Rosdahl and Kowalski TEXTBOOK OF BASIC NURSING

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rosdahl and KowalskiTEXTBOOK OF BASIC NURSING

Rosdahl and KowalskiTEXTBOOK OF BASIC NURSING

Ch. 100

Hospice Nursing


Evolution of the Hospice Movement Evolution of the Hospice Movement

• *Hospice: philosophy of care

• Hospice programs care for terminally ill persons, while treating them with dignity.

• The goal of hospice care: to provide as much pain relief as possible, while helping the client to meet basic needs.

•


Sample Criteria for Admission to a Hospice

Sample Criteria for Admission to a Hospice

• *Dx of progressive, terminal illness

• Control of symptoms is primary goal after determining no curative treatment is available*

• Life expectancy of no more than 6 months

• DNR/I order

• Many hospices admit people with cancer, as well as other diagnosis such as HIV/AIDS*


Goals of Hospice Goals of Hospice

• Hospice care focuses on four areas of human needs

– Physical

– Psychological/emotional

– Social/cultural

– Spiritual


Key ConceptKey Concept

• A hospice program may be located in a place other than the client’s home.

• For example, a number of hospices have been established in prisons.

• The National Prison Hospice Association (NPHA) has been instrumental in developing these programs for prison inmates. Locations include Texas, Connecticut, and Angola Prison in California.


Characteristics of a HospiceCharacteristics of a Hospice

• Centrally administered, autonomous program

• **Goal is intensive palliative not curative care

• *Major unit of care is the client and his or her family

• Team members should practice interdisciplinary care.

• Support for hospice staff as well as client’s caregivers

• Services extended to the family during the time of bereavement (Medicare requires a 1-year follow-up.)

• Services based on client’s physical needs, not financial resources



• The hospice concept incorporates control of physical and psychological symptoms, continuous access to medical and nursing services, trained caregivers, and bereavement support for survivors

• *Assessment and treatment of pain and other symptoms, assist with patient-centered communication and decision making and coordination of care.

• *pain management is a vital component

• Cure is not the goal—the focus is on relief and comfort. Hospice attempts to make the dying process an experience of coming together for clients and families.


Service Coordination Service Coordination

• Hospice staff members coordinate a client’s care in the client’s home for as long as possible.

• Funding

– Private insurance, Medicare and Medicaid assistance

– Services usually covered on a per-diem (by the day) basis

• Equipment

– Durable medical equipment is also covered by third-party payors.


Symptom Management Symptom Management

• The client, the family caregivers, and hospice team plan together to manage pain and other symptoms.

• Clients usually discontinue radiation therapy or chemotherapy before admission to a hospice.

• Hospice clients are often encouraged to designate

– Do Not Resuscitate (DNR)

– Do Not Intubate (DNI)

– Do Not Hospitalize (DNH)


Client and Family as Care Unit Client and Family as Care Unit

• Initial home visit by an RN

• Other hospice team members make most of the home visits.

• Team members assist family members

– Funeral planning and plans for the future

– Refer clients for writing a will and financial planning

– Support groups

*Compassion Fatigue-natural stress reaction, may result in the inability to care for loved one

S/S-hoplessness, difficulty concentrating, suicide


Respite CareRespite Care

• Respite: caregivers occasionally “take a break”

– Usually for a period less than 30 days*

• Several way to give family a break

– Admit client to inpatient hospice, hospital, or nursing home

– Arrange for supplemental home care for a few days

• Cost of respite care is often covered by third-party payors


Interdisciplinary Care Interdisciplinary Care

• Interdisciplinary team (IDT) or group (IDG)

– Physicians, nurses, medical social workers, therapists (occupational, physical, speech, respiratory, massage), clergy, bereavement coordinators, dietitians, pharmacologists, home health aides, homemakers, and volunteers

– Nurse role-maintain a sense of humor *

• A plan of care (POC) is established for each client; input is obtained from the client, the primary caregivers, and members of the IDT.


Interdisciplinary Care, cont.Interdisciplinary Care, cont.

• Role of primary caregivers

– Identify changes in the client’s condition that might not be noticeable to others

– Suggest approaches to care that meet with everyone’s approval

– *Provide a constant liaison between the client and the hospice team

– Perform some functions of daily care



• Role of volunteers

– Provide emotional support, run errands, assist with physical care, provide short periods of respite, and help with child care and household tasks

– Assist families to share their feelings



• Role of on-call services

– Services of hospice staff are available 24 hours a day

– Staff members answer questions or concerns with reassurance and assistance.

– Staff members may make home visits at any time to help families deal with physical or emotional problems, and they come when the client dies.


Emotional SupportEmotional Support

• Fears of the client

– Being alone when dying

– Having uncontrolled pain

• Family needs to let client know

– That they care

– That they are sad about the situation

• Family members also need emotional support


Spiritual SupportSpiritual Support

• Most hospice teams have chaplains available for consultation.

• Various religious groups have different rituals and procedures related to illness, death, and care of the body after death.

• Hospice team

– Determine the desires of the client and family early in the process and follow these requests

– Consult with the client’s religious advisor

– Respect each client’s cultural and religious customs


Bereavement Care Bereavement Care • *Bereavement (grieving) is part of the process of

dealing with a loved one’s death.

• Hospice members

– Attend funeral services

– Urge family members to talk about their loved one, reminisce about the person, share their feelings, and to work through their grief

– Make home visits*

– Encourage families to attend grief support groups, both before and after the client dies

– *Follow-up for a full year after a client’s death


Support for Hospice Staff Support for Hospice Staff

• Hospice staff members need emotional support

– Support groups or other outlets must be available.

– Grieving when clients die is normal and acceptable.


Assisting the Client to Meet Basic Needs Assisting the Client to Meet Basic Needs

• The hospice nurse

– Helps clients to meet basic needs

– Does not provide a great deal of direct physical care

– Focuses on identifying the needs of the client and family

– Case manager coordinates the client’s care with other members of the team and with the family

– Major role in symptom control


Oxygen and Airway Oxygen and Airway

• Assisting in respiratory distress

– Maintain a patent airway**

– Stress reduction and position change

– Arrange for air to circulate or cool the room

– Elevate the head of the bed

– Assess vital signs, level of consciousness frequently

– Thoracentesis, medications

– Postural drainage, nebulizer treatments

• Assisting in seizures

– Anti-seizure medications


Nutrition and Hydration Nutrition and Hydration

• Anorexia

– Encourage clients to eat or take fluids

• Most studies show people benefit from low oral intake**

– Appetite-stimulant medications may help

– Provide frequent, small meals and snacks

– Ensure the client receives good mouth care before and after meals

– Vitamins, tranquilizers, antidepressants, antiemetics


N/VN/V

• Nauseated clients should lie on their right side

• Relaxation techniques

• Antiemetics

– Dolasteron mesylate (Anzemet)*

• Carbonated beverages

• Dry food

• Ice chips


Symptom Control in Hospice Care Symptom Control in Hospice Care

Refer to Important Medications 99-1.


Nutrition and Hydration, cont. Nutrition and Hydration, cont.

• Dehydration

– Assess for and report dehydration and complications

– The physician, together with the client and family, can determine appropriate treatment (if any) for dehydration or electrolyte imbalance.

– Alleviate dryness of the mouth by using ice pops, ice chips, drops of water, or allowing client to suck on a wet washcloth or a piece of hard candy.


Elimination Elimination

• Diarrhea

– Follow the primary healthcare provider’s order for specific treatment.

– Low-residue diet lessens stimulation

– Eliminate specific foods causing gas or cramps.

– Encourage clients to drink a variety of fluids.

– Ensure good skin care around the rectum

– Remind caregivers to wear gloves.


Elimination, cont. Elimination, cont.

• Constipation

– Determine if a bowel obstruction exists

– Encourage a high-residue diet if tolerated

– Provide mild laxatives or suppositories if necessary.

– Bowel regimen



• Sometimes, clients think they are constipated because they are not having daily bowel movements.

• Teach them that a bowel movement every 2 to 3 days is common because of physical inactivity and low oral intake.


Sleep and Rest Sleep and Rest

• Insomnia and hypersomnia

– Assist the client to sleep by providing comfort measures.

– *Soft music, relaxation tapes, self-hypnosis and guided imagery

– Depressed clients often sleep too much (hypersomnia).

• Goal of hospice care

– Adequate sleep at night

– Maintain normal activity, as much mobility as possible during the day


Personal Care and ComfortPersonal Care and Comfort

• Skin breakdown

– Non-intact skin can be a source of infection and pain.

– Encourage and assist client to change position often.

– Wear gloves when treating skin that is not intact.

– Keep the client’s skin clean and dry.

– Special mattresses may help prevent skin breakdown.

– Regular pain medications help client move more comfortably


Management of Odor Management of Odor

• Disagreeable odor may embarrass clients

• To control odor

– Aerosolized sprays

– Wintergreen oil

– Charcoal filter dressing

– Mechanical air filter


Emotional Concerns Emotional Concerns

• Depression

– Clients or family members may need treatment for depression.

– Listen with empathy and validate feelings.

– Provide antidepressant medication for clinical depression if ordered.

– Refer to a psychologist or psychiatrist if necessary


Emotional Concerns, cont.Emotional Concerns, cont.

• Anxiety

– *Major causes

• Fear of severe pain

• Fear of being alone

• Fear of dying ALONE

• Concern about the future for their loved ones

– Clients become agitated or paranoid

• Listen and offer reassurance.

• Provide anti-anxiety medications as ordered.


Pain Management Pain Management • Evaluation of pain

– Evaluate client’s pain and its level of interference with activities, rest, and general comfort.

– Ask client what makes pain worse or better.

– Classify pain as to its location, intensity, and severity.

– 5th v/s!!**

– *Medications are increased as pain intensity increases

– Narcotic dose may be aggressively increased if necessary-titrate up**


Medications Used in Pain ManagementMedications Used in Pain Management

Refer to Important Medications 99-2.

Corticosteroids-appetite stimulants*


Nursing AlertNursing Alert

• Many non-opioids are mild anticoagulants and must be used with caution.

– Evaluate respiratory function when taking opiates**


Pharmacologic TherapyPharmacologic Therapy

• Administration routes

– *Oral medications are the first choice

• Sublingual

• Buccal

– Rectal

– Skin patch

– Subcutaneous or IV

• Saline lock/heparin lock* to avoid venipuncture

– Patient-controlled analgesia (PCA) pumps


Pharmacologic Therapy, cont.Pharmacologic Therapy, cont.

• Around-the-clock medication administration

– Twelve-hour pain medication taken regularly

– PCA pumps

– Continuous-administration pumps

• Titration**

• Caregivers should give clients medications before pain occurs or before it increases.

• Allay fears of the caregivers about the client’s addiction to narcotics or other medications.


Pharmacologic Therapy, cont.Pharmacologic Therapy, cont.

• Management of side effects

– Sedation

– Respiratory depression

– Dangerous lowering of blood pressure

– Constipation

– Somnolent



• It is important to remember that hospice clients have lowered intake and activity and often have a bowel movement only every 2 to 3 days. This is normal. It is important to reassure the client and the caregivers in this case.

• People who smoke, abuse drugs and other substances, or who have been very athletic often require more medication to achieve comfort.

• People with severe liver or kidney damage may require higher dosages of pain-relieving medication.


Psychosocial Modalities for Pain Management

Psychosocial Modalities for Pain Management

• Clients may benefit from psychotherapy, support groups, or pastoral counseling.

– Client education

– Encourage activities that distract clients from pain.

– Encourage exercise, if possible.

– Use guided imagery, self-hypnosis, guided relaxation, and visualization.

– Biofeedback technique


Physical Modalities for Pain Management Physical Modalities for Pain Management

• Encourage clients to maintain physical activity.

• Encourage cutaneous stimulation modalities.

• Apply ice on the contralateral side

• Acupuncture and acupressure

• Transcutaneous electrical nerve stimulation


Palliative Radiation, Medications, and Surgery

Palliative Radiation, Medications, and Surgery

• Palliative radiation

– IV injection of radioactive materials

• Medications

– Hormones

• Surgical interventions

– Temporary nerve block

– Permanent nerve block

– Ablative surgery

• debulking

– Palliative surgery


Children in Hospice Programs Children in Hospice Programs

• Evaluate each child individually.

• Be specific in explaining death.

• Help children to understand that they have contributed to the world and family.

• Let them know they will be greatly missed.

• **Encourage family to explain death to the child in terms of their religious beliefs.

• Refer the family to a support group.


When the Client DiesWhen the Client Dies

• Assist the client’s loved ones with end-of-life work.

• Ensure that caregivers know what to expect and what to do when death occurs.

• Instruct caregivers to call the hospice nurse when a client dies.

• Support the

• *Refer to bereavement support group

– Let family know they will continue to be involved in hospice for the next year

• Family’s wishes and assist with technical details.

Rosdahl and Kowalski TEXTBOOK OF BASIC NURSING

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