e l n e c geriatric curriculum end-of-life nursing education consortium
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E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium. SESSION 10: Preparation for and Care at the Time of Death Fairfield University Quinnipiac University School of Nursing ELDER Project. Objectives: Upon completion of this session, the participant will be able to …. - PowerPoint PPT PresentationTRANSCRIPT
E L N E C Geriatric Curriculum
E L N E C Geriatric CurriculumEnd-of-Life Nursing Education Consortium
SESSION 10: Preparation for and
Care at the Time of Death
Fairfield UniversityQuinnipiac University
School of Nursing ELDER Project
E L N E C Geriatric Curriculum
Objectives: Upon completion of this session, the participant will be able to …
1. Describe typical changes and events at the time of dying.
2. Examine the role of the palliative care team at the time of death.
3. Identify self-care strategies for the health care team that promote well-being and health.
E L N E C Geriatric Curriculum
Dying is an Individualized Personal Experience
E L N E C Geriatric Curriculum
Palliative Care Team Roles at EOL
• Support older adults/residents, families, and staff prior to and following the death
• Coordinate care• Advocate for patients and families• Being present, bearing witness• Provide pain and symptom
management• Role model self-care behaviors
E L N E C Geriatric Curriculum
ACTIVITY: Roles of Palliative Care Team at EOL
Advocate Pain & Symptom Management
Being Present Modeling Self-Care Behaviors
E L N E C Geriatric Curriculum
An 85-year-old client with end-stage heart disease arrives unconscious at the emergency department after sustaining her third myocardial infarction. The doctor has told the daughter that without CPR her mother could die today. The healthcare worker finds the daughter crying by the client's bedside. What should the healthcare worker do?•
1. ask the daughter if she would like to reconsider treatment2. talk to the doctor about moving the client to a more
private place3. stay with the daughter, using silence to give comfort4. assure the daughter that she doesn't need to stay with her
mother
E L N E C Geriatric Curriculum
Offering Support During the Death Vigil• Common fears
–Being alone with resident
–Not knowing when death occurs
–Painful death
E L N E C Geriatric Curriculum
Nearing-Death Phenomena
• “The Rally”• Symbolic language• Visions• Inability to let go• Saying good-bye
E L N E C Geriatric Curriculum
Two Roads to Death
NORMAL
THE USUAL ROAD
THE DIFFICULT ROAD
Sleepy
Semicomatose
Lethargic
Comatose
Seizures
Myoclonic Jerks
Mumbling Delirium
HallucinationsTremulous
ConfusedRestless
DEAD
Obtunded
Ferris et al., 2003
E L N E C Geriatric Curriculum
Frequency of Symptoms Last 48 Hours
Fürst & Doyle, 2004; Lunney et al., 2002
56%51%
42%32%
22%14%
12%
0%10%20%30%40%50%60%70%80%
E L N E C Geriatric Curriculum
Pain when Death is Imminent
• Common among NH residents at EOL
• Assume pain is present after ruling out other possible causes of distress!
E L N E C Geriatric Curriculum
Opioids at EOL• Consider routes
– Oral– Rectal– Subcutaneous
• There is no evidence that opioids hasten death!
E L N E C Geriatric Curriculum
Noisy Respirations• Noise produced by turbulent
movements of secretions in upper airways; this symptom occurs in the imminently dying
• Also called “death rattle”
• Occurs in 23–92% ofdying patients
E L N E C Geriatric Curriculum
Anticholinergics• Hyoscine hydrobromide
(Scopolamine)• Glycopyrrolate (Robinul)• Hyoscyamine (Levsin)• Atropine Sulfate
E L N E C Geriatric Curriculum
Nondrug Strategies• Reposition patient or resident on his
side • Gently suction mouth
if the secretions areeasily reached
• Provide excellent oral care• Educate and reassure family
E L N E C Geriatric Curriculum
• Occurs in the last days or hours of life• May be exhibited by thrashing, muscle
twitching or jerks, fidgeting, frequent attempts to get out of bed, calling out, moaning, non-purposeful movement
• Focus on providing comfort rather than treating the cause
Ingham & Caraceni, 2002
Terminal Restlessness
E L N E C Geriatric Curriculum
Symptoms of Imminent Death• Decreased urine output• Cold and mottled extremities• Vital sign and breathing changes• Respiratory congestion• “Death rattle”• Delirium/confusion• Restlessness
Kehl, 2004; Matzo, 2009; Rousseau, 2002
E L N E C Geriatric Curriculum
Signs That Death Has Occurred
• Absence of heartbeat, respirations• Pupils fixed• Pale color• Body temperature drops• Muscles, sphincters relax
E L N E C Geriatric Curriculum
Grief is:
• 1. the emotional response to a loss2. the outward, social expression of a loss3. the depression felt after a loss4. the loss of a valued object or loved one
E L N E C Geriatric Curriculum
The best response to a client who is anticipating a loss is to: •
1. educate them about disease progression2. stress that prognosis is difficult to predict3. provide therapeutic presence and practice active
listening4. advise the daughter to focus more on the present
than the future
E L N E C Geriatric Curriculum
In speaking with clients and families about grief, the healthcare worker explains that grief:
1. is a process with predictable stages of work to be done2. begins when people expect a loss or death3. lasts a year or less, and then survivors should adapt to the
loss4. includes personal feelings that are understood by
everyone
E L N E C Geriatric Curriculum
Care Following Death• Bathing and dressing
the body• Positioning the body• Respect cultural
practices• Allow for closure
E L N E C Geriatric Curriculum
In caring for the body after death, it is most important to:
•
1. make sure the body is sent to the morgue within an hour after death
2. have family members participate in the bathing and dressing the deceased
3. notify all family and team members regarding the patient's death
4. provide a clean, peaceful impression of the deceased for the family
E L N E C Geriatric Curriculum
The wife of a client who recently died states: "Last night I thought I heard him say ‘Good night, Honey’ just like he always did. Do you think I am going crazy?" The most helpful response is:
1. "You might want some extra support accepting your husband's death. I'll have the doctor make a referral to a psychologist."
2. "Many people see or hear the one who has died. You must miss him saying 'good night'."
3. "Many people believe that ghosts or spirits visit their loved ones. Do you believe in ghosts or spirits?"
4. "That must be frightening for you. Do you have a friend or relative who can stay with you so that you are not alone?"
E L N E C Geriatric Curriculum
Care Following Death (cont.)
• Rigor mortis 2-4 hrs after death• Embalming• Removal of body
E L N E C Geriatric Curriculum
The hospice team is caring for the family of a man who died several days ago after a long illness. His wife is concerned that their 9 year old son has become withdrawn and is easily angered. Which action is most appropriate?
1. Refer the boy to a specialist for complicated (abnormal) grief reaction.
2. Suggest that the boy be excused from his usual activities.3. Give opportunities for the boy to express his feelings.4. Tell stories rather than facts about death to the boy.
E L N E C Geriatric Curriculum
Acknowledging Death• Inform staff• Inform roommate• Memory book• Recognition wall• Paying tribute
E L N E C Geriatric Curriculum
Lifestyle Management: Burnout Prevention for Staff•Healthy body•Healthy mind•Healthy spirit•Healthy social life
E L N E C Geriatric Curriculum
The healthcare team may experience feelings of anxiety and grief when caring for dying clients. To deal with these feelings it is important to:
• 1. get the assistance of team members when necessary2. transfer to another unit to avoid caring for dying patients3. keep an emotional distance from clients and families4. schedule counseling at weekly intervals to deal with loss
issues
E L N E C Geriatric Curriculum
Activity: Self-Care AssessmentTake a moment to consider the
frequency with which you do the following acts of self-care. Rate using the scale below:
4 = often3 = sometimes2 = rarely1 = are you kidding? It never even crosses my mind!
E L N E C Geriatric Curriculum
Conclusion
Family members will always remember the last days, hours, and minutes of their loved
one’s life. Nurses have a unique opportunity to be invited to spend these
precious moments with them and to make those moments memorable in a positive
way.
E L N E C Geriatric Curriculum
References City of Hope & the American Association of Colleges of
Nursing, 2007; Revised, 2010. The End-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training
Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in
collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator).
Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858