Growth & Development 2/End of Life

Technology & End of Life Care: -What is a major cause of death? -place of death shifted to hospitals & care facilities nowadays. (distances family from the death experience) Technology has created numerous ethical issues -"because we can prolong life, does it necessarily mean we should?" Is a controversial question Sociocultural Context: -Death Denying (we don't like to talk about it) Common Perceptions: -cure is the ultimate goal, alleviating suffering is not as valuable. -failure of curative treatment is not synonymous with nursing failure, it is synonymous with client failure. Ex: if a pt codes and they die, the nurse may think they did something wrong. The pt was just going to code anyways. Not the nurses failure. -comfort focused care will result in lesser quality care. "Nothing more can be done". Shift towards end of life care. Focus on comfort.

-chronic, degenerative disease is major cause of death.

Assisted Suicide: -Refers to providing another person the mean to do what? Aka what? -Prohibited in the majority of states, there is very strict criteria. 1.) Who is not involved in assisted suicide? -it is a violation of what? Proponents: terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives & timing/circumstance of their deaths. Opponents: greater access to symptoms management/psychosocial support for people approaching end of life

-to end his or her own life. Aka "physician assisted suicide" if someone is diagnosed with a terminal disease, physician can prescribe a lethal dose that the pt can take at their choosing after going through the process. 1.) Nurses are not involved -a violation of the Code for Nurses by the ANA

Hospice Care: What is it? -Focus is still on comfort of the pt. Difference between this & palliative care is that we are done with life prolonging treatments/interventions. End of life is near, they are terminal. We focus efforts on making them comfortable. -is defined as a coordinated program of interdisciplinary services provided by professional caregivers and trained volunteers to pts with serious, progressive illness that are not responsive to cure. 1.) What is the media length of stay in a hospice program? -most are allowed to be on hospice when they have a life expectancy of how long? Principles of hospice: -death must be accepted -pt's total care is best managed by an interdisciplinary team whose members communicate regularly. Ex: nurses, therapists, pastors, etc. Work together to make their last bit of time meaningful. -pain/symptoms of terminal illness should be managed -involve family -home care of the dying is necessary, & bereavement care must be provided to family members. Hospice Care Eligibility: 1.) There must be what present with the pt? 2.) If pt is at home, there must be who present when pt is not longer able to safely care for themself? 3.) The pt needs to understand they will no longer be receiving the traditional what? 4.) to be on hospice, you must have a life expectancy of what? -if a person lives greater than 6 months, which can happen, they can stay on hospice as long as they have approval from who saying what? 5.) Care must be provided by who? Hospice Care Eligibility & Benefits: -eligibility must be reviewed periodically -benefits continue as long as provider certifies presence of terminal illness with a life expectancy of 6 months or less -if someone says, I thought I was ready for hospice, but I'm not I am still wanting to fight the disease. You can revoke the hospice benefits at any time & resume traditional coverage under Medicare/Medicaid for the terminal illness. Hospice Services & Benefits: -Nursing care provided by or under the supervision of RN, 24 hours a day -physicians services -home health aide/homemaker -physical, occupational, speech therapists. Someone can still go to therapy with a terminal illness if they are still mobile & it benefits them. -bereavement follow up for up to 13 months after death of pt for the family. Reinforces that hospice is taking care of family & pt

1.) 17.4 days. -6 months or less Hospice Care Eligibility: 1.) a serious, progressive illness & be aware/informed of this & they will no longer be receiving cure focused care 2.) a caregiver should continually be present 3.) Medicare/Medicaid benefits due to their terminal illness. Ex: if someone becomes septic, we won't give them a bunch of fluids & give them meds to get their BP up. If we run into these issues, we won't address those issues. If they need to go to hospital for something to increase their comfort, they can get treatment to increase their comfort, but won't be to save their lives. 4.) 6 months or less. -if they have approval from a physician certification of the terminal illness. That it is still present & they still expect them to pass within 6 months. 5.) by a Medicare certified hospice program

Managing Physiologic Responses: Delirium 1.) a disturbance in LOC, psychomotor behavior, memory, thinking, attention, & sleep/wake cycles -let family know this is okay, remain calm when talking to them, keep them safe during this periods of delirium. -pt's can have a good day where they are alert and then die. Can cause families to be hopeful that pts are getting better. Educate family on this -keep family in mind, acknowledge this can be distressing 2.) If underlying cause is not treatable, medications such as haloperidol/lorazepam can help reduce anxiety. Ex: if it is caused from a UTI 3.) Nonpharmacologic things: confusion may mask fear of dying. Provide music, gentle massage, spiritual intervention, etc.

1.) Delirium. Ex: can have someone who is agitated, be confused, may say wild things, not recognize family, etc. we don't know how this will affect each person.

1.) Refers to the personal feelings that accompany an anticipated or actual loss 2.) Refers to individual, family, group, & cultural expressions of grief/associated behavior 3.) Refers to period of time during which mourning for a loss takes place -grief/mourning behaviors change over time as people learn to live with the loss -loss is an ongoing developmental process. Time does not heal the bereaved individual completely 5 Stages of Grief: -not every pt or family member experiences every stage. Many pt's never reach acceptance -pt's/family members stage can fluctuate on a day to day basis -can move forward, backward, or skip stages. Does not have to be in order. 1st Stage: Denial -"this can't be true" feelings of isolation, may search for another health care professional who will give more favorable opinion, may seek unproven therapies. (Don't contradict this, let them express themselves) 2nd Stage: Anger -"Why me?" Feelings of rage, resentment, envy towards God, family, nurses, etc. 3rd Stage: Bargaining -"I just want to be able to.." Pleading for more time to reach an important goal. Ex: if I do chemo, I'll make it to my grandson's graduation. I'll do this, so I can have more time to get to here. They realize this is happening, but they are gonna do something to make the time a bit longer 4th Stage: Depression -"I just don't know how my kids are going to get along after I'm gone" Sadness, grief, mourning for impending loss. (Let them grieve. Don't say things like it will be okay") 5th Stage: Acceptance -"I've lived a good life, I have no regrets" Pt/family have no anger or regrets 4.) Complicated Grief: grief outside the norm. Grief that has gone on for years and years, husband has not touched wife's closet, etc. Basically, no progress and person cannot get past stage of depression.

1.) Grief 2.) Mourning 3.) Bereavement

Palliative Care: -An approach to care for the seriously ill that addresses comprehensive symptoms management, psychosocial care, & spiritual support. Ex: diagnosed with serious illness like chrones disease/heart failure. Is causing issues & side effects of medications. Palliative care will say there is a cardiac doctor managing heart disease. As a palliative care provider, we manage the symptoms/side effects that it is causing. What can we do to make you feel better & not as miserable? Such as: symptom management. If you cant drive, how do we get you to be able to go somewhere you usually go to? -Hospice is a form of palliative care -palliative care is broader than hospice care 1.) We do not want to start palliative care at end of life. We start it when? -does not begin when cure focused treatment ends but most beneficial when providing along with treatments. (Looking at the whole person, & not just the disease itself). 2.) Palliative Care could benefit more people if it were available across care settings & earlier in the disease process.

1.) When someone is diagnosed and starts experiencing these side effects & symptoms to make them as comfortable as possible.

Managing Physiologic Responses: Anorexia and Cachexia 1.) Is progressive anorexia an expected & natural part of the dying process? 2.) Cachexia is a severe weakness of weight loss & muscle wasting that is often accompanied by a severe chronic illness. 3.) No data supports an association between tube feedings & improved quality of life or improvement of symptoms -it may not even help with their symptoms. If their organs are shutting down (intestines) and you keep shoving food in there, they cant digest those things and it will sit in their stomach, making them feel bloated and uncomfortable. 4.) Pharmacological agents are available to stimulate appetite: -Dexamethasone (Decadron) -Megestrol acetate (Megace) -Dronabinol (Marinol) Managing Physiologic Responses: Promoting Nutrition for Terminally Ill Patients -offer pt what he or she prefers/can most easily tolerate. Small portions -add milk shakes, meal replacement drinks -ice chips made from frozen fruit juice -place nutritious foods at bedside (juice, milkshakes) -schedule meals when family members can be present to prove company & stimulation -instruct family on other ways of showing love/care other than by feeding. Ex: watch tv, talk to them, make them comfortable -allow pt to refuse foods/fluids. You don't have to convince them or force them.

1.) Yes it is

Advance Directives: 1.) utilized when a pt is no longer what? 2.) Durable power of attorney: a legal document through which the signer appoints/authorizes another individual to make medical decisions on his or her behalf when they are no longer to do what? 3.) Living Will: a type of advance directive in which the individual documents what? 4.) Can you have both a power of attorney & a living will? -or you can just have one of each 5.) Physician orders for life sustaining treatment (POLST): a form that translates pt preferences expressed in advance directives to medical "orders" that are transferable across settings. Ex: form is filled out by pt's provider. It gives orders that are transported from setting to setting. If someone is a DNR, or does not want life saving procedures, etc.

1.) no longer of sound mind or able to speak for themselves 2.) When they are no longer able to speak for themselves. 3.) documents treatment preferences. It provides instructions for the care of the person in the event the person is terminally ill & not able to communicate their wishes. Ex: they want CPR, they don't want to receive blood, etc. 4.) Yes

Managing Physiologic Responses: Dyspnea (labored/difficulty breathing. SOB) 1.) is often not associated with what? 2.) Treatment varies depending on pt's general physical condition/imminence of death 3.) Like pain, pt's may interpret increased dyspnea as a sign that death is approaching. It may scare them or stress them out. If we can help manage the symptoms we need to do that. Dyspnea Assessment: -symptom intensity/distress -auscultation -assessment of fluid balance -skin color/temp -cough/sputum 4.) Administer medical treatment for the underlying pathology of what is going on with them to cause the SOB. -bronchodilators/corticosteroids. Will allow more air to move through lungs -blood products. Not super common, but will allow more hemoglobin -diuretics 5.) Help pt/family manage anxiety -anxiolytics, benzo, relaxation techniques, means to urge them to call for assistance (call light, give them your phone number, tell them when you will be back, etc.) 6.) Alter the perception of breathlessness -Administer oxygen (not like 15 L, but a small amount of O2 can help with SOB), low dose opioids (decreases drive to breathe) 7.) Conserving Energy -bedside commode, wheelchair, items within reach, etc.

1.) with visible signs of distress. They may just look like they're breathing hard.

After Death Care: 1.) in many states, nurses are authorized to make the pronouncement of death 2.) Determination of death is made through a physical assessment that includes what? 3.) Body changes after death: skin becomes dusky/blue, waxen appearance, cool, blood pooling in dependent areas of body, urine & stool may be evacuated. Prepare for pads under pt 4.) After death, family members are allowed to stay with their loved one -expressions range from quiet to wailing -respect their wish for privacy 5.) Pt should always be lying flat on their back After Death Care: Nursing 1.) Notify physician after auscultation for cessation of heart/lung sounds 2.) Clean the body -family may wish to be present or assist -families may have culturally specific rituals 3.) remove any soiled dressings/gowns -place in dentures/prosthetics of any kind 4.) keep body in normal anatomical position, lying flat on their back, arms at their side 5.) Once family has left: -policies vary on tube removal. -in absence of guidance: shut off infusions & leave IV access in place -place body in bag with source of identification; follow rules on transport to morgue -if at home or facility, may need to contact funeral home. Policies vary depending where you are

2.) auscultation for the cessation of heart/lung sounds

Health of the Middle Adult: 40-65 Physiological: -Gradual decline in functioning -recovery from illness takes longer -increase in chronic illness Psychosocial: -Erikson's stages: Generativity vs. Stagnation (establish & guide next generation, focus less on self. Give back to people/world) -increased awareness of one's own mortality Other things that begin to happen: -fatty tissue is redistributed, men tend to develop abdominal fat, women thicken through the middle -skin is drier -wrinkle lines -gray hair appears, men may lose hair -**cardiac output begins to decrease -muscle mass, strength, and agility gradually decrease -**there is a loss of calcium from bones, especially in premenopausal women -fatigue increases -visual acuity diminishes, especially for near vision -hearing acuity diminishes, especially for high pitched sounds -**hormone production decreases, resulting in menopause or andropause.

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Health of the Young Adult: 20s-30s Physiological: -reached full physical growth capacity -functional reproductive system -more objective & realistic thinking (not as impulsive) Psychosocial: -(erikson's stages) intimacy vs isolation: finding person/group that is outside of parent's. Finding our people. "Leaving the nest." -commonly working on establishing career/family. Health Promotion of the Young Adult: Promoting Health: -continue regular health exams (physicals, eyes, dental, etc.) Injuries: -leading cause of death. Ex: as a nurse, what is this person doing that may lead them to have an injury? Such as snowboarding, skydiving, etc. -encourage driver's education Substance Abuse: -increases risk-taking behavior -discuss relationship between driving & injuries related to that -education on OTC/prescription drugs. Causes many issues Suicide: -immediate referral of signs noticed. Make sure they are safe Pregnancy: -encourage prenatal care STI: -safe sex practices (recognize symptoms of STI) -women: Pap smears (recommended every 3 years) & annual pelvic exam -men: HPV vaccine Nutrition: -poor choices common )fad diets, fast food, energy drinks, etc. -monitor for eating disorders during this age due to busy lifestyles

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