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Caring for the Dying Patient

Keith Rischer RN, MA, CEN

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Today’s Objectives…

Discuss the current ethical issues surrounding end of life care.

Identify goals of end of life care. Compare & contrast the emotional & spiritual

needs of the family and client who is dying. Contrast early vs. late physical changes in the

client who is dying. Describe nursing goals and priorities for

managing the client who is dying. Contrast the needs of the family with the nurse

in the client who has died.

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End of Life Ethics

Assisted Suicide Withdrawal food/fluids Passive vs. Active

Euthanasia Legalized active

euthanasia in US• Oregon “Death

w/Dignity Act”

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Advance Directives

Living will• Legal document instructs measure of care

desired if incapable• Shortcomings

Life & death choices over unknown set of circumstances

Some ethicists believe document is “worthless”

Durable power of attorney

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Concerns of Dying Patient

Fear of physical pain and suffering Symptom burden Fear of unknown Fear of loneliness Anonymity Loss of choice over destiny Loss of dignity Loss of consortium Separation and lack of connection Spiritual Financial

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Early Physical Changes

↓ Appetite ↑Weight loss Assistance with ADLs Pain (> or < ) Increased HR; Potential O2 deficiency Drowsiness Fatigue

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Early Emotional Changes

Months to Weeks• Hope

DesirableExpectational

• Withdrawal• Changes in mood

Anger, irritable, hope, denial, ect

• World view changes; gets smaller• Attending to business

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Spiritual Distress

Signs of Spiritual Distress Doubt Despair Guilt Anger Boredom Isolation Statements of regret Statements of unresolved

hurt

Nursing Interventions Ask about their source

of strength Discuss sources of

spiritual strength throughout their lives

Assess support system Assess coping Refer to clergy/chaplain Ministry: ex. Stephens

Ministry at churches

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Family Needs

Focus on dying patient without losing the present and future

The work of daily life goes on Anticipatory grief Increase in responsibilities (house,

finances, work, children, and acting as a caregiver).

Need for support from family, community, spiritual faith.

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Goals of Nursing Care for the Dying Hospice

• Improve quality of life w/terminal illness Control symptoms

• Pain• N&V• Fatigue• SOB

Identify-prioritize needs Promote meaningful interactions w/family and

others Facilitate peaceful death

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Nursing Care:Holistic

Chaplain/ Clergy visit Hospice/ respite care Hospice/Home Care

• Provide CNA daily for ADL hygiene and care• More frequent RN visits• More frequent Social Worker visits• Talk candidly about end of life= how it will

likely be for that specific patient

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Nursing Care:Physical Priorities

Pain management N&V management Fatigue management Skin care Mouth care Urinary care Respiratory care Comfort

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Nursing Care: Physical Priorities

Attend to any needs of patient• Pain

Long acting analgesics with medication for breakthrough pain May need to increase doses of medication Counsel pt./family on pain cycle and breakthrough pain

• Nausea Antiemetics…Zofran Foods that taste good with increased protein and fat Ensure or supplements

• Comfort Comfortable bed Chair pillows

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Why Pain?Why Pain?

• Practitioners are not trained in state-of-the art Practitioners are not trained in state-of-the art pain management pain management

• Myths about addiction, dependence, and Myths about addiction, dependence, and tolerance aboundtolerance abound

• The toll that unrelieved pain takes on the body The toll that unrelieved pain takes on the body and mind is not understood or acknowledgedand mind is not understood or acknowledged

• Fear that pain intervention might cause the Fear that pain intervention might cause the patient to diepatient to die

• Flawed assessmentsFlawed assessments• Disconnect Disconnect • Failure to look at non-physical sourcesFailure to look at non-physical sources

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Nursing Care: Physical Priorities

• MobilityCane, walker, Prevent fallsFalls often indicate change in status

• SleepSleeping more? Less? Look at medications and

physical status. Normal to increase in sleeping.• Fatigue

Do what only matters, find what is important to patient

Hospice volunteer for family for relief

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Nursing Care: Physical Priorities

Neuro• Changes due to disease (brain mets, lack of oxygen?)

CV• May need fan for cool or light weight blankets for warmth

Lungs• Teach use of several pillows, O2 may be needed

Skin• Teach positioning, turning, and prevention of breakdown

GI• Use of stool softeners is a must; may need laxatives later on

Urinary• May have incontinence (pads, diapers, last resort is foley)

Medications• Order what is needed for comfort

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Changes with Weeks Remaining:Physical Changes

Profound weakness• Bedbound• Falling if ambulating• Muscle weakness

Potential skin breakdown Increased care needed VS

• ↑ HR ↓ Pulse

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Dyspnea Managment

Morphine sulfate Diuretics Bronchodilators Antibiotics Anticholinergics

• Atropine Sedatives Oxygen

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Changes with Weeks Remaining:Emotional Changes

↑ Fear, apprehension or peacefulness ↑ withdrawal into self Often sees “spiritual beings”

• God; previous family members who have died speaking out to them

Only allows family and loved ones in their world Starts to say goodbye to loved ones A sense of peace and finished business may be

felt OR a sense that there is not enough time left to finish life

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Changes with Weeks Remaining: Family Needs

How to care for their love one• Focus is home care management• May not be able to get to PCP’s office• May involve equipment and teaching nursing care for ADLs

O2, transfer techniques, shower chair, turning techniques, decubitus care, mouth care, foley care, ect

Pain relief Symptom management Medication management increases

• Subq meds, rectal suppositories Psychological support increases Focus on quality of life vs. quantity

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Imminent Death:Nursing Care

Medication management• If unable to swallow (subq, rectal suppositories)• For death rattle “Scopolamine patch” works• Pain management• Comfort measures increase

Turning, mouth care, positioning of limbs, warm/cool measures, eye drops, ect

• Assistance respiratory with positioning

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Imminent Death:Physical Changes

Actively Dying: 48-72 hours remain Confusion and disorientation

• Metabolic changes Withdraws from family “going” somewhere

• Decreased consciousness May refuse all fluid and food

• Body conservation of energy for function Total care ↓ alertness ↑ drowsiness

• Metabolic changes and decreased oxygen to brain ↑ Restlessness ↓ BP ↑HR (120-150)

• Peripheral circulation diminishing to vital organs• Mottling of extremities

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Imminent Death:Physical Changes

Incontinence of urine and bowel• Increased muscle relaxation and decreased consciousness • May be incontinent around the foley catheter

Dependent areas become cyanotic & cold Skin color is pale and mottling of skin occurs (knees, legs,

nose) Slower pupil response to light, & eyes fixed stare-even in

sleep• Muscle becomes slack, decreased oxygen

Speech may be difficult and soft• Muscle becomes slack

Hearing is thought to remain present Vision may be lost

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Imminent Death:Physical Changes

Cheyne-Stoke respirations • Metabolic and oxygen changes• Decreased RR• Death rattle

Profuse perspiration• Decreased circulation to all organs as they are

shutting down ↓ urinary output

• Decreased vital organ/ kidneys shutting down Body temp varies

• May decrease or rise

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Imminent Death:Emotional Needs

Sense of peacefulness in the room Family and loved ones present Caring feeling by loved ones Its going to be OK Its OK to go now Your work is done I love you/ I forgive you

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Imminent Death: Family Needs

Presence of Nurse Care for patient Support for patient and family Educate family throughout the process to avoid

the feeling of not knowing what next Be the detail person

• Be prepared for how family will handle death• Know emergency numbers for family/hospice

Make final arrangements• Mortuary; pick up equipment, clean up room.

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Imminent Death: Family Needs

Encourage them to stay with patient Touch and talk with patient Be vigilant about what the patient hears, even

though he/she cannot respond Encourage active comfort measures

• Light massage, mouth care, Allow them time to privately grieve with family Acknowledge the process of dying

• Skin cooling, cyanosis, Cheyne-Stokes, urinary incontinence (all this is normal)

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Pronouncement of Death Cessation of blood pressure, pulse and respirations. In hospice is pronounced by RN (or Social Worker in

some states)• Blood pressure may be not be able to be palpated for

hours before death• Final respirations may be gasping• Eyes are fixed (pupils fixed and dilated)• No apical pulse

Needs of the Family After Patient’s Death

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Presence of a support system• Family, chaplain, nurse, social worker

Make sure someone is with them • Don’t leave them alone to go home• No One Dies Alone at ANW

Vounteers who stay during last hours Call family members if needed (when unexpected) Allow time for the family to spend with the patient who died

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Needs of the Nurse After the Patient’s Death

Support system• Other staff, friends, family (who can listen to you)

Physical and emotional rest Attend memorial or burial service for closure Final separation from family Remind yourself that you made a difference

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Near Death Experiences

Altered state of consciousness during brief cessation of VS (cardiac arrest)

• Tunnel of light• Sense of being separated from body• Fear & anxiety-torment

Afterwards for patient• More spiritual minded-less material focused• Less fearful of death

Nurse’s role• “What do you remember about being unconscious?”• “Did you have a sense of being separate from your body while

we were reviving you?”• Avoid negative statements during code