Hospice and End of Life
criteria for bipolar II
-criteria met for atleast one hypomanic + atleast one major depressive episode -hypomanic:minimum 4 days not severe enough marked impairment or hospitalization -never manic episode
what range is toxic for lithium
1.5
qualifications of Major depressive disorder
2 wks or more of sad mood and disinterest in activities
death rattle
A sound made by a dying patient caused by air passing through the mucus collected in the throat or bronchial tubes -often more distressing to family members than is the presence of the secretions to the patient
The nurse is caring for a 5-year-old boy who is terminally ill. Which intervention would best meet the needs of this dying child?
Assure the child that he did nothing wrong.
types of bipolar disorder
Bipolar I Bipolar II Cyclothymia
Open awareness
Client and others know about the impending death and feel comfortable discussing it.
postcrisis phase
Determining responsibility, communicating with a wide range of stakeholders, perhaps apologizing, and establishing systems for coping with similar crises in the future.
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.
Financial pressures on health care providers Client reluctance to accept this type of care Advances in "curative" treatment in late-stage illness
Durable Power of Attorney for Health Care
A type of advance directive executed by a competent adult that appoints another individual to make medical treatment decisions on his or her behalf in the event that the person making the appointment loses decision-making capacity.
when is ECT indicated
when patients fail to respond to the meds, need for a rapid, definitive response, and during pregnancy when meds aren't available
infor
• Parents responsible for decision on child care • Physician/Advanced Practitioner Assent • Nurses Responsibility • Special situations May call ethics comiitee
What must nurses remember about pain?
Believe patient's report of pain and effect • Under-treatment is common • Poorly managed affects psychological, emotional, social, and financial well being -never withhold pain meds - if ineffective they may get meds every hour -may receive sublingual
The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does the nurse display?
Beneficence
DYSPNEA INTERVENTIONS
Blood transfusion for anemia or erythropoietin, • Low dose morphine • Bronchodilators, corticosteroids • Low flow oxygen • Benzodiazipines • Diuretics • Air movement (aka FAN) • Energy conservation (BSC, electric bed, elev HOB)
A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?
Durable power of attorney for health care
A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following?
Faith and belief
Months before death s/s
Gradual generalized weakness •Fatigue •Social isolation •Decreased appetite
A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client?
Respect the client's and family members' choices.
The nurse is caring for a child with a terminal illness who is dying. The parents are concerned that their child will be in pain. What can the nurse do to help the parents understand that pain control needs are being addressed? Select all that apply.
The nurse explains that pain medications will be given at scheduled times rather than on only a prn basis. The nurse explains that care, such as turning and repositioning, will only be done as frequently as tolerated by the child. The nurse explains that the staff offers back massages to the child in an effort to help with pain and relaxation. The nurse explains that the staff will be sure to assess the child's pain level both by verbal and nonverbal cues.
what foods contain tyramine
aged cheese, bologna, salami, raisins, beer, chianti red wine, soy sauce, pickled foods, chocolate
What is cachexia
aka wasting syndrome. results in severe wasting of lean body mass and weight loss.
cheynes stokes
alternating periods of deep, rapid breathing followed by periods of apnea; regular
During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kübler-Ross stage of acceptance, which statement by the nurse is most appropriate?
"Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse."
What are things to consider with communication?
"Tell me more about what is on your mind" • Provide reassurance only when it is realistic • Proactive approach • Allow sufficient time to process new information • May require several meetings to accomplish
The family member of a client with terminal metastatic cancer who is experiencing cachexia-related weight loss asks the nurse why the client is losing weight despite taking in a large amount of calories per day. What is the nurse's best response?
"This weight loss is related to the cancer itself and occurs despite an intake of adequate calories."
A 25-year-old client with cancer who is experiencing unrelieved pain rated a 9 on the pain scale requests that the hospice nurse induce a state of unconsciousness until the client dies. Which statement by the nurse demonstrates an understanding of a key difference between conscious sedation and euthanasia?
"Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death."
what is situational depression
- a short-term response *triggered by a life event* and the symptoms will resolve when the stressor no longer exists, or the individual is able to adapt to the situation
What are requirements for hospice
-Prognosis of < 6 months to live -Willingness to forgo life-sustaining care -Medicare part A
palliative care
-curative treatment along with relieving pain, aimed at reducing pain and symptoms of illness\ Interdisciplinary model of care, they try to keep pt home • Comprehensive care for patients whose disease is not responsive to cure • Prevent and relieve suffering • Care extends to patients' families • Psychological, social, spiritual care • Pain and symptom control • GOAL: improve patient and family quality of life
5 stages of grief
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
legal hierarchy f
1. Legal guardian with health-care decision- making authority 2. Spouse 3. Adult children of patient 4. Parents of patient 5. Adult siblings of patient
DSM-5 Criteria
5 or more s/s at least 1 being sadness: 2 wks or more of eating changes, hypersomnia, insomnia, impaired concentration, self blame, anergia, suicidal thoughts
A nurse assesses a client with a terminal illness and determines that the client is in denial about the condition. Which of the following would be most important for the nurse to do when developing the client's plan of care?
Accept the client's denial of the situation.
SSRI contraindications
Hypersensitivity, renal dysfunction, hepatic dysfunction, and pregnancy and lactation
What causes serotonin syndrome?
Increased dose of Serotonergic medications MAOIs TCAs Tranadol St Johns Wort
Describe the denial stage
Acts as though nothing has happened and refuses to accept the fact of the loss -"This cant be true", and may talk to another MD
Hours before death (or actively dying phase)
Neurologic: obtunded, nonresponsive, hearing may remain •Cardiopulmonary: ↑ pulse (may be irregular or difficult to palpate) and ↑or ↓ RR, ↓ BP, periods of apnea (>40 s) or agonal breathing •Renal: oliguria/anuria •Skin: worsening mottling of extremities
Which of the following is an appropriate intervention for the client with pulmonary edema?
Administer the prescribed sedative to decrease anxiety.
The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using?
Palliative care
TCAs (tricyclic antidepressants) example
Amitriptyline (Elavil)
Suspected awareness
An awareness context in which a person suspects that his or her prognosis involves death, but this suspicion is not confirmed by those who know the truth.
A nurse is providing care to a terminally ill client who is experiencing dyspnea. Which of the following would be most appropriate to do to assess the severity of the client's complaint?
Ask the client to rate the dyspnea on a scale of 0 to 10.
ORAL/RESP SECRETIONS
Atropine ophthalmic PO/SL every 4 to 6 hours • Atropine IV/IM/SC every 4 to 6 hours • Glycopyrrolate (Robinal) PO every 8 hours • Scopolamine, transdermal patch behind the ear every 3 days -may have death rattle which is just secretions -HOB 30 degrees
A nurse has been working in hospice care for 10 years. Based on her experience, she drafts her plan of care with the understanding that the most significant barrier to improving care at the end of life is the:
Attitude of health care professionals toward terminal illness.
POST-MORTEM CARE
Care of the patient - dignity • Label tags - toe, shroud and belongings • Place tag on toe • Place patient in shroud and zipper • Place tag on outside of shroud • Place tag on belongings • Contact transport to morgue • Complete death discharge summary - forms go with patient • Contact Lifelink within 1 hour of death -hospice will call the funeral home and the funeral home will get a hold of the body
recovery phase
Client regains physical and emotional control
palliative sedation
Controversial • Offered to those close to death not responsive to usual therapies • Not euthanasia • Goal is to relieve symptoms, not hasten death • Use for intractable pain, dyspnea, seizures, delirium • Patient and family should be fully informed • Induces unconsciousness • Haloperidol, midazolam, phenobarb, ketamine, Chlorpromazine -relieves s/s but doesn't hasten death -in hospice family may push PCA pump if pt is unable
Describe the anger stage
Expresses resistance and sometimes feels intense anger at a religious deity, other people or the situation -WHY ME, rage, resent, and direct these feelings towards God, allow pt to feel anger, anger is the grief of what they will be losing
criteria for cyclothymic disorder
For at least 2 years there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
A patient with a "Do Not Resuscitate" (DNR) order requires large doses of a narcotic for pain that rates a 10 on a 0-10 scale. After the patient requests pain medication, the nurse assesses a respiratory rate of 12 breaths per minute. What intervention by the nurse would be considered ethical?
Give the pain medication without fear of respiratory depression.
A nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. Which of the following would be the priority to promote healthy accommodation of the loss by the family?
Helping the family recognize the loss has occurred
Describe the acceptance stage
I have lived a good life, I have no regrets
Describe the bargaining stage
I just want to see my niece get married, bargain to see a significant event
Describe the depression stage
It is a normal reaction. Encourage patient by giving realistic praise while letting patient express his/her feelings -grief over impending loss
Tx: bipolar disorder
Lithium, antipsychotics, anticonvulsants, antidepressants
What can trigger dyspnea?
May be frightening, feel like drowning or suffocation -may be triggered by anxiety, resp rate goes up
Days before death s/s
Neurologic: somnolence, restlessness, further dulled senses (except hearing), possible "rally" in energy •Cardiopulmonary: ↑ pulse and ↑ or ↓ RR, ↓ BP, more frequent periods of apnea or agonal breathing, inability to clear secretions •Renal: ↓ urinary output + incontinence or retention •Skin: feverish or cold, mottling of extremities, pallor
Weeks before death s/s
Neurologic: ↑ sleepiness, possible delirium, dulled senses (except hearing) •Cardiopulmonary: ↑ pulse and ↑ RR, ↓ BP, Periodic apnea or agonal breathing, inability to clear secretions •Renal: ↓ urinary output + incontinence or retention •Skin: feverish or cold, possible perspiration, pallor
Which of the following nursing interventions will encourage the dying client to continue verbalizing?
Nod and use responsive comments such as "Yes."
A hospice nurse is visiting the home of a client who was recently diagnosed with a terminal illness. The nurse is developing the client's plan of care and is assessing beliefs and preferences about end-of-life care. The nurse would expect to complete this assessment at which time?
Over the course of several visits
TCAs (tricyclic antidepressants) side effects
anticholinergic effects, orthostatic hypotension, sedation, weight gain, tachycardia, sexual dysfunction
negative s/s of schizophrenia
blunted affect, poverty of speech, social withdrawal, poor motivation
mottling
changes in skin color (pale and bluish) of the hands, arms, feet, and legs when death is near
interdisciplinary collaboration
communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care
Moral dilemma
conflicts between two or more principes
MAOI contraindications
depression meds=hypertensive crisis
Seasonal affective disorder
depression that involves recurrent depressive episodes in a seasonal pattern
dyspnea
difficult or labored breathing
bereavement
period during which mourning for a loss takes place
grief
personal feelings that accompany an anticipated or actual loss
Tx of Seasonal Affective Disorder
phototherapy (cool white fluorescent light) bupropion
Rally
renew strength towards death
4th phase of therapeutic relationship
resolution: pt no longer needs services end of relationship
extrapyramidal symptoms
side effects of antipsychotic medications that affect a person's gait, movement, or posture, parkinsonism, akathesia, acute dystonic reactions
if given morphine they may get...
stool softeners
advanced care planning (ACP)
the medical interventions that one would or would not want in the case one is no longer able to voice one's own decisions
Mutual pretense awareness
the patient, the family, and the health care professionals are aware that the patient is dying, but all pretend otherwise
What happens to pt in OR w/ DNR status?
they resend it and 24 hrs after procedure they can go bck to DNR
veracity
truthfulness, honesty
what should be avoided w/ MAOI
tyramine
s/s of lithium toxicity
vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle weakness, twitching
crisis phase
when the client becomes physically aggressive
tx of postpartum depression
zarelso given over IV
AFTER-DEATH CARE
• Auscultate for absence of breathing and heart sounds(2 nurses have to listen for hospitals) • Urine and stool may be evacuated • Wash the body • Remove soiled linens • Remove tubes, IV's etc. • Place in semi-fowler position • Encourage visitation of family/friends - care of the family • Privacy should be honored • Bereavement Tray - some facilities -The hospice nurse will pronounce death of pt -body becomes dusky and blue may look waxy -if pt is going to have an autopsy, everything must stay in, things will be taken out by autopsy
EMERGENCY KITS for hospice
• Contain ready-to-administer doses of various medications • Small doses of oral morphine liquid for pain or shortness of breath • Benzodiazepine for restlessness • Acetaminophen suppository for fever • Family members can be instructed to administer • avoid prolonged suffering • Avoid re-hospitalization -may have Dilaudid or morphine -nurses have to do narc count
ASSESSING FOR ANTICIPATORY MOURNING
• Identify roles and relationships among the family members: • How autonomous/interdependent are family members? • What are the implicit and explicit expectations or "rules" for behavior within the family? • What is the family's ability to integrate new information? • What is the style of communication in the family • How able are the family members to assume new roles and responsibilities?
EXCEPTIONS TO PARENTAL CONSENT
• Mature Minor, some minors can make their decisions on treatment and must be 14 or older • Emancipated minor, legal capacity of an adult, maybe court order, financially independent, mother younger than 18, pregnant • Assent, they can agree, the age of assent depends on child's developmental level • Dissent, disagreeing with treatment • Refusal of medical treatment, only used when child's life is in danger
1st sign of HTN crisis
headache
what is the 1st phase of a therapeutic relationship
orientation: directed by nurse provide info to pt starts at admin
criteria for bipolar I
at least one episode of mania
nonmal
do no harm
bipolar onset is when
20s-30s
therapeutic range of lithium
0.6-1.2 mEq/L
Atypical Antidepressants
Wellbutrin, trazadone
working Phase of the therapeutic relationship
evaluate the client's progress towards meeting his goals
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following?
Participating in assisted suicide violates the Code of Ethics for Nurses.
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?
Prepare to treat any drug side effects.
The family of a dying client being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite?
Preparing cool or cold foods that may be better tolerated
orientation phase
Rapport building is our priority as we get to know our patient and plan the care that will occur in the working phase
NUTRITION INTERVENTIONS
Small portions of favorite foods • Cool foods may be better tolerated • Milk shakes, meal replacement drinks, liquid supplements • Place nutritious foods at bedside • Schedule meals with family members • Ice chips made of frozen fruit juices • Allow patient to refuse foods and fluids
escalation phase
The pt's responses represent escalating behaviors that indicate movement toward a loss of control s/s: pale or flushed face, yelling, swearing, agitation, hostility
A nurse is developing a teaching plan for a terminally ill client and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan?
The stages are applicable to any loss.
Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate?
There remains a conspiracy of silence about dying despite progress in the area.
A client is confused about advance directives and asks the nurse to explain them. What information will the nurse include in client teaching about advance directives?
They provide information about client wishes for health care situations. They may contain a living will.
A client has just died following urosepsis that progressed to septic shock. The client's spouse says, "I knew this was coming, but I feel so numb and hollow inside." The nurse should know that these statements are characteristic of what phase?
Uncomplicated grief and mourning
ARTIFICIAL NUTRITION AND HYDRATION
Unintended weight loss and dehydration are expected characteristics of progressive illness • Starvation should not be viewed as failure • Tube or IV feedings do not contribute to comfort • Survival is not increased • Symptoms of dry mouth, confusion do not improve with artificial nutrition They don't require as much food
A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, "I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family." Which emotional reaction does the nurse recognize that the client is experiencing?
acceptance
Living Will
a document in which a person states his or her wishes about life support and other treatments
persistant depressive disorder
a form of depression that is not severe enough to be diagnosed as major depressive disorder, at least 2 years
Physicians Order for Life-Sustaining Treatment (POLST)
a form that translates patient preferences expressed in advance directives to medical "orders" that are transferable across settings and readily available to all health care providers, including emergency medical personnel
Postpartum depression
a new mother's feelings of inadequacy and sadness in the days and weeks after giving birth 10-14 days
Neuroleptic Malignant Syndrome
a potentially fatal hyperpyrexia with temp of over 104, looks like EPS except for temp
catharsis
a release of emotional tension
double effect
a situation in which an action has both a positive effect and a negative effect
Closed awareness
a type of awareness in which the client is unaware of impending death
respite care
a type of care provided for caregivers of homebound ill, disabled, or elderly patients
hospice
a type of palliative care, focusing on comfort at the end-of-life.
Do Not Resuscitate
a written physician's order instructing healthcare workers to not perform lifesaving cardiopulmonary resuscitation -yellow paper
Uncomplicated grief and mourning
emotional feelings of sadness, anger, guilt, and numbness; physical sensations such as hollowness in the stomach and tightness in the chest, weakness, and lack of energy; and behaviors such as crying, visiting places that are reminders of the deceased, social withdrawal, and restless overactivity
3rd phase of therapeutic relationship
exploitation: makes full use of services offered
t or f: there are depression meds approved for pregnant women
false
Complicated grief and mourning
feelings of general worthlessness or hopelessness that persist, prolonged for longer than a year symptoms that interfere with ADL's, destructive behavior, suicidal ideation and/or attempts
The hospice nurse is providing care to a child experiencing pain during the dying process. Which action would the nurse include in the plan of care for the child?
frequently changing the child's position using a gentle touch
Kussmaul breathing
gasping, labored breathing, also called air hunger hyperventilation (with very deep, but not labored, respirations
show codes
half-hearted effort at resuscitation is made
positive s/s of schizophrenia
hallucinations, delusions, abnormal thoughts, bizarre behavior, confused thoughts
The nurse is providing care to a terminally ill client and his family who practice the Islamic faith. Which of the following concepts would the nurse need to integrate into this client's plan of care? Select all that apply.
he caste of the client and family will determine their view of death. The way a person dies is of great individual importance. Pain is viewed as a mechanism for cleansing. Death occurs through God's permission.
2nd phase of therapeutic relationship
identification: pts working w/ nurse
triggering stage of aggression
initiates client response s/s: restlessness, anxiety, pacing, irritability, rapid breathing
adverse reactions of MAOI
insomnia, wt gain, dry mouth, dizziness, tremors, liver toxicity
tardive dyskinesia
involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors
Multidisciplinary
is all of the doctors focusing on their specific part non coordinated care
slow code
knows what they're doing is futile and ppl take their time to get there bc they know it wont do anything
Moral distress
one is aware of correct action but hospital restraints stand in the way
Anticipatory Grief and mourning
opportunity for family members to reminisce, resolve relationships, plan for the future and say good bye