when the time is near palliative care education for front-line workers
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When the Time is Near
cerah.lakeheadu.ca
Palliative Care EducationFor Front-line Workers
In First Nations Communities
The last hours of living
Over 90% of those who suffer a long illness will die
The last hours can be the most significant time of our lives
Think about…
• The importance of final hours which are independent of the site of dying/death
• Addressing physical, psychological, social, and spiritual needs
• Skilled around-the-clock care • Anticipating medication, equipment, and
supply needs
Caring in the last hours
• If possible, the setting should allow loved ones private, 24-hour access without disturbing others
• There is a need for regular reassessment of the patient’s condition and the family’s ability to cope with rapid and unexpected changes
• Caregivers must respond quickly and modify plans especially when a dying person is at home if readmission to hospital is to be avoided
Who can receive palliative care in Canada?• Any person with a life expectancy of less than six
months• Any person about whom you can say: “If she/ he
died within the next year, I would not be surprised”
• Any person with an incurable, progressive disease
• Any person who elects a palliative or comfort- care approach
What to expect weeks to months before death:• Social withdrawal, personal reflection, less
communication or sometimes a desire to address old conflicts
• Increased sleep and decreased intake of food and water
• Postponing death until meaningful events occur• Saying good-bye, looking for permission to die,
expressions of soul weariness (i.e. “I’m tired of living”)
Caring for the Terminally Ill: Honouring the Choices of the People, p. 66-67
(CHPCA, 2008)
Communication with the individual who is unconscious• Plan ahead to reduce family distress(Caring for the Terminally
Ill: Honouring the Choices of the People, p. 92)
• Assume the individual who is unconscious can hear everything
• Encourage families and friends to create an environment that is familiar and pleasant
• Recognize touch as heightening communication
www.cerah.lakeheadu.ca
Choices about eating & drinking• 2/3 of individuals who are terminally ill
experience a loss of appetite• The reduced need for food is a normal part of
the dying process• Most individuals who are dying are not hungry or
thirsty• Weight loss is expected in an individual who is
dying• A dry mouth is also a common occurrence
Caring for the Terminally Ill: Honouring the Choices of the People, p. 38-42
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If a person stops eating but is still taking in fluids:
• S/he is able to live for weeks to months• Their feelings of hunger are blunted• Their mental function may remain normal until
just before death
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If a person stops drinking…• S/he may typically live 1-3 weeks but in rare
cases may live as long as 6 weeks• Dehydration results in a gradual loss of
consciousness• Death while dehydrated may be more peaceful
and comfortable than death with intravenous (IV) fluids
• Good mouth care is an important part of comfort care
Reasons to recommend the use of tube feeding or IV fluids• Artificial nutrition and hydration can be used
temporarily to support a person who may recover from a non-terminal illness
• May improve comfort for individuals who express hunger or thirst
• May be used to keep a person alert while awaiting a special visit or event prior to death
• Client or family members’ religious beliefs or strong feelings may require continued use of these treatments until death
Reasons not to recommend tube feeding or IV fluids (1 of 2)• Can lead to increased lung secretions, shortness
of breath, swelling, edema, and incontinence• Lack of IV fluids and tube feeding often results in
a gradual, peaceful loss of consciousness• Artificial nutrition may prolong the dying process• Most dying people do not experience hunger or
thirst
Reasons not to recommend tube feeding or IV fluids (2 of 2)
• Restraints may be necessary to hold IVs or feeding tubes in place which may distress the person and/or family members
• Tube feeding does not provide taste pleasure or social contact around meals
Some suggestions about making good decisions around eating and drinking• Evaluate the person for treatable causes of
reduced intake such as depression, painful teeth, or other correctable problems
• Consider a trial of an appetite stimulant• Acknowledge the emotional and social meanings
of food• Recognize the naturalness of stopping eating and
drinking at the end of life
Other physical changes
• Sore mouth• Difficulty breathing• Skin problems• Feeling weak• Constipation• Not sleeping well and feeling tired
Caring for the Terminally Ill: Honouring the Choices of the People, p. 43-52
Delirium (1 of 3)
• A disordered altered mental state that may present with hallucinations, agitation, paranoia, sleeplessness, confusion, moaning and groaning, incoherent speech and continual aimless physical activity
Caring for the Terminally Ill: Honouring the Choices of the People, p. 69-70
Delirium (2 of 3)
• May occur in the last 12-24 hours of life• Makes the assessment of pain and
symptoms extremely challenging• It can be devastating for families to watch
their loved one in a state of terminal delirium• Some possible causes may include brain
metastases, and renal and liver failure• Early onset of delirium should be investigated
as some causes of delirium are reversiblewww.cerah.lakeheadu.ca
Delirium (3 of 3)
• Some suggestions• Educate yourself, staff, and families about the
difference between pain and terminal delirium• Advocate on behalf of the client and their
family• Do not abandon the client or their family
Continued presence of staff may assist in maintaining a calm environment and supporting the family and client
Some changes when death is near• Coolness of the skin• Decreased alertness• Disorientation or delirium• Restlessness• Decreased intake food and water• Incontinence and/or decreased urine output• Changes in vital signs (i.e. pulse, blood pressure)• Changes in breathing patterns
Caring for the Terminally Ill: Honouring the Choices of the People, p. 93-95
Signs and symptoms hours/ minutes before death• Large fixed pupils• Inability to move• Faster but weaker pulse• Lowered blood pressure• Cheyne-Stoke respirations (increasing periods
of time in between breaths)• “Death rattle” (noisy breathing due to collection
of mucus in the throat)www.cerah.lakeheadu.ca
Clinical signs and symptoms of death
• Total lack of response to external stimulus• No muscular movement• No reflexes• No vital signs: breath/pulse/blood pressure
Caring for the Terminally Ill: Honouring the Choices of the People, p. 96
www.cerah.lakeheadu.ca
When death occurs
• What to do if you think death has happened
• Caring for yourself
Caring for the Terminally Ill: Honouring the Choices of the People, p. 96-98
www.cerah.lakeheadu.ca
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