care at the end of life 11 lecture note powerpoint presentation
TRANSCRIPT
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 CARE
Holistic view Comprehensive Effective Compassionate Cost effective
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
NURSES’ INVOLVEMENT IN END-OF-LIFE CARE
Advocate for improved quality of life for the person with serious illness
Attend 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 control Relieve psychosocial distress Coordinate care across settings with high-
quality communication between healthcare providers
Prepare 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 values
Provide support and education during the decision-making process, including the benefits and burdens of treatment
NURSES WHO CARE FOR THE DYING
Are well educated Have appropriate supports in the clinical
setting Develop close collaborative partnerships with
hospice and palliative care service providers
NURSES WHO CARE FOR THE DYING
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
NURSES NEED TO BE AWARE OF PERSONAL FEELINGS ABOUT DEATH
Improves ability to meet holistic needs of the patient and family
Clarifies one’s own beliefs and values
MEANING OF HOPE SHIFTS
From striving for cure to achieving relief from pain and suffering
No “right” or “correct” way to die: It's everybody's right to live independent and die with dignity
LEARNING OUTCOME 2Recognize changes in demographics, economics,
and service delivery that require improved nursing interventions at the end of life.
CHANGING STATISTICS
Primary cause of death 10 leading causes of death account for 80% of all
deaths in the United States Heart disease Malignant neoplasms Cerebrovascular disease Chronic lower respiratory disease Accidents Diabetes mellitus
CHANGING STATISTICS
Primary cause of death 10 leading causes of death account for 80% of all
deaths in the United States Influenza Pneumonia Alzheimer’s disease Renal disease Septicemia
CHANGING STATISTICS
Demographic trends Today, more deaths occur at home The average life span is 77.9 years compared to
only 50 in 1900 the average life expectancy in Jordan is 73.1
Social trends Today, caregivers are more likely to be
professionals rather than family members
EXACT CAUSE OF DEATH DIFFICULT TO DETERMINE IN THE OLDER PERSON
Multiple comorbid conditions (is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder)
Acute injury added Unexpected pathology
MOST AMERICANS PREFER TO DIE AT HOME
50% die in hospitals 25% die in long-term-care facilities 20% die at home or the home of a loved one 5% die in other settings
SURVEY RESULTS OF HEALTHCARE SYSTEM CARE OF DYING PEOPLE
Excellent: 3% Very good: 8% Good: 31% Fair: 33% Poor: 25%
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
BARRIERS TO QUALITY END-OF-LIFE CARE 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
NURSE’S ROLE IN PAIN TREATMENT
Initial and ongoing assessment of levels of pain
Administration of pain medication Evaluation of effectiveness of pain
medication
HOW NURSES CAN ALLEVIATE THE DISTRESS ASSOCIATED WITH UNTREATED PAIN Ongoing assessment of levels of pain Administration of pain medication Evaluation of the effectiveness of the pain
management plan
NEGATIVE OUTCOMES OF PAIN
Potential to hasten death Associated with needless suffering at the end
of life People in pain do not eat or drink well Inability to engage in meaningful
conversations with others Isolation in order to save energy and cope
with the pain sensation
REASONS FOR UNDERTREATMENT OF PAIN
Patient’s inability to communicate due to Delirium Dementia Aphasia (speechless) Motor weakness Language barriers
CAUSES OF INADEQUATE CARE AT END OF LIFE
Disparity in access to treatment Insensitivity to cultural differences
Attitudes about death Attitudes about end-of-life care African-Americans prefer aggressive life-
sustaining treatments Mexican-Americans, Korean-Americans, and
Euro-Americans prefer less aggressive treatment
CAUSES OF INADEQUATE CARE AT END OF LIFE
Mistrust of the healthcare system Pain is subjective and self-report is
considered accurate
PAIN CHARACTERISTICS IN COGNITIVELY-IMPAIRED OLDER PERSONS
Moaning or groaning at rest or with movement
Failure to eat, drink, or respond to presence of others
Grimacing or strained facial expressions
PAIN MANNERISMS IN COGNITIVELY-IMPAIRED OLDER PERSONS
Guarding or not moving body parts Resisting care or noncooperation with
therapeutic interventions Rapid heartbeat, diaphoresis, change in vital
signs
PATIENT QUESTIONS REGARDING USUAL REACTIONS TO PAIN
Do 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 PAIN
Is 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 PAIN
Does 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 PROCESS
Chronic Associated with long-term illness Always present Varies in intensity Tolerance to pain develops Associated factors
Depression Poor self-care Decreased quality of life
PAIN DURING THE DYING PROCESS
Neuropathic pain Nerves are damaged Burning, electrical, or tingling sensations Deep and severe
Nociceptive pain Tissue inflammation or damaged tissues Cardiac ischemia
PAIN DURING THE DYING PROCESS
Unrelieved pain during the dying process Hastens death
Increases physiological stress Diminishes immuno-competency Decreases mobility Increases myocardial oxygen requirements
Causes psychological distress to the patient and family Suffering Spiritual distress
LEARNING OUTCOME 4Identify the diverse settings for end-of-life care and
the role of the nurse in each setting.
EMPHASIS OF SUPPORTIVE CARE DURING THE DYING AND BEREAVEMENT PROCESS Quality of life Living a full life up until moment of death
HOSPICE CARE
Focuses on the whole person Mind Body Spirit
Support and care Patients Family and caregivers
Continues after death of a loved one
HOSPICE CARE
Multidisciplinary team of professional caregivers Nurse
Manages pain and controls symptoms Assesses patient and family abilities to cope Identifies available resources for patient care Recognizes patient wishes Assures that support systems are in place
HOSPICE CARE Multidisciplinary team of professional
caregivers Physician Pharmacist Social workers Others
Last phase (6 months) of incurable disease Live as fully and comfortably as possible
HOSPICE SETTINGS
Freestanding Hospital Home health agencies with home care
hospice Home Nursing home or other long-term-care
settings
ADMINISTER PAIN MEDICATION ROUTINELY
Prevent breakthrough pain and suffering Long-acting drugs provide consistent relief
Chronic pain Short-acting or immediate release agents for prn
use Acute pain
PAIN CONTROL AT THE END OF LIFE
Opioids Codeine Morphine is gold standard Hydromorphine Fentanyl Methadone Oxycodone
NOTE: DO NOT USE MEPERIDINE OR PROPOXYPHENE WITH OLDER PERSONS
Adjuvant analgesics Enhance effectiveness of other drug classes
Muscle relaxants Corticosteroids Anticonvulsants Antidepressants Topical Useful for treatment with lower doses and less side
effects
ROUTES OF ADMINISTRATION Oral
For patient who can swallow Requires higher dosage
Oral mucosa or sublingual For patients with difficulty swallowing May require more frequent administration
Rectal For patients with difficulty swallowing or
problems with nausea and vomiting Patient needs to be able to reposition easily
ROUTES OF ADMINISTRATION Transdermal
Delivers 72 hours of pain medication Topical
For pain as a result of herpes, arthritis, or local invasive procedures
Parenteral For patients who cannot swallow
Epidural or intrathecal Use if unable to achieve pain control by other methods
MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATION Identify when pain is most severe Initiate constipation treatment at time
opioids are started Keep patient warm Encourage music listening Visit with spiritual advisor
MULTIPLE APPROACHES TO MANAGE ADVERSE REACTIONS TO PAIN MEDICATION Provide comfort measures
Back rub Position change Warm milk
ALTERNATIVE PAIN MANAGEMENT APPROACHES
Acupuncture Massage therapy Reiki therapy: a combination of all other
alternative therapeutic methods Chiropractors: is a health care discipline and
profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine
Herbal medications
ADVERSE EFFECTS OF ANALGESIC MEDICATIONS
Constipation Respiratory depression Nausea and vomiting Myoclonus: is brief, involuntary twitching of a
muscle or a group of muscles Pruritis
BODY CHANGES INDICATING IMPENDING DEATH Circulation
Mottling of lower extremities Mottling 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 throat
Cheyne-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 DEATH
Skin Clammy Dusky, gray coloration
Eyes Discolored Deeper set Bruised appearance
DISCUSS THE DEATH PROCESS AND REASSURE THOSE PRESENT
Support family decisions to be present or to leave
Reinforce that the dying process is as individualized as process of living
CORE PRINCIPLES FOR END-OF-LIFE CARE Respect the dignity of patients, families, and
caregivers Display sensitivity and respect for patient
and family wishes Use appropriate interventions to accomplish
patient goals Alleviate pain and symptoms Assess, manage, and refer psychological,
social, and spiritual problems
CORE PRINCIPLES FOR END-OF-LIFE CARE
Offer continuity and collaboration with others Provide access to palliative care and hospice
services Respect the rights of patients and families to
refuse treatments Promote and support evidence-based clinical
practice research
MUCOSAL AND CONJUNCTIVAL CARE
Provide oral hygiene several times a day Ice chips to relieve the feeling of dry mouth
can be used as long as the swallowing reflex is present
Soothing ointments or petroleum jelly may be used on the lips
Lack of dentures makes speech and swallowing difficult
MUCOSAL AND CONJUNCTIVAL CARE
Disease processes contribute to halitosis and thrush
Artificial tears: are lubricant eye drops used to treat the dryness and irritation associated with deficient tear production
Ophthalmic saline solutions Opened 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 drinking
Anorexia may result in ketosis, leading to a peaceful state of mind and decreased pain
Initiation of parenteral or enteral nutrition neither improves symptom control nor lengthens life
SKIN CARE Monitor skin changes
Edema Bruising Dryness Venous pooling
Avoid shearing forces Reposition frequently Gentle massage or lotion application may be
provided by the family
INCONTINENCE CARE
Bowel and bladder incontinence frequently occurs at the end of life
Provide protective pads Apply barrier cream Encourage change of position Discourage the use of indwelling catheters
TERMINAL DELIRIUM
Can be distressing to family or caregivers Presents as “confusion, restlessness, and/or
agitation, with or without day-night reversal” Visual, auditory, and olfactory hallucinations
may occur during this time Is often irreversible and may vary from
patient to patient
TERMINAL DELIRIUM
Management techniques include identifying underlying cause, reducing stimuli and anxiety, and discontinuing all nonessential medications
NEUROLOGIC CHANGES
Distressing for the family Remind them that the patient may still be able to
hear Encourage the family to “let go” Give the patient permission to die
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
PRONOUNCEMENT OF DEATH
Absence of carotid pulses Pupils are fixed and dilated Absent heart sounds Absent breath sounds
POSTMORTEM CARE Needs to be done promptly, quietly,
efficiently, and with dignity Straighten limbs before death, if possible Place head on pillow After pronouncement
Glove Remove tubes Replace soiled dressings Pad anal area
POSTMORTEM CARE
After pronouncement Gently wash body to remove discharge, if
appropriate Place body on back with head and shoulders
elevated Grasp eyelashes and gently pull lids down Insert dentures Place clean gown on body and cover with clean
sheet
FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION
Note time of death and chart Notify attending physician
Chart any special directions Notify family members
Allow time with loved one Gather eyeglasses and other belongings Prepare necessary paperwork for body
removal
FOLLOW POLICIES AND PROCEDURES OF THE INSTITUTION
Call funeral home (or other appropriate personnel) for body transport
Note on chart What personal artifacts were released with the
body What belonging were released Who received the belongings
Tag or provide body identification as per policy
ALLEVIATE PATIENT AND FAMILY FEARS AND ANXIETIES
Prior to death Maintain hope for the patient and family
After death Relief statements Rationalizations Educate about mourning and bereavement
EXPRESSIONS OF GRIEF
First 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 depression
Third phase: reorganization or resolution