End of Life

Physician assisted Euthanasia

a practice whereby a physician provides a means to a patient with the knowledge that the patient will use the means to commit suicide

What drugs can you give to decrease secretions?

anticholinergic drugs=atropine

Intervention for agitation that is not due to pain

may select a neuroleptic drug, such as Haldoperidol (antipsychotic), instead of opioids, steroids, benzodiazepines due to adverse effects

A *durable power of attorney (DPOA)* is a person

who makes decisions about financial affairs for the patient

Common Physical Signs and Symptoms of Approaching Death (Chart 7-1)

。Cool extremities: (↓ perfusion) 。Increased sleeping: (↓ metabolism) 。Fluid and Food decrease: (↓metabolic needs) 。Incontinence: (relaxed perineal muscles) 。Congestion and Gurgling: ( coughing) 。Changed breathing patterns: (no breathing or shallow breathing) 。Disorientation: (slow circulation to brain) 。Restlessness: (↓metabolism and slow circulation to brain) --Reduced noise levels, dim lighting, do not restrain, consider sedation

Interventions of withholding or withdrawing life-sustaining measures

。Discuss this with family first 。Provide opioids + sedatives to reduce discomfort 。Silence alarms to focus on patient & not technology

Choice for family after death

。Organ or tissue donation? 。First component of post death ritual --Wake, view the body, funerals with music, prayers, funeral mass, eulogies 。Cremation or traditional burial & internment of the body 。Committal Service at grave, tomb or crematorium

Ethical Issues associated with End of Life care

。Principle of Double Effect 。Moral Distress 。Withdrawal of life-sustaining technology 。Organ and tissue Donation

Table 7-2 in book and Slide 12! Hospice VS Palliative Care

Hospice: 。6 months or more to live 。Curative treatment has stopped 。Care is provided in 60-90 day periods with an opportunity to continue if eligible 。Ongoing care is provided by RNs, Social Workers, chaplains, and volunteers Palliative Care: 。In any stage of a serious disease 。Consults are provided at times of considerations for curative treatment or therapies that prolong life 。Care is not limited by timed periods 。Care in form of consultations for recommendations for comfort care

Dehydration versus Overhydration

IV's may cause overhydration because of reduced heart function, which leads to increased amounts of fluid in the lungs, edema (ascites) and vomiting. *Dehydration when death is near causes dry mouth and thirst* --Provide sips of water or sprays of water into mouth

Psychosocial Management

。"Be with" the patient and communicate 。Respect cultural differences 。Be realistic 。Encourage reminiscence回憶 (reflect on memories) 。Promote spirituality 。Avoid explanations of loss 。Provide referrals to bereavement specialists 。Teach about physical signs of death 。Ensure symptom management with palliative care

Nausea & Vomiting in the Dying patient

。Anorexia breakdown of body fats, which results in ketosis, which to a sense of well-being 。IV or parenteral feedings *do not *improve symptoms or* prolong life* at the time of impending death 。*Nausea (without vomiting) is common*. --caused by constipation, bowel obstructions, slow gastric emptying, side effects of morphine --Compazine or Zofran is used 。Constipation - offer fleets enema or mineral oil enema with disimpaction

Direct causes of death

。Heart failure 。Respiratory failure 。Shock secondary to infection, blood loss, or organ dysfunction, that leads to lack of perfusion

Moral Distress

。Moral distress occurs when nurses cannot turn their personal moral choices into moral actions for the patient. 。This can happen when the nurse knows the proper course of action for a patient, but the institution makes it impossible to pursue that action 。Or when the nurse knows that a treatment will not help the patient, but the family insists that the treatment be provided.

Hypotension

As death nears cardiac output decreases 。Blood pressure decreases 。Pulse is often rapid (tachycardia) & irregular 。Extremities become cool to touch --Cyanosis of nail beds, skin and lips --Mottled color on skin of legs 。Renal perfusion decreases & kidneys stop functioning --Urine output is reduced

Death

Cessation of integrated tissue and organ function 。Lack of heart beat 。Absence of spontaneous respirations 。Irreversible brain dysfunction

Weakness Management during Dying

Dysphagia - if impaired ability to swallow --Risk of aspiration limit oral intake to sips and soft food and *do not replace with IV's etc. * Fluid replacement could cause respiratory secretions, edema, ascites, etc. *Dehydration is a natural process associated with dying* Choose alternate route for drugs if dysphagia

Principle of Double Effect

This is an ethical principle that involves taking an action that may have a good effect as well as a harmful effect. The harmful effects are not intended, but anticipated. --This occurs when an action has 2 effects, one good & one bad Example: The nurse provides opioids to relieve pain for someone who is dying (This is a good effect). However opioids cause respiratory and cardiovascular depression that could lead to death (This is a bad effect) *If the person dies due to the provision of an opioid intended to relieve severe pain, this is not active euthanasia* It is morally & legally permissible to administer opioids to relieve pain, while recognizing that the patient might die from the use of the opioids. However it is immoral and illegal to administer opioids, if the primary intention is to cause death in the patient.

Crying in the presence of families is considered。。

an expression of empathy and caring

What makes the distressed family interpret as a sign of pain ***

confusion, restlessness, that is accompanied with moaning, groaning, and grimacing. --but it is actually *agitation*

Dyspnea: Subjective Experience

。Described as shortness of breath (SOB), feeling of suffocation or tightness in the chest 。Common cause of distress and major cause of suffering --The final cause of death is lack of oxygen to the brain 。As death nears, respirations may either become fast or slow or shallow or labored. --*Cheyne-Stokes* respirations or Apnea ： Regular periods of deep rapid breathing followed by no breathes for 5 to 30 seconds 。Assess dyspnea by including onset, severity (0-10), precipitating factors, and quality --(i.e.. Time of day, position, anxiety, pain, cough, emotional distress)

After death

。Encourage the family to express grief from loss to prevent dysfunctional grieving later 。Resolution of grief begins with acceptance of the loss --This needs open, honest dialogue and opportunities to view, touch, hold or kiss the person's body 。Families are often comforted by the presence of nurses who cared for their loved one

Management of Refractory Symptoms of Distress

。In some cases when pain or other symptoms are unmanageable or unbearable during the last hours of life *palliative sedation* may be appropriate to lower the patient's LOC ---Examples of drugs used are: Versed, barbiturates, or propofol) 。The goal is *NOT* to hasten促進 death, but to relieve distress and provide comfort --*This is not considered Euthanasia安樂死***

Cultural Considerations

。Many ethnocultural & religious differences guide people to observe dying, death, & mourning ---Cultures tend to influence the rituals of mourning & support the grieving process For example: 。Prior to death the "Sacrament of the Sick" for Catholics 。Priests, ministers, chaplains & Rabbi visit loved ones and family & offer prayers to God 。Muslims prefer that someone from the patient's mosque performs a ritual of bathing the wrapping dead person's body in a cloth

Organ & Tissue Donation

。Organs and tissues can be procured after *cardiac or brain death* 。Federal law, Medicare, and the Joint Commission require that: --Hospitals must have written protocols regarding tissue and organ donation --Hospitals *must give* the family members the chance to authorize donation of their family member's tissues and organs

Dyspnea: Interventions

。Oxygen - 2- 6 liters NC, D/C O2 if not effective 。Opioids - Morphine is standard of treatment --Alters perception of air hunger and decreases anxiety --Dilates pulmonary vasculature and reduces pulmonary congestion --Start with 5 to 6 mg po q 4 hours during day and 10 mg at bedtime (or IV give 1 - 2mg every 5-10 minutes until relieved ) 。Bronchodilators for wheezing/ Steroids for bronchospasm and inflammation 。Diuretics (Lasix) for fluid overload 。Antibiotics = respiratory infection 。Drugs to decrease secretions (Anticholinergics - atropine) 。Suction oral mucosal - but this causes trauma to the mucous membranes 。Comfort measures --Elevate head of the bed; Cool room or provide a breeze with a fan; --Reduce the number of visitors at a time

Pain -What is safer for renal failure pts

。Pain is a common problem at the end of life (EOL) --Pain is subjective & influenced by emotions, past experiences & culture 。Pain should not be undertreated because of fears of addiction or respiratory depression 。*There is no maximum allowable dose of morphine.*** It should be increased to relieve patients of severe pain. --Meperidine/Demerol is not useful for chronic pain. --Consider long acting opioids, oral (rectal for dysphagia) --Short acting opioids - Morphine elixirs (sublingual, buccal mucosa or rectal) even to comatose pts. --Fentanyl citrate is safer for renal failure pts. It lacks active metabolites that tend to increase delirium.

Postmortem Care Iggy: Chart 7-6

。Provide care with respect 。Invite family to assist with care and allow for religious/cultural activities, chaplains 。If no autopsy = remove or cut tubes according to policy* 。Close the patient's eyes and insert dentures 。Wash as needed, straighten the patient, lower the head of bed to flat, place a pillow under the head 。Place waterproof pads under perineum to catch urine, etc. 。Clean the room 。Notify the hospital chaplain if requested by family 。Ensure that the death certificate has been signed 。Prepare for transfer to morgue or funeral home in a shroud with identification tags on extremities according to agency policy.

Prepare for the Event

。Provide opportunities to express preferences regarding where they want to die, for funeral & burial arrangements --This helps have a sense of control over the situation 。Provide opportunities to say "good bye" --as a part of the grief process 。Encourage family to stay with them during this time. Dying alone is one of the greatest fears expressed by patients.

Seizure Management

。Seizures are not usually common at end of life 。For those at risk (advanced AIDS,) provide around the clock drug therapy to maintain a high seizure threshold 。Benzodiazepine (valium) or phenobarbital --Given rectally or sublingual lorazepam oral solution

Nurse's Grief

。Taking time to grieve with the family over the loss of a patient helps prevent "blunting" of feelings 。Nurses who work with dying patients often experience "burn out, unexpressed grief, increased number of sick days, or post traumatic stress. They need counseling to work through their own feelings associated with death, grief, & loss

A person with a *durable power of attorney for health care (DPOAHC)* is identified in most ADS**

。This person makes health care decisions for the patient who loses the capacity to make his/her own decisions 。This does not happen until the physician states that the patient lacks the capacity to make his own decisions due to cognitive impairment 。A comatose patient does not have decisional ability

When organ donation follows Brain Death

。To keep the patient's organs perfused until removal of the organ maintain systolic blood pressure of 90 mmHg 。Maintain urine output of 30 ml/hr --Usually accompanied with IV's and dopamine 。Maintain oxygen saturation at 90% or greater.

Common Emotional Signs of Approaching Death (Chart 7-2)

。Withdrawal 。Vision-like Experiences - these are "not" hallucinations or drug reactions --Affirm these experiences 。Letting go - sometimes anxious behavior until loved ones say "It is okay to go" 。Saying goodbye - touching, hugging, crying, saying words of endearment (I love you, etc) can be comforting to all

More on Withholding or Withdrawing Life-sustaining Measures

An act of omission. Examples are discontinuing treatments that might prolong the life of a person who cannot be cured by the treatment. 。Mechanical ventilation 。Implantable cardiac defibrillators or pacemakers 。Hemodialysis

Euthanasia

signifies an action of killing for some humanitarian reason

Involuntary active euthanasia

the action to end the patient's life is taken without the patient's consent

Hospice care

。A philosophy and system of care for clients who have limited life expectancies 。Hospice uses an interdisciplinary approach to assess and address holistic needs of patient and family to *facilitate quality of life and a peaceful death.* 。Care is at home, long term care or assisted-living facilities, or hospice houses 。Most frequent users are patients with cancer, dementia, end stage COPD, cardiac and neurological diseases 。Medicare Hospice Benefits pay for services for Medicare recipients who have a prognosis of *6 months or less to live*. Medicaid or private insurance may pay for others 。Patients usually agree to forgo curative treatments.

Palliative Care

。A philosophy of care for life threatening diseases that assists with goals of care, assists with informed decision making, and facilitates *quality symptom management.* 。This type of care is offered in the form of consultations from physicians, nurse practitioners, or teams of interdisciplinary healthcare providers. 。Focus is relief of physical, mental & spiritual distress for incurable disorders for those who are not eligible for Hospice. 。The goal is to *prevent suffering to improve quality of life (QOL)* 。The goal is* not to "cure the patient"*, but for symptom management

Manifestations of Death Iggy: Chart 7-5

。Absence of respirations, pulse & heartbeat 。Fixed & dilated pupils, eyes may stay open with no blinking 。Muscles and sphincters relax --Release of stool & urine 。Waxen body color 。Body temperature drops 。Sounds of fluid trickling internally

Nursing Care for Comatose Patient

。Artificial tears, if unable to blink 。Lighting at low level 。Keep skin clean and dry 。Cover with a light blanket 。Use incontinent pads or pants 。Turn q 2 hours & maintain joint positions

Restlessness and Agitation Management

。Assess causes of agitation: --Pain? urinary retention? Constipation? Or other reversible cause? 。Consider delirium which is common towards the end of life = a syndrome manifested by changes in level of consciousness (LOC), attention, and cognition with an abrupt onset and a fluctuating course --Hypoactive (quiet) delirium --Agitated (noisy) delirium with yelling, hallucinating, etc. 。You may see confusion, restlessness, that is accompanied with moaning, groaning, and grimacing. This is distressful to the family, who often interpret this *as a sign of pain*

Living Wills -defi -EX

A type of AD that expresses the type and amount of care a person would want if incapacitated and near death Examples: CPR, artificial ventilation, artificial nutrition or hydration

Advanced Directives (ADs)

ADs - are legal written documents that allow a person of sound mind (competent) to plan for health care and financial affairs in the event of incapacity. The PDSA requires that a representative of every health care ask patients when they are admitted if they have a written Advance Directive

Withdrawing or withholding life-sustaining therapy

AKA passive euthanasia involves discontinuing one or more therapies that might prolong the life of the person who cannot be cured by the therapy ---This is supported by the ANA, AMA and many religious groups

Family Presence during Resuscitation

The literature indicates that families have a right to be present during resuscitation 。Being present helps with bereavement processes 。Being present *has not caused* them more anxiety, depression, or grief among families 。However, nurses who lack experience with resuscitation efforts report discomfort with families present

Aromatherapy

promotes relaxation and reduces anxiety --Lavender, rose, ginger, lemongrass, rosemary, etc.

Active Euthanasia

requires that healthcare providers take actions that purposefully and directly cause death of the patient. (drugs or treatments) --Nurses should NOT be involved with this activity. It is not supported by the ANA.