CASE SCENARIO Mrs.

Esther Larson, a client who has been recently admitted to a hospice program, confides in the nurse that she feels overwhelmed with the number of things she must attend to now that shes facing the possibility of death. She says, My thoughts are all over the place, I dont now where to start.! "hat communication techni#ues, based on the critical thin ing model, could the nurse use to help her at this point$

OBJECTIVES %eneral &b'ective( )fter the case presentation the students will be able to enhance their nowledge and competence in the care and therapeutic communication of older adults facing death. Specific &b'ectives( Specifically, the students will be able to( *efine Eric sons Last Stage of +sychosocial ,heory, which is Ego Integrity -s *espair. Integrate the .. ey areas of nursing competencies in the care of Esther. /ormulate and apply nursing care plan utili0ing the nursing process in the care of the patient. &utline the promotive and preventive management of elderly patient in hospice program approaching death.

EGO INTEGRITY VS DESPAIR Psychosocial Conflict: Integrity versus despair Majo !"#stion: 1*id I live a meaningful life$1 Basic Vi t"#: "isdom I$%o tant E&#nt: 2eflecting bac on life Integrity versus despair is the eighth and final stage of Eri Eri son3s theory of psychosocial development. ,his stage occurs during late adulthood from age 45 through the end of life. *uring this period of time, people reflect bac on the life they have lived and come away with either a sense of fulfillment from a life well lived or a sense of regret and despair over a life misspent. ,hose who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means loo ing bac with few regrets and a general feeling of satisfaction. ,hese individuals will attain wisdom, even when confronting death. ,hose who are unsuccessful during this phase will feel that their life has been wasted and will e6perience many regrets. ,he individual will be left with feelings of bitterness and despair.

'os%ic# Ca # ,he word hospice! stems from the Latin word hospitum! meaning guesthouse. It was originally used to describe a place of shelter for weary and sic travelers returning from religious pilgrimages. ,oday there are more than 7,899 hospice programs in the :nited States. ;ospice programs cared for <45,999 people enrolled in Medicare in =994, and nearly ..7 million people in the :nited States in =998>. ;ospice is not a place but a concept of care. Eighty percent of hospice care is provided in the patient3s home, family member3s home and in nursing homes. Inpatient hospice facilities are sometimes available to assist with care giving ?hospicefoundation.org@. "hat is ;ospice$

;ospice is a special conc#%t of ca # designed to provide comfort and support to patients and their families when a lifeAlimiting illness no longer responds to cureAoriented treatments. ;ospice care neither prolongs life nor hastens death. ;ospice staff and volunteers offer a s%#ciali(#) *no+l#),# of medical care, including pain management. ,he goal of hospice care is to improve the #uality of a patient3s last days by offering co$fo t an) )i,nity. ;ospice addresses all symptoms of a disease, with a special emphasis on cont ollin, a %ati#nt-s %ain and discomfort. ;ospice deals with the #$otional. social an) s%i it"al i$%act of the disease on the patient and the patient3s family and friends. ;ospice offers a variety of /# #a&#$#nt an) co"ns#lin, s# &ic#s to families before and after a patient3s death. T'ERAPE0TIC COMM0NICATION

)ctive Listening B Ceing attentive to what the client is saying, verbally and nonA verbally. Sharing &bservationsAma ing observations by commenting on how the other person loo s, sounds, or acts. Sharing EmpathyA ,he ability to understand and accept another persons reality, to accurately perceive feelings, and to communicate understanding. Sharing ;opeA Dommunicating a sense of possibility! to others. Encouragement when appropriate and positive feedbac . :sing ,ouchA Most potent form of communication. SilenceA ,ime for the nurse and client to observe one another, sort out feelings, thin of how to say things, and consider what has been verbally communicated.

STAGES O1 DESPAIR +hilosopher Soren Eier egaard, in his Sickness Unto Death ?.F7<@, suggested that despair could be understood as comprising three stages( Spiritlessness, which applies to those who outwardly seem wellAad'usted and successful yet inwardly live in a state of deep and perilous despairG despair in weakness and despair about weakness, which has to do with a refusal to become authentically and fully one3s self and the e6istential guilt?what Sartre called mauvaise foi or 1bad faith1@ of this cowardly refusal to move forward and frustrating inability to retreat bac to their former identityG and, thirdly, the despair of defiance, which pertains to the capacity of despair to turn, sometimes #uite suddenly, to elation, e6citement, optimism, enthusiasm, hypomania or mania and frenetic creative activity as so often seen in extremis during the manic phase of bipolar disorder.

22 N0RSING CORE COMPETENCIES A3 SA1E AND !0A4ITY N0RSING CARE P o/l#$ I)#ntification: Esther verbali0es uncertainty about choices. C"#s: My thoughts are all over the place, I dont now where to start!, as verbali0ed by Esther. I$%lication: ,he final stage of Eri son3s ?.<F=@ theory is later adulthood ?age 49 years and older@. ,he crisis represented by this last life stage is integrity versus despair. Eri son proposes that this stage begins when the individual e6periences a sense of mortality. ,he final life crisis manifests itself as a review of the individual.s lifeAcareer. *espair is the result of the negative resolution or lac of resolution of the final life crisis. ,his negative resolution manifests itself as a fear of death, a sense that life is too short, and depression. *espair is the last dystonic element in Eri son3s ?.<5<, .<F=@ theory. Si,nificanc#: )ssess the level of an6iety and uncertainty of Esther. Cuild an open and trusting relationship with the patient. +rovide care that reduces Esthers discomfort.

 2espect Esthers lifestyle, social conte6t and spiritual needs and document observations in line with care plan. Support the freedom of Esther, her family or significant others to discuss spiritual and cultural issues in an open and nonA'udgmental way within scope of own responsibilities and s ills. Encourage Esther to attend support groups Improve the #uality of remaining life of Esther so she can en'oy time with family and friends and e6perience a natural, painAfree death and enable her to live as fully and as comfortable as possible. B3 MANAGEMENT O1 RESO0RCES AND ENVIRONMENT /ollow organi0ation policies, protocols and procedures. +rovide emotional support using effective communication s ills +rovide a supportive and comfortable environment that enables Esther and her family to provide care in a familiar setting. +romote emotional e6pressiveness

C3 'EA4T' ED0CATION /eelings of worth, pride, and usefulness needs to be maintained Suggest natural seasoning for foods such as lemon or onion as sense of taste and smell decline. Encourage inta e of high fiber diet and at least two to three liters of fluid to prevent constipation. +rotect from ha0ards as agility and balance decline with aging. Spiritual assessment must be non 'udgemental and accepting of Esther3s spiritual beliefs. Symptom management, handsAon care of patient, caring for body functions, and teaching regarding the signs and symptoms of approaching death are important to relive fears. "atch out for signs of despair such as lose of interest in activities that once were pleasurable, e6perience loss of appetite or overeating, have problems concentrating, remembering details, or ma ing decisions. "atch out for signs of depression, patient may feel sad, an6ious, empty, hopeless, worried, helpless, worthless, guilty, irritable, hurt, or restless. ,each Esther +hysical Dhanges as death approaches( o ,he blood pressure decreasesG the pulse may increase or decrease. o ,he body temperature can fluctuateG fever is common.

o ,here is increased perspiration often with clamminess. o ,he skin color changes. o Creathing changes also occur. 2espirations may increase, decrease or become irregularG periods of no breathing are common. o Congestion will present as a rattling sound in the lungs andHor upper throat. o ,he arms and legs of the body may become cool to the touch. ,he hands and feet become purplish. ,he nees, an les and elbows are blotchy. ,hese symptoms are a result of decreased circulation. o ,he patient will enter a coma before death and not respond to verbal or tactile stimuli. D3 4EGA4 RESPONSI4ITY )dhere with 2) <.8I or +hilippine Jursing Law of =99= /or rendering #uality care. Even though the Esther is dying she should be relieved from pain and suffering.

,he +atient Self *etermination )ct passed by the :S Dongress in .<<9 has had a significant impact in bringing attention to advance care planning through the use of advance directives. ,his act re#uires institutions receiving Medicare and Medicaid reimbursement to inform patients about the use of advance directives. )dhere with 2) 87I= also nown as Senior Diti0ens )ct for guidelines on the privileges of senior citi0ens. Employee 2etirement Income Security )ct of .<87 ,he Employee 2etirement Income Security )ct law was established to protect older retired people who maintain retirement benefit accounts. &lder )mericans )ct

,he &lder )mericans )ct was enacted in .<45 to address elder care. It was originally established to help the elderly become more social and involved in the community with grants and special pro'ects, but also encompasses other pressing issues affecting seniors, li e abuse in nursing homes.

El)# J"stic# Act 5667 B a law passed in =99I states that it is a federal offence to perpetrate or aid elderly abuse whether in elderly homes or own homes. E3 ET'ICO8MORA4 RESPONSIBI4ITY +2IJDI+LES( ):,&J&MKLthe patients right to selfAdetermination.

+hysicians should encourage dialogue about endAof life care and use of advance directives so that autonomy can be preserved even if patients decision ma ing capacity is lost. CEJE/IDEJDELdoing what is good or beneficial for the patient. +hysicians should do what they believe is in the patients best interest, but this action must not conflict with the patients right to selfAdetermination. J&JM)LE/IDEJDEL )voidance of infliction of intentional harm. Many physicians view participation in physician assisted suicide as a violation of this principle. M:S,IDEL/airness in the delivery of healthcare. +hysicians should advocate for treatment of their dying patients which is 'ust and without discrimination. /I*ELI,KL,ruthfulness and faithfulness in delivering healthcare. +hysicians should be truthful to their dying patients regarding the diagnosis and prognosis and advocate for their dying patients wishes even when those patients decisionAma ing capacity has been lost. ,he *ying +ersons Cill of 2ights(

I have the right to be treated as a living human until I die. I have the right to maintain a sense of hopefulness, however changing its focus may be. I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this may be. I have the right to e6press my feelings and emotions about my approaching death in my own way. I have the right to participate in decisions concerning my care. I have the right to e6pect continuing medical and nursing attention even though cure! goals must be changed to comfort! goals. I have the right to not die alone. I have the right to be free of pain. I have the right to have my #uestions answered honestly. I have the right to retain my individuality and not be 'udged for my decisions, which may be contrary to the belief of others. I have the right to e6pect that the sanctity of the human body will be respected after death. I have the right to be cared for by caring, sensitive, nowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death. 13 PERSONA4 AND PRO1ESSIONA4 DEVE4OPMENT )ssess own performance against standard of practice. :sing the selfAassessment forms will identify any areas in which you may need refreshing or upgrading.

Identify own limitations, strengths and wea nesses, values and beliefs to provide holistic care for the patient. Sets attainable ob'ectives to enhance nursing nowledge and s ills. :pdate your nowledge in caring for patients who are dying to ensure that you always have the current nowledge and s ills necessary to provide safe, caring and effective health care. ,here are many ways in which update your nowledge and s ills(wssd ,a ing a formal course, seminar or wor shop 2eviewing manuals or documents related to your wor )ttending professional conferences and conventions A these are very good to learn the latest trends and developments in your profession Independent study A this can include reading of boo s and trade publications, or using the Internet to do research and study. *emonstrate good manners and right conduct at all times and congruence of words and actions. G3 !0A4ITY IMPROVEMENT Entertain attentively the #ueries of the Esther related to her an6iety. Model ageAappropriate communication s ills to illustrate suitable means for Esther. +rovide education about death and dying for patient and family members. Monitor Esthers health status. *isseminate e6pert clinical nowledge and s ills and provide a resource service. Improve nursing care basing on the feedbac s from the significant others. Maintain a helpdes for health care providers. Domplete Esthers records. '3 RESARC' ,he ,herapeutic Effects of the +hysicianA&lder +atient 2elationship( Effective Dommunication with -ulnerable &lder +atients ?*iMatteo, et al ?=998@ It examines the complexities of communication between physicians and their older patients, and considers some of the particular challenges that manifest in providers interactions with their older patients, particularly those who are socially isolated, suffering from depression, or of minority status or low income ,he study states that even when older patients have appropriate access to medical services, they also need effective and empathic communication as an essential part of their treatment. Effective communication with physicians and health care professionals at all levels can serve as a vital lin to health and adaptation to the aging process. It offers guidelines for improved physicianAolder patient communication in medical practice, and e6amines interventions to coordinate care for older patients on multiple dimensions of a biopsychosocial model of health care. In =998, hospice treatment was utili0ed by ..7 million people in the :nited States. More than oneAthird of dying )mericans utili0es the service.

)ccording to Jational ;ospice and +alliative Dare &rgani0ation ?J;+D&@, in =9.., estimated ..45million patients received services from hospice. ,his estimate includes( .,95<,999 patients who died under hospice care in =9.. I.I,999 who remained on the hospice census at the end of =9.. ? nown as carryovers!@ =8F,999 patients who were discharged alive in =9.. for reasons including e6tended prognosis, desire for curative treatment, and other reasons ? nown as live discharges!@ ,he Donnecticut ;ospice, Inc. as the first hospice in the :nited States and the first palliative hospital, has a 7 programs( ;&ME D)2EA caregivers are connected through a videoAphone system, +icture,el. IJ+),IEJ, D)2EA designed for patients with advanced irreversible illnesses. +E*I),2ID D)2EA as Dhildrens +laceG designed to provide the necessary components of child and family care. IJ,E2*ISDI+LIJ)2K D)2EA team approach!, the team assess and refer patients to other disciplines as the need arises. I3 RECORD MANAGEMENT +rovide a complete and accurate patient profile. *ocumentation of data must be relevant to the client. 2ecording of data must be written in a way that is factual and succinct but not 'udgmental or derogatory. 2efrain from releasing records and data about patient without proper authority to ensure confidentiality and privacy. Secure and store records in a safe place and should not be shared with unauthori0ed persons. J3 COMM0NICATION ,he dying process usually begins well before death actually occurs. *eath is a personal 'ourney that each individual approaches in their own uni#ue way. Jothing is concrete, nothing is set in stone. ,here are many paths one can ta e on this 'ourney but all lead to the same destination. Be aware of the person's health issues. Older adults may have health problems that add difficulty to speaking and understanding. Be sure you consider the person's healthbefore you engage in communication. Be attentive to the environment in which you are communicating . Be sure to evaluate the environment in which you are communicating, which might have an effect on hearing and speech problems. Speak clearly and articulately, and make eye contact. Older adults may have trouble hearing. It is important to articulate your words and speak clearly. Direct your speech at the individual's face -- not to their side.

Adjust your volume appropriately. here is a difference between enunciating and talking loudly. !earn to adapt your voice to the needs of the individual. Take it slow, be patient, and smile. " sincere smile shows that you understanding. It also creates a friendly environment in which to communicate. Ask open ended !uestions and genuinely listen. #esist the temptation to fire off a series of yes$no %uestions. "ustomi#e care by seeking information about older adults$ cultural beliefs and values pertaining to illness and death. &uman beings are culturally bound and develop ways to understand relationships among people, nature, life, and death. %&press understanding and compassion to help older patients manage fear and uncertainty related to the aging process and chronic diseases. 'any older patients e(perience an(iety, uncertainty, and frustration with regard to their own aging process as well as aging-related chronic diseases. Ask !uestions about older adults living situation and social contacts. &ealth care visits provide an opportunity to e(plore an older adults) living situation and social contacts*issues that ultimately could have more serious health conse%uences than the stated reason for the visit. 'nclude older adults in the conversation even if their companion is in the room. +reate a triadic conversation by maintaining a direct communication channel with the older adult. %ngage in shared decision making. Involving the patient in decision making engenders trust, reduces malpractice claims, and enhances patient and provider satisfaction. (se direct, concrete, actionable language when talking to older adults. ry to use concrete, direct words rather than abstract, vague words. 93 CO44ABORATION an) TEAM:OR9 N Dontributes to decision ma ing regarding patients! needs and concerns N +articipates actively in patients care management N 2ecommends appropriate intervention to improve patient care N 2espects the role of the other members of the health team N Maintains good interpersonal relationships with patients, colleagues and other members of the health team. N 2efers patients to allied health team partners N )cts liaison H advocate of the patients N +repares accurate documentation of efficient communication of services 4EVE4S O1 CARE P #&#nti&#

;ave a comprehensive care assessment regarding Esthers condition in order to identify and relieve suffering through prevention of physical, psychological, social and spiritual distress. May refer to psychologist to prevent and relieve burdens brought by depression, an6iety and other mental health problems

P o$oti&# +romote the highest possible #uality of life such as( A +reserve the dignity and comfort of Esther. A )ssure that Esthers directives are followed A+rovide support to Esther and the family as well. A&pening a dialogue about spiritual concerns of Esther can be therapeutic in itself. It helps reduce the spiritual suffering of Esther by focusing on meaning and dignity It helps to create a sense of purpose and meaning that ma es Esthers life worthwhile. A+rovide endAofAlife counselling to the dying and their familiesG and advocate for good medical care. A*evelop an appropriate and effective sharing of information, active listening, determination of goals and preferences and medical decision ma ing with Esther. A:se therapeutic communication and openAended #uestions with Esther to be able to e6press her thoughts and fears related to the dying process.