HOSPICE CAREHOSPICE CARE

Prepared byPrepared byNesreen faroukNesreen farouk police officerpolice officer

22ndnd Term Doctorate Degree Term Doctorate Degree

Under Supervision ofUnder Supervision ofDr. Namat Alla GOMADr. Namat Alla GOMA

lecturer of lecturer of Medical-Surgical NursingMedical-Surgical Nursing,,Faculty of NursingFaculty of Nursing

Ain Shams UniversityAin Shams University

20102010

Out LinesOut Lines

Introduction.Introduction.

Definitions.Definitions.

History of Hospice.History of Hospice.

Characteristics of Hospice.Characteristics of Hospice.

Goal of Hospice Care.Goal of Hospice Care.

Advantages of Hospice Care.Advantages of Hospice Care.

Disadvantages of Hospice Care.Disadvantages of Hospice Care.

Myths of Hospice Care.Myths of Hospice Care.

Hospice Care team.Hospice Care team.

Hospice care services.Hospice care services.

Ethical and Legal issues regarding hospice care.Ethical and Legal issues regarding hospice care.

Nursing Role for patient who dies at home.Nursing Role for patient who dies at home.

Application for nursing process in hospiceApplication for nursing process in hospice care for dyeing patient.care for dyeing patient.

IntroductionIntroduction

There is a common belief that a hospice is There is a common belief that a hospice is

where everyone goes to die. That is not true. where everyone goes to die. That is not true.

Hospice care is based on a philosophy of Hospice care is based on a philosophy of

emotional, spiritual, physical support, and emotional, spiritual, physical support, and

comfort for people in the final phase of life comfort for people in the final phase of life

twelve to fourteen days, after which many twelve to fourteen days, after which many

patients return homepatients return home. .

HospiceHospice

Hospice is a philosophy of care. Hospice is a philosophy of care.

The hospice philosophy or The hospice philosophy or

viewpoint accepts death as the viewpoint accepts death as the

final stage of lifefinal stage of life..

Hospice care is meant for the time when Hospice care is meant for the time when

cancer treatment can no longer help you, cancer treatment can no longer help you,

and you are expected to live 6 months or and you are expected to live 6 months or

less& when a life-limiting illness no longer less& when a life-limiting illness no longer

responds to cure-oriented treatmentsresponds to cure-oriented treatments

Hospice CareHospice Care

Hospice Care ProgramHospice Care Program

It is a Program that provides a It is a Program that provides a

centralized plan of palliative and centralized plan of palliative and

supportive services to dying persons supportive services to dying persons

and their families.and their families.

Hospice ConceptHospice Concept

It offers a comprehensive program of care It offers a comprehensive program of care

to patients and families facing a life to patients and families facing a life

threatening illness. Hospice is primarily a threatening illness. Hospice is primarily a

concept of care, not a specific place of concept of care, not a specific place of

care.care.

Hospice HistoryHospice History

In 1967In 1967 Dame Cicely Saunders, a British Dame Cicely Saunders, a British

physician, was the first to apply the term "hospice" to physician, was the first to apply the term "hospice" to

specialized care for the terminally ill. specialized care for the terminally ill.

Believed in holistic hospice care, combining Believed in holistic hospice care, combining

the talents of physicians, nurses, social workers the talents of physicians, nurses, social workers

to address every aspect of patient care.to address every aspect of patient care.

In 1981In 1981 The hospice concept to The hospice concept to

discuss the needs of terminally ill discuss the needs of terminally ill

patients and their families. It is patients and their families. It is

goal was to restore dignity, and goal was to restore dignity, and

add value to the last months of add value to the last months of

patients' lives.patients' lives.

In 1985 In 1985 The hospice continued to The hospice continued to

grow and meet the needs of more patients grow and meet the needs of more patients

from a larger area.from a larger area.

In 1997 In 1997 A strong team of dedicated A strong team of dedicated

professionals had been assembled and was professionals had been assembled and was

now servicing many places. The name was now servicing many places. The name was

changed to the now-familiar Hospice Care changed to the now-familiar Hospice Care

Team. Team.

Characteristics of HospiceCharacteristics of Hospice

It is a major unit of care for patient It is a major unit of care for patient and family.and family.

Its services are extended to the Its services are extended to the family during the time of family during the time of bereavement ( shock ).bereavement ( shock ).

Hospice care can be discontinued Hospice care can be discontinued with agreement of the patient, with agreement of the patient, family and attending physician.family and attending physician.

Goals of Hospice CareGoals of Hospice Care Enable patients to continue an alert, Enable patients to continue an alert,

pain- free life.pain- free life.

Manage any symptoms.Manage any symptoms.

Affirm life and does not hasten orAffirm life and does not hasten or

postpone death.postpone death.

Treats the person rather than the disease.Treats the person rather than the disease.

Focus on quality rather than length of life.Focus on quality rather than length of life.

Provide family-centered care.Provide family-centered care.

Involve the patient and the family inInvolve the patient and the family in

making decisions.making decisions.

Hospice care can be given in the Hospice care can be given in the patient's home, a hospital, nursing patient's home, a hospital, nursing home, or private hospice facility.home, or private hospice facility.

Care is provided for the patient and Care is provided for the patient and family 24 hours a day, 7 days a week.family 24 hours a day, 7 days a week.

Advantages of Hospice CareAdvantages of Hospice Care

Provide specialized palliative care.Provide specialized palliative care.

Provide expertise for difficult problems.Provide expertise for difficult problems.

Allows terminally ill children and theirAllows terminally ill children and their

families to remain together in the comfortfamilies to remain together in the comfort

and dignity of their home.and dignity of their home.

Rely on knowledge and skill of anRely on knowledge and skill of an

interdisciplinary team of professionals. interdisciplinary team of professionals.

Advantages (Cont.)Advantages (Cont.)

Treats the client, not the disease.Treats the client, not the disease.

Emphasizes the quality of life, not theEmphasizes the quality of life, not the

durationduration

Provide expert in managing pain andProvide expert in managing pain and

symptom.symptom.

Allow a terminally ill person to be as Allow a terminally ill person to be as

comfortable and pain-free as possible.comfortable and pain-free as possible.

Disadvantages of HospiceDisadvantages of Hospice Restrictions placed on the various Restrictions placed on the various

aspects of treatment.aspects of treatment.

Hospitalizations are discouraged once aHospitalizations are discouraged once a

patient is under hospice care.patient is under hospice care.

Participation in experimental treatments Participation in experimental treatments

or clinical trials isn’t allowed as they are or clinical trials isn’t allowed as they are considered life-prolonging. considered life-prolonging.

Some treatments or procedures that Some treatments or procedures that are considered life- prolonging, such as are considered life- prolonging, such as tube feeding may not be covered.tube feeding may not be covered.

Pressure on places may restrict Pressure on places may restrict length of stay.length of stay.

Need to secure funding.Need to secure funding.

Seven Myths of Hospice CareSeven Myths of Hospice Care

Myth #1:Myth #1: Hospice Care Means Giving Up Hope. Hospice Care Means Giving Up Hope.

Myth #2:Myth #2: Patients can only receive hospice Patients can only receive hospice

care for a limited amount of time.care for a limited amount of time.

Myth #3:Myth #3: Hospice Is Only for Cancer Patients. Hospice Is Only for Cancer Patients.

Myth #4:Myth #4: Hospice Is Only for Patients who Are Hospice Is Only for Patients who Are

Close to Death or Actively Dying.Close to Death or Actively Dying.

Myth #5:Myth #5: A patient needs Medicare or Medicaid to A patient needs Medicare or Medicaid to afford hospice services.afford hospice services.

Myth #6:Myth #6:A physician decides whether a patient A physician decides whether a patient

should receive hospice careshould receive hospice care

Myth #7:Myth #7: : Once a patient elects hospice care, he or : Once a patient elects hospice care, he or she cannot return to traditional medical treatment.she cannot return to traditional medical treatment.

Myth #4:Myth #4: Hospice Is Only for Patients who Are Hospice Is Only for Patients who Are

Close to Death or Actively Dying.Close to Death or Actively Dying.

Hospice Care TeamHospice Care Team

Doctors.Doctors.

Nurses. Nurses.

Primary care giver .Primary care giver .

Spiritual counselors.Spiritual counselors.

Social workers.Social workers.

Volunteers.Volunteers.

Role of the PhysicianRole of the Physician  

Directed the services required to theDirected the services required to the

patientpatient

Obtain admission history and physicalObtain admission history and physical

examination, prescribed tests andexamination, prescribed tests and

medication.medication.

Follows the client throughout the illness and Follows the client throughout the illness and certifies death.certifies death.

  

Role of the NurseRole of the Nurse  

Makes an initial home visit to assess.Makes an initial home visit to assess.

Observe the patient ongoing conditionObserve the patient ongoing condition

and discuss findings with team members.and discuss findings with team members.

Administer the medications as prescribedAdminister the medications as prescribed

patient compliance and evaluate .patient compliance and evaluate .

Determine the effects of medicationDetermine the effects of medication

regimen.regimen.

Answer the questions and assist otherAnswer the questions and assist other

team members as needed.team members as needed.

Work with staff members to assist theWork with staff members to assist the

family in bereavement and reorganize family in bereavement and reorganize

their livestheir lives..

Ensure that each patient’s care is maximized.Ensure that each patient’s care is maximized.

Role of Role of Primary Care GiversPrimary Care Givers

  

Identify changes in the patient s Identify changes in the patient s condition that might not be noticeable to condition that might not be noticeable to others.others.

Suggest approaches to care that meet Suggest approaches to care that meet with everyone’s approval.with everyone’s approval.

Role of Role of VolunteersVolunteers  

Provide emotional support run errandsProvide emotional support run errands

assist with physical care.assist with physical care.

Help with child care and house hold tasks.Help with child care and house hold tasks.

   Provide care for their families.Provide care for their families.

Provide special empathy and understanding.Provide special empathy and understanding.

Spiritual CounselorsSpiritual Counselors

Many people in hospice care have Many people in hospice care have

connections to some spiritual services in connections to some spiritual services in

their community, but the hospice can provide their community, but the hospice can provide

additional services, if desired.additional services, if desired.

Social WorkersSocial Workers::

Social workers provide counseling and Social workers provide counseling and

support. They can also help patient sort out support. They can also help patient sort out

insurance and other financial concernsinsurance and other financial concerns. .

Bereavement CounselorsBereavement Counselors

Trained bereavement counselors offer Trained bereavement counselors offer

support and guidance for loved one's support and guidance for loved one's

family during and after his or her death. family during and after his or her death.

They continue to provide support for up They continue to provide support for up

to a year after loved one's death.to a year after loved one's death.

Hospice Care ServicesHospice Care Services Interdisciplinary team.Interdisciplinary team.

Pain and symptom control.Pain and symptom control.

Spiritual & Respite care.Spiritual & Respite care.

Home care and inpatient care.Home care and inpatient care.

Family conferences.Family conferences.

Bereavement care.Bereavement care.

Staff support.Staff support.

Coordination of careCoordination of care

Hospice Care SettingsHospice Care Settings

Home Hospice Care. Home Hospice Care.

Hospital-Based Hospices. Hospital-Based Hospices.

Long Term Care Facility-BasedLong Term Care Facility-Based Hospices Hospices

Ethical and Legal Dimensions Regarding Ethical and Legal Dimensions Regarding Hospice CareHospice Care

Advance Directives.Advance Directives.

Euthanasia.Euthanasia.

Passive Euthanasia.Passive Euthanasia.

Active Euthanasia. Active Euthanasia.

Assisted Suicide.Assisted Suicide.

Terminal Weaning.Terminal Weaning.

Cardiopulmonary Resuscitation.Cardiopulmonary Resuscitation.

Comfort Care.Comfort Care.

Life-Sustaining Treatment.Life-Sustaining Treatment.

Relation between Loss and Relation between Loss and Hospice PatientHospice Patient

Definition of LossDefinition of Loss

It is actual or potential situation in It is actual or potential situation in

which a valued person objects or which a valued person objects or

situation is changed or removed.situation is changed or removed.

Sources of LossSources of Loss

Loss of loved or valued person.Loss of loved or valued person.

Loss as an element of illness.Loss as an element of illness.

Separation from an accustomed Separation from an accustomed

environment and people who environment and people who

provide security.provide security.

Types of LossTypes of Loss

Actual loss.Actual loss.

Perceived loss.Perceived loss.

Anticipatory loss.Anticipatory loss.

Maturational loss.Maturational loss.

Situational loss.Situational loss.

GRIEFGRIEFDefinitionDefinition

It is a emotional and behavioral It is a emotional and behavioral

reaction to loss, it occurs with loss reaction to loss, it occurs with loss

caused by separation as well as with caused by separation as well as with

loss caused by death. Grief is loss caused by death. Grief is

manifested in thoughts, feeling, and manifested in thoughts, feeling, and

behaviors. behaviors.

DEATH AS A FINAL LOSSDEATH AS A FINAL LOSS

DefinitionsDefinitionsDyingDying

It is a process of decline in body functions that It is a process of decline in body functions that

results in death. results in death.

DeathDeath is a final cessation of all vital functions in a is a final cessation of all vital functions in a

person. person.

Types of DeathTypes of Death

• Heart Lung Death. Heart Lung Death.

• Cerebral or Brain Death.Cerebral or Brain Death.. .

Manifestations of Impending DeathManifestations of Impending Death

Relaxation of the facial musclesRelaxation of the facial muscles

Difficulty swallowing.Difficulty swallowing.

Gradual loss of the gag reflex.Gradual loss of the gag reflex.

Diminished body movement and reflexes.Diminished body movement and reflexes.

Cyanosis of the extremities.Cyanosis of the extremities.

Weak, and irregular pulse. Weak, and irregular pulse.

Low blood pressure. Low blood pressure.

Coldness of skin. Coldness of skin.

Rapid, shallow, irregular or abnormally,Rapid, shallow, irregular or abnormally,

respirations.respirations.

Changes level of consciousness. Changes level of consciousness.

THE DYING PERSON'S BILL OF THE DYING PERSON'S BILL OF

RIGHTSRIGHTS

o Should be treated as living human being.Should be treated as living human being.

oMaintain a sense of hopefulness.Maintain a sense of hopefulness.

o Should have the right to be cared.Should have the right to be cared.

o Let he/she express feelings and emotions Let he/she express feelings and emotions

about death in his/her own way.about death in his/her own way.

o Participate in decisions. Participate in decisions.

Should not leave him/her to diealoneShould not leave him/her to diealone..

Be free from pain. Be free from pain.

Should have questions answered Should have questions answered

honestly. honestly.

Should obtain help from family. Should obtain help from family.

Discuss and enhance religious or spiritualDiscuss and enhance religious or spiritual

experiences.experiences.

STAGES OF DYINGSTAGES OF DYING

Denial and isolation.Denial and isolation.

Anger "why me?“Anger "why me?“

Bargaining.Bargaining.

Depression "crying and not speaking Depression "crying and not speaking

much“.much“.

Acceptance "preparing to death”.Acceptance "preparing to death”.

Nursing Role for a Client Who Dies at HomeNursing Role for a Client Who Dies at Home

Remove all equipmenRemove all equipmen

Prepare the body for transportation. Prepare the body for transportation.

Make sure the physician has been notified.Make sure the physician has been notified.

Refer the family to a bereavement support Refer the family to a bereavement support

group.group.

Application of Nursing Process to Application of Nursing Process to Care Dying PersonCare Dying Person

Physical & Emotional AssessmentPhysical & Emotional Assessment

Assess holistic client conditions.Assess holistic client conditions.

Assess discomforts of dying client.Assess discomforts of dying client.

Assess patient's and family's emotional Assess patient's and family's emotional

condition.condition.

Assess adequacy of coping behavior.Assess adequacy of coping behavior.

Assess patients attitude toward death.Assess patients attitude toward death.

Spiritual AssessmentSpiritual Assessment

Assess religious belief, need for hope.Assess religious belief, need for hope.

Assess client and family's attitude toward death Assess client and family's attitude toward death

and dying. and dying.

Assess client's preferences concerning death Assess client's preferences concerning death

desire to be at home or in a hospital or hospice desire to be at home or in a hospital or hospice

setting, setting,

Assess decisions concerning resuscitation, Assess decisions concerning resuscitation,

advanced life support, organ donation.advanced life support, organ donation.

Nursing DiagnosisNursing Diagnosis

Ineffective breathing pattern related to disease Ineffective breathing pattern related to disease

progressionprogression

Fear related to deathFear related to death

Grief related to loss.Grief related to loss.

Powerlessness related to terminal illness.Powerlessness related to terminal illness.

Ineffective coping related to increased emotional Ineffective coping related to increased emotional

and physical dependence on other. and physical dependence on other.

PlanningPlanning Deciding on realistic goals, both long Deciding on realistic goals, both long

and short term for the dying client.and short term for the dying client.

Planning to meet the physical,Planning to meet the physical,

emotional, developmental and spiritualemotional, developmental and spiritual

needs. needs.

Support client's self-esteem by askingSupport client's self-esteem by asking

for their opinions and make decisionsfor their opinions and make decisions

with the client not for the client.with the client not for the client.

ImplementationImplementation

Meeting the client's physical needs.Meeting the client's physical needs.

Meeting psychological needs.Meeting psychological needs.

Meeting spiritual needs.Meeting spiritual needs.

Psychological support.Psychological support.

Therapeutic communication.Therapeutic communication.

Maintenance of self-esteem and sense of Maintenance of self-esteem and sense of

dignity.dignity.

Promoting comfort.Promoting comfort.

Prevention of loneliness.Prevention of loneliness.

Providing a soothing environment.Providing a soothing environment.

Meeting family needs. Meeting family needs.

EvaluationEvaluation

Evaluation activities include the following:Evaluation activities include the following:

Listening to the client's reports of feeling in control Listening to the client's reports of feeling in control

of the environment surrounding death.of the environment surrounding death.

Observing the client's relationship withObserving the client's relationship with

significant others.significant others.

Listening to the client's thoughts and feelingsListening to the client's thoughts and feelings

related to hopelessness or powerlessness. related to hopelessness or powerlessness.

. .

Application of Nursing Process to Care Application of Nursing Process to Care of Hospice Patient's Body after Dyingof Hospice Patient's Body after Dying

AssessmentAssessment Determine that the patient is dead by ABC.Determine that the patient is dead by ABC.

Determine if the physician and family haveDetermine if the physician and family have

been notified.been notified.

Notify the nursing supervisor.Notify the nursing supervisor.

Check the medical record for the name of theCheck the medical record for the name of the

mortuary where the body will be taken. mortuary where the body will be taken.

PlanningPlanning

Contact the mortuary and inform them.Contact the mortuary and inform them.

Ask when mortuary personnel may be Ask when mortuary personnel may be expected to arrive.expected to arrive.

Contact any individuals involved in organ Contact any individuals involved in organ

procurement.procurement.

Obtain a postmortem kit or supplies for Obtain a postmortem kit or supplies for

cleaning, wrapping, and identifying the body.cleaning, wrapping, and identifying the body.

ImplementationImplementationo Pull the curtains about the bed. Pull the curtains about the bed. o Don gloves. Don gloves. o Remove all medical equipmentRemove all medical equipment

connected.connected.o Remove hairpins or clips and dentures. Remove hairpins or clips and dentures. o Close the eyelids.Close the eyelids.o The body is carefully batted. The body is carefully batted. o Place the body supine with the armsPlace the body supine with the armso extended at the side or folded over theextended at the side or folded over the

abdomen. abdomen.

Place a small rolled towel beneath thePlace a small rolled towel beneath the

chin to close the mouth.chin to close the mouth.

Apply one or more disposable padsApply one or more disposable pads

between the legs and under thebetween the legs and under the

buttocks.buttocks.

Attach an identification tag to the ankleAttach an identification tag to the ankle

or wrist.or wrist.

Wrap the body with a sheet. Wrap the body with a sheet.

** Tidy bedside area and dispose ofTidy bedside area and dispose of

soiled equipmentsoiled equipment . .

** Remove gloves and wash your handsRemove gloves and wash your hands . .

** Leave the room and close the doorLeave the room and close the door . .

** Make an inventory of valuables andMake an inventory of valuables and

send them to an administrative officesend them to an administrative office..

** Notify housekeeping after the body isNotify housekeeping after the body is

removed from the roomremoved from the room..

EvaluationEvaluationThe body is cleaned and preparedThe body is cleaned and prepared . .

The body is transferred to mortuaryThe body is transferred to mortuary

DocumentDocument

Assessments that indicate patient is died.Assessments that indicate patient is died.

Time of death. Time of death.

Persons notified of death. Persons notified of death.

Care of the body.Care of the body.

Time body is transported to the morgue.Time body is transported to the morgue.  

Postmortem CarePostmortem Care

Care of the body after death (Involves Care of the body after death (Involves

cleaning and preparing the body to cleaning and preparing the body to

enhance its appearance during viewing enhance its appearance during viewing

at the funeral home, ensuring proper at the funeral home, ensuring proper

identification and releasing the body to identification and releasing the body to

mortuary personal. mortuary personal.

Any Question?

Thank You