Care at the end of life.wvamc version

Supplemental Ethics Points

DE Hierarchy of Decision-makers (If no POA-HC)

1. The spouse, unless a petition for divorce has been filed

2. An adult child

3. A parent

4. An adult sibling

5. An adult grandchild

6. An adult niece or nephew

Disqualified if pt. has a PFA or “no contact” order

If no one, Court of Chancery may appoint as guardian an adult who

exhibits special care +concern, + who is familiar w/ patient's values.

Do we need the Principle of the Double Effect to justify giving morphine at end-of-life?

– NO

– “Double Effect” is when there are 2 known, expected effects,

one good and one bad. (ex. Separating conjoined twins where

one will die)

– Morphine at end of life (at appropriate doses)

does not cause respiratory depression.

is not a meaningful factor in hastening death (many studies)

– So, we do not hasten death by treating pain or shortness of

breath with appropriate doses of opioids. (see handout)

Living Wills are inadequate

• Only 36% of Americans have a living will

• L.W’s often not available when needed

• Uncertainty about “qualifying conditions”

• DNR orders based on L.W.’s are not portable

TRADITIONAL ETHICS

Autonomy

Beneficence

Non-

Maleficence

Justice

Veracity

• Interdependence

• Preventing Harm

• Providing Care

• Communication

• Maintaining Relationships

ETHICS OF CARE

Feminist writers: Tong, Gilligan, Prendergast

“Autonomous Man”

vs.

“Communal

Woman”

CARE AT THE END OF LIFE:

One Chance

to Do It Right

Presented by: Sheila Grant, BSN, RN, CHPN

DISCLOSURES

• I am employed by Heartland Hospice, IV, and Homecare as a

Nurse-Liaison.

OBJECTIVES

1—Describe the concept “Convergence of Symptoms”.

2—Identify 7 common symptoms of the active phase of

dying.

3—Identify strategies for controlling each of those

symptoms.

4—Describe ‘terminal agitation”, its possible causes,

and options for treatment.

5—Explain the principles of communicating bad news.

Most People Die

After a prolonged illness

With gradual deterioration

With an active dying phase at the end of life

MOST CLINICIANS

Have little or

no formal

training in

managing

the dying

process.

Most Families

Have even

less

experience

or knowledge

of the dying

process.

FAMILIES WILL REMEMBER

A “good death”

OR a “difficult

death”.

A difficult death

may lead to

anger,

depression, or

complicated

grief

CARE PROVIDED DURING THE LAST DAYS

Affects not just

the patient, but

families and

everyone

involved in a

patient’s care.

THERE IS NO SECOND CHANCE TO GET IT RIGHT

of Symptoms

No matter what disease the person is dying

from, the symptoms begin to look the same

in the final stage.

The failure of one organ system affects all

the others. [“multi-system organ failure”]

In the final stage, you will treat the symptoms

(for comfort), NOT the disease (for cure).

Concerns in the last hours of life

Pain

Shortness of Breath

Secretions

Feeding and hydration

Changes in

Consciousness

Circulatory dysfunction

Delirium

PAIN

You may need to change the route and dose of

pain medicine, due to increased pain, inability

to swallow, or decreased metabolism.

LIQUID MORPHINE (Roxanol)

Often used in the last few days or when

patient is unable to swallow pills.

Partially absorbed by mucous membranes in

the mouth.

Begins to relieve pain/SOB in about 15-20

minutes.

PAIN MEDICINE IS BEST GIVEN ATC, not PRN

If allowed to

wear off, pain

becomes harder

to treat,

requiring higher

doses.

P.O Narcotics Peak in 1 hour

Half-life is 4 hours

Respiratory Depression + Opioids

Normal adult Resp. Rate = 12-20 [count for 60 sec.]

Respiratory depression ONLY occurs with the first few doses of an opioid and with new increases in dose. Tolerance to Resp. Dep. occurs quickly.

(stable dose w/RR>12—OK to give dose)

[Source: EPEC Pain Module]

Fact: Morphine Toxicity

Occurs in this sequence:

1. Drowsiness

2. Confusion

3. Loss of consciousness

ONLY after these will you see:

4. Respiratory drive significantly compromised

* If patient is AWAKE and COMPLAINING—OK to

give pain medicine.

GOAL is steady pain relief—don’t skip doses without a good reason.

When judging whether to hold dose, consider:

New or recently increased dose?

Is patient difficult to arouse?

Is Resp. rate < 12 ?

If yes, hold the dose. If no, give the dose.

HOSPICE NURSES

Are expert in

managing opioids for

pain relief

Have access to

Hospice Medical

Director

Can be a resource

*FENTANYL PATCH— NOT recommended at end-of-life

Pt’s. may not have enough SQ

fat stores to absorb the drug.

Poor absorption due to changes

in circulation and metabolism.

Rapid titration often necessary

as pain levels and LOC change

at the end of life. Patch takes

about 18 hours to reach peak

levels.

DYSPNEA—SOB

Increased respiratory

rate

Then, decreased rate

Apnea

Cheyne-Stokes

breathing

Agonal breaths

CHEYNE-STOKES BREATHING

If Patient Is Actively Dying w/ SOB

Avoid using an O2 mask (comfort)

Nasal Canula O2 may help

Fan may help, blowing air toward pt’s. face

Morphine is drug of choice for “air hunger”

Lorazepam, if anxiety is present

SECRETIONS

Due to oral and

tracheal secretions

Gurgling (“death rattle”)

No sign that this

bothers the patient

DEFINITELY bothers

those listening

Suctioning is NOT

recommended

TO DRY UP EXCESS SECRETIONS, GIVE:

• Hyoscyamine

(Levsin) or Atropine drops

• Transdermal Scopolomine

(Scop patch)

• Also, try repositioning the

patient

*All 3 equally effective in a recent comparative study, but Scopolamine takes 24 hrs. to reach steady state.

Decreased P.O. Intake

Decreased appetite,

weight loss, wasting,

weakness

Decreased fluid intake,

dehydration,

hypotension, dry mouth

Decreased P.O. intake is normal at end-of life.

Doesn’t bother patients.

They DO complain of dry mouth. Treat with frequent mouth care.

Educate families regarding decreased P.O. intake—Normal at end-of-life.

CHANGES IN CONSCIOUSNESS

Drowsiness

Difficulty

Awakening

Unresponsive

to stimuli

CIRCULATORY DYSFUNCTION

Cardiac

– Tachycardia

– Hyper/Hypotension

– Peripheral cooling and cyanosis/mottling

Renal

– Dark Urine (tea-colored)

– Oliguria (<400 ml./day)/ Anuria

EDUCATE FAMILY—Normal / No treatment needed

DELIRIUM—treat w/benzos, haldol, etc.

Symptoms:

– Confusion,

day/night reversal

– Agitation

– Purposeless,

restless

movements

– Moaning

– Acute onset

Terminal Agitation

Checklist

Medication review (polypharm.,

toxicity, side effects?)

Hx/ of substance abuse?

Retention or urine/stool?

Signs of fever or sepsis ?

Dyspnea ?

Assess pain/suffering

Non-Physical Causes of T.A.

Fear/Anxiety……

Environment……

Severe mental

anguish………….

IDT can offer support, treat

cautiously w/anxiolytics, consider

music tx., therapeutic touch

Reduce stimuli, involve familiar

faces @ bedside, consider

aromatx.

If recovery is impossible and

death is near, consider terminal

sedation

TWO ROADS TO DEATH

The usual road--easy

– Sleepy

– Lethargic

– Semi-comatose

– Death

The DIFFICULT ROAD

Restless

Confused

Hallucinations

Delirium

Myoclonic jerks,

seizures

Comatose

Death

PROGNOSIS AT END-OF-LIFE

Very difficult to be precise

Better to give a general estimate (“days to weeks”)

Always remind patients & families of the unpredictability of the dying process.

Unconscious Patients Near Death

May still hear, even if

they can’t respond.

Advise caregivers and

family members to

talk to the patient as if

he/she were

conscious.

WHEN DEATH OCCURS

Heart stops beating

Breathing stops

Pupils become fixed and dilated

Skin color becomes pale and waxen

Body temperature cools

Urine and stool may be released

Eyes may remain open

Jaw may fall open

Observers may hear trickling of internal fluids, even after death.

FAMILY MEMBERS OR CAREGIVERS

May want to spend time with the body after the death

A peaceful environment may facilitate grieving, so. . .

Staff should take time to position the body, remove tubes, disconnect machinery, and clean up any mess

LOVED ONES

May benefit from a recounting of events leading up to the death.

Staff may be able to help families understand and “frame” the events.

Families may need time alone with the body, or to observe customs & traditions.

Communicating the Bad News

1—Get the setting right

2—Provide a “warning

shot”

3—Tell the news

4—Respond to emotions

with empathy

5—Conclude with a plan

Remember . . .

We have only ONE CHANCE to get it right.

Your Expertise Can Provide a Smooth Passage for the Patient and Family

HOSPICE can HELP by offering

Expert symptom control

Education and support for your staff

Psycho-social support for pt. and family

Spiritual care

Volunteer services

Bereavement care for 13 months or longer

Coverage for medications and equipment

QUESTIONS/STORIES?