Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of- Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association AOA: Treating our Family and Yours
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Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association.
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Osteopathic EPECOsteopathic EPEC Osteopathic EPECOsteopathic EPEC Education for Osteopathic Physicians on End-of-Life
Care
Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational
use.
American Osteopathic AssociationAOA: Treating our Family and Yours
EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12
Last Hours of Living
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American Osteopathic AssociationAOA: Treating our Family and Yours
Last hours of living• Everyone will die
• < 10% suddenly
• > 90% prolonged illness
• Last opportunity for life closure
• Little experience with death• Exaggerated sense of dying
process
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American Osteopathic AssociationAOA: Treating our Family and Yours
Prognostication
• Skill of prediction and art of communication
• When?• Advise in terms of ranges:
hours to days days to weeks weeks to months
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American Osteopathic AssociationAOA: Treating our Family and Yours
Preparing for the last hours of life . . .• Time course unpredictable
• Any setting that permits privacy, intimacy
• Anticipate need for medications, equipment, supplies
• Regularly review the plan of care
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American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Preparing for the last hours of life• Caregivers
• Awareness of patient choices
• Knowledgeable, skilled, confident
• Rapid response
• Likely events, signs, symptoms of the dying process
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American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12, Part 1
Physiological Changes, Symptom Management
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American Osteopathic AssociationAOA: Treating our Family and Yours
Objectives
• Assess and manage the pathophysiologic changes of dying
• Care for the whole person, not just the symptoms
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American Osteopathic AssociationAOA: Treating our Family and Yours
Physiologic changes during the dying process• Increasing weakness, fatigue
• Decreasing appetite / fluid intake
• Decreasing blood perfusion
• Neurologic dysfunction
• Loss of ability to close eyes
• Pain
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Weakness / fatigue• Decreased ability to move
• Joint position fatigue
• Increased risk of pressure ulcers
• Increased need for care• Activities of daily living
• Turning, movement, massage, OMT
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American Osteopathic AssociationAOA: Treating our Family and Yours
American Osteopathic AssociationAOA: Treating our Family and Yours
Counsel about palliative care interventions• Be clear about intent of intervention
“We would like to increase his morphine dose because we are concerned that he might be experiencing some pain (or shortness of breath).”
• Inquire as to understanding of action and concerns
“What is your understanding of the proposed actions. Do you have any concerns?”
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… Counsel about palliative care interventions• Address spoken (and unspoken)
concerns
“We do not believe this action will hasten death, nor is this the intent.”
“Our goal is to enable him to die a natural and peaceful death, letting it unfold at its own pace.”
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Signs that death has occurred . . .• Absence of heartbeat,
respirations
• Pupils fixed
• Color turns to a waxen pallor as blood settles
• Body temperature drops
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American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Signs that death has occurred• Muscles, sphincters relax
• Release of stool, urine
• Eyes can remain open
• Jaw falls open
• Body fluids may trickle internally
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Telephone notification of death
• Inquire as to where the person is and whether alone (if driving while on a cell phone, advise the person to pull over and park)
• Identify self, relationship to the deceased (physician/nurse on-call), give brief advanced alert (I’m sorry I have some bad news.”) and give the news
• Listen more than you speak. If questions arise, answer them briefly. For more detailed inquiries, reassure the caller that these can be answered later.
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American Osteopathic AssociationAOA: Treating our Family and Yours
…Telephone notification of death
• Do NOT say that the person must come in right away – give permission to let feelings settle; suggest coming in with a family member or friend
• Give clear instructions as to where to go and whom to contact when arriving at the hospital, home or facility
• Finish with an empathic statement, such as “This must be very hard for you…Please let me know if there is anything else I can do to help.”
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American Osteopathic AssociationAOA: Treating our Family and Yours
After expected death occurs . . .• Care shifts from patient to
family / caregivers
• Different loss for everyone
• Invite those not present to bedside
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. . . After expected death occurs• Take time to witness what has
happened
• Create a peaceful, accessible environment
• When rigor mortis sets in
• Assess acute grief reactions
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American Osteopathic AssociationAOA: Treating our Family and Yours
Moving the body
• Prepare the body
• Choice of funeral service providers
• Wrapping, moving the body• Family presence
• Intolerance of closed body bags
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Other tasks• Notify other physicians,
caregivers of the death• Stop services• Arrange to remove equipment /
supplies
• Secure valuables with executor
• Dispose of medications, biologic wastes
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American Osteopathic AssociationAOA: Treating our Family and Yours
Bereavement care• Bereavement care
• Attendance at funeral
• Follow up to assess grief reactions, provide support
• Assistance with practical matters• Redeem insurance
• Will, financial obligations, estate closure
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American Osteopathic AssociationAOA: Treating our Family and Yours
Dying in institutions
• Home-like environment• Permit privacy, intimacy
• Personal things, photos
• Continuity of care plans
• Avoid abrupt changes of settings
• Consider a specialized unit
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American Osteopathic AssociationAOA: Treating our Family and Yours
Expected Death
Summary
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American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12, Part 3
Loss, Grief, Bereavement
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American Osteopathic AssociationAOA: Treating our Family and Yours
Objectives
• Identify, manage initial grief reactions
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American Osteopathic AssociationAOA: Treating our Family and Yours
Loss, grief with life-threatening illness . . .• Highly vulnerable
• Frequent losses• Function / control /
independence
• Image of self / sense of dignity
• Relationships
• Sense of future
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American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Loss, grief with life-threatening illness• Confront end of life
• High emotions
• Multiple coping responses
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Loss, grief, coping
• Grief = emotional response to loss
• Coping strategies• Conscious, unconscious
• Avoidance
• Destructive
• Suicidal ideation
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Normal grief• Physical
• Hollowness in stomach, tightness in chest, heart palpitations
• Emotional• Numbness, relief, sadness, fear,
anger, guilt
• Cognitive• Disbelief, confusion, inability to
concentrate
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American Osteopathic AssociationAOA: Treating our Family and Yours
Complicated grief . . .
• Chronic grief• Normal grief reactions over
very long periods of time
• Delayed grief• Normal grief reactions are
suppressed or postponed
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. . . Complicated grief
• Exaggerated grief• Self-destructive behaviors
eg, suicide
• Masked grief• Unaware that behaviors are a
result of the loss
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Tasks of the grieving
• Accept the reality of the loss
• Experience the pain caused by the loss
• Adjust to the new environment after the loss
• Rebuild a new life
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Assessment of grief
• Repeated assessments• Anticipated, actual losses
• Emotional responses
• Coping strategies role of religion
• Interdisciplinary team assessment, monitoring
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American Osteopathic AssociationAOA: Treating our Family and Yours
Grief management• If reactions, coping strategies
appropriate
• Monitor
• Support
counseling rituals
• If inappropriate, potentially harmful
• rapid, skilled assessment, intervention
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American Osteopathic AssociationAOA: Treating our Family and Yours