nurs II: end of life

pain management of end of life

- pain regiment should continue - inability to communicate should not be interpreted absence of pain - routes may change: sublingual, rectal (doctor order required to change route) - monitor bowels

eligibility of criteria for hospice care:

- serious, progressive illness - limited life expectancy - informed choice of palliative care over cure-focused tx - presence of a family member or other caregiver continuously in home - medicare pt A: medical assistance eligibility - life expectancy: < 6 months - physician certification of terminal illness - care must be provided by a medicare-certified hospice program

examples of palliative care:

- surgery related to disease (colostomy, tumor (pain)) - radiation (reduce tumors)

proxy directive:

- the appointment and authorization of another person to make medical decisions on behalf of the person who created the advance directive when he or she can no longer speak for himself or herself - is an important addition to the living will or medical directive that specifies the signer's preferences

5 stages of grief (from diagnose to death):

1. Denial: Denies that sick and dying, my insist that doctor is wrong 2. Anger: Directed at healthcare team or family 3. Bargaining: Tries to make a deal with healthcare provider or higher power 4. Depression: May cry often, withdrawn 5. Acceptance: At peace with knowledge, writing a will, making amends (Hospice)

principles of hospice care:

- Death must be accepted - Patient's total care best managed by interdisciplinary team whose members communicate regularly** - Pain, other symptoms must be managed - Patient, family should be viewed as single unit of care** - Home care of dying necessary - Bereavement care must be provided to family members - Research, education should be ongoing

delirium:

- Disturbances in LOC, psychomotor behavior, memory, thinking, attention, sleep wake cycle - Patients with delirium may become hypoactive or hyperactive, restless, irritable, and fearful. Sleep deprivation and hallucinations may occur - Assess underlying cause: - med SE - dx process - dying process - depression - spiritual distress

delirium interventions:

- Family: unresolved conflict - Spiritual guidance - CAM: massage, music, aromatherapy, lighting, pets - Haldol and Ativan (possible palliative sedation) - Educate families on dying process

assess phychological and spiritual components of dyspnea:

- Intensity, distress, interference with activities - Auscultate lung sounds - Edema - Temperature - Skin color - Sputum (color, consistency, amount)

death:

- Is defined as the permanent cessation of respiratory and circulatory functions - Determination is made through a physical examination that includes auscultation for the absence of breathing and heart sounds

end-of-life-care:

- Motivated by aging population - Shift from death due to communicable disease to non-communicable. - Ability to prolong life with use of technology (ethical dilemma )

signs of approaching death:

- Refusal of food, fluids - Urinary output decreases - Weakness, sleep - Confusion, restlessness (delirium) - Secretions in throat ("death rattle") - Breathing pattern (apnea, Cheyne-Stokes ) - Weak, irregular pulse in extremities - Mottling of lower leg - Decreased temperature control - Bowel Incontinence may occur

recommendations for honoring individual preferences near the of end of life:

- Widespread and timely access to comprehensive coverage for palliative care services - Improved communication between providers vGreater emphasis on advance care planning - Professional education and development - Stronger public education and engagement

advance directives:

- are written documents that allow competent people to document their preferences regarding the use or nonuse of medical treatment at the end of life, specify their preferred setting for care, and communicate other valuable insights into their values and beliefs. - It is legal document you use to provide guidance about what types of treatments you may want to receive in case of a future, unknown medical emergency. - It also is where you say who can speak for you to make medical treatment decisions when you cannot speak for yourself (called a "surrogate"). - All adults should have an advance directive

dyspnea management:

- bronchodilators and corticosteroids - low dose of opioids (morphine) - low-flow O2 (psych comfort) - haldol (anxiety)

palliative care:

- can pursue curative tx - at any age, at any stage of serious illness - administered in hospitals, extended care facilities, nursing homes, and the person's home

death and dignity act:

- legalized physician-assisted suicide via legislation - ANA does not support assisted suicide but rather stresses the nurses role in symptom management, creating environments that encourage care for patient and families as well as identifying fears and concerns.

hospice care:

- most forgo curative tx - requires medical prognosis of six months or less - administered by family and visiting nurses in the person's home

common end of life symptoms:

- pain - dyspnea - nausea - weakness - anxiety

4 principles of health care ethics:

1. Respect for Autonomy 2. Nonmaleficence (not causing harm to others). 3. Beneficence (prevent harm, provide benefits). 4. Justice (appropriate distribution of benefits, risks, and costs).

4 levels of hospice care:

1. Routine Home Care: Most common 2. Inpatient Respite Care: 5-day family relief 3. Continuous Care: Crisis 4. General Inpatient Care: Inpatient stay for symptom management

key domains to care for the dying for a more humane process:

1.Structure and processes of care 2.Physical aspects of care 3.Psychological, psychiatric aspects of care 4.Social aspects of care 5.Spiritual, religious, existential aspects of care 6.Cultural aspects of care 7.Care of imminently dying patient 8. Ethical, legal aspects of care

A nurse who provides care on an acute medical unit has observed that health care providers are frequently reluctant to refer clients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. A.Financial pressures on health care providers B.Client reluctance to accept this type of care C. Strong association of hospice care with prolonging death D.Advances in "curative" treatment in late-stage illness E.Ease of making a terminal diagnosis

A.Financial pressures on health care providers B.Client reluctance to accept this type of care D.Advances in "curative" treatment in late-stage illness

hope-hindering categories:

Abandonment and isolation, uncontrollable pain/discomfort, and devaluation of personhood

The nurse is caring for a client at the end of life. The client is prescribed a regularly scheduled dose of narcotics and short-acting narcotic for breakthrough pain. Which action should the nurse take when administering the narcotics to manage this client's pain? A.Assess for signs of drug dependence. B.Prepare to treat any drug side effects. C.Recognize that dosages will be restricted. D.Administer all analgesics on a PRN basis.

B. prepare to treat any drug side effects

framework for communication in palliative care (term):

COMFORT: C: communication O: orientation M: mindfulness F: family O: openings R: relating T: team

POLST

POLST form is a medical order for the specific medical treatments you want during a medical emergency. It is for when you become seriously ill or frail and toward the end of life. A POLST form does not replace an advance directive — they work together. While all adults should have an advance directive, not all should have a POLST form

medicare hospice benefit

a Medicare entitlement that provides for comprehensive, interdisciplinary palliative care and services for eligible beneficiaries who have a terminal illness and a life expectancy of less than 6 months

hospice

a coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill patients and their families

with hospice, care must be provided by what

a medicare-certified hospice program

palliative care is comfort and living well at _______

any stage of illness

proxy directive/Durable power of attorney:

appoints another person to make medical decisions on behalf of the patient and is added to the advance directive

FICA:

assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive pt care F: faith and belief I: importance C: community A: address in care

anorexia:

cachexia (weakness and wasting of the body due to severe chronic illness) syndrome is characterized by disturbances in carbohydrate, protein, and fat metabolism; endocrine dysfunction; and anemia. The syndrome results in severe asthenia (loss of energy).

interdisciplinary collaboration

communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care

palliative care comprehensive care for what kind of patients

for patients whose disease is not responsive to cure ex: AIDS, COPD, cancer, ALS - care extends to patients' families

palliative care is conceptually broader than ______ care, bc it is an approach to care and a structured system for care delivery

hospice care

mourning

individual, family, group, and cultural expressions of grief and associated behaviors

What is one of the most common and feared responses by patients to terminal illness?

pain

bereavement

period during which mourning for a loss takes place

spirituality

personal belief systems that focus on a search for meaning and purpose in life, intangible elements that impart meaning and vitality to life, and a connectedness to a higher or transcendent dimension

grief

personal feelings that accompany an anticipated or actual loss

palliative care

philosophy of and system for delivering care that expands on traditional medical care for serious, progressive illness to include a focus on quality of life, function, decision making, and opportunities for personal growth

terminal illness

progressive, irreversible illness that despite cure-focused medical treatment will result in the patient's death

autonomy:

self-determination; in the health care context, the right of the individual to make choices about the use and discontinuation of medical treatment

cheyne-stokes:

sign of approaching death - periods of apnea followed by periods of deep and rapid breathing

advance directive does what

states a pt's wishes for tx

prognosis

the expected course of an illness and the chance for recovery

assisted suicide:

the use of pharmacologic agents to hasten the death of a terminally ill patient; illegal in most states

palliative sedation

the use of pharmacologic agents, at the request of the terminally ill patient or the patient's legal proxy, to induce sedation, or near-sedation, when symptoms have not responded to other management measures; the purpose is not to hasten the patient's death but to relieve intractable symptoms

nursing considerations for pain:

•As the end of life nears, patients may be less able to swallow oral medications due to somnolence or nausea. •Patients who have been receiving opioids should continue to receive equianalgesic doses via rectal or sublingual routes. •Concentrated morphine solution can be effectively delivered by the sublingual route, because the small liquid volume is well tolerated even if swallowing is not possible. •Oral and rectal medications are short acting so medications may be given q 3-4 hours •As long as the patient continues to receive opioids, a regimen to combat constipation must be implemented. •If the patient cannot swallow laxatives or stool softeners, rectal suppositories or enemas may be necessary. •Educate the family about continuation of comfort measures as the patient approaches the end of life, how to administer analgesics via alternative routes, and how to assess for pain when the patient cannot verbally report pain intensity. •Reassure family they will not "cause" the death of the patient by administering a dose of analgesic medication.