Care at the End of Life 11 Lecture Note PowerPoint Presentation.

Care at the End of Life

11Lecture Note PowerPoint Presentation

LEARNING OUTCOME 1Describe the role of the nurse in providing quality

end-of-life care for older persons and their families.

NURSES’ UNIQUE QUALIFICATIONS TO PROVIDE END-OF-LIFE CARE

Holistic view Comprehensive Effective Compassionate Cost effective

NURSES’ INVOLVEMENT IN END-OF-LIFE CARE

Spend the most time with patients and their family members at the end-of- life than any other member of the healthcare team

Provide education, support, and guidance throughout the dying process

NURSES’ INVOLVEMENT IN END-OF-LIFE CARE

Advocate for improved quality of life for the person with serious illness

Attend to physical, emotional, psychosocial, and spiritual needs of the patient

NURSES WHO HELP THE PATIENT DIE COMFORTABLY AND WITH DIGNITY PROVIDE THE FOLLOWING BENEFITS OF GOOD NURSING CARE:

Attend to pain and symptom control Relieve psychosocial distress Coordinate care across settings with high-

quality communication between healthcare providers

Prepare the patient and family for death

NURSES WHO HELP THE PATIENT DIE COMFORTABLY AND WITH DIGNITY PROVIDE THE FOLLOWING BENEFITS OF GOOD NURSING CARE:

Clarify and communicate goals of treatment and values

Provide support and education during the decision-making process, including the benefits and burdens of treatment

NURSES WHO CARE FOR THE DYING

Are well educated Have appropriate supports in the clinical

setting Develop close collaborative partnerships with

hospice and palliative care service providers

NURSES WHO CARE FOR THE DYING

Must be confident in their clinical skills Are aware of the ethical, spiritual, and legal

issues they may confront while providing end-of-life care

NURSES NEED TO BE AWARE OF PERSONAL FEELINGS ABOUT DEATH

Improves ability to meet holistic needs of the patient and family

Clarifies one’s own beliefs and values

MEANING OF HOPE SHIFTS

From striving for cure to achieving relief from pain and suffering

No “right” or “correct” way to die: It's everybody's right to live independent and die with dignity

TABLE 11-1QUESTIONS AND CRITICAL THINKING IN PREPARATION TO CARE FOR DYING PATIENTS

LEARNING OUTCOME 2Recognize changes in demographics, economics,

and service delivery that require improved nursing interventions at the end of life.

CHANGING STATISTICS

Primary cause of death 10 leading causes of death account for 80% of all

deaths in the United States Heart disease Malignant neoplasms Cerebrovascular disease Chronic lower respiratory disease Accidents Diabetes mellitus

CHANGING STATISTICS

Primary cause of death 10 leading causes of death account for 80% of all

deaths in the United States Influenza Pneumonia Alzheimer’s disease Renal disease Septicemia

CHANGING STATISTICS

Demographic trends Today, more deaths occur at home The average life span is 77.9 years compared to

only 50 in 1900 the average life expectancy in Jordan is 73.1

Social trends Today, caregivers are more likely to be

professionals rather than family members

EXACT CAUSE OF DEATH DIFFICULT TO DETERMINE IN THE OLDER PERSON

Multiple comorbid conditions (is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder)

Acute injury added Unexpected pathology

MOST AMERICANS PREFER TO DIE AT HOME

50% die in hospitals 25% die in long-term-care facilities 20% die at home or the home of a loved one 5% die in other settings

SURVEY RESULTS OF HEALTHCARE SYSTEM CARE OF DYING PEOPLE

Excellent: 3% Very good: 8% Good: 31% Fair: 33% Poor: 25%

BARRIERS TO QUALITY END-OF-LIFE CARE

Failure of healthcare providers to acknowledge the limits of medical technology

Lack of communication among decision makers

Disagreement regarding the goals of care Failure to implement a timely advance care

plan

BARRIERS TO QUALITY END-OF-LIFE CARE Lack of training about effective means of

controlling pain and symptoms Unwillingness to be honest about a poor

prognosis Discomfort telling bad news Lack of understanding about the valuable

contributions to be made by referral and collaboration with comprehensive hospice or palliative care services

LEARNING OUTCOME 3Describe how pain and presence of adverse

symptoms affect the dying process.

NURSE’S ROLE IN PAIN TREATMENT

Initial and ongoing assessment of levels of pain

Administration of pain medication Evaluation of effectiveness of pain

medication

HOW NURSES CAN ALLEVIATE THE DISTRESS ASSOCIATED WITH UNTREATED PAIN Ongoing assessment of levels of pain Administration of pain medication Evaluation of the effectiveness of the pain

management plan

NEGATIVE OUTCOMES OF PAIN

Potential to hasten death Associated with needless suffering at the end

of life People in pain do not eat or drink well Inability to engage in meaningful

conversations with others Isolation in order to save energy and cope

with the pain sensation

REASONS FOR UNDERTREATMENT OF PAIN

Patient’s inability to communicate due to Delirium Dementia Aphasia (speechless) Motor weakness Language barriers

CAUSES OF INADEQUATE CARE AT END OF LIFE

Disparity in access to treatment Insensitivity to cultural differences

Attitudes about death Attitudes about end-of-life care African-Americans prefer aggressive life-

sustaining treatments Mexican-Americans, Korean-Americans, and

Euro-Americans prefer less aggressive treatment

CAUSES OF INADEQUATE CARE AT END OF LIFE

Mistrust of the healthcare system Pain is subjective and self-report is

considered accurate

PAIN CHARACTERISTICS IN COGNITIVELY-IMPAIRED OLDER PERSONS

Moaning or groaning at rest or with movement

Failure to eat, drink, or respond to presence of others

Grimacing or strained facial expressions

PAIN MANNERISMS IN COGNITIVELY-IMPAIRED OLDER PERSONS

Guarding or not moving body parts Resisting care or noncooperation with

therapeutic interventions Rapid heartbeat, diaphoresis, change in vital

signs

PAIN TREATMENT BASED ON ACCURATE PAIN ASSESSMENT

Systematic Ongoing

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN

Do you usually seek medical help when you believe something is wrong with you?

Where does it hurt the most? How bad is the pain (may use the facility

pain indicator such as smiley face or rate the pain on a scale of 1 to 10)

How would you describe the pain (sharp, dull, shooting)?

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN

Is the pain accompanied by other troublesome symptoms such as nausea, diarrhea, and so on?

What makes the pain go away? Are you able to sleep when you are having

the pain?

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN

Does the pain interfere with your other activities?

What do you think is causing the pain? What have you done to alleviate the pain in

the past?

PAIN DURING THE DYING PROCESS

Acute Sudden onset Usually associated with single cause or event

PAIN DURING THE DYING PROCESS

Chronic Associated with long-term illness Always present Varies in intensity Tolerance to pain develops Associated factors

Depression Poor self-care Decreased quality of life

PAIN DURING THE DYING PROCESS

Neuropathic pain Nerves are damaged Burning, electrical, or tingling sensations Deep and severe

Nociceptive pain Tissue inflammation or damaged tissues Cardiac ischemia

PAIN DURING THE DYING PROCESS

Unrelieved pain during the dying process Hastens death

Increases physiological stress Diminishes immuno-competency Decreases mobility Increases myocardial oxygen requirements

Causes psychological distress to the patient and family Suffering Spiritual distress

LEARNING OUTCOME 4Identify the diverse settings for end-of-life care and

the role of the nurse in each setting.

PALLIATIVE CARE

Philosophy of care Highly structured system for care delivery

EMPHASIS OF SUPPORTIVE CARE DURING THE DYING AND BEREAVEMENT PROCESS Quality of life Living a full life up until moment of death

PALLIATIVE CARE SETTINGS

Hospitals Outpatient clinics Long-term-care facilities Home

HOSPICE CARE

Focuses on the whole person Mind Body Spirit

Support and care Patients Family and caregivers

Continues after death of a loved one

HOSPICE CARE

Multidisciplinary team of professional caregivers Nurse

Manages pain and controls symptoms Assesses patient and family abilities to cope Identifies available resources for patient care Recognizes patient wishes Assures that support systems are in place

HOSPICE CARE Multidisciplinary team of professional

caregivers Physician Pharmacist Social workers Others

Last phase (6 months) of incurable disease Live as fully and comfortably as possible

HOSPICE SETTINGS

Freestanding Hospital Home health agencies with home care

hospice Home Nursing home or other long-term-care

settings

LEARNING OUTCOME 5Explore pharmacological and alternative methods of

treating pain.

ADMINISTER PAIN MEDICATION ROUTINELY

Prevent breakthrough pain and suffering Long-acting drugs provide consistent relief

Chronic pain Short-acting or immediate release agents for prn

use Acute pain

ANTICIPATE AND TREAT ADVERSE EFFECTS OF PAIN MEDICATION

Nausea Constipation

PAIN CONTROL AT THE END OF LIFE

Non-opioids for mild to moderate pain Acetaminophen NSAIDs

PAIN CONTROL AT THE END OF LIFE

Opioids Codeine Morphine is gold standard Hydromorphine Fentanyl Methadone Oxycodone

NOTE: DO NOT USE MEPERIDINE OR PROPOXYPHENE WITH OLDER PERSONS

Adjuvant analgesics Enhance effectiveness of other drug classes

Muscle relaxants Corticosteroids Anticonvulsants Antidepressants Topical Useful for treatment with lower doses and less side

effects

ROUTES OF ADMINISTRATION Oral

For patient who can swallow Requires higher dosage

Oral mucosa or sublingual For patients with difficulty swallowing May require more frequent administration

Rectal For patients with difficulty swallowing or

problems with nausea and vomiting Patient needs to be able to reposition easily

ROUTES OF ADMINISTRATION Transdermal

Delivers 72 hours of pain medication Topical

For pain as a result of herpes, arthritis, or local invasive procedures

Parenteral For patients who cannot swallow

Epidural or intrathecal Use if unable to achieve pain control by other methods

MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATION Identify when pain is most severe Initiate constipation treatment at time

opioids are started Keep patient warm Encourage music listening Visit with spiritual advisor

MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATION Provide comfort measures

Back rub Position change Warm milk

ALTERNATIVE PAIN MANAGEMENT APPROACHES

Acupuncture Massage therapy Reiki therapy: a combination of all other

alternative therapeutic methods Chiropractors: is a health care discipline and

profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine

Herbal medications

ADVERSE EFFECTS OF ANALGESIC MEDICATIONS

Constipation Respiratory depression Nausea and vomiting Myoclonus: is brief, involuntary twitching of a

muscle or a group of muscles Pruritis

LEARNING OUTCOME 6Identify the signs of approaching death.

BODY CHANGES INDICATING IMPENDING DEATH Circulation

Mottling of lower extremities Mottling is sometimes used to describe uneven

discolored patches on the skin of humans as a result of cutaneous ischemia (lowered blood flow to the surfaces of the skin).

Pulmonary “Death rattle”: s a medical term that describes

the sound produced by someone who is near death when saliva accumulates in the throat

Cheyne-Stokes respirations: is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea

BODY CHANGES INDICATING IMPENDING DEATH

Skin Clammy Dusky, gray coloration

Eyes Discolored Deeper set Bruised appearance

DISCUSS THE DEATH PROCESS AND REASSURE THOSE PRESENT

Support family decisions to be present or to leave

Reinforce that the dying process is as individualized as process of living

LEARNING OUTCOME 7Describe appropriate nursing interventions when

caring for the dying.

CORE PRINCIPLES FOR END-OF-LIFE CARE Respect the dignity of patients, families, and

caregivers Display sensitivity and respect for patient

and family wishes Use appropriate interventions to accomplish

patient goals Alleviate pain and symptoms Assess, manage, and refer psychological,

social, and spiritual problems

CORE PRINCIPLES FOR END-OF-LIFE CARE

Offer continuity and collaboration with others Provide access to palliative care and hospice

services Respect the rights of patients and families to

refuse treatments Promote and support evidence-based clinical

practice research

MUCOSAL AND CONJUNCTIVAL CARE

Provide oral hygiene several times a day Ice chips to relieve the feeling of dry mouth

can be used as long as the swallowing reflex is present

Soothing ointments or petroleum jelly may be used on the lips

Lack of dentures makes speech and swallowing difficult

MUCOSAL AND CONJUNCTIVAL CARE

Disease processes contribute to halitosis and thrush

Artificial tears: are lubricant eye drops used to treat the dryness and irritation associated with deficient tear production

Ophthalmic saline solutions Opened eyes become easily irritated

Halitosis: is a term used to describe noticeably unpleasant odors exhaled in breathing

ANOREXIA AND DEHYDRATION

Patients may choose to stop eating and drinking

Anorexia may result in ketosis, leading to a peaceful state of mind and decreased pain

Initiation of parenteral or enteral nutrition neither improves symptom control nor lengthens life

SKIN CARE Monitor skin changes

Edema Bruising Dryness Venous pooling

Avoid shearing forces Reposition frequently Gentle massage or lotion application may be

provided by the family

INCONTINENCE CARE

Bowel and bladder incontinence frequently occurs at the end of life

Provide protective pads Apply barrier cream Encourage change of position Discourage the use of indwelling catheters

TERMINAL DELIRIUM

Can be distressing to family or caregivers Presents as “confusion, restlessness, and/or

agitation, with or without day-night reversal” Visual, auditory, and olfactory hallucinations

may occur during this time Is often irreversible and may vary from

patient to patient

TERMINAL DELIRIUM

Management techniques include identifying underlying cause, reducing stimuli and anxiety, and discontinuing all nonessential medications

NEUROLOGIC CHANGES

Distressing for the family Remind them that the patient may still be able to

hear Encourage the family to “let go” Give the patient permission to die

TYPE AND LEVEL OF CARE AT THE END OF LIFE

Comfort measure only (CMO) Advance directives Use of feeding tubes Euthanasia is illegal

Euthanasia refers to the practice of ending a life in a manner which relieves pain and suffering

LEARNING OUTCOME 8Describe postmortem care.

PRONOUNCEMENT OF DEATH

Absence of carotid pulses Pupils are fixed and dilated Absent heart sounds Absent breath sounds

POSTMORTEM CARE Needs to be done promptly, quietly,

efficiently, and with dignity Straighten limbs before death, if possible Place head on pillow After pronouncement

Glove Remove tubes Replace soiled dressings Pad anal area

POSTMORTEM CARE

After pronouncement Gently wash body to remove discharge, if

appropriate Place body on back with head and shoulders

elevated Grasp eyelashes and gently pull lids down Insert dentures Place clean gown on body and cover with clean

sheet

FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION

Note time of death and chart Notify attending physician

Chart any special directions Notify family members

Allow time with loved one Gather eyeglasses and other belongings Prepare necessary paperwork for body

removal

FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION

Call funeral home (or other appropriate personnel) for body transport

Note on chart What personal artifacts were released with the

body What belonging were released Who received the belongings

Tag or provide body identification as per policy

LEARNING OUTCOME 9Discuss family support during the grief and

bereavement period.

ALLEVIATE PATIENT AND FAMILY FEARS AND ANXIETIES

Prior to death Maintain hope for the patient and family

After death Relief statements Rationalizations Educate about mourning and bereavement

EXPRESSIONS OF GRIEF

First phase: “numb shock”: the feeling of distress and disbelief that you have when something bad happens accidentally; "his mother's death left him in a daze"; "he was numb with shock"

Second phase: emotional turmoil or depression

Third phase: reorganization or resolution

CARING FOR THE CAREGIVER

What have I done to meet my own needs today?

Have I laughed today? Did I eat properly, rest enough, exercise, and

play today? How have I felt today? Do I have something to look forward to?