VN057 GERONTOLOGY 815,
CHAPTER 15
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End-of-Life Care
The American Way of Dying
Not seen as a natural progression Uncomfortable with death fragmented, disorganized & inadequate
guidance forced to attempt to follow changing rules &
regulations set up by multi bureaucracies Gvt insurance
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ATTITUDES TOWARD DEATH AND
END-OF-LIFE PLANNING
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Attitudes end-of-life care and death planning Ideally, discussions before a health crisis variety of options-end of life decisions
difficult too many choices
values, cultural & spiritual beliefs, & life experiences all affect choices
Most say that they do not fear death as much as they fear how they will die
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Advance Directives
Specific end-of-life decisions Written- official documents
Fewer issues-both providers & family advance directive living will durable power of attorney for health care
Specify the type and amount of intervention desired by an individual
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Advance Directives (cont.) Copies to
PCP, hospital of choice, extended-care facility, power of attorney for health care, anyone else as appropriate
A competent person retains the right to change his or her mind about treatment at any time Intubation or feeding Full code to DNR DNR to full or chem code Comfort care to any of the above
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Advance Directives (cont.)
Not official or required- Medic-alert bracelet or necklace with code
status Copy on refrigerator if person lives @ home
Caregiver Attitudes Toward End-of-Life Care
providers see death as a professional failure rather than the inevitable end to the human experience
• Caregivers need to be able to communicate effectively –deal with grief, loss & bereavement at the end of life
patient, family significant others
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Death among older adults is typically caused by a(n):A. acute illness.B. accident.C. chronic and debilitating conditions.D. sudden, unexpected condition.
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VALUES CLARIFICATION RELATED TO DEATH AND
END-OF-LIFE CARE
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Ethical Dilemmas
value systems of patient & caregiver are often very different
Caregivers benefit from spending time identifying their personal end of life values
Understanding the value systems of others help the nurse provide quality end-of-life care, even when his or her values are not the same
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Values Clarification
Death, dying, and the end of life have different meanings for every person
Each individual must examine his or her own values
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What Is a “Good Death”?
research to identify specific end-of-life outcomes most valued & desired by those nearing the end of life & by their families
Common theme: given their choice, most people wish to be treated with respect and dignity and to die quietly and peacefully, with loved ones nearby
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Patients’ Wishes Related to End of Life
Most dying patients have similar desires
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Where People Die
90% indicated a wish to die at home less than 25% actually occur there 50% occur in hospitals 25%in extended-care facilities
Hospice care The focus is palliative providing comfort meeting the needs of patients & their families
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Hospice care is usually available for the last __________ of life.A. month.B. 6 months.C. 1 year.D. 2 years.
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Medicare covers hospice when death is expected to occur within 6 months Not always exact timing-some lee way Not always cancer
CHF Dementia COPD etc
Hospice Care
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Palliative Care
Focus-reduce or relieve symptoms without cure neither hastens nor postpones death
Interventions designed to make the best of the time left & live as active and complete a life as possible until death comes
“Comfort Care”
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Palliative Care (cont.)
Individuals choosing palliative care usually choose to decline procedures Invasive diagnostic tests cardiopulmonary resuscitation (CPR) artificial ventilation artificial feeding,
prolong the dying process
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Collaborative Assessments and Interventions for End-of-Life Care
Commitment & collaboration of all caregivers
Disciplines must work together cooperatively & creatively
positive attitude to solve any problems requires mutual respect & communication
between all team members
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Communication at the End of Life
responsibility for providing & maintaining effective communication nurses and assistive caregivers, who spend
the most time with dying patients Nurses need to work to develop a climate
that encourages open communication
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Communication at the End of Life (cont.)
demonstrate verbally and nonverbally you are approachable not detached or indifferent
demonstrate willingness to listen suggestions, requests, or criticisms made by
the dying person or, more likely, by family
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PSYCHOSOCIAL PERSPECTIVES, ASSESSMENTS, AND INTERVENTIONS
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Cultural Perspectives
cultural beliefs influence people think, live & interact with other people-they also affect how a person approaches death
nurse’s responsibility to assess each person to find out their preferences & viewpoints Develops trust & can plan culturally sensitive
care
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Communication About Death
The Western perspective emphasizes patient’s “right to know” diagnosis and prognosis patient can make informed decisions
Asians & Native Americans often believe speaking about death or other bad things decreases hope and produces bad outcomes
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Decision-Making Process
Amount and type of intervention that will be accepted
Individual/cultural focus on helping people cope with death focus on living and prolonging life
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Decision-Making Process (cont.)
Significance of pain and suffering Western perspective focuses on freedom from
pain and suffering Non-Western cultures often see pain as a test
of faith or a preparation for the afterlife something that is to be endured rather than
avoided
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Spiritual Considerations
Determine if there are specific religious beliefs or practices important to the patient or their family members
Assess whether they have a preferred spiritual counselor
Offer choices when available Determine whether the person wishes
any spiritual counselor to be notified
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Spiritual Considerations (cont.)
respect for the patient’s religious and spiritual views Avoid imposing your own beliefs Be present, be available, and listen Avoid moving beyond your role and level
of expertise unless you have specific ministerial or pastoral training in death and dying
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Depression, Anxiety, and Fear
It is one thing to know that you will die eventually; it’s another to realize that you have lived most of your life and that death is likely to be a reality soon
Individuals must decide whether they will give up and let fear, anxiety, or depression overwhelm them or whether they will do something to remain in control of whatever time they have remaining
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One of the most important things caregivers can do for a dying person is to:A. not talk about when they will die.B. allow them to be alone as much as
possible.C. talk to them about a “do not resuscitate”
status.D. spend more time with them.
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PHYSIOLOGIC CHANGES, ASSESSMENTS,
AND INTERVENTIONS
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Pain
Biggest concern of the dying person and their significant others
Can interfere with the ability to maintain control, cope, and complete end-of-life tasks
Increases the likelihood of fatigue, depression, and loss of appetite
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Pain (cont.)
Interferes with the ability of the dying person to make thoughtful decisions & communicate effectively with loved ones at a critical time
Relief of pain begins with careful assessment
Perform assessment early & often patient’s status can change dramatically in a
relatively short period
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Pain (cont.) Pain is what the patient says it is, but
many older patients who have lived with multiple discomforts often underreport pain Don’t want to be a bother Afraid of addiction to medication
Medical personnel Family patient
Self-reported logs or journals are helpful patient and significant others more focused and
attuned to subtle changes in the individual
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Fatigue and Sleepiness
May be caused by underlying disease processes, stress, anxiety, or medications
can interfere with ability to carry out end-of-life tasks, including communicating with loved ones
Because of metabolic changes [& depression] patient may begin to sleep more and may be difficult to awaken as the end of life nears
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Cardiovascular Changes
Diminished peripheral circulation likely to worsen as death nears resulting in dry, pale, or cyanotic extremities
Peripheral pulses are often weak Blood pressure often decreased by 20 or
more points from normal range and may be difficult to hear
Body temperature may elevate significantly as death nears
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Respiratory Changes Shortness of breath, difficulty breathing
(dyspnea), and Cheyne-Stokes respirations during sleep are commonly observed in older adults as death nears
Mild respiratory difficulty usually can be relieved by changing positioning, elevating the upper body, opening windows or using a fan to increase ventilation, or administering oxygen by nasal cannula Narcotics often given for air hunger
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Gastrointestinal Changes
Loss of appetite (anorexia) and muscle wasting (cachexia) are commonly observed with advanced terminal conditions, particularly some forms of cancer
Dry mouth (xerostomia) and ulcerations of the mouth
Nausea and vomiting are not signs of impending death; rather, they are distressing symptoms of underlying problems
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Gastrointestinal Changes (cont.)
Constipation is a common and distressing problem for the terminal patient
Diarrhea is a less common problem at the end of life, but one that can have a profound effect on the quality of life
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Urinary Changes
Oliguria common-decreases in fluid intake, blood pressure, and kidney perfusion
Urinary incontinence common Absorbent pads or indwelling catheter
used to reduce need for bed changes that may disturb the dying person
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Integumentary Changes
Skin breakdown is a problem malnourished Lack of mobility incontinence
Interventions to prevent skin tears or pressure sores proper skin cleansing
careful handling of skin frequent turning and positioning measures to reduce pressure
soft, nonconstricting, nonirritating clothing helps promote comfort and minimizes risk for skin dryness and rash
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Sensory Changes with end of life
Vision- diminishes and the visual field narrows
Hearing-acute until death even if the person does not respond Calm, supportive, loving messages should be
delivered, even when unresponsive Negative or disturbing conversations should
be avoided
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Changes in Cognition Delirium-present in over 80% @ end of
life Causes
Hypotension oxygen deprivation
Apnea hypoventilation,
Fever neurologic changes metabolic abnormalities
Hyperglycemia -uremia -dehydration other physiologic or emotional disturbances
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DEATH
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Family Members and Significant Others
Often wish to be present at the time of death
Some can spend only limited time wish to be called only when there is a
significant change in the person’s status Others would rather be notified only after
death has occurred
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Indicators of Imminent Death
Increased sleepiness Decreased responsiveness Confusion in a person who has been
oriented Hallucinations about people (sometimes
deceased family members) Increased withdrawal from visitors or
other social interaction
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Indicators of Imminent Death (cont.)
Loss of interest in food and fluids Loss of control of bowel and bladder Altered breathing patterns
shallow breathing Cheyne-Stokes respirations rattling or gurgling
Involuntary muscle movements and diminished reflexes
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After Death
family members should be allowed to sit at the bedside and say farewells or grieve as long as they need
It is appropriate for the nurse to discreetly remove oxygen, IV lines, or other medical devices
Cultural practices regarding grieving and preparation of the body should be respected and accommodated whenever possible
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Postmortem Care
Removal of soiling and application of a clean sheet or shroud according to agency policies
In most cases, the head is elevated slightly to prevent discoloration
Eyes are gently closed, dentures are inserted, and a small towel is rolled and tucked under the jaw to close the mouth
Personal belongings should be identified, listed, and bagged for return to the family
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Funeral Arrangements
Most older people have given some thought to their final resting place, and many have made specific plans, issued specific directions regarding their wishes and, in some cases, even paid for their funeral
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Bereavement
Survivors often express having ambivalent feelings regarding the death On one hand, they feel a sense of relief that
the struggle is over and that the loved one is at rest
On the other hand, they seriously grieve and miss the loved one’s presence
Even when death is anticipated, the initial feeling of shock and numbness typically occurs
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Bereavement (cont.) reality of the loss strikes survivors often experience s/s of depression
loss of appetite inability to sleep avoidance of social interaction uncontrolled bouts of crying
In normal grieving, the frequency and severity of these signs of grieving gradually decrease over time, but the loss of a loved one never goes away completely
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Kübler-Ross model-Five Stages of Grief Denial — "This can't be happening to me.“ Anger — "Why me? It's not fair!""Who’s to
blame?“ Bargaining — "I'll do anything for a few more
years."hope that the individual can delay death.
Depression —"I'm going to die soon so what's the point?”
Acceptance — "It's going to be okay."