End of Life Care
Agitation/Restlessness = Delirium
Terminal Restlessness observable and characterized by the inability to rest - Frightening to pts /families since it I - Not generally reversible - Often associated with confusion Delirium may be related to: 1. Pain as the problem 2. Urinary retention 3. Or consider other multiple causes: hypoxia, electrolyte imbalance, septicemia, metabolic encephalopathy due to organ failure, psychological disturbances (fear), spiritual distress
In the US, while competent
The person has the legal right to decide about end of life care with some restrictions. EOL Controversies: Suicide/Assisted Suicide Futile Care -Pallative sedation
Non-pharmacologic Interventions
Therapeutic Touch Relaxation Techniques Guided Imagery Massage Superficial Heat or Cold Music If medication may cause death but it will achieve adequate symptom control, even if RR is less than 10 it is ethical in hospice
The nurse is caring for a patient whose spouse died two weeks ago. The nurse observes that the patient does not engage in active conversation and avoids eye contact. Which stage of grief is the patient in? 5. Denial 6. Anger 7. Depression 8. Acceptance
7
When going to the hospital, which forms should patients be encouraged to bring with them in case end-of-life care becomes an ethical or legal issue? 5. Euthanasia 6. Organ donor card 7. Advance directives 8. Do not resuscitate (DNR)
7
Difficult but Necessary Conversations...
Clarify the Issues with patient and family - What is your understanding of the situation? What did the doctor tell you? What would you like done if you are not going to get better? How much do you want to know and/or be involved in the decision? - Identify the Goal: Identify the Goal: Is therapy aimed at a cure or comfort?
Extended release opioids
Never be chewed, opened, or crushed. If can no longer swallow will need to be converted to another route (ER rectally; transdermal, subcutaneous or IV ). Avoid initiating Fentanyl (duragesic) patch in narcotic naive patients
MOLST & POLST
Provider Orders for Life Sustaining Treatment This is a Physician/APRN Order Sheet A Bright Pink or Yellow, medical order form indicating life sustaining treatment wishes for seriously ill patients. Puts treatment choices of a patient into actionable medical orders. Portable from one care setting to another. -no matter where you are, they don't want someone to do CPR
What does a patient have access to with hospice?
RN case manager that makes home visits 1 to 7x/ week Nurse's aid for 2 hours 5x/week Homemaker 2x/week Spiritual Care provider visits 1x/week Social worker 1-4x/week Volunteer 3x/week MD or ARNP home visit as needed What a hospice patient does NOT get? 24 hr care (Unless they pay for it themselves.) Hospice is at home and a hospice house is for pts that cant get relief at home
Typical Hospice Hospice House House RN Assignment
Rm 1 - Martha - 64 y/o with metastatic breast cancer, pain and dyspnea symptom management Rm 2 - Teresa - 89 y/o with end stage Alzheimer's, one week respite, daughter at wedding Rm 3 - James - 67 y/o with end stage COPD, multiple falls at home Rm 4 - Jack - 77 y/o transferred from the ER actively dying s/p CVA Rm 5 - Arnold 53 y/o small cell lung cancer with delirium
Asthenia
weakness
The family attorney informed a patient's adult children and wife that the patient did not have an advance directive after he suffered a serious stroke. The nurse recognizes that the person who is responsible for making the decision about end of life measures when the patient cannot communicate his or her specific wishes is which of these? 5. The patient's wife 6. A notary and attorney 7. The primary health care provider 8. Such decisions cannot be made if the patient is unable to communicate.
5
The nurse cares for a patient in the terminal stage of leukemia who has opted for hospice care. When is the patient considered to be eligible for hospice care? 5. When two primary health care providers certify that the patient has less than 6 months to live. 6. When a primary health care provider certifies that the patient has less than 6 months to live. 7. When it is certain that the patient is going to die within 9 months. 8. When one primary health care provider guarantees that the patient cannot recover further.
5
A nurse finds that a terminally ill patient has cold, clammy, and wax-like skin. What should the nurse infer from this assessment? 5. The patient is improving. 6. The patient is likely to die soon. 7. The patient has edema and needs diuretics. 8. The intravenous fluids have extravasated.
6
A terminally ill patient has become confused, disoriented, and restless. The patient is incoherent and has clouding of consciousness. The nurse identifies that the patient has had constipation for 3 days. What action should the nurse take next? 5. Obtain a prescription for a benzodiazepine. 6. Administer laxatives to treat constipation. 7. Do not take any measures as this is normal during the terminal stage. 8. Inform the family members that the patient is breathing the last breaths.
6
A patient is admitted to a hospital with Cheyne-Stokes respirations. What would the nurse expect the assessments findings to reveal? 5. A respiratory rate of less than 5 breaths per minute 6. A respiratory rate of more than 30 breaths per minute 7. Alternating periods of apnea and deep, rapid breathing 8. Noisy and congested breathing
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A patient with bronchial carcinoma reports anorexia and nausea. What measures should the nurse implement to help this patient? 5. Provide large meals twice a day. 6. Offer bland food with spices. 7. Provide small portions of favorite foods. 8. Immediately put the patient on intravenous fluids.
7
The nurse provides care on an oncology unit and is discussing the difference between hospice care and palliative care with the patient's family. What is an appropriate explanation by the nurse? 5. Hospice care involves only chemotherapy that is given in a hospital. 6. Hospice care involves radiation therapy and chemotherapy that are given in a hospital. 7. Hospice care is provided after a person decides to forgo curative treatment. 8. Hospice care allows a person to undergo both curative and palliative treatment together.
7
There has been improvement in the health of an elderly patient who has been in hospice care for 6 months. What should the nurse suggest to this patient? 5. The patient can leave hospice care only when the primary health care provider allows doing so. 6. The patient must continue for another 6 months in hospice care before leaving. 7. The patient is in hospice care and is not eligible for curative treatment. 8. The patient can withdraw from hospice care and can receive other health services.
8
A patient in the terminal stage of acute myeloid leukemia has become unconscious. On examination, a nurse finds that the patient's mouth is very dry. How would the nurse help the patient to restore the moisture? Select all that apply. 6. Give ice chips. 7. Give sips of fluids. 8. Use moist cloths for the oral mucosa. 9. Apply lubricant to the lips and oral mucus membrane as needed. 10. Provide complete and regular oral care.
8, 9, 10
A nurse is providing care to a terminally ill client who admits to experiencing dyspnea. Which of the following would be the best to do to assess the severity of the client's symptom? a) Ask the client to rate the dyspnea on a scale of 0 to 10. b) Have the client state if the dyspnea is mild, moderate, or severe. c) Question the client about when the dyspnea eases or worsens. d) Auscultate the client's lung sounds for changes.
A
Other Strategies to Promote Comfort in Patients at EOL
Avoid Lab Draws Avoid Diagnostic Workups Avoid IV insertions Avoid IM/SC injections Avoid IV Fluid - risk of overload Avoid Deep Suctioning Avoid Tube Feeding in actively dying pt.
Treatment of Pain at EOL
CONTINUE ALL ANALGESICS LONG ACTING ANALGESICS ARE PREFERRED AS LONG AS PT HAS OPIOID TOLERANCE! - Use simplest dosage schedules and least invasive modalities first - 1) oral morphine liquid - 2) long acting oral morphine with bowel meds - Recognize dose limits of non-opioid - Acetaminophen (Tylenol) is limited to 4 gm/24hrs.
Caring for your First Dying Patient
Can provoke deep emotion. Seek out post-clinical debriefing Tell the story of the death and express your feelings related to the experience. Remember that tears can be a normal, nonverbal expression of feelings related to loss.
Capacity vs. Competence
Can the person... Understand the subject /decision? Understand the consequences/importance of the decision? Make and communicate rational choices?Generally speaking in health care we are referring to "capacity" to mean lacks the ability to make reasonable medical decisions. If no DPOA-HC, then may need to be referred to the legal system (a court/judge) for a "competency"hearing as may need to have a guardian appointed so that someone can make decisions.
Sources of Pain at EOL
For cancer patients Tumor invasion of organ or bone Nerve compression/destruction Obstruction by tumor Occlusion Muscle spasm Treatment related - neuropathy, fibrosis, enteritis, post herpetic neuralgia, stomatitis For other patients Complications of Immobility Joint pain - Backaches - osteoporosis, osteoarthritis, compression fractures Neuropathic Pain -PVD, per
Support for the nurse
Formal Debriefing - team or individual Acknowledge limitations Ask for help Journal writing Exercise Relaxation Socialization Hobbies Play
Other Nursing Interventions Encourage Communication:
Maintain a calm unhurried presence Pay attention to non-verbal cues Don't be afraid of conversation or of silence Be sensitive to cues Ask open ended questions: be willing to ask how the patient is feeling Listen
What is being done to improve the dying experience?
More emphasis on Advance Directives Increase Hospice services -(gold standard for quality EOL care) Increase Palliative care services Education for MDs & RNs on quality EOL care -More books, clinical placements, addition of EOL content to curricula
Primary Treatment of Dyspnea
Morphine (or other opioids) is/are the standard treatment for dyspnea near death Intended effects: Decreases the patient's perception of breathlessness, reduces respiratory drive, reduces oxygen consumption Side effects: May decrease respiratory rate, leading to increase in CO2 and arterial pH, with a decrease in O2 sat, may compromise patient's respiratory status Will cause somnolence
Interventions for Terminal Agitation/Restlessness / Delirium
Nursing Interventions: 1. Maintain Patient Safety 2. Requires ATC treatment with meds Meds May Include: Haldol PO Q8hrs ATC Lorazepam (Ativan) Q 6-8 hrs ATC Beware: ativan may worsen s/s of delirium!
Common Patient Goals in Hospice...
Pt will maintain dignity until death occurs. Pt will not experience pain, nausea, dyspnea, delirium, or other distressing physical symptoms. Pt will verbalize acceptance of death. In addition to Pt will not experience a fall or injury Pt's skin will remain intact.
Hospice Interdisciplinary Team
Family caregiver must assume responsibility for 24 hr. direct care -RN available for consulting (but is NOT present 24 hrs/day)!!!!!!! -In private homes, a hospice house, or long term care facilities. - Services include: nursing, medical, social services, spiritual care, bereavement, volunteers - Patient and family are single unit of care
Pain at end of life
Feared most about dying Unrelieved pain can consume the attention and energy of those who are dying, and cause despair A common symptom which can be controlled using standard treatment in > 95% cases Can decrease, increase, or remain at same level at EOL
Patient Self Determination Act
Requires providers to tell patients what their state provides in form of an advance directive Requires hospitals to inform patients of their right to accept or refuse medical treatment and to draw up advanced directives Does not require patients to have or draw up advance directive
Identify the Need for Spiritual Support:Spiritual Support
Spiritual assessment to identify what is important to patient ((It may NOT be religionIt Offer & arrange clergy visits If spiritual distress exists, acknowledge the pain & encourage verbalizationthe Arrange for appropriate religious rituals
Nursing Interventions for Grieving
a. Presence, active listening, touch, silence b. Identify and facilitate support systems c. Use of bereavement specialists, bereavement resources d. Normalizing grief process and individual differences e. Identifying and expressing feelings g. Disenfranchised grief-acknowledgment h. Public funerals, memorial services, rites, rituals and traditions; private rituals i. Culturally Sensitive Spiritual care j. Identifying need for additional assistance and making referrals
Morphine in narcotic naive pt
Start with small doses Increase morphine dose if ineffective Request ER morphine if pt, requires > 6 rescue doses/24hrs. Severe pain often better managed with IV morphine (monitoring RR and LOC)
A patient is admitted to the palliative care unit after having an unsuccessful kidney transplant surgery. The nurse in charge is educating the caregivers about appropriate symptom management. Which statement made by the nurse is accurate?
Surround the patient with familiar sounds, sights, and smells incase delirium occurs
Criteria for Ethical Communication of Information
The communication should be - Timely and desired by the patient - Accurate - Understandable to the patient and family - Conveyed in a "gentle, respectful, and compassionate manner"
Anorexia
loss of appetite
Bereavement
state of sorrow over the death or departure of a loved one
Role of the nurse in EoL care
"Nurses play an extremely important role in assessment of symptoms and control of pain (and suffering) in dying patients because they have the most frequent and continuous patient contact."
The IOM defined a "good death" as one that is:
"free from avoidable distress and suffering for patients, families, and their caregivers; in general accord with the patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards." What most people say they want: 1. To be free of pain. 2. 70% say they want to die at home with loved ones present. 3. Families say they want their family members "to be the same person they knew" and "comfortable."
Advance Directives
1. Living Will 2. Durable Power of Attorney for Health Care (DPOA - HC) 3. Medical Directives such as Do Not Resuscitate (DNR) Forms & Statues vary from state to state RN responsible to know state laws Ideally drawn up prior to hospitalization or crisis Drawing them up is a process NH advanced directives
Which of the following should the RN recommend the patient try from his "hospice E-kit" when he states his pain is 8/10? a) Oral Haldol liquid b) Oral Morphine liquid c) Oral Acetaminophen d) Oral Atropine sulfate drops
B
What are the primary differences between an Advance Directive and a POLST form?
ADVANCE DIRECTIVE •For anyone 18 and older •Provides instructions for future treatment •Appoints a Health Care Representative •Does not guide Emergency Medical Personnel •Guides inpatient treatment decisions when made available POLST For persons with serious illness — at any age Provides medical orders for current treatment Guides actions by Emergency Medical Personnel when made available Guides inpatient treatment decisions when made available Maybe we are using the wrong terminology? DNR Do not resuscitate AND Allow natural death
Hospice e-kit
Acetaminophen (Tylenol) suppository Morphine oral concentrated liquid Prochlorperazine (Compazine) tabs & suppository (treats N/V or anxiety) Lorazepam (Ativan) oral tabs Haloperidol (Haldol) oral liquid (antiphycotic) Atropine oral drops (increases HR) Only stay on meds that help your quality of life (does it increase you comfort)
Why is "date of LBM" so important in hospice???
Bc morphine is the standard treatment
Medical Directives state what a patient would or would not want in specific circumstances such as:
DNR (Do Not Resuscitate) Often decided during hospitalization but some states have out of hospital DNR (POLST = "portable DNR") Means that if a patient cardiac arrests, CPR will not be employed How effective is CPR? 12% for cardiac arrests that occur outside hospitals and between 24% - 40% for those that happen in the hospital
What's the difference?
DPOA Trusted person makes decisions for pt who cannot (i.e. pt is confused or in coma) Need MD order to activate it Living Will The patient describes what they would or would not want in circumstances at the end of life. Is usually just at end of life.
A nurse taking care of a patient receiving palliative care feels that the patient is uncomfortable with the caregivers' choices. What course of action should the nurse take to alleviate the feeling of moral distress when even the primary health-care provider agrees with the caregivers?
Discuss the situation with another nurse
Phase 2 - Interventions
Intervention phase to improve end-of-life decision making and to reduce the frequency of mechanically supported, painful, prolonged dying in seriously ill hospitalized clients. MDs were provided estimates of client 6-month survival, estimates of outcomes for CPR, and estimates on functional disability for clients at 2 months Specially trained RN made multiple contacts with clients, families, physicians, and hospital staff to elicit preferences, improved understanding of outcomes, encourage attention to pain control, and facilitate advance directives planning and client-M.D. communication
Additional treatments for Dyspnea
Oxygen for dyspnea is not a standard of care for all individuals with dyspnea at EOL -depends on clients perception of the need and perception of its effect Lorazepam (Ativan) Furosemide orally, IV, SC or IM prn s/s heart failure Albuterol via MDI or nebulizer prn wheezing -Drying agents -hyoscyamine -scopolamine -atropine
EOL symptoms
Pain Weight loss Weakness/fatigue anorexia insomnia constipation depression dyspnoea anxiety
Which service is needed???
Palliative Care Anyone with a serious illness, regardless of life expectancy, can receive palliative care You may receive palliative care and curative care at the same time Some treatments and medications may be covered by insurance Where are services provided? -Home, Assisted living facility, Nursing facility, Hospital Hospice Care Someone with a life expectancy < 6 months Only treatments and medicines aimed at relieving symptoms are provided by hospice Medicare and/or Medicaid pays ALL charges related to hospice Where are services provided? -Home, Assisted living facility, Nursing facility, Hospital, Hospice House
Models (besides acute care) to Guide EOL Care
Palliative Care Hospice
Signs of Impending Death(Weeks to Days Weeks to Days before Death)
Some or all of the following: Lack of interest in food and drink Difficulty swallowing Increased sleeping Social withdrawal Restlessness Increasing confusion about time and place Pain may increase, decrease or stay the same
Cachexia
a condition of physical wasting away due to the loss of weight and muscle mass that occurs in patients with diseases such as advanced cancer or AIDS
Dying in the US...We Still NEED To Do Better!
-characterized by poor non-existent communication about goals of medical care -often involves physical suffering due to.... underreporting pain, under prescribing of pain medication and understanding of pain meds -characterized by lack of concordance of care with patient and family preferences
Poor Appetite Near the End of Life
"A decrease in appetite near the end of life is normal and expected." "We will continue to offer food and fluid to your loved one, but it is okay if he/she declines it."
Summary of Grief Responses
1. Anticipatory Grief May occur when a death is expected. Anticipatory grief may help the family but not the dying person. (does not always occur.) 2. Normal Grief - Normal or common grief begins soon after a loss and symptoms lessen over time. 1. Many bereaved people will have grief bursts or pangs. 2. Numbness, shock, loss of appetite, guilt, dreams, anxiety 3. Complicated Grief There is no right or wrong, but some responses are very different: Chronic grieving or Minimal grieving
Postmortem Care
1. Pronouncement - absence of pulse & respirations by RN or MD or ARNP. 2. Documentation on Death Certificate. 3. Express sympathy for the family "I am sorry for your loss." 4. Allow family to mourn however they wish. 5. Ask family if they would like to say a prayer. 6. Possibly offer family time alone with deceased. 7. Notify MD, family, organ bank and funeral home. 8. Ensure that deceased is clean; remove IV tubing, foley, etc. --> If no autopsy 9. Replace dentures, attach ID tags/shroud per agency policy
A family is considering hospice for their loved one who is terminally ill, but they are concerned that they cannot afford hospice care. Which response by the nurse is accurate? 1. "The hospice program usually has a small co-pay." 2. "The hospice provides better quality of care than the family can." 3. "The hospice assists with curative treatments for dying patients and their families." 4. "The hospice Medicare program pays for all equipment and medications that are related to the patient's primary hospice diagnosis."
4
A family member of a patient who is nearing death expresses that the patient is having audible and irregular breath sounds. Which explanation to the family member is appropriate? 1 The irregular sounds will improve with regular suctioning of secretions. 2 The issue could be due to an incorrect position. 3 The irregular breathing will likely correct itself in a short time. 4 The issue is caused by accumulation of mucus or fluid in the airways.
4
The nurse finds that a terminally ill patient is experiencing nausea and vomiting. Which would be an appropriate nursing action? 1. Encourage or provide three big meals rather than small frequent meals. 2 No action is required, as this issue is common during the last days of life. 3 Prevent family members from bringing home-cooked food, which might overwhelm the patient. 4 Administer antiemetic drugs before meals, as ordered.
4
A nurse who does not believe in God is caring for a terminally ill patient. The patient asked the nurse to arrange for a pastoral visit. What action should the nurse take? 5. Arrange for a chaplain. 6. Refuse to arrange for a chaplain. 7. Share views about God with the patient. 8. Educate the patient about atheism.
5
The caregiver of a patient with chronic illness experiences grief after the death of the patient. The caregiver recalls positive memories of the deceased patient, and the nurse notices that the caregiver is accepting the reality of the death of the patient. What type of grief does the nurse identify in the caregiver? 5. Adaptive grief 6. Anticipatory grief 7. Complicated grief 8. Prolonged grief disorder
5
Hospice
A philosophy of care stressing comfort care as opposed to curative care. Uses an interdisciplinary approach to address physical, social, emotional, and spiritual needs of patient and family For individuals in the last phase of life (<6 months) due to a life-limiting, progressive disease Does not provide interventions to cure or prolong the disease!!!!! -can not be looking for curative treatments Affirms life and regards dying as a normal process that is neither hastened nor postponed Family gives the meds in hospice and 24 hr care is not given but you can call
Signs of Impending Death(Days to Hours Days to Hours before Death)
All or some of the last slide and... Change in the breathing pattern Cheyne-stokes, agonal, gurgling, periods of apnea Respirations may sound moist Patient may feel cool to touch Skin may be pale or mottled Incontinence or decrease/no urine output Visions of people not visible to others Hearing and vision may deteriorate May be unable to respond to touch or sound Example - When will he die?
Durable Power of Attorney for Health Care (DPOA)
Allows a person to appoint a decision maker (proxy) in the event of future incapacity. Applies only if person is unable to make his/her own decisions (is incapacitated), not just EOL! Is activated and deactivated by HCP not judiciary.
Living Will
Advance Directive that states that the patient would not want life prolonging procedures... if s/he were known to be dying "No, do NOT start tube feedings if I am unlikely to get better..." Yes, I DO want CPR, but do NOT put me on a ventilator if I am unlikely to get better..." Copy should be in client's home, medical record at M.D. office and hospital medical record Is not the same as a DNR
What happens when a patient can no longer speak for himself (lacks capacity)?
Advanced Directives: Written method for patients to plan and communicate their care & treatment choices when they can no longer speak or think for themselves based on the principle of autonomy.
HCP behaviors that can enhance family satisfaction during EOL Decision Making
Assuring the family the patient will not be abandoned by the health care team. Assuring the family that we will do everything to try to ensure the patient will not suffer. Providing support for the family's decision whatever the family decides.
The nurse is providing palliative care to a patient who is in the last stage of cancer. What does the nurse monitor in the patient as part of neurologic assessment? Select all that apply. A. Urine output B. Pupil response C. Nutritional intake D. Presence of reflexes E. Level of consciousness
B, D, E
Principle of Double Effect
Distinguishes between the primary therapeutic intent - to relieve suffering -, and the possible side effect/outcome (e.g. sedation, loss of consciousness, and potential for accelerated death). However, studies have shown that providing symptom relief does not always ally shorten the patient's life span---in fact in some cases it prolongs it slightly
So, who should decide about end of life care for a patient?
Do you believe the physician should? -Paternalism Do you believe the person should? -Autonomy or Respect for persons Do you believe the family should have input This is a non-Western perspective May be considered beneficence
Morphine
Drug of Choice Multiple Routes No Ceiling Tx for Dyspnea Familiar to HCPs May cause nausea and constipation
Dyspnea at EOl
Dyspnea is subjective - SOB is objective Occurs in up to 50% of dying patients A marker of the terminal phase of life Invokes fear /anxiety Difficult to control
Assessment of breathing and risk for dyspnea
Gurgling/rattling - Periods of Apnea -"Chain stokes" respirations - Agonal respirations - Assess for: respiratory infection bronchospasm (diminished breath sounds or wheezing) fluid overload (ascites, peripheral edema, crackles on auscultation)
Why are Dying Patients Suffering?
Health Care System is based on Acute Care Model Americans' aversion to death leads to avoidance of discussion of end of life issues Lack of discussion about Advance Directives and/or non-adherence Fear of litigation Lack of training by medical and nursing schools Underutilization of palliative care experts (IOM)
The nurse is providing physical care to the end-of-life patient who remains in a state of confusion, incoherence, and anxiety and often hallucinates. The nurse anticipates that the patient's condition is caused by the administration of opioids and corticosteroids. What nursing management does the nurse implement for this patient? Select all that apply. F. Assess for spiritual distress. G. Encourage consumption of ice chips. H. Assess the patient's tolerance for activities. I. Stay physically close to the frightened patient. J. Provide a room that is quiet, well-lit, and familiar.
I, J
When Patients can no longer safely take PO
IV infusion with IV pump with PCA Subcutaneous infusion with SC (ex = CADD) pump with PCA If Too lethargic, sedated, delirium, CVA, dyspneic: 1) Sublingual 2) IV route - If pt has a central line 3) Rectal - Macy Catheter 4- subcutaneous infusion Usually avoid starting a peripheral IV or inserting PEG
Health Care Surrogate Decision Maker Law
If the patient lacks ability to make decisions AND Does NOT have a DPOA, guardian, or designated health care proxy identified... SOME states (44) have enacted a law that allows close family members to make decisions -In order: spouse, adult children, aunts/uncles, grandchildren, close friends -Not available in NH until 2015 -Currently not available in MA
Dying in the USA
Less than 10% die suddenly and unexpectedly. - Example - MVA More than 90% of people die after a long period of illness, with gradual deterioration, until an active dying phase at the end. Leading cause of death is heart disease and cancer
Pathophysiology of Dying
Inadequate blood flow to body tissues deprives cells of their source of oxygen, which leads to anaerobic metabolism with acidosis, hyperkalemia, and tissue ischemia. Dramatic changes in vital organs leads to release of toxic metabolites & destructive enzymes. This sequence is referred to as multiple organ dysfunction syndrome. Multi-system organ dysfunction occurs first in the liver, heart, then brain In patients with septicemia, it also occurs in the lungs. A lethal dysrhythmia such as ventricular fibrillation or pulseless electrical activity can occur at any point during the process of shock and/or hypoxemia, which ultimately leads to the cessation of cardiac output. Shortly after cardiac arrest, respiratory arrest occurs; when respiratory arrest occurs first, cardiac arrest follows within minutes.
A registered nurse is teaching a patient about palliative care (PC). Which information about PC stated by the patient indicates a need for further teaching? "It focuses on relief of pain and stress associated with a severe illness." "It is provided in hospital, outpatient, and community settings." "It focuses on the care of terminally ill patients with less than 6 months to live." Rationale: Hospice care focuses on the care of terminally ill patients with less than 6 months to live. "It is given simultaneously with curative treatment that meets the patient's goals."
It focuses on the care of terminally ill patients with less than 6 months to live
Teaching Family about Morphine
It is NOT the most potent medication available and its effect is related to the dose It is started at very low and safe doses It is used because it works quickly It is often taken by patients with pain or dyspnea for YEARS Sedation often decreases after few days Need laxatives with opioids
Who decides when you die?
It's hard enough for a dying patient to declare an end to medical intervention. It's far harder when anguished loved ones disagree
Seizures
Know who is at risk Give anti-convulsants ATC to prevent seizure - consult with MD If seizure activity: Diastat (Diazepam) rectal gel, or (Lorazepam) Ativan
Support the family
Learn who is "family" Help the family to say goodbye—show family members how to be with this person at this time Respect cultural and religious beliefs Prepare family members for the death Be present with the family during the death, if possible
Goals of Treatment of Pain
Patient Verbalization of pain control, rated 0-2 and/or verbalization of comfort Absence of grimacing, guarding, moaning Acceptable sedation RR 10 - 20 No nausea No myoclonus
Assessment of EOL pain
Patient's Goal: Is it to be pain free? Pain History - disorder, medications, treatment (massage, manipulation) Pain description - characterize, rate on 0-10 scale;
Evidence of Poor Quality of Life Near Death
Phase 1 Collection of Data only (no intervention) Results: 50% of patients suffered moderate to severe pain for a majority of the time (as reported by family) •Only 47% of MDs knew when their patients preferred to avoid CPR •38% of clients who died spent at least 10 days in an ICU. -costs 10,000 to keep someone alive in the ICU
Palliative care
Philosophy of care with goal of preventing and relieving suffering through management of symptoms from early through the final stages of an illness. Provides active and compassionate therapies. No specific therapy is excluded from consideration. "Palliative Care is...""An extra layer of support for you as you deal with this illness." "Work WITH your current doctors .You lose nothing. Potential for increased comfort."
Hospice
Plan is for no further treatment, which usually means no further hospitalization Patient can change their mind, hospice benefit is then revoked "Hospice" often translates into being on a specific insurance benefit -However - palliative care has no specific insurance benefit -Medicare Hospice Benefits - requires M.D. to sign document stating < or = six month life expectancy or - Requires patient to give up hospital benefits - Does not mandate patient sign DNR- -Pays for ALL meds, medical equipment and care r/t dx !!!!!
Bleeding at EOL
Prepare family for possibility Instruct them to obtain dark towels Client should be medicated with analgesic or sedating medication if bleeding occurs
Which is true regarding physical and psychological changes in the early stage of death?
Pt may not experience hunger or thirst as the body slows down
A Good Death - The Future of Health and Care of Older People
To know when death is near, and to understand what to expect. To be able to retain control of what happens. To be afforded dignity and privacy. To have control over pain relief and other symptom control. To have choice and control over where death occurs (at home or elsewhere). To have access to info and expertise of whatever kind is necessary. To have access to any spiritual or emotional support required. To have access to hospice care in any location, not only in hospital. To have control over who is present and who shares the end. To be able to issue advance directives which ensure wishes are respected. To have time to say goodbye. To be able to leave when it is time to go, and not to have life prolonged pointlessly.
Poor Appetite Nausea/Vomiting
VERY common at the end of life:Possible PRN medication choices for management: Zofran (Ondansentron) Prochloperazine (Compazine) ATC Metochlorpramide (Reglan) (don't use if obstruction is complete or with colicky abdominal pain.) ABHR (Ativan, Benadryl, Haldol, Reglan) - compounded; very effective but causes significant sedation
Having a GoalGoal Guides EOL Therapies
What is the goal? - (To die comfortably? To stay alive until......? To beat this illness?). Is the intervention going to make the desired outcome more likely? Is the intervention going to cause harm or discomfort? - IV fluid can cause pulmonary congestion, edema, full bladder/urgency to void -To treat UTI or not?
Common Questions about Advance Directives
Who should I name as my proxy/DPOA? If I complete an Advance Directive, can I change my mind? If I change my mind, what should I do about my Advance Directive? Does my religion have a position on end of life care and advance directives? But only about 33% of American adults actually have a living will If incapacitated, who will make decisions?
Difficult Decisions at EOL
Withholding artificial nutrition and hydration Withdrawal of ongoing interventions (dialysis or ventilators) Pain and symptom management Sedation Where and how to receive care
What about inserting a foley catheter at the end of life?
Yes bc it could relieve symptoms When Symptoms Symptoms are Controlled... There is often a shift in focus from biomedical to psycho social - spiritual Patients are free to address their "final agenda"
Supporting Anticipatory Grief
a. Emotional support b. Encourage verbalization c. Assist with role change, education and/or resources d. Encourage life review e. Educate the patient/family about dying process f. Encourage patient/family to complete unfinished business g. Provide presence, active listening, touch and reassurance
