care can foster a sense of power and control for the patient.


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•Four specific fears Pain Shortness of breath Loneliness and abandonment Meaninglessness

•Management Coping strategies


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•Tendency to associate death with pain

•Physiologically: No indication that death is always painful

•Psychologically: Pain may occur based on anxieties or separations related to dying


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•Terminally ill patients experiencing pain should have pain-relieving drugs available.

•Most patients want their pain relieved without the side effects of grogginess or sleepiness. Do not want to be deprived of

ability to interact with others


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•The sensation of air hunger results in anxiety for the patient and family members.

•Current therapies involve the use of opioids, bronchodilators, and oxygen, depending on the cause of the dyspnea.


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•Do not want to be alone•Worry loved ones cannot

cope and will abandon them•Want someone they know

and trust to stay Loved one or caregiver provides comfort and support.


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•High-quality nursing responses Holding hands, touching, and listening

•Simply providing companionship allows a sense of security.


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•Leads most to review their lives Intentions during life and examining actions

Expressing regret Helps recognize life’s value

•Worth needs to be expressed


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•Nurse can assist patients and their families in identifying positive qualities of patient’s life.

•Respect and accept practices or rituals associated with patient’s life review without being judgmental.


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•Therapeutic communication is important nursing intervention.

•Use empathy and active listening.

•Allow patients and families time to express their feelings and thoughts.


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•Silence is OK.•Listening to the silence

sends a message of acceptance and comfort.


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•Unusual communication by patient may take place at end of life. Confused, disoriented, or garbled


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•Patients may speak To or about family members or others who have died before them

To give instructions to those who survive them

To speak of projects yet to be completed


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•Active, careful listening allows identification of specific patterns in patient’s communication. Increased risk for inappropriate labeling of behaviors


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•Symptom management•Priority is to meet

physiologic and safety needs.

•Deserve same care as people who are expected to recover


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•Needs Oxygen Nutrition Pain relief Mobility Elimination Skin care


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•After patient is pronounced dead, the nurse prepares or delegates preparation of the body for immediate viewing by the family.


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•Considerations when preparing body Cultural customs In accordance with state law Agency policies and procedures


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•Considerations when preparing body Close the patient’s eyes. Replace dentures. Wash the body as needed.

▪ Place pads under perineum. Remove tubes and dressings. Straighten body.

▪ Leave pillow to support head.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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•Family should be allowed privacy and as much as time as they need with the deceased person.


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•Unexpected or unanticipated death Preparation of the body for viewing or release to a funeral home depends on state law and agency policies and procedures.


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•Role of caregiver includes Working and communicating with the patient

Supporting concerns Helping resolve any unfinished business


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•Role of caregiver includes (cont’d) Working with family members and friends

Dealing with own needs and feelings


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•Recognizing signs and behaviors among family members who may be at risk for dysfunctional grief reactions is an important nursing intervention.


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•Risk for dysfunctional grief Dependency Negative feelings about the dying person

Inability to express feelings Concurrent life crises History of depression


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•Risk for dysfunctional grief (cont’d) Difficult reactions to previous losses

Perceived lack of social or family support

Low self-esteem Multiple previous bereavements Alcoholism Substance abuse


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•Encouragement to continue their usual activities

•Discuss their activities and maintain some control over their lives

•Discuss what can and cannot change

•Encouragement to take care of themselves


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•Many nurses who care for dying patients are passionate about providing quality EOL care.

•Caring for dying patients is intense and emotionally charged.


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•Common for nurse to feel helpless and powerless when dealing with death. Feelings of sorrow, guilt, and frustration need to be expressed.

Should be aware of how these feelings affect them


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•Recognize and acknowledge what can and cannot be controlled.

•Recognize personal feelings to allow openness.

•Okay to cry with the patient or family during the grieving process


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•78-year-old man has stage IV lung cancer with metastasis to liver, pancreas, and stomach.

•No treatments were successful.


•Patient has completed a directive to physicians: Stated not to initiate life-prolonging measures


•Patient admitted to ICU through ED for respiratory distress Placed on ventilator and sedated

•Spouse is fearful and requests all measures to prolong life.


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•Multidisciplinary team scheduled to meet with spouse to discuss plan of care


1.How might you assess the spouse’s understanding of the situation?

2.What complications from the disease process might he encounter? How can you minimize these?


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3. What psychosocial issues should be addressed?


(Relates to Chapter 11, “Palliative Care at End of Life,” in the textbook) Copyright © 2011,...

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Transcript of (Relates to Chapter 11, “Palliative Care at End of Life,” in the textbook) Copyright © 2011,...