palliative care; a nursing response

Palliative Care; A Nursing ResponseE. Veronica Cheney, RN, BSNS

American Nurses Association – Palliative Care Scope of Practice

“Purpose: Nurses have always been at the bedside of dying patients. Their role in

providing the highest quality of remaining life and support at the end of life for both patients

and their loved ones is traditional, accepted, and expected. The nurse’s fidelity to the

patient requires the provision of comfort and includes expertise in the relief of suffering,

whether physical, emotional, spiritual, or existential. Increasingly, this means the nurse’s

role includes discussions of end-of-life choices before a patient’s death is imminent.

The purpose of this ANA Position Statement is to articulate the roles and responsibilities of

registered nurses in providing expert end-of-life care and guidance to patients and families

concerning treatment preferences and end-of-life decision making. It is meant to provide

information to guide the nurse in vigilant advocacy for patients throughout their lifespan as

they consider end-of-life choices, and includes discussion of personal ethical dilemmas that

can occur when caring for the dying.”

(ANA, 2014)), http://www.nursingworld.org/

The Goal of Palliative Nursing

“The goal of hospice and palliative care nursing “is to promote and improve the patient’s quality of life through the relief of suffering along the course of illness, through the death of the patient, and into the bereavement period of the family”

(ANA & HPNA, 2007, p.1).

WHO Definition of Palliative Care

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

World Health Organization. (2014). WHO definition of palliative care. Retrieved from World Health Organization: http://www.who.int/cancer/palliative/definition/en/


Palliative care: provides relief from pain and other distressing symptoms;

affirms life and regards dying as a normal process;

intends neither to hasten or postpone death;

integrates the psychological and spiritual aspects of patient care;

offers a support system to help patients live as actively as possible until death;



Palliative care: offers a support system to help the family cope during the patients

illness and in their own bereavement;

uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;

will enhance quality of life, and may also positively influence the course of illness;

is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.


The Beginning ManifestationsFor all patients entering the end stages of disease and those with chronic comorbidities

Failure to Thrive

Malnutrition is the key pathophysiological finding Institute of Medicine – weight loss of more

than 5%, decreased appetite, poor nutrition, physical inactivity

Malnutrition manifests as: weight loss, loss of functional skills and psychological decline

Ali, MD, N. (2012). Failure to thrive in elderly adults. Medscape Reference.

Common Medical Conditions Associated with Failure to Thrive

Cancer: metastases

Chronic lung disease; respiratory failure

Chronic renal failure; insufficiency

Depression; psychosis, other psychiatric disorders

Hip or large bone fractures; functional impairment

Inflammatory bowel disease; malnutrition, malabsorption

MI, CHF, heart failure

Recurrent & chronic infections; UTI, pneumonia

Stroke: dysphagia, cognitive loss


Failure to Thrive Etiology “The Dwindles” Diseases (medical illness)

Delirium

Dementia

Drinking alcohol; substance abuse

Drugs - medications

Deafness, blindness, other sensory deficits

Dysphagia

Depression

Desertion

Destitution

Despair


The Six Phases of Dying

Dying is a process (3-6 months)

All patients behave the same way Eating -- tasting -- looking at food Sleep wake cycle reverses Decreased functional ability Increased assistance with ADL’s

www.hospiceofmarion.com

Terminal Stage Signs (last 2-3 months) Beyond cure or rehab Progressive illness Anorexia/Cachexia (wasting) Syndrome Progressive weakness Increasing debility/dependence Declining condition Psychosocial & spiritual needs Family in crisis


Pre-active Stage Signs (lasts 2-3 weeks) Little oral intake Increasing breathlessness Rising heart rate Reversal of sleep-wake cycle Delirium Restlessness Fluctuating level of consciousness Spiritual events – “visits” from those already

passed/angels


Imminent Death Syndrome (days-hours)

Decreased responsiveness/consciousness

Decreased intake of food/water

Decreased urine output

Skin color and temperature decrease

Mottling

Decreased heart rate and blood pressure fluctuations

Swallowing dysfunction

Breathing changes/apnea

Restlessness

Gaze as if through you


Agonal Stage Signs (last 2-3 hours)

Stupor or coma Tachypnea Cheyne-Stokes/agonal pattern Imperceptible radial pulses (last 4-6 hours) Tachycardia or bradycardia Pupils dilated, fixed (last 15-30 minutes)


Death Event (last 2-3 moments)

Spiritual experiences (moment of death) Bolt upright as if seeing; smiling Epiphora (final tear) Bright reflection Sense of calm (end of suffering/reunion)


Symptom ManagementSymptoms associated with end-of-life and their management

Medication Dosing Rule of Thumb

Most medications start on the PRN bases Assess pain and anxiety frequently using the numeric

pain scale (you can adapt the pain scale for anxiety when the patient is alert)

If you have to dose a patient four consecutive times with PRN medications notify the MD/NP as soon as possible for medication adjustment (either increasing the dose, initiating routine, or increasing the frequency of administration)

The above applies to respiratory distress and excess secretion control medications such as Robinol

Medication Dosing Rule of Thumb

Initial end-of-life medications will start out PO/SL. When the patient is no longer able to swallow switch medications to the subcutaneous route

Subcutaneous (SQ) medications are more effective, ensures all medication is administered (not draining out of the mouth) and absorbs within ten minutes ensuring fast metabolism for effective symptom management

When using the SQ route ensure flushing with 0.3 ml NS after medication administration and no more than 2ml (flush included) to each SQ port (might require more than 1 site)

Pain Management

Pain Management Top priority Initially assess pain with numeric pain intensity scale As patient progresses use the behavioral pain scale Most common medications morphine and

hydromorphone Manage acute breakthrough pain Initiate bowel regimine for side effect management of

constipation

D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.

Pain Medication Recommendations

Medication Dose (Starting doses age >70) Route

Morphine-Roxanol Tabs: 15mg or 30mg Oral Solution: 10mg/5ml, 20mg/5ml, and

100mg/5ml

PO/SL

Morphine Sulfate Injection 0.5mg (5mg/ml) 1 hour dose limit 4-6mg SQ

Hydromorphone-Dilaudid Tabs: 2, 4, 8mg Oral Solution: 5mg/5ml

PO/SL

Hydromorphone-Dilaudid Injection

0.1mg (1mg/ml) 1 hour dose limit 0.4 – 0.6mg SQ

Oxycodone-OxyFAST 20mg/ml PO/SL

University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card: https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf

Pain Scales: Wong-Baker

Google Images (2014)

Behavioral Pain Scale (BPS)

Google Images (2014)

Anxiety

Anxiety An expected finding Etiology:

Chronic mental health disorders – Generalized anxiety disorder

Chronic use of antianxiety medications

Fear of the unknown

Spiritual distress

Fear of dying, dying alone

Dyspnea

Worry over family and unresolved life issues

Adapt the pain scales (see previous slides) for level of anxiety

Anxiety Medication RecommendationsMedications Dose Route

Diazepam – Valium

Tab: 5 and 10 mgOral Solution: 2mg/5ml

Injection: 5mg/mlRectal Solution: 2.5, 5 and 10

mg

PO/SL/SQ/PR

Lorazepam – Ativan Tabs: 0.25, 0.5, 1 and 2.5 mgInjection: 2mg/ml PO/SL/SQ

(IAHPC), I. A. (2013, January). WHO-Essential Medicines in Palliative Care. Retrieved from World Health Organization: http://www.who.int/selection_medicines/committees/expert/19/applications/PalliativeCare_8_A_R.pdf

Terminal Restlessness/Agitation

Definition: Terminal restlessness is a syndrome observed in patients in their last days of life. It is a variant of delirium and refers to a spectrum of signs of central nervous system irritability that may include restlessness, agitation, distressed vocalizing, twitching, myoclonic jerking or recurrent fitting (Binns, 2014)

Patients that are too week to stand but insist on getting up Uncomfortable even with adequate pain management Yelling and calling out Extremely agitated Hallucinations Psychotic episodes Paranoia

Hospice Patients Alliance. (2014). Terminal restlessness or agitation. Hospice patients alliance.

Determining the Cause Oliguria – bladder distention (end-of-life catheter placement might

be required)

Assess pain

Oxygenation

Repositioning

Constipation

Infection

Metabolic changes

Emotional distress; spiritual assessment of needs

New medications

Pre-active phase of death


Terminal Restlessness and agitation Medication Recommendations

Medication Dose Route

Haloperidol – Haldol® Tabs: 0.5, 1, 2, 5, 10 mg. Available in oral and injectable solutions PO/SL/SQ

Risperidone - Resperdal® Tabs: 0.25, 0.5, 1, 2, 3, or 4 mg PO

Olanzapine - Zyprexa® Tabs: 2.5, 5, 7.5, 10, 15 & 20 mg PO/IM

Quetiapine - Seroquel® Tabs: 25, 50, 100-400 mg PO


DyspneaShortness of air

Dyspnea Recommendations Dyspnea is managed with opioid medications. Start with a loading dose Repeat loading dose bolus hourly until well

controlled Adjust medications as needed Reposition Initiate O2 if required Treat cause of dyspnea, i.e. anxiety, and or

pain.


Weakness & Fatigue

Weakness and fatigue

A common occurrence with palliative patients

Sometimes diet can assist in converting fat to energy

Let the patient decide on activity level Encourage frequent rest periods Can assist patient in cope with suffering


Constipation

Constipation

Most distressing symptom Expected with use of opioids Bowel regimen should always be in place with

opioid use Signs and symptoms: abdominal cramps,

nausea and vomiting, continued urge to defecate

Poor oral intake increases risk for dehydration and constipation


Constipation Medication Recommendations


Senna 1-2 tabs daily or BID PO

Docusate 100mg daily or BID PO

Bisacodyl Tabs: 5-15 mg daily or BID10 mg suppository PR PO/PR

Milk of Magnesium 30 ml daily or BID PO

Miralax 17 g in 8 oz water daily PO

Lactulos 15-30 ml daily or BID PO


Secretion ControlRecovery position

Poor Secretion Control A result of type 1 or type 2 excessive secretions

Type 1: Oral secretions of the mouth

Type 2: Bronchial secretions

Death Rattle – air moving over secretions in the airway Suctioning is not recommended:

Causes discomfort and distress

Leads to agitation

Increases secretion production

Positioning (see recovery position) Robinul does not cross blood brain barrier which reduces

occurrence of CNS stimulus


Secretion Control Medication Recommendations



Robinul Tabs: 1mgInjection: 0.2 mg/ml PO/SL/SQ

Atropine Sublingual: 1 gttInjection: 0.1 mg SL/SQ

Scopolamine 1mg Transdermal

Levsin Tabs/Drops: 0.125mg PO

The Recovery Position

Google Images, (2014)

The Recovery Position

Placing a patient in the recovery position will help to relieve dyspnea Uses gravity to facilitate drainage of excessive secretions built up in

the lungs and esophagus Relieves pressure on bony prominences Reduces the need to turn the patient frequently which disrupts

comfort in the later phases of death and can cause severe pain Caution: Some patients with certain medical conditions such as

COPD may not tolerate this position Place a pillow under the accessible arm, between legs, and under feet Remove all pillows from under the head and place a towel with a pillow

case on it under the cheek touching the mattress Teach family what to expect (excessive odorous secretions requiring

frequent oral care) Do not use Yonkers with bedside suction

Nausea & Vomiting

Nausea and vomiting

May develop early Etiology of pharmacological therapy –

chemotherapy May lead to dehydration Leads to anorexia Causes discomfort Increases anxiety

Nausea & Vomiting Medication Recommendations


Haloperidol – Haldol 0.5 – 4 mg PO/SL/SQ

Ondansetron – Zofran 4-8 mg PO

Scopolamine 1.5 mg Transdermal

Metoclopramide – Reglan 5-20 mg PO/SQ


Nutritional Problems

Nutritional Problems Little oral intake – reduction of caloric intake to

support physiological needs Nutritional needs decrease with progression of dying

phases Traumatic to family members – does not bother the

patient Offer soft foods and/or favorite foods – patient may

request favorite foods Hunger is suppressed due to the body no longer

requiring nutrition Provide support and education to the family


Vital Signs

Vital Signs Blood pressure and oxygenation decrease in imminent stage of

dying

Unreliable in the indication of impending death

Research does not support obtaining vital signs

Febrile conditions are a natural process of the dying phase

Can treat with Tylenol PO/PR – only if fever is causing distress to the patient

Administering antipyretics for elevated temperatures can cause distress, discomfort, and increased agitation in patients that do not appear to be effected by the febrile state

Obtaining respirations and heart rate can help to determine increased pain, anxiety, and dyspnea to guide PRN medication administration

Bruera, S., Chisholm, G., Santos, R., Crovador, C., Bruera, E., & Hui, D. (2014, April 14). Variations in vital signs in the last days of life in patients with advanced cancer. Journal of pain syptom management(14), S0885-3924. doi: doi: 10.1016/j.jpainsymman.2013.10.019

Family Support & EducationTherapeutic Self

Family Support and Education Ensure the patients right to make informed decisions about their end of life

care

Cultural assessment and provision of needed cultural requirements

Ensure appropriate referrals, social services, pastoral, Hosparus etc.

Providing education at the beginning and throughout the process can reduce stress and increase comfort for the patient and family

Continued education to support the family establishes trust

Empower the family through education to foster feelings of control – teaching oral care, cool cloths, feeding (when the patient is still able to swallow)

Nutritional education – oral intake of foods and fluids

Encourage family and patients to ask questions

Educate family on signs and symptoms of pain, dyspnea, and anxiety

Educate that at times visitor restriction may be necessary to reduce patient anxiety, agitation, and restlessness

Educate on safety – during terminal restlessness phases

References(IAHPC), I. A. (2013, January). WHO-Essential Medicines in Palliative Care. Retrieved from

World Health Organization:

http://www.who.int/selection_medicines/committees/expert/19/applications/PalliativeCar

e_8_A_R.pdf


American Nurses Association. (2010, June 14). Registered Nurses Roles and Responsibilities in

Providing Expert Care and Counseling at the End of Life. Retrieved from Position

Statement: http://www.nursingworld.org/mainmenucategories/ethicsstandards/ethics-

position-statements/etpain14426.pdf

Bruera, S., Chisholm, G., Santos, R., Crovador, C., Bruera, E., & Hui, D. (2014, April 14).

Variations in vital signs in the last days of life in patients with advanced cancer. Journal

of pain syptom management(14), S0885-3924. doi: doi:

10.1016/j.jpainsymman.2013.10.019

D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today,

7(7), 22-27.


University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:

https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf

World Health Organization. (2014). WHO definition of palliative care. Retrieved from World

Health Organization: http://www.who.int/cancer/palliative/definition/en/

palliative care; a nursing response

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