PNE 101 LEC. Ch. 38 End-of-Life Care. Fundamentals Nursing Skills & Concepts. Timby 11th Ed.

For hospice care you have to told and have it certified by a physician that you only have so many months to live to be eligible. How many?

6 months

_______ is generally determined on the basis that breathing and circulation have ceased.

Death

Paranormal experiences

Experiences outside scientific explanation such as seeing, hearing, or feeling the continues presence of the deceased.

T/F: In terminally ill patients they receive copious amounts of pain killers. Should you be afraid that they might become addicted?

False

Discuss the philosophy of hospice care.

Hospice care involves helping clients to live their final days in comfort, with dignity, and in a caring environment.

What age group has the highest rate of suicide and attempted suicide?

Older adults

T/F: Another sign of resolution of guilt is the person can describe the deceased person's good and bad qualities. True or false?

True

Terminal illness

a condition from which recovery is beyond a reasonable expectation (illness with no potential for cure).

Forensic Autopsy

a medicolegal examination to determine if a crime has been committed

Grief work

activities involving grieving such as burial rituals

Acute Care

an unstable client gets sophisticated technology and labor intensive treatment. Usually in hospitals and very expensive. What kind of care is this?

Postmortem care

care of the body after death

Name at least five signs of multiple organ failure.

1. hypotension 2. rapid heart rate 3. difficulty breathing 4. cold and mottled skin 5. decreased urinary output

Define terminal illness.

A terminal illness is one from which recovery is beyond reasonable expectation

Morgue

area where dead bodies are temporarily held or examined

Grieving

process of feeling acute sorrow over a loss

If death has occurred who is responsible of notifying the family?

the physician

Resolution of grief (3)

1. time taken for mourning. 2. ability to talk about the dead person w/o becoming emotionally overwhelmed. 3. able to described the good/bad qualities of the deceased.

Respite care - short term

can be arranged in an inpatient facility; hospital or nursing home for up to 5 days each time; inpatient respite care pays 95% of Medicare-approved amount.

Shroud

covering for a dead body

Waiting-for-permission phenomenon

terminally ill client's forestalling of death when he or she feels that loved ones are not yet prepared to deal with the client's death.

Confirming Death is generally determined on:

the basis that breathing/circulation have ceased.

Dying with dignity

the process by which the nurse cares for dying clients with respect, no matter what their emotional, physical, or cognitive state.

Home Care (4)

1. Care provided in a person's home to assist him or her with activities of daily living. 2. Many Pt's prefer to die at home. 3. Assess primary caregivers/respite care maybe helpful 4. Nurses help coordinate community svcs. secure home equipment, & arrange for home nursing visits.

Stage 4 of Dying: DEPRESSION (table 38-1 p. 876)

1. Define: (a deeply sad mood), indicates the realization that death will come sooner rather later. 2. Typical comment:

Stage 2 of Dying - ANGER (table 38-1 p. 876)

1. Define: The emotional response to feeling victimized; occur because there is no way to retaliate against fate. 2. Typical comment: "Why me?'

Stage 3 of Dying - BARGAINING (table 38-1 p. 876)

1. Define: a psychological mechanism for delaying the inevitable, involves a process of negotiation, usually with God or some other higher power. 2. Typical comment: "Yes, me, but if only......"

Stage 5 of Dying: ACCEPTANCE (table 38-1 p. 876)

1. Define: attitude of complacency that occurs after clients have dealt with their losses and unfished business. 2. Typical comment: "I am ready." EX). completing legal and financial matters to provide the best security for survivors and they address social and spiritual matters

Stage 1 of Dying - DENIAL (table 38-1 p. 876)

1. Define: psychological defense mechanism by which a person refuses to believe certain info, helps people to cope initially with the reality of death 2. Typical comment: "No, not me"

What are Kubler-Ross's five stages of death?

1. Denial 2. Anger 3. Bargaining, 4. depression 5. acceptance ***NOTE: Kubler-Ross stages of dying.

Promoting acceptance of dying include: (4)

1. Emotional support 2. Support patient's decision (includes the arrangement of care needed) 3. Involve elderly patient if possible 4. Follow dying patient's bill of rights

Medicare home hospice benefits include: (11)

1. Hospice nurse/physician on-call 24/7 a week 2. Hospice aide/homemaker services 3. Medications for symptoms control/pain relief 4. Medical supplies/equipment 5. Physical therapy, occupational therapy, & speech-language pathology services 6. Social work/counseling services for the client/caregivers 7. Dietary counseling services 8. Short-term respite care 9. Short-term inpatient care for pain/symptoms mgmt. 10. Grief/loss counseling for client/family 11. Any other Medicare-covered services needed to manage pain/other symptoms as recommended by the hospice team

Providing terminal care involves: (7)

1. Hydration 2. Nourishment 3. Elimination 4. Hygiene 5. Positioning 6. Breathlessness 7. Comfort

Throughout a terminal illness and immediately before a client's death a nurse meet his or her basic physical needs. What are they?

1. Hydration 2. nourishment 3. elimination 4. hygiene 5. positioning 6. comfort.

Describe two methods by which nurses can promote the acceptance of death in dying clients.

1. Nurses can promote acceptance by providing emotional support to dying clients 2. helping the client to arrange their care

Who is can legally pronounce a client dead?

1. Physician 2. Physician Asst. 3. Medical examiner 4. Coroner ***NOTE: In 20 states the nurses are authorized.

Psychological reactions commonly identified as the stages of grief include: (3)

1. Shock/disbelief: the refusal to accept that a loved one is about to die or has died. 2. Developing awareness: the physical/emotional responses such as feeling sick, sad, empty, or angry. 3. Idealization: an exaggeration of good qualities of the deceased.

Hospice services can be terminated when: (3)

1. a client's health improves 2. the client's illness goes into remission 3. the client withdraws for any reason ***NOTE: Once hospice care is terminated, care can be provided under the client's original Medicare coverage & the client can reapply for hospice at any time if circumstances change.

Name the five stages of dying.

1. denial 2. anger 3. bargaining 4. depression 5. acceptance (described by Dr. Elisabeth Kübler-Ross)

In terminal ill patients elimination of urine and stool become hard and sometimes retaining urine and stool is evident. What are some things a health care worker might give the client to help the process along? (3)

1. enemas 2. suppositories 3. catheter

Name three components of postmortem care.

1. involves cleaning the body 2. ensuring proper identification 3. releasing the body to mortuary personnel Although grieving is painful, it promotes resolution of the loss. One sign that a person is resolving his or her grief is that he or she can talk about the deceased person without becoming emotionally overwhelmed.

Hospice (2)

1. is used to indicate both a facility for providing the care of terminally ill clients and concept of such care itself. 2. 1960's in England/US in the 70's; final days in a caring environment.

NCLEX-Style Review Questions #4 When a terminally ill client refuses to eat or drink, what nursing measures can be independently implemented? Select all that apply. 1. Inserting a nasogastric feeding tube. 2. Providing frequent oral hygiene measures 3. Humidifying the room air 4. Offering hard candies periodically 5. Administering intravenous fluids

Answer: 2, 3, 4. Rationale: When a terminally ill client refuses to eat or drink, nurses can provide comfort measures that include providing frequent oral hygiene, humidifying room air, and offering hard candies. Inserting a nasogastric feeding tube and administering intravenous fluids are collaborative measures ordered by a physician and implemented by nurses.

NCLEX-Style Review Questions #3 If a terminally ill client made the following statements to a nurse, which is the best evidence that the client is in the bargaining stage? 1. "There must be some mistake in the pathology report." 2. "If I can just live until my son graduates, I won't ask for anything else." 3. "I don't know why would deserve to die at such a young age." 4. "I hope my death comes quickly; I'm ready to go."

Answer: 2. Rationale: The bargaining stage is evidenced by negotiating an extension to life to reach or accomplish some future event. Denial is a stage in which the terminal client refuses to believe valid information. Anger is a stage characterized by retaliation for feeling victimized. Depression occurs when the client is saddened by the inevitable end to life. When the client reaches the stage of acceptance, he or she is at peace with the finality of life.

NCLEX-Style Review Questions #5 When a client has died, under what circumstance can HC providers proceed w/the protocol for harvesting organs for transplantation? 1. The deceased client has a document indicating his/her desire to be an organ donor. 2. The nursing supervisor believes the deceased has suitable organs for transplantation. 3. The deceased client has died of homicide/suicide rather natural causes. 4. The physician has declared/documented the client's time of death.

Answer: 3 Rationale: Organ harvesting cannot occur unless the deceased client's next of kin gives permission to do so. This is true even if the client signed an organ donor card prior to death. After obtaining permission from the next of kin, the organ procurement officer notifies the transplant team who will harvest and transport the organs. The client must be declared dead by standard medical criteria, but organ procurement cannot proceed based on this alone.

NCLEX-Style Review Questions #1 When the nurse cares for a client with no hope of recovery, which of the following is the most conclusive criteria for declaring the person brain dead? 1. A lack of response to verbal stimulation 2. Urine output less than 100 mL/24 hours 3. No spontaneous respiratory efforts 4. Unequal pupils in response to light

Answer: 3. Rationale: Spontaneous breathing is related to a functioning brain stem. Brain death is based on evidence that the whole brain including the brain stem is no longer functioning. Unresponsiveness is not the most conclusive criterion, although it supports the cluster of data suggesting neurologic dysfunction. A client with a urine output less than 100 mL/24 hours is anuric, but the client's brain may not be permanently affected. Bilateral dilated pupils are more ominous than unequal pupils are.

NCLEX-Style Review Questions #2 Place the stages of dying in their usual sequence as identified by Dr. Elisabeth Kubler-Ross. Use all the options. 1. Depression 2. Anger 3. Acceptance 4. Denial 5. Bargaining

Answer: 4, 2, 5, 1, 3. Rationale: The correct usual sequence of the stages of dying identified by Dr. Elisabeth Kübler-Ross are denial, anger, bargaining, depression, and acceptance.

Multiple organ failure info #2

As the cardiovascular system, pulmonary, hepatic, & renal systems cease to function cells release their intracellular chemicals. Preexisting hypoxia is first complicated by a localized rather than generalized inflammatory response that causes the signs of multiple organ failure, heralding approaching death. This process may take place gradually over hours or days.

Hospice Services

Clients receive care in their homes & a multidisciplinary team of hospice professionals/volunteers supports care given by the family.

Define respite care.

Respite care provides temporary relief for caregivers of dying loved ones.

List at least five aspects of terminal care.

Some aspects that nurses address when providing terminal care are: 1. hydration 2. nourishment 3. elimination 4. hygiene 5. positioning 6. comfort

Which organ has failed with these signs: -Fever -Confusion -Hypoesthesia (reduced sensation) -Hyporeflexia (reduced reflexes) -Stupor -Coma? (Table 38-2 p. 881)

The brain

Which organ has failed with these signs: -hypotension -weak, irregular, and rapid pulse -cold, clammy, and mottled skin? (Table 38-2 p. 881)

The heart

Which organ has failed with these signs: -Oliguria -Anuria -Pruritus (itching skin)? (Table 38-2 p. 881)

The kidneys

Which organ has failed with these signs: -Internal bleeding -edema -jaundice -impaired digestion, - distention - anorexia, - nausea, and vomiting? (Table 38-2 p. 881)

The liver

Which organ has failed with these signs: -Dyspnea -accumulation of fluid("death rattle")? (Table 38-2 p. 881)

The lungs

As signs of death approach who is responsible for notifying the family?

The nurse

Explain why a discussion of organ donation must take place as expeditiously as possible following a client's death.

When the criteria for organ donation are met, permission for organ removal must be obtained in a timely manner to ensure a successful transplant. Criteria used to confirm that a client has died include cessation of breathing and heart beat and absence of whole brain function

Multiple organ failure info #1

When the supply of oxygen begins to fall below levels required to sustain life, cells, followed by tissues/organs, begin to deteriorate. The cardiovascular system, pulmonary, hepatic, & renal systems are most vulnerable of failure.

Coroner

a public official who does not necessarily have a medical background but both have legal authority to investigate deaths that may not be the result of natural causes or order a forensic autopsy to investigate a death.

Multiple organ failure

condition in which two or more organ systems gradually cease to function; which directly relates to the quality of cellular oxygenation.

Pathological grief

dysfunctional grief; refusing to or cannot accept someone's death. EX). Survivors may keep house/room as deceased one left it.

Clinical autopsy

exam of the organs and tissues of a human body after death; can conclusively determine the cause of death

Residential care

form of intermediate care; usually a nursing home and the patient receives around the clock care and these patients can't live independently.

Anticipatory grief

grieving that begins before the loss occurs

Brain death

irreversible loss of function of the whole brain, including the brainstem

What is the best position to prevent choking and aspiration in a patient?

lateral

Death certificate

legal document confirming a person's death and indicates the presumptive cause of death.

Hydration

maintenance of adequate fluid volume

Terminal care

medical care of the terminally ill

Mortician

person who prepares the body for burial or cremation; is responsible for filing the death certificate with the proper authorities (carries the morticians signature and some states their license number).

Medical examiner

physician who has specialized training in forensic pathology.

Palliative care

provides relief from distressing symptoms, easing pain & enhancing quality of life.

Respite care

relief for the caregiver by a surrogate

What is one of the last reflexes to disappear as death approaches?

sucking

Grief response

the psychological and physical phenomena experienced by those grieving

As a terminal patient approaches death they often cease eating for various reasons. What would the doctor put them on the make sure they have adequate nutrition?

total parenteral nutrition or tube feeding

When death often occurs shortly after a significant family member communicates that he or she is strong enough and ready to "let go".

waiting for permission phenomenon