Care at the End of Life 11Lecture Note PowerPoint Presentation

LEARNING OUTCOME 1Describe the role of the nurse in providing quality end-of-life care for older persons and their families.

NURSES UNIQUE QUALIFICATIONS TO PROVIDE END-OF-LIFE CAREHolistic viewComprehensiveEffectiveCompassionateCost effective

NURSES INVOLVEMENT IN END-OF-LIFE CARESpend the most time with patients and their family members at the end-of- life than any other member of the healthcare teamProvide education, support, and guidance throughout the dying process

NURSES INVOLVEMENT IN END-OF-LIFE CAREAdvocate for improved quality of life for the person with serious illnessAttend to physical, emotional, psychosocial, and spiritual needs of the patient

NURSES WHO HELP THE PATIENT DIE COMFORTABLY AND WITH DIGNITY PROVIDE THE FOLLOWING BENEFITS OF GOOD NURSING CARE:Attend to pain and symptom controlRelieve psychosocial distressCoordinate care across settings with high-quality communication between healthcare providersPrepare the patient and family for death

NURSES WHO HELP THE PATIENT DIE COMFORTABLY AND WITH DIGNITY PROVIDE THE FOLLOWING BENEFITS OF GOOD NURSING CARE:Clarify and communicate goals of treatment and valuesProvide support and education during the decision-making process, including the benefits and burdens of treatment

NURSES WHO CARE FOR THE DYING Are well educatedHave appropriate supports in the clinical settingDevelop close collaborative partnerships with hospice and palliative care service providers

NURSES WHO CARE FOR THE DYING Must be confident in their clinical skillsAre aware of the ethical, spiritual, and legal issues they may confront while providing end-of-life care

NURSES NEED TO BE AWARE OF PERSONAL FEELINGS ABOUT DEATHImproves ability to meet holistic needs of the patient and familyClarifies ones own beliefs and values

MEANING OF HOPE SHIFTSFrom striving for cure to achieving relief from pain and sufferingNo right or correct way to die: It's everybody's right to live independent and die with dignity

TABLE 11-1QUESTIONS AND CRITICAL THINKING IN PREPARATION TO CARE FOR DYING PATIENTS

LEARNING OUTCOME 2Recognize changes in demographics, economics, and service delivery that require improved nursing interventions at the end of life.

CHANGING STATISTICSPrimary cause of death10 leading causes of death account for 80% of all deaths in the United StatesHeart diseaseMalignant neoplasmsCerebrovascular diseaseChronic lower respiratory diseaseAccidentsDiabetes mellitus

CHANGING STATISTICSPrimary cause of death10 leading causes of death account for 80% of all deaths in the United StatesInfluenza PneumoniaAlzheimers diseaseRenal diseaseSepticemia

CHANGING STATISTICSDemographic trendsToday, more deaths occur at homeThe average life span is 77.9 years compared to only 50 in 1900the average life expectancy in Jordan is 73.1Social trendsToday, caregivers are more likely to be professionals rather than family members

EXACT CAUSE OF DEATH DIFFICULT TO DETERMINE IN THE OLDER PERSONMultiple comorbid conditions (is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder)Acute injury addedUnexpected pathology

MOST AMERICANS PREFER TO DIE AT HOME50% die in hospitals25% die in long-term-care facilities20% die at home or the home of a loved one5% die in other settings

SURVEY RESULTS OF HEALTHCARE SYSTEM CARE OF DYING PEOPLEExcellent: 3%Very good: 8%Good: 31%Fair: 33%Poor: 25%

BARRIERS TO QUALITY END-OF-LIFE CAREFailure of healthcare providers to acknowledge the limits of medical technologyLack of communication among decision makersDisagreement regarding the goals of careFailure to implement a timely advance care plan

BARRIERS TO QUALITY END-OF-LIFE CARELack of training about effective means of controlling pain and symptomsUnwillingness to be honest about a poor prognosisDiscomfort telling bad newsLack of understanding about the valuable contributions to be made by referral and collaboration with comprehensive hospice or palliative care services

LEARNING OUTCOME 3Describe how pain and presence of adverse symptoms affect the dying process.

NURSES ROLE IN PAIN TREATMENTInitial and ongoing assessment of levels of painAdministration of pain medicationEvaluation of effectiveness of pain medication

HOW NURSES CAN ALLEVIATE THE DISTRESS ASSOCIATED WITH UNTREATED PAINOngoing assessment of levels of painAdministration of pain medicationEvaluation of the effectiveness of the pain management plan

NEGATIVE OUTCOMES OF PAINPotential to hasten deathAssociated with needless suffering at the end of lifePeople in pain do not eat or drink wellInability to engage in meaningful conversations with othersIsolation in order to save energy and cope with the pain sensation

REASONS FOR UNDERTREATMENT OF PAIN Patients inability to communicate due toDeliriumDementiaAphasia (speechless)Motor weaknessLanguage barriers

CAUSES OF INADEQUATE CARE AT END OF LIFE Disparity in access to treatmentInsensitivity to cultural differencesAttitudes about deathAttitudes about end-of-life careAfrican-Americans prefer aggressive life-sustaining treatmentsMexican-Americans, Korean-Americans, and Euro-Americans prefer less aggressive treatment

CAUSES OF INADEQUATE CARE AT END OF LIFE Mistrust of the healthcare systemPain is subjective and self-report is considered accurate

PAIN CHARACTERISTICS IN COGNITIVELY-IMPAIRED OLDER PERSONSMoaning or groaning at rest or with movementFailure to eat, drink, or respond to presence of othersGrimacing or strained facial expressions

PAIN MANNERISMS IN COGNITIVELY-IMPAIRED OLDER PERSONSGuarding or not moving body partsResisting care or noncooperation with therapeutic interventionsRapid heartbeat, diaphoresis, change in vital signs

PAIN TREATMENT BASED ON ACCURATE PAIN ASSESSMENTSystematicOngoing

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAINDo you usually seek medical help when you believe something is wrong with you?Where does it hurt the most?How bad is the pain (may use the facility pain indicator such as smiley face or rate the pain on a scale of 1 to 10)How would you describe the pain (sharp, dull, shooting)?

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAINIs the pain accompanied by other troublesome symptoms such as nausea, diarrhea, and so on?What makes the pain go away?Are you able to sleep when you are having the pain?

PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAINDoes the pain interfere with your other activities?What do you think is causing the pain?What have you done to alleviate the pain in the past?

PAIN DURING THE DYING PROCESSAcuteSudden onset Usually associated with single cause or event

PAIN DURING THE DYING PROCESSChronicAssociated with long-term illnessAlways presentVaries in intensityTolerance to pain developsAssociated factors DepressionPoor self-careDecreased quality of life

PAIN DURING THE DYING PROCESSNeuropathic painNerves are damagedBurning, electrical, or tingling sensationsDeep and severeNociceptive painTissue inflammation or damaged tissuesCardiac ischemia

PAIN DURING THE DYING PROCESSUnrelieved pain during the dying processHastens deathIncreases physiological stressDiminishes immuno-competencyDecreases mobilityIncreases myocardial oxygen requirementsCauses psychological distress to the patient and familySufferingSpiritual distress

LEARNING OUTCOME 4Identify the diverse settings for end-of-life care and the role of the nurse in each setting.

PALLIATIVE CAREPhilosophy of careHighly structured system for care delivery

EMPHASIS OF SUPPORTIVE CARE DURING THE DYING AND BEREAVEMENT PROCESSQuality of lifeLiving a full life up until moment of death

PALLIATIVE CARE SETTINGSHospitalsOutpatient clinicsLong-term-care facilitiesHome

HOSPICE CAREFocuses on the whole personMindBodySpiritSupport and carePatientsFamily and caregiversContinues after death of a loved one

HOSPICE CAREMultidisciplinary team of professional caregiversNurseManages pain and controls symptomsAssesses patient and family abilities to copeIdentifies available resources for patient careRecognizes patient wishesAssures that support systems are in place

HOSPICE CAREMultidisciplinary team of professional caregiversPhysicianPharmacistSocial workersOthersLast phase (6 months) of incurable diseaseLive as fully and comfortably as possible

HOSPICE SETTINGSFreestandingHospitalHome health agencies with home care hospiceHomeNursing home or other long-term-care settings

LEARNING OUTCOME 5Explore pharmacological and alternative methods of treating pain.

ADMINISTER PAIN MEDICATION ROUTINELYPrevent breakthrough pain and sufferingLong-acting drugs provide consistent reliefChronic painShort-acting or immediate release agents for prn useAcute pain

ANTICIPATE AND TREAT ADVERSE EFFECTS OF PAIN MEDICATION NauseaConstipation

PAIN CONTROL AT THE END OF LIFENon-opioids for mild to moderate painAcetaminophenNSAIDs

PAIN CONTROL AT THE END OF LIFEOpioids CodeineMorphine is gold standardHydromorphineFentanylMethadoneOxycodone

NOTE: DO NOT USE MEPERIDINE OR PROPOXYPHENE WITH OLDER PERSONSAdjuvant analgesicsEnhance effectiveness of other drug classesMuscle relaxantsCorticosteroidsAnticonvulsantsAntidepressantsTopicalUseful for treatment with lower doses and less side effects

ROUTES OF ADMINISTRATIONOralFor patient who can swallowRequires higher dosageOral mucosa or sublingualFor patients with difficulty swallowingMay require more frequent administrationRectalFor patients with difficulty swallowing or problems with nausea and vomitingPatient needs to be able to reposition easily

ROUTES OF ADMINISTRATIONTransdermalDelivers 72 hours of pain medicationTopicalFor pain as a result of herpes, arthritis, or local invasive proceduresParenteralFor patients who cannot swallowEpidural or intrathecalUse if unable to achieve pain control by other methods

MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATIONIdentify when pain is most severeInitiate constipation treatment at time opioids are startedKeep patient warmEncourage music listeningVisit with spiritual advisor

MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATIONProvide comfort measuresBack rubPosition changeWarm milk

ALTERNATIVE PAIN MANAGEMENT APPROACHESAcupunctureMassage therapyReiki therapy: a combination of all other alternative therapeutic methodsChiropractors: is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spineHerbal medications

ADVERSE EFFECTS OF ANALGESIC MEDICATIONSConstipationRespiratory depressionNausea and vomitingMyoclonus: is brief, involuntary twitching of a muscle or a group of musclesPruritis

LEARNING OUTCOME 6Identify the signs of approaching death.

BODY CHANGES INDICATING IMPENDING DEATHCirculationMottling of lower extremitiesMottling is sometimes used to describe uneven discolored patches on the skin of humans as a result of cutaneous ischemia (lowered blood flow to the surfaces of the skin).Pulmonary Death rattle: s a medical term that describes the sound produced by someone who is near death when saliva accumulates in the throatCheyne-Stokes respirations: is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea

BODY CHANGES INDICATING IMPENDING DEATHSkinClammyDusky, gray colorationEyesDiscoloredDeeper setBruised appearance

DISCUSS THE DEATH PROCESS AND REASSURE THOSE PRESENTSupport family decisions to be present or to leaveReinforce that the dying process is as individualized as process of living

LEARNING OUTCOME 7Describe appropriate nursing interventions when caring for the dying.

CORE PRINCIPLES FOR END-OF-LIFE CARERespect the dignity of patients, families, and caregiversDisplay sensitivity and respect for patient and family wishesUse appropriate interventions to accomplish patient goalsAlleviate pain and symptomsAssess, manage, and refer psychological, social, and spiritual problems

CORE PRINCIPLES FOR END-OF-LIFE CAREOffer continuity and collaboration with othersProvide access to palliative care and hospice servicesRespect the rights of patients and families to refuse treatmentsPromote and support evidence-based clinical practice research

MUCOSAL AND CONJUNCTIVAL CAREProvide oral hygiene several times a dayIce chips to relieve the feeling of dry mouth can be used as long as the swallowing reflex is presentSoothing ointments or petroleum jelly may be used on the lipsLack of dentures makes speech and swallowing difficult

MUCOSAL AND CONJUNCTIVAL CAREDisease processes contribute to halitosis and thrushArtificial tears: are lubricant eye drops used to treat the dryness and irritation associated with deficient tear production Ophthalmic saline solutionsOpened eyes become easily irritated

Halitosis: is a term used to describe noticeably unpleasant odors exhaled in breathing

ANOREXIA AND DEHYDRATION Patients may choose to stop eating and drinkingAnorexia may result in ketosis, leading to a peaceful state of mind and decreased painInitiation of parenteral or enteral nutrition neither improves symptom control nor lengthens life

SKIN CAREMonitor skin changesEdemaBruisingDrynessVenous poolingAvoid shearing forcesReposition frequentlyGentle massage or lotion application may be provided by the family

INCONTINENCE CAREBowel and bladder incontinence frequently occurs at the end of lifeProvide protective padsApply barrier creamEncourage change of positionDiscourage the use of indwelling catheters

TERMINAL DELIRIUMCan be distressing to family or caregiversPresents as confusion, restlessness, and/or agitation, with or without day-night reversalVisual, auditory, and olfactory hallucinations may occur during this timeIs often irreversible and may vary from patient to patient

TERMINAL DELIRIUMManagement techniques include identifying underlying cause, reducing stimuli and anxiety, and discontinuing all nonessential medications

NEUROLOGIC CHANGESDistressing for the familyRemind them that the patient may still be able to hearEncourage the family to let goGive the patient permission to die

TYPE AND LEVEL OF CARE AT THE END OF LIFEComfort measure only (CMO)Advance directivesUse of feeding tubesEuthanasia is illegal

Euthanasia refers to the practice of ending a life in a manner which relieves pain and suffering

LEARNING OUTCOME 8Describe postmortem care.

PRONOUNCEMENT OF DEATH Absence of carotid pulsesPupils are fixed and dilatedAbsent heart soundsAbsent breath sounds

POSTMORTEM CARE Needs to be done promptly, quietly, efficiently, and with dignityStraighten limbs before death, if possiblePlace head on pillowAfter pronouncementGloveRemove tubesReplace soiled dressingsPad anal area

POSTMORTEM CARE After pronouncementGently wash body to remove discharge, if appropriatePlace body on back with head and shoulders elevatedGrasp eyelashes and gently pull lids downInsert denturesPlace clean gown on body and cover with clean sheet

FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTIONNote time of death and chartNotify attending physicianChart any special directionsNotify family membersAllow time with loved oneGather eyeglasses and other belongingsPrepare necessary paperwork for body removal

FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTIONCall funeral home (or other appropriate personnel) for body transportNote on chartWhat personal artifacts were released with the bodyWhat belonging were releasedWho received the belongingsTag or provide body identification as per policy

LEARNING OUTCOME 9Discuss family support during the grief and bereavement period.

ALLEVIATE PATIENT AND FAMILY FEARS AND ANXIETIESPrior to deathMaintain hope for the patient and familyAfter deathRelief statementsRationalizationsEducate about mourning and bereavement

EXPRESSIONS OF GRIEFFirst phase: numb shock: the feeling of distress and disbelief that you have when something bad happens accidentally; "his mother's death left him in a daze"; "he was numb with shock"Second phase: emotional turmoil or depressionThird phase: reorganization or resolution

CARING FOR THE CAREGIVERWhat have I done to meet my own needs today?Have I laughed today?Did I eat properly, rest enough, exercise, and play today?How have I felt today?Do I have something to look forward to?

************************************************************************************