End-of-Life Care

* Why Nursing?

* Focus of Healthcare

*The Other Side

*Overview: Death and Dying

Lungs and heart cease to function Multiple organ dysfunction syndrome (MODS)

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Clinical death: short interval after the cessation of heartbeat and breathing when no evidence of brain function is present CPR?

Death is a natural process

*Goals for End-of-Life Care

* Control symptoms * Identify client needs * Promote meaningful interactions between the client and
significant others

* Facilitate a peaceful death

*Physical Assessment
* Cold, mottled, cyanotic skin * Decreased BP & HR * Changes in respirations * Lethargy with long periods of sleep * Difficulty in communication * Fluid & Food intake decreases * Constipation Incontinence * Restlessness / Distress

*Symptoms of Distress at
End-of-Life
Pain Dyspnea Fatigue Weakness Constipation Anorexia Delirium

Agitation
Nausea Vomiting

*Fatigue Management
* Aspiration precautions * Mouth care and moisture for lips * Altered routes of medication administration if
needed

* Least invasive route * Most effective treatment

*Pain Management
* Pain - symptom that dying clients fear most * Schedule pain medications * Consider alternative route

*Dyspnea
*Subjective experience *Uncomfortable awareness of breathing *Breathlessness or severe shortness of breath

*Copious secretions, cough, chest pain, fatigue, air hunger

*Related to diagnosis primary, secondary, side effects of
treatment

*Dyspnea Management
*Treat
primary cause and relieve the psychological distress that accompanies the symptom

*Morphine sulfate *Diuretics *Bronchodilators *Antibiotics

Anticholinergics Sedatives Oxygen

*Dyspnea Management
Nonpharmacologic Interventions

*Facilitate the circulation of cool air *Apply wet cloths to patients face *Position *Facilitate rest

*Nausea and
or gynecologic cancers.

Vomiting

*Prevalent in patients with AIDS or breast, stomach, *Common Causes *Pharmacologic therapy *Uremia *Hypercalcemia *Constipation *Bowel obstruction *Secondary to disease processes

* Management of Nausea / Vomiting

* Antiemetic agents * May require combination of antiemetics (e.g., rectal
suppositories, gels or oral meds)

* Treat underlying cause if possible

*Restlessness and Agitation

Management
* Treat the underlying cause

* Administer sedatives
* Consult with a spiritual and/or bereavement counselor

*Psychosocial Assessment
* Fear * Anxiety * Cultural considerations and bereavement * Feelings of client and significant others

*Approaching Death
* Withdrawal * Vision-like Experiences * Letting Go * Saying Goodbye

*The Grieving Process

Kubler-Ross Theory

* * * * *

Denial: Initial stage - "It can't be happening" Anger: "Why me? It's not fair"

Bargaining: "Just let me live to see my children graduate"

Depression: "I'm so sad, why bother with anything?" Acceptance: "It's going to be OK"

*Physical and Emotional Support

*Be realistic about the facts of death & dying *Encourage reminiscence of clients life
memories and stories of events

*Promote spirituality including religion *Foster hope for clients and their families *Avoid explanations of the loss *Communicate with the client *Provide referrals to bereavement specialists

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*Need for information
*Opportunity to disclose feelings *Maintaining a sense of control *Need for knowing that their life has meaning
and purpose

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*Need for information *Permission to speak *To be listened to

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*Palliative Care
Philosophy
* Compassionate * Supportive * Holistic

Goals
* Treatment of symptoms * Emotional & Spiritual Support * Improve quality of care at the end of life * Does not hasten or postpone death

*Hospice Care
*Interdisciplinary approach to
end-of-life care

*Provide services to clients at

home or in extended care facility *Medicare *Prognosis of 6 months or less to live

*Agree to forgo curative

treatment

*Postmortem Care
*Focus of care shifts from the patient to the family and those who
provided care.

*Even though the loss has been anticipated for some time, no one
will know what it feels like until it actually occurs.

*Time spent with the body immediately after death will help
people deal with acute grief.
body is acceptable.

*Allow Families and caregivers to say goodbye. Touching the *Position the patient's body (head of bed up 30 degrees),
disconnecting any lines (unless an autopsy is to be performed, then tubes are left in place and tied).

*Postmortem Care
* Legal considerations (death certificate)

* Autopsy
* Organ Donation * Religious/Spiritual considerations * Transfer of the body

* Family presence

*Advance Directives
*Legal documents
*Prepared by competent individuals *Opportunity for patient to convey wishes for
end-of-life care before no longer capable of making own decisions

*Advance Directives
*Living Wills *Durable Power of Attorney *Mental Health Treatment Declaration *Do Not Resuscitate (DNR) Orders

*Euthanasia
*Passive *Withdrawing or withholding treatment
that might prolong a patients life

*Not attempting to prevent death *Active *Giving a treatment or agent that ends a
patients life

*Taking action to cause death