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END OF LIFE CARE

PRESENTED BY

DEEPA S MADHU,RN

ADH

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KEY OBJECTIVES

Key objectives to deliver these improvements in end -of -life Care have been identified as follows, To increase the awareness among nurses

regarding death and dying, the contents of end life care improves choices and should also act as a lever to improve service quality.

To ensure that all people are treated with dignity and respect at the end of their lives.

To ensure that all clinical symptoms and psychological distress amongst people approaching end of their lives are kept to an absolute minimum.

ADH

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KEY OBJECTIVES To ensure that all discussions around choices

for end of life care are identified, documented, evaluated, respected , and acted upon.

To ensure that healthy social care professionals at all levels receive the education and training that enables them to provide high quality care.

To ensure that cares and families who take care of pt. are supported both during pts. life and are offered bereavement support.

ADH

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GOALS OF END OF LIFE CARE

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END OF LIFE CARE GOALS

End-of-life care provided by the hospital includes a) providing appropriate treatment for any

symptoms according to the wishes of the patient and family;

b) sensitively addressing such issues as autopsy and organ donation;

c) respecting the patient’s values, religion, and cultural preferences;

d) involving the patient and family in all aspects of care; and

e) responding to the psychological, emotional, spiritual, and cultural concerns of the patient and family.

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GUIDING PRINCIPLES FOR COMPREHENSIVEEND-OF-LIFE NURSING CARE

1. Patient and family preference for treatment and care will be discussed and respected. Nurses will ask about patient and family goals and preferences, include patient and family in the decision process, provide assistance and resources to formulate advance care plans, and honor written health care directives.

2. Undesirable symptoms will be relieved. Nurses will believe reports of distress, do their best to relieve all undesirable

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. symptoms, anticipate and prevent undesirable symptoms when possible, and provide urgent treatment of severe symptoms.

3. Emotional, spiritual, and personal suffering will be addressed. Nurses will ask about emotional, spiritual, and personal suffering and offer the help of interdisciplinary or community resources.

4. Patients will be prepared for their death, and families will be prepared for the death of their loved one. Nurses will provide honest information on what is likely to happen and provide guidance in planning how to handle predictable events.

5. Grieving will be acknowledged. Nurses will provide a quiet and safe place for families to grieve, accommodate family wishes to be with the deceased loved one, and acknowledge that grieving is a long-term process.

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CORE NURSING RESPONSIBILITIES:

1.Skilled Clinician: A skilled clinician who understands end-

of-life symptom management and can provide the best comfort care. 2. Advocate :

An advocate who can ensure that all members of the health care team are available. 3. Guide

A guide who can walk with patients and their families through the dying experience.

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NURSES’ UNIQUE QUALIFICATIONS TO PROVIDE END-OF-LIFE CARE

Holistic view Comprehensive Effective Compassionate Cost effective

Must be confident in their clinical skills Are aware of the ethical, spiritual, and legal

issues they may confront while providing end-of-life care.

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NURSES’ INVOLVEMENT IN END-OF-LIFE CARE

Spend the most time with patients and their family members at the end-of- life than any other member of the healthcare team

Provide education, support, and guidance throughout the dying process

Advocate for improved quality of life for the person with serious illness

Attend to physical, emotional, psychosocial, and spiritual needs of the patient

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END OF LIFE CARE TEAM

Physician:The role of the physician in the care of

dying patients cannot be overstressed. Not only do physicians direct clinical care, but they have the expertise in disease pathology. Most importantly, patients and families to the physician for guidance during these difficult times.

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. Social Worker:Social workers are skilled in

communication and group facilitation and are knowledgeable about community resources. They can be critical in helping patients with long-term planning, in helping to facilitate family discussions, and in counseling patients and families. Chaplain or Spiritual Care Worker:

Treatment decisions are sometimes based on religious beliefs. This is often a time for self reflection and contemplation. Patients may need help articulating and thinking through some of the basic questions of life

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. Pharmacist: A wide array of pharmacological

treatments exist for pain and symptom control. The pharmacist has expertise in available medications, drug interactions, optimal delivery methods, and indications for use.

Dietician: Patients and families often struggle with nutrition and hydration issues. Dieticians can counsel on types of foods to prepare, supplements, and feeding methods.

Other Team Members: Other team members may include physical, occupational, and speech therapists, as well as psychologists, volunteers, and clinical nurse specialists.

The best nursing care at the end of life is provided in a team atmosphere.

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WHEN TO START END OF LIFE CARE.

Illnesses or conditions that could be considered potentially life-threatening or life-limiting.

❖ A change in functional status with dependencies in two or more activities of daily living.

❖ Repeat hospitalizations and emergency room visits.

❖ Anyone for whom you would answer “yes” to the question:

“Would you be surprised if this person were alive in one to two years?”

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WHAT DO PATIENTS AND FAMILIES WANT FORCARE AT THE END OF LIFE?

Several themes emerge when looking at patient and family preferences:

❖ Pain and symptom management: Patients want assurances that physical discomfort will be relieved.

❖ Family involvement: Patients want their families involved in decision making and in care.

❖ Preparation for death: Patients want to know what will happen as they near death.

❖ Completion: Patients want the opportunity to say good-bye and leave some kind of legacy.

❖ Affirmation of the whole person: Patients want to be recognized as still having something to contribute. They want to be a person first than a person who is dying.

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BARRIERS TO QUALITY END-OF-LIFE CARE

Failure of healthcare providers to acknowledge the limits of medical technology

Lack of communication among decision makers Disagreement regarding the goals of care Failure to implement a timely advance care plan Lack of training about effective means of

controlling pain and symptoms Unwillingness to be honest about a poor

prognosis Discomfort telling bad news Lack of understanding about the valuable

contributions to be made by referral and collaboration with comprehensive hospice or palliative care services

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TYPE AND LEVEL OF CARE AT THE END OF LIFE

Comfort measure only (CMO) Advance directives Use of feeding tubes Euthanasia is illegal

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

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.

postmortem care.

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PRONOUNCEMENT OF DEATH

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

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POSTMORTEM CARE

Needs to be done promptly, quietly, efficiently, and with dignity

Straighten limbs before death, if possible

Place head on pillow After pronouncement

GloveRemove tubesReplace soiled dressingsPad anal area

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.

After pronouncementGently wash body to remove

discharge, if appropriatePlace body on back with head and

shoulders elevatedGrasp eyelashes and gently pull lids

downPlace clean gown on body and cover

with clean sheet

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FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION

Note time of death and chart Notify attending physician Chart any special directions Notify family members Gather eyeglasses and other

belongings Prepare necessary paperwork for body

removal

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.

Call funeral home (or other appropriate personnel) for body transport

Note on chartWhat personal artifacts were

released with the bodyWhat belonging were releasedWho received the belongings

Tag or provide body identification as per policy

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ALLEVIATE PATIENT AND FAMILY FEARS AND ANXIETIES

Prior to deathMaintain hope for the patient and

family After death

Relief statementsRationalizationsEducate about mourning and

bereavement

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.

Death is not a medical event. It is a personal and family story of profound choices, of momentous words, and telling silences.

—Steve Miles, M.D.

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REFERENCES 1. K nauss W et al. SUPPORT: A controlled trial to improve

care for seriously ill hospitalized patients. JAMA 1995;274(20):1591-1598.

2.Doyle D, Hanks GWC, et al. Oxford Textbook of Palliative Medicine, 2nd ed. New York University Press, 1998

3.Okun S. A framework for collaborative consumer centered care. Innovations in End-of-Life Care. 2003;5(3). www.edc.org/lastacts.

4. American Nurses Association: Position statement on pain management and control of distressing symptoms in dying patients. Effective date, December 5, 2003.

5. Hospice and Palliative Nurses Association. Position Statement. Palliative Sedation at End of Life. www.hpna.org.

JCA Fifth edition,1, APRIL,2014