Chapter 38 End-of-Life Care

Carolyne Richardson-Phillips, MS, RNPNU 145

Pages 841-853

Learning OutcomesBy the end of this session, the PN student will be able to:1.Define terminal illness2.List the five stages of dying and give an example of each3.Describe two methods by which nurses can promote acceptance of death in dying clients4.Discuss & contrast the available settings that a dying client may choose for care5.Discuss the philosophy of hospice care6.Discuss the client’s basic physical needs that are common in terminal care7.Name at least five signs of multiple organ failure8.Explain the process of discussing organ donation & why it is important as soon as possible after a client’s death9.Describe the process of confirming death10.Discuss what is performed with postmortem care11.Discuss the components of grieving and describe a sign that may indicate a person is resolving his/her grief 12.Discuss general gerontologic considerations with death and dying13.Discuss different religious cultural aspects in death & dying of a client14.Develop a nursing care plan using NANDA approved nursing diagnosis, expected outcomes, interventions & methods of outcome evaluation for a client diagnosed with hopelessness

Terminal Illness• Condition from which recovery is beyond reasonable expectation• Dr. Elisabeth Kubler-Ross-authority on dying • Stages of Death & Dying:• Denial: psychological defense mechanism; person refuses to

believe certain information• Anger: emotional response to feeling victimized-person displaces

anger onto someone else or with complaints • Bargaining: psychological mechanism for delaying the

inevitable- a process of negotiation, usually with God or some higher power

• Depression: (sad mood) indicates the realization that death will come

• Acceptance: attitude of complacency

Death & Dying (cont’d) • Not an easy task-Facing death with a client, child, and family • Time where patience is stretched, rules fall apart• It is tiring, discouraging, sad• Requires a profound look at acceptance for the nurse caring for

someone who is dying• Self-exploration of one’s self: most important preparation for

dealing with the dying • Defense Mechanism Used: Coping

Promoting Acceptance• Emotional care: • Helping to choose how & where to receive terminal care• Comfort in preparing an advance directive• Educate about available settings• Dying Person’s Bill of Rights: nurse cares for dying clients with

respect, no matter what their emotional, physical or cognitive state; Box 38-1, pg. 844

• Nurses• Help clients pass thru each stage• Provide Emotional support • Supporting choices with terminal care• Facilitate directives to maintain the client’s personal dignity and

focus of control• Listen to feelings & allow client to verbally work through

emotions• Become nonjudgmental sounding board• Acknowledge client as unique & worthwhile

Home Care

Residential Care

Hospice Care

Acute Hospital Care

Arrangements For Care• Home care: Remain at home- travel to hospital or clinic for brief

treatments, tests, evaluations• Nurses help to secure home equipment, VNA

• Respite care Support: Relief for caregiver by someone else• Hospice care: Involves helping clients live their final days in

comfort, (relief from distressing symptoms-easing pain), dignity, and in a caring environment• Multidisciplinary team & volunteer support -Provides support for

family members significant others-during care & after client’s death

• Eligibility: 6 months or less to live; certified by a physician & can be re-certified if continue to meet Hospice and Medicare requirements

Arrangements For Care (cont’d)

• Hospice care: Termination of care• Two ways• If withdraw to receive treatment not covered in hospice plan• No longer meets Medicare criteria

• Residential care: Form of intermediate care.• Nursing homes or long-term care facilities - usual settings for

subacute care• Acute care: Sophisticated technology and labor intensive

treatment- when condition is unstable; most expensive care

Nurses Providing Terminal Care• Hydration: adequate fluid volume• Nourishment: little interest in eating -may choose a tube feeding or total

parenteral nutrition• Elimination: incontinent of urine/stool or may have retention of urine and

constipation• Skin care: very important-potential for skin breakdown R/T incontinence• Hygiene: keep dying clients clean, well groomed, free of unpleasant

odors-frequent mouth care• Positioning: lateral position helps prevent choking or aspiration-change &

reposition every 2 hours or more if possible• Comfort- goal keep free from pain

• Try to prevent dull consciousness, inhibit communication, or suppress respirations

• Given non-narcotics initially –then a combination of non-narcotics & narcotics; *may change route from oral to parenteral or transdermal

• Analgesia –more effective when meds given on a routine schedule • Ex: Schedule every 4 hours or in a continuous release form through a

transdermal patch rather than when necessary (PRN)

Nurses Providing Terminal Care (cont’d)• Fear of taking Medications

• Addiction should not interfere with efforts to relieve pain• Develop tolerance to pain-relieving property of analgesic drugs• Some who are tolerant to opioids (narcotic meds)-develop

resistance to respiratory depression• If client is alert & does not become sedated from med- respiratory

depression is minimized • Constipation another common consequence of narcotic analgesia

• Other medications given: Anti-anxiety, tranquilizers, anti-depressants• Family involvement: care by family tends to maintain bonds and help

survivors cope with future grief• Welcome the opportunity to assist

• Dying Person: • Waiting for permission phenomenon• Some clients forestall dying when thy feel their loved ones not

ready to accept their death-once they do-then die shortly after

Approaching Death• Dealing with death-two major fears the dying person has:• Fear of pain• Fear of being alone

• Pain-accepted as being “whatever the experiencing person says it is and existing whenever he says it does”

• Need reassurance- comfort needs will be met• Two or more organ systems gradually cease to function• Oxygen begins to fall below levels required to sustain life, cells,

followed by tissues and organs ----begin to deteriorate• Heart• Skin • Liver • Lungs• Kidneys• Brain

Approaching Death: Family Notification• NOTIFY physician first• Then Nurse informs family that death is approaching• If death has occurred already--- physician is responsible for

notifying family• Nurse: meeting family/relatives• Nurse or other support person- meets family and informs them• Private room if possible or client’s bedside

• Be aware that people show their grief in different ways

Cultural Considerations: Religious• Catholic: Prayers done-Priest

• Burial, cremation & organ donation permitted• Life support withdrawal- controversial

• Protestantism: Prayers offered-Minister• Burial, cremation, autopsy permitted- organ donation okay except for

some Baptists – Pentecostals• Judaism: burial within 24 hours; 7 day mourning period (Shiva)• Jehovah’s Witnesses: believe that the soul dies with body; will be

resurrected at the end-time & will be born again as spiritual sons of God• Islamic: Men wash the body of a man after death; women wash -body of a

woman after death• Buddhists: believe that after death-body should not be disturbed by

movement, talking, crying• Hindus: Pour holy water into the mouth of dying person; oldest son

arranges for funeral & cremation within 24 hours of death; embalming is forbidden

• Native Americans: believe that spirit lives on after death; ancestor worship is practiced

Discussing Organ Donation• Anyone may be an organ donor• Parent or legal guardian must sign a donor card if donor is under

18 years of age• If donation criteria met, possibility of harvesting organs is

discussed with next of kin• Organ procurement officer discusses harvesting of organs• To protect health care facility from legal consequences,

permission is obtained in writing• Organs need to be harvested within a few hours for them to be

viable for another person

Confirming Death• Breathing - circulation have ceased• Legally: physician-responsible for pronouncing a client dead• In some states-nurses may do pronouncing

• Brain death -there is irreversible loss of function of the whole brain, including the brain stem. (Uniform Definition of Death Act in 1980) • Incontestable criterion – person dead or alive-Irreversible

cessation of circulatory and respiratory functions, or cessation of all brain functions

• Irreversible brain death- unreceptiveness, unresponsiveness to pain, no respirations, PaCO2 > or = to 60 mmHg after 100% of O2, absence of central & deep reflexes, flat ECG

Death• Death certificate -Legal document attesting that the person named

on the form has been found dead and also contains the presumptive cause of death.• Mortician-(prepares body for burial or cremation) files

certificate• Autopsy- examination of organs and tissues of a human body after

death• Useful for determining cause of death• Physician’s responsibility to obtain permission

• A coroner- person legally designated to investigate deaths that may not be the result of natural causes• Has the authority to order an autopsy• Does not need permission from next of kin

Postmortem Care• Care of body after death• Involves cleaning –preparing body to enhance appearance during

family viewing • May need to replace hospital gown, clothes, clean client of

incontinence• Facility may have a postmortem kit

Grieving• Grieving- Process of feeling acute sorrow over a loss• Painful but Helps survivors to resolve the loss

• Anticipatory grieving –before loss occurs experienced by family, friends & client

• Grief work-activities involving grieving (burial preparation etc.)• Grief response –universal –psychological & physical phenomena• Psychological reactions – Stages of Grief• Shock and disbelief• Developing awareness (feeling sick, sad, empty, angry)• Restitution period (recognition of loss)• Idealization (exaggeration of the good qualities of deceased

• Pathologic grief-Dysfunctional: may keep possessions of a deceased loved one exactly as they were at the time of death for a prolonged period of time---may attempt to contact the deceased with séances

Grieving (cont’d)• Paranormal experience-Outside scientific explanation• Seeing, hearing, feeling continued presence of deceased

• Pathologic or Dysfunctional Grief • Cannot accept someone’s death• Manifest bizarre or morbid behaviors

• Resolution of Grief• No standard length of time for “normal” grieving

• Signs of resolving grief: • Abe to talk about the deceased without becoming too emotional• Describing the deceased good and bad qualities

• Important to accept and support all in whatever stage they are in –try not to direct progress• Nurses: need to be available for comfort

Nursing Interventions with Grieving Clients• Use skills that are most effective and appropriate for client & family• Attentive listening• Silence • Open and closed questioning• Paraphrasing• Clarifying and reflecting feelings• Summarizing• Use therapeutic communication relevant to client’s stage of grief

Nursing Process• Assessment• Diagnoses (Review page 851)• Plan• Interventions• Supportive care—Be there for client-family• Assist with ADLs• Turn & reposition at least q 2 hours• Monitor VS, skin, I & O• Assess cognitive status, depression, anxiety• Administer pain meds-monitor effectiveness & side effects• Provide nutrition & fluids• Allow client/family to express fears• Provide education & information

Gerontological & Others for Considerations

• Allow dying client to continue to have interpersonal relationships• Some develop illness & die within 6 months of the death of a spouse• Encourage the individual who has experienced death to discuss their

feelings• Elderly read obituaries to learn what is happening to their friends (a form

of effective coping mechanism)• Death--individualized experience influenced by prior experiences, cultural

practices & personal development• Encourage Hospice if meet criteria• Include client in all aspects of care-helps to maintain self-esteem & dignity• Many older adults & others prepare advanced directives concerning health

care and identify a durable power of attorney• Health care-evaluate use of antidepressants & other therapies for older

adults who have depression• Older adults have the highest rate of suicide • Important for health care personnel to assess suicide risk & to implement

appropriate precautions

Legal Definitions• End of Life Treatment Decisions• Advanced Health Care Directives

• Durable Power of Attorney-Health Care Proxy• Appoints an agent the person trusts to make decisions in

the event of incapacity• Living Will: provides specific instructions about kinds of

healthcare that should be provided or foregone• DO-NOT-Resuscitate (DNR): no attempts to be made to resuscitate

a client who stops breathing or whose heart stops beating• End of Life Treatment Decisions• DNI – Do Not Intubate: Not Inserting a tube in the trachea for

continue life support• Comfort Measures Only: Goal of treatment is a comfortable

dignified death with no life-sustaining measure• Do-Not-Hospitalize: used in nursing homes and residential

settings

References

• Timby, B. K. (2013) (10th ed.). Fundamental Nursing Skills and Concepts. Philadelphia: PA., Lippincott Williams & Wilkins

• Images retrieved from we site www.http:// googleimages.com in September 2015

• Taylor, C., Lillis, C., LeMone, P., Lynn, P., (2011) (7th ed.) Fundamentals of Nursing The Art and Science of Nursing Care

Lippincott Williams & Wilkins, Philadelphia: PA.