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."