Unit 6: Palliative Care

(Grief interventions) Provide a ____________ space for the patient and family. When offering to help, state something _______________ rather than general Encourage grieving individuals to express their ______________ Encourage _____________ review and reminiscing

(Grief interventions) Provide a *private* space for the patient and family. When offering to help, state something *specific* rather than general Encourage grieving individuals to express their *feelings/emotions* Encourage*Life review* and reminiscing

Instead of saying *"I'm sorry"* to the patient, whats a better type of statement?

*"I Wish..."* statements It denotes empathy but also shows limitations in treatment

You are making a bereavement visit to the 35-year-old daughter and primary caregiver of a female patient who died three months ago. The daughter reports she is experiencing mild breathlessness, loss of appetite, and difficulty concentrating. You should recognize that the daughter is experiencing: A- A normal grief reaction B- A complicated grief reaction C- An abnormal grief reaction D- A dysfunctional grief reaction

*A- A normal grief reaction*

What type of pain are antidepressants and anticonvulsants most beneficial for? A- Acute pain B- Somatic nociceptive pain C- Neuropathic pain D- Visceral nociceptive pain

*C- Neuropathic pain*

During your assessment, you notice Robert, who has a diagnosis of dementia, rubbing his right shoulder. What should you do next? A- Ask Robert if he is in pain. B- Give Robert pain medication. C- Contact Robert's healthcare provider to order an x-ray. D- Apply heat to the shoulder.

A- Ask Robert if he is in pain.*

A/n ____________ is appropriate for elderly or those who are not going to get better. A/n ________________ is appropriate for everyone young and old

A/n *POLST* is appropriate for elderly or those who are not going to get better. A/n *Advanced Directive* is appropriate for everyone young and old

This is a "long form" with many steps/instructions. It *assigns Medical Power of Attorney* *Signed by two people*: someone involved, and someone unrelated/uninvolved It is appropriate for everyone, young and old

Advanced Directive

In advanced diseases, *An_________* and *Cach___________* are often found

Anorexia & Cachexia (lack of nutrition and wasting of muscle and fat)

Who is palliative care for?

Anyone with a serious illness, *regardless of age*

Why do hospitals absorb palliative care costs generally?

Because in the long run its cheaper than paying to keep someone alive or to pay for treatments.

defined as a period of grief and mourning that occurs after loss

Bereavement

What demographic of patients are often under treated for pain due to fears of addiction, the belief that they do not perceive pain the same way, or inappropriate knowledge of pharmacological interventions

CHITLINS

Grandparents, parents, siblings, aunts, uncles, extended family, neighbors, classmates, teammates, friends All of these people can be affected (and grieve) by the death of a

Child (it takes a village to raise a child, and it takes a village to mourn the death of one)

For parents, the death of a child is often described as one of life's most devastating experiences. However, grief is seldom acknowledged for the _______________, who may experience the grief "two fold"

For parents, the death of a child is often described as one of life's most devastating experiences. However, grief is seldom acknowledged for the *grandparents*, who may experience the grief "two fold" They experience the grief of losing heir grandchild, but they also witness their own child's grief

This set includes the ELNEC modules 1, 2, 3, 4,5 (not 6). Plus the Death With DIgnity Act reading. Only required to complete 1, 2 & 5.. and read over DWDA reading. From moodle: "Pay special attention to the *communication techniques and strategies* in 2 and 5"

GIT IT!

(Attentive Listening) *Be silent!*, never say *"I understand"* as you simply can't. *Do not change the subject* even if its difficult. *avoid giving advice unless asked* and *encourage reminiscing*

Gotcha

Defined as the emotional response to loss Individualized feelings and responses made to real, perceived, or anticipated loss.

Grief

This type of care is regulated by CMS and is limited to care that occurs only in the *last 6 months* of life. Usually *delivered wherever the patient calls "home"*

Hospice

With this type of care, the patient, once enrolled, no longer receives other disease-modifying treatments

Hospice

Basically, don't tell someone who's grieving the loss of a loved one anything that : - *negates their feelings*, - implies that you *know how they feel* - tells them it was *god's plan* -That they *should be over it by now* - how lucky they were for the time they did have - etc

Just don't be a heartless dick

Kids and older adults are at risk for poor pain management. So are patients who are *non-________*, patients with a history of *______________ abuse* (require more), patients who don't have *_____________*($!), and patients who don't speak *_______________*

Kids and older adults are at risk for poor pain management. So are patients who are *non-verbal*, patients with a history of *substance abuse* (require more), patients who don't have *insurance*($!), and patients who don't speak *English*

Something *meaningful left behind by the deceased* Memory making, mementos, etc.

Legacy Work

Defined as the "absence of possession or future possession, with the response of grief and mourning"

Loss

Medicare will cover hospice, but it won't cover 24/7 care or room and board. WHo covers those?

Medicaid or Private insurance

Hospice is covered by

Medicare

This involves being *non-verbally present* while also being *attentive*, *in the moment*, *non-judgmental* and *empathetic* *__________________ Presence*

Mindful Presence

Assessing fatigue: - Monitor V/S - Observe ability to move about without dyspnea or nausea - Evaluate hydration level - Test muscle strength, symmetry and endurance for neuro changes - Check their medications - Check their labs

OK

Fatigue is subjective and can be assessed just like pain, by using intensity scales, origins, what relieves it etc. Treat Fatigue like Pain

OKAY!!!!

Grief assessment is ___________ throughout course of illness for the patient, family significant others, as well as the bereavement period after death

ONGOING

Children are often under treated for pain. This other demographic of patients are under treated because they are simply never assessed. They are less likely to admit they have pain. They may experience a degree of chronic pain already.

Older Adults

Children are often under treated for pain... why?

Physiological indicators(BP, O2, HR) may not give as accurate of a picture. Grimacing and crying may not be good indicators.

Sometimes the best thing a nurse can do when working in palliative care is to simply provide...

Presence Be a fully present listener, rather than a problem solver. Use nonverbal communication as much as verbal communication

This Disease and dying trajectory represents the course for a person with an illness that causes a prolonged decline ending in death. This is the pattern for frail older adults often demonstrate, especially those with illnesses such as Alzheimer's.

Progressive Deterioration

This disease/death trajectory involves the steady decline of a patient in the terminal phase of illness such as pancreatic cancer. Death usually results in weeks to months

Steady Decline

Who drives the "goals of care" in terms of palliative care?

The patient and their families

The presence (or absence) of _________________ systems can influence how nurses move through the stages of adaptation and coping with patient deaths.

The presence (or absence) of *Support* systems can influence how nurses move through the stages of adaptation and coping with patient deaths. (emotional support by family, peers and coworkers greatly increases one's ability to adapt and cope with the care of the dying)

How long does someone have to be a resident of Oregon to participate in the Act?

There is no minimum residency requirement. A patient must be able to establish that s/he is currently a resident of Oregon

Should you use the words death and dying with the patient and their family?

YES (obviously when appropriate..but don't tiptoe around it)

Should you tell someone who is grieving the loss of a loved one *you shouldn't feel that way* or *you'll eventually get over it* ?

You're a monster

*Loss*, *Grief*, and *Bereavement* should be assessed upon _________________ and bereavement care should continue after death of patient.

admission

Doctors fearing prescribing opioids. Rural pharmacies not carrying newer meds. Inner city pharmacies not carrying opioids out of fear from robbery. Fear of taking pain meds due to fear of addiction. Older adults thinking that pain is a normal process. These are all possible _____________ to pain relief

barriers

How do we identify the most appropriate treatment for the type of pain the patient experiences?

by performing a *comprehensive pain assessment*

*Grief in younger children* may present as all sorts of emotions. rebellious behaviors, rages, nervousness, hyperactivity Excessive dependency on remaining parent. Wish filling dreams, denial

ok

*What is this like for you?....* good question to ask bereaved/grieving *Tell me about your loved one* or *What I remember most about your loved one is...*

ok

In practicing patient autonomy, it is important to find out *how much or little* the patient wants to know about their illness. its their right!

ok

Pain can be *physical/biological* (actual caused pain) *psychological* (depression/anxiety can worsen it) *Social* (quality of life, expense, cultural values or practices: stoicism etc.) *spiritual* (Questioning god? "why me?")

ok

Ask for permission before beginning a lengthy talk with a patient or family. Ask __________________ questions

open ended

Hospice is a *service* not a

place

What is the universal language of children?

play So let them use it as often as possible

Most people want to say things like "I love you", "i'm sorry", "I forgive you"... If we don't tell them of their prognoses we ________ them an their loved ones of these opportunities

rob

Family caregivers rarely...

take care of themselves

Jack is a 6-year-old who just died at home with hospice from an aggressive type of brain cancer. His parents and his 12-year-old sister are having a very difficult time dealing with this terrible loss. Which of the following would be a help to them after Jack's death? A- Hospice bereavement care B- The American Cancer Society C- The hospital's child life worker D- The pediatric oncologist

*A- Hospice bereavement care*

Mrs. Woodrow tells you that her mother has been staying with her and is having difficulty sleeping due to poorly controlled pain. Which quality of life domain is Mrs. Woodrow's mother struggling with? A- Social B- Psychological C- Physical D- Spiritual

*C- Physical*

Which disease and dying trajectory best represents the course for a person with Alzheimer's disease? A- Sudden death B- Steady decline C- Short disease trajectory D- Progressive deterioration

*D- Progressive deterioration*

Hospice covered by Medicare... but it will not pay for _____________ care

24/7 care (won't pay for room and board)

This disease/dying trajectory involves periodic crises and eventually death. The classic examples of this trajectory are Heart Failure and COPD. Patients steadily decline but can live for years, albeit with many acute exacerbations that often lead to hospitalization

Chronic Illness

Palliative care puts an emphasis on high quality ________________ between patients, families and healthcare providers.

Communication We want to have patient driven care, which strives to help achieve their wishes

*Co_________________* is a frequent symptom of patients at the end of life

Constipation

The death with dignity act requires: 1)* 18 years of age or older* 2) a *resident of Oregon* 3) *capable of making and communicating health care decisions for him/herself* 4) *diagnosed with a terminal illness* that will lead to death *within six (6) months*. *It is up to the attending physician* to determine whether these criteria have been met.

Death With Dignity Act

Death rattle occurs around ______ to _________ hours before death... Why do we not perform suctioning?

Death rattle occurs around *8*to *24* hours before death... Why do we not perform suctioning?*Because it can cause more discomfort or agitate pt. further*

We need to asses *fatigue* just like we assess *pain*.. we should also assess *Dys__________* similarly: (severity scale, improved/worsened by, compounding physical problems, anxiety, effect on ADL/sleep etc)

Dyspnea

People tend to die from the _______________ inward (cold, mottled, bluish, pale hands etc.)

EXTREMETIES

- One's own fears of mortality - Lack of personal experience surrounding mortality - General insensitivity - Sense of guilt/failure - Desire to support sense of hope (even if false) - Disagreement with choices of patient/family - Lack of cultural knowledge - Personal grief issues - Ethical concerns These are all barriers to communication for the ___________-

Healthcare professional

In the past, healthcare workers such as nurses were told to *control emotions* and to *emotionally distance themselves* from patients and families. However, patients at the end of their lives require intense interpersonal involvement and _________________ care.

In the past, healthcare workers such as nurses were told to *control emotions* and to *emotionally distance themselves* from patients and families. However, patients at the end of their lives require intense interpersonal involvement and *compassionate* care.

One of the most feared symptoms of patients with serious illness, especially cancer

Pain

Pain is not only a change in nervous system, or a physical symptom. Pain is based on _________________ experience as well as __________________ experience

Pain is not only a change in nervous system, or a physical symptom. Pain is based on *individual experience* as well as *Past experience* It is whatever they say it is

Most hospitals have a _________________ care team. Your role as a nurse is to *advocate* for patient access to this team and to work with the team to develop a plan of care consistent with patient's wishes.

Palliative

With hospice, the patient signs off their *Medicare Part A (hospital payment)* once they choose to receive hospice care. Many hospice agencies will provide home ______________ care as well in order to have a smoother transition from one to another.

Palliative

Who can give a patient a prescription under the Death With Dignity Act?

Patients who meet certain criteria can request a prescription for lethal medication from a licensed *Oregon physician*. The physician must be a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) licensed to practice medicine by the Board of Medical Examiners for the State of Oregon. *The physician must also be willing to participate in the Act*. Physicians are not required to provide prescriptions to patients and participation is voluntary. Additionally, some health care systems (for example, a Catholic hospital or the Veteran's Administration) have prohibitions against practicing the Act that physicians must abide by as terms of their employment.

There are *4 domains of quality of life* (each one can influence the others) List them

Physical Psychological Spiritual Social

When medications (such as narcotics) which are prescribed by physicians with the *intent to alleviate pain* have the unintended secondary effect of suppressing respiration which may result in death. (These are not reportable under the Death with Dignity Act.) "The _____________ Effect"

The *Double effect*

Are DWDA participating patients reported to the State of Oregon by name?

The State does collect the names of patients in order to cross-check death certificates. However, the law guarantees the confidentiality of all participating patients (as well as physicians) and the Oregon Health Authority does not release this information to the public or media.

The four domains of quality of life are: Physical Ps______________ S______________ S_______________

The four domains of quality of life are: Physical Psyschological Social Spiritual

A patient says they aren't *sleeping* or *eating* well (physical) but why might we assess the other 3 domains of quality of life?

Those physical symptoms might be manifestations of another domain issue... Psych Spiritual Social

When a patient reports "pain all over", you should consider psychosocial domain of pain. This may be "*T__________ pain* or *Existential distress*

Total Pain

Sometimes medical technology can be a bad thing. How?

We use it on people who are actively dying, thus causing discomfort or pain for the patient, caregiver distress and family suffering. shtuff like that

When _____________ are exposed to death frequently, they may not have time to resolve grief issues of one death before another one occurs.

When *nurses* are exposed to death frequently, they may not have time to resolve grief issues of one death before another one occurs.

Your patient has myoclonus? This could be a sign of incoming seizures, its uncomfortable for pt and family etc...

contact care team for interventions

Grief in children is based on their ____________________ stages, and can be *normal* and/or *complicated*

developmental

2013 *Clinical Practice Guidelines for Quality of Care* Developed by the *National Consensus Project (NCP)* came up with *8* _______________ of palliative care

domains

Studies have shown that relatively *small doses* of oral or parenteral opioids can be used to treat...

dyspnea

Survivor Personality Coping Skills Hx of Substance Abuse Relationship to the deceased Survivors spiritual belief system Type of death Survivors culture These are factors effecting ___________

grief

People who are in a the dying phase may have a __________________ when dehydrated.

low grade fever

Mr. S. has stage IV lung cancer and was admitted to your unit yesterday because of shortness of breath. His breathing has improved with treatment and you tell him you are hoping to get to know him better so you can provide the best care possible. Which of the following statements reflects your interest in getting to know him? A- "Can you tell me what has given your life meaning?" B- "Do you know much about your disease?" C- "Is your cancer treatment helping you?" D- "If I can do anything to help you, let me know."

*A- "Can you tell me what has given your life meaning?"*

You are speaking with the sister of a male patient who died after suffering fatal injuries in a car accident. In order to plan for bereavement follow-up for the patient's family, it is important that you assess: A- The family support system B- If the sister can take a month off from work to grieve sudden death C- If the patient qualified for hospice services before the accident D- Whether the patient had an advance directive

*A- The family support system*

Jane, a 72-year-old woman with end-stage renal disease, tells you she thinks she doesn't want to continue dialysis anymore. Which of the following would be your best response to this statement? A- "Of course you want to continue dialysis, it is keeping you alive." B- "Don't talk like that, your family loves taking you to your treatments." C- "That is a very important statement, can you tell me more about that?" D- "I understand why you wouldn't want to do it; it is so exhausting for you."

*C- "That is a very important statement, can you tell me more about that?"*

You are teaching your colleagues about myths and realities of communication in palliative care. Which is a correct statement about communication? A- "We can never give someone too much information." B- "We communicate only when we choose to communicate." C- "The majority of messages we send are non-verbal." D- "Communication is primarily words and their meanings."

*C- "The majority of messages we send are non-verbal."*

You are performing a pain assessment on Matilda. Your assessment reveals that Matilda has pain rated as a 5 in her left hip that worsens with movement. She has been having this pain off and on for the last three years. Which of the following pain assessment components have you not addressed in your assessment? A- Duration B- Aggravating factors C- Alleviating factors D- Intensity

*C- Alleviating factors*

(types of grief) Affects 2-3% of worlds pop. Factors that contribute to this grief are *lack of support network*, *concurrent losses*, *poor coping skills*, *loneliness*

*Complicated* grief

Patient (and family) centered care that optimizes quality of life by anticipating, preventing and treating suffering. This type of care addresses physical, emotional, social and spiritual needs. It facilitates patient autonomy, access to information and personal choice.

Palliative Care

This type of care can be *offered at any time in the disease trajectory*. It in fact *should be part of care at the time of initial serious diagnosis* *Can occur in any clinical setting*

Palliative Care

With this type of care, a patient can *continue to receive disease modifying treatment* along with it. This type of care can *continue through to the end of life* should the patient refuse other end of life care options and it will also address the *family bereavement processes* long after the patient dies

Palliative Care

Many patients are *unaware* of their..... This knowledge may change what they wish to do for themselves and their loved ones

limited life expectancy

There are 3 sections to a POLST: A- *CPR?* (YES or DNR) B- *How much care* do you want? (Comfort, Basic, Full)) C- *Nutrition*? (tubes or no tubes

neat

is Palliative care End of Life care?

no Palliative care services are provided *concurrently* with or independent of disease modifying treatments. Its about living with a serious illness, while receiving treatment for that illness.

Does care end at the time of death?

no We send cards, we follow up with phone calls, we help them with community care and resources

(Grieving interventions) Provide ________ support as appropriate. Honor _______ practices Send _____________ to bereaved Attend the ___________ after the patient death Make a supportive _________ to the bereaved

(Grieving interventions) Provide *spiritual/religious support* as appropriate. Honor *cultural/religious* practices Send *cards/notes* to bereaved Attend the *funeral/memorial* after the patient death Make a supportive *phone-call* to the bereaved

You are caring for Ms. P, a 55-year-old woman with cancer. She received pain medication less than two hours ago. A nursing assistant reports that Mrs. P is complaining of pain again. The nursing assistant says, "She can't be hurting as much as she says she is." What is the most appropriate response? A- Pain is whatever the patient says it is. Let's assess her further. B- Maybe she is just drug-seeking. C- I will tell her gently that she must wait four hours between doses. D- I just gave her pain medication. She can't need anything again so soon.

*A- Pain is whatever the patient says it is. Let's assess her further.*

How does a patient get a prescription from a participating physician?

1) The patient must make *two oral requests to the attending physician, separated by at least 15 days.* 2) The patient must provide a *written request to the attending physician*, *signed in the presence of two witnesses*, at least *one of whom is not related to the patient*. 3) The *attending physician and a consulting physician must confirm the patient's diagnosis and prognosis* 4) The attending physician and a consulting physician *must determine whether the patient is capable of making and communicating health care decisions for him/herself*. 5) *If either physician believes the patient's judgment is impaired by a psychiatric or psychological disorder* (such as depression), the patient must be *referred for a psychological examination*. 6) The attending physician must *inform the patient* of *feasible alternatives* to the Act including *comfort care, hospice care, and pain control* 7) The attending physician *must request, but may not require*, the patient to *notify their next-of kin of the prescription request*. A patient can rescind a request at any time and in any manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate. Physicians must report all prescriptions for lethal medications to the Oregon Health Authority, Vital Records. As of 1999, pharmacists must be informed of the prescribed medication's ultima

(3 sections of POLST) Section 1 (level of treatment/care): - Comfort... - Basic... - Full... Describe these three options under section 1

COMFORT: Keep comfortable, *no hospital unless its for comfort*, natural death BASIC: *hospital*, IV meds, Abx, Fluids. *NO machines* (ventilators etc.) FULL: *all measures*

Children may be limited in their ability to _______________ and describe their feelings or grief. Children's cognitive development may interfere with their ability to __________________ the irreversibility, universality and inevitability of death So Assess them always, and base it on their cognitive/developmental levels

Children may be limited in their ability to *verbalize* and describe their feelings or grief. Children's cognitive development may interfere with their ability to *understand* the irreversibility, universality and inevitability of death

Acknowledging one's own biases and values and how they may affect you or your level of care for others. *Cultural _______________*

Cultural humility

What language would you prefer to speak? DO you have any foods you would especially enjoy or would like to avoid? Do you have a preference for Male or Female caregiver? These are questions concerning ______________ competent care

Culturally

*____________________ loss* is a succession of losses experienced by nurses who work with patients with life threatening illnesses and their families, often on a daily basis.

Cumulative Loss

A distressing, persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion that is disproportional to recent activity and interferes with usual function

FATIGUE

- Drugs related to comfort - Medical equipment - Care team visits - Social work/counseling - Aid for ADL/bathing - Short term inpatient (5 day hospitalization for symptom management)(to give relief to family or for brief symptom management) - Bereavement services - Music therapy, massage These are all provided by

HOSPICE

Past personal/professional experiences with ____________ can influence a professional healthcare worker's ability to cope with caring for dying patients and their families. For example: LTC facilities staff may be pessimistic about growing old in general

Past personal/professional experiences with *death/dying* can influence a professional healthcare worker's ability to cope with caring for dying patients and their families. For example: LTC facilities staff may be pessimistic about growing old in general

This type of disease/death trajectory involves unexpected and rapid death: MIs, accidents, violence. It was the typical dying trajectory of the 1900s

Sudden Death

There are several (4 according to our lecture) main trajectories of serious illness. Describe: Sudden... Steady... Slow... Lingering (aka dwindling aka progressive decline)...

Sudden...*unexpected and fast (accidents) Steady...*steep trajectory*, *short "terminal phase" (period of evident decline)* Slow...*Periodic crisis, but then death* Lingering (dwindling)...*Frailty/Alzheimers, Dementia etc. expected death*

The majority of hospice care is delivered in: A- The home B- Residential facilities C- Hospitals D- Inpatient hospice facilities

*A- The home*

(types of grief) Begins *after death* of a loved one and includes *separation response* and *response to stress*. May be confused, uncertain about their identity or social role. May disengage from usual activity or experience disbelief/shock

*Acute* grief

(types of grief) grief which occurs *before a loss*, associated with diagnosis of an acute, chronic or terminal illness. Experienced by the patient, family, caregivers.

*Anticipatory* grief

You are working with Mr. T who has just been told his heart failure is getting worse. You go into his room to see how he is doing after the team has shared this information with him. He is staring out the window, looking sad. How do you start your conversation? A- "Isn't it a beautiful day today Mr. T.?" B- "I saw that the team was just here, can you tell me about their conversation with you?" C- "Are you feeling ok?" D- "I heard you just got bad news, but I know of someone just like you who lived for three more years."

*B- "I saw that the team was just here, can you tell me about their conversation with you?"*

Which of the following individuals would be at highest risk for the under-treatment of pain? A_ A 40-year-old female with cancer B- An 87-year-old male with osteoarthritis C- A 54-year-old male with good prescription coverage D- A 29-year-old female with a history of GI bleed

*B- An 87-year-old male with osteoarthritis*

A 92-year-old patient dying of end stage heart failure tells you that she is worried that her life had no meaning. What member of the palliative care team would you want to be sure is involved in her care? A- The physician B- The chaplain C- The advanced practice nurse D- The occupational therapist

*B- The chaplain*

What should drive decision-making in palliative care? A- Finding a cure for the illness B- The patient's goals of care C- The need for end-of-life care D- The wishes of the inter-professional team

*B- The patient's goals of care*

_________________ is an emotional and physical burden created by the *trauma of helping others in distress or who are suffering* which leads to a reduced capacity for empathy toward suffering in the future. While, __________________ is overall emotional and physical exhaustion; depersonalization, or feelings of cynicism and detachment from one's job.

*COMPASSION FATIGUE* is an emotional and physical burden created by the *trauma of helping others in distress or who are suffering* which leads to a reduced capacity for empathy toward suffering in the future. While, *BURNOUT* is overall emotional and physical exhaustion; depersonalization, or feelings of cynicism and detachment from one's job.

WHen a patient is experiencing "total pain" its important to assess their _______________ state

*Emotional* state: Depression, fear, anxiety, hopelessness etc.

(Barriers to pain management) Dr. S prefers not to prescribe opioids to his patients with lung cancer because he's afraid they will stop breathing.

*Healthcare Professional* Barriers

(Barriers to pain management) Tom went to get his pain medication prescription filled but will have to wait three days for the pharmacy to get it in

*Healthcare System* barrier

(Barriers to pain management) Mr. M lives in an area of the city with few pharmacies.

*Healthcare system* barrier

A patient just got bad news... You need to really avoid saying *"I'm _______________"*

*I'm Sorry* It feels shallow, it makes you seem aloof, you may be misinterpreted as taking responsibility for any negative outcomes.

(types of grief) Described as the *usual feelings, behaviors and reactions to a loss*. Can be physical, emotional, cognitive, behavioral.

*Normal* grief

(Barriers to pain management) Mrs. J does not want her husband to take pain medications because she has heard they are addicting

*Patient/Family* Barrier

(Barriers to pain management) Mrs. T, age 84, says "I won't take pain medications because they make me constipated"

*Patient/Family* Barrier

If family spends all time in room, get their input on pt. pain status. Use as an assessment for pain in unresponsive pt This is referred to as a

*Proxy Report* for Pain

(Barriers to pain management) Joan's insurance denied coverage for her newly prescribed medication for her neuropathy

*healthcare system* barrier

Defined as the outward, social expression of a loss. How one outwardly expresses a loss may be dictated by cultural norms/customs

Mourning

Can someone who doesn't live in Oregon participate in the death with dignity Act?

NEIN!

Is there some sort of "program" for participation in the Death With Dignity Act? Do people fill out an application to the State of Oregon or the Oregon Health Authority?

NO It is up to qualified patients and licensed physicians to implement the Act on an *individual basis*. The Act requires the Oregon Health Authority to collect information about patients who participate each year and to issue an annual report.

*Burnout* is... *Compassion Fatigue* is...

*Burnout* is...feelings of hopelessness, stress of being overworked, and lack of support or appreciation. *it occurs over a period of time* *Compassion Fatigue* is...the result of *secondary exposure to traumatic events, such as multiple patient deaths.*

Which of the following describes palliative care's philosophy and delivery? A- Care is provided by one healthcare provider, usually a nurse. B- Palliative care is offered when the patient no longer wants treatment for their disease. C- It supports the patient and family's hope for quality of life and dignity. D- The focus is only on the final six months of life.

*C- It supports the patient and family's hope for quality of life and dignity.*

Mr. T. is taking an NSAID for bone pain. Which of the following statements suggests he may be experiencing a worrisome side effect from the NSAID? A- I am having trouble urinating. B- I noticed that my skin has gotten very dry. C- Yesterday I had an episode of black, tarry stools. D- My eyes have been very itchy and irritated lately.

*C- Yesterday I had an episode of black, tarry stools.*

If a person has: - *A terminal condition* - *Permanently unconscious* - A condition that *life sustaining treatments aren't beneficial* - A *progressive illness that is fatal and advanced* AND they don't have an advanced directive or healthcare representative. Then we would go down the list of possible decision makers...

- Guardian - Spouse - Designated Adult - Adult Kids - Parents - Siblings - Friend or Relative - Att. Physician w/ ethics

This type of pain is generally due to damage to the nervous system

Neuropathic pain

Palliative care services are paid for in the US by *Phi___________________*, *F________-For Service methods* or from *direct ______________ support* Practitioners *may* bill medicare for palliative care, but reimbursement is often *very low* Hospitals *absorb* palliative care costs because in the long run they save money by delivering it to their sickest and most vulnerable patients. (cheaper than continuing to keep them alive with all their technology)

Palliative care services are paid for in the US by *Philanthropy*, *Fee-For Service methods* or from *direct hospital support*

*Grief in older children* may include depressed traits, social withdrawal, sleep issues, antisocial behavior authority resentment, attempted suicide, substance abuse, sexual promiscuity, compulsive behaviors

ok

This type of pain is related to *damage* to *bones*, *soft tissues* or *internal organs* Includes visceral and Somatic pain.

Nociceptive Pain

Which of the following statements is true about serious, chronic illnesses? A- The majority of annual U.S. healthcare spending goes toward chronic illnesses. B- Very little annual U.S. healthcare funding is spent in acute care admissions for chronic illnesses. C- Much attention and financial support goes toward improving quality of life for persons with chronic illnesses. D- The focus of serious illness is often on improving quality of life rather than finding a cure.

*A- The majority of annual U.S. healthcare spending goes toward chronic illnesses.*

Which of the following statements reflects that you are responding appropriately to a conflict between you and a physician regarding a patient's decision to stop chemotherapy? A- "Why can't you understand that this patient has had enough?" B- "This decision is the patient's decision - it is not ours to make." C- "Just because there is a chemotherapy available, it doesn't mean you have to give it to her." D- "I am so tired of you doctors continuing to treat patients who are ready to let nature take its course."

*B- "This decision is the patient's decision - it is not ours to make."*

You are asked to describe palliative care to a family member. Which of the following statements would be best to include in your discussion? A- Palliative care's main purpose is to improve pain. B- Palliative care supports the patient's goals of care. C- Palliative care is end-of-life care for the imminently dying patient and their family. D- Palliative care is curative care.

*B- Palliative care supports the patient's goals of care.*

Yolanda has osteoarthritis of the left knee for which she is receiving acetaminophen 1000mg every six hours. She rates her pain at a 4 every time you ask. What do you think an appropriate next step would be at this time? A- Discuss increasing the acetaminophen to every four hours with the IDT. B- Discuss adding an immediate-release opioid with the IDT. C- Ask Yolanda what an acceptable pain score is for her. D- Ask the IDT if Yolanda would benefit from an antidepressant for pain.

*C- Ask Yolanda what an acceptable pain score is for her.*

You are teaching a patient how to take her new prescription for morphine, an opioid pain medication. Which of the following teaching statements reflects an understanding of potential adverse effects? A- Be careful with these medications because they can cause addiction. B- Only take this medication if you are really suffering. C- This medication causes constipation, so you need to take a laxative to prevent that. D- This is the medication they prescribe when you are getting near the end of life.

*C- This medication causes constipation, so you need to take a laxative to prevent that.*

You are talking with the staff on your unit about the emotional challenges of working with dying patients and their families. Which of the following is an appropriate response to the grief the staff has been experiencing recently? A- Avoid talking about the recent deaths, focusing on the patients who have survived. B- Seek the support of the family of the dying patient to comfort the staff. C- Share with the staff that personal grief should not be expressed by healthcare professionals. D- Consult with the hospital chaplain or spiritual care counselor for staff support.

*D- Consult with the hospital chaplain or spiritual care counselor for staff support.*

When medications (such as barbiturates) are prescribed by physicians to *induce a coma* with the *intent of alleviating pain* This keeps the patient unconscious who would otherwise be painful when nearing their natural death. _________________ sedation

*terminal sedation*

You are talking with the wife of a patient who died recently. Which statement can you make that would be most helpful? A- "I know exactly how you are feeling." B- "It must be hard to accept that this has happened." C- "His suffering is over. He's in a better place now." D- "I'm here for you. Call me if you need anything."

*B- "It must be hard to accept that this has happened."*

(4 types of complicated grief) - *normal* grief reaction but *doesn't subside*/*continues for long time* aka _______________ grief - *normal* grief reactions that are *suppressed/postponed* and the survivor *avoids the pain of the loss* aka _________________ grief - *intense reaction* that may include nightmares, delinquent behaviors, phobias, suicidal thoughts. aka _________________ grief - when survivors *aren't aware* that their behaviors interfere with normal functioning (cancelling lunch to go to cemetery every day). aka ______________ grief

(4 types of complicated grief) - *normal* grief reaction but *doesn't subside*/*continues for long time* aka *CHRONIC* grief - *normal* grief reactions that are *suppressed/postponed* and the survivor *avoids the pain of the loss* aka *DELAYED* grief - *intense reaction* that may include nightmares, delinquent behaviors, phobias, suicidal thoughts. aka *EXAGGERATED* grief - when survivors *aren't aware* that their behaviors interfere with normal functioning (cancelling lunch to go to cemetery every day). aka *MASKED* grief

You have been the pediatric nurse caring for a young boy with a malignant brain tumor who just died on your unit. The parents are in the room with their son and ask you if you would stay with them. Your best response is: A- "I am here and I will not leave you until you are ready for me to." B- "I have to take care of my other patients, but I will be back to check on you in a few minutes." C- "I am so sorry this has happened to you." D- "I know you are sad but your son is in a better place now and is no longer suffering."

*A- "I am here and I will not leave you until you are ready for me to."*

You are caring for a patient with end-stage liver disease. He tells you that he knows he only has a few weeks to live and is so sad that he won't be around to see his daughter graduate next year from college. You listen attentively and then respond: A- "Would it be helpful to write a letter to her or a card that can be given on that special day?" B- "Let's hope you will be here; no one ever really knows when the final days are near." C- "I am so sad for you; I would hate if my dad couldn't come to my graduation." D- "I am sure your daughter will understand that you wished you would be there."

*A- "Would it be helpful to write a letter to her or a card that can be given on that special day?"*

Which of the following demonstrates good self-care that may help you in preventing compassion fatigue and burnout when taking care of many patients with serious illness and their families? A- Establish healthy eating, sleeping, and exercise habits especially when rotating shifts. B- Volunteer for extra shifts to cover your overworked colleagues. C- Ask to take care of all the very ill patients and families because you have the expertise many of your colleagues don't have. D- Make sure you go to every funeral and service for all the deceased patients you have cared for.

*A- Establish healthy eating, sleeping, and exercise habits especially when rotating shifts.*

John is a 70-year-old male whose wife died from COPD two months ago. They were very close, married for 52 years, and had no children. He comes by the nursing unit to bring you all candy and a thank you note for all the times you cared for her the past year. He tells you he is struggling to want to eat since she always was the cook, and is just not ready to go out to dinner with his buddies, even though they keep asking him. Your assessment is that John is: A- Experiencing normal grief after his wife died two months ago B- Depressed because he doesn't want to go out with his buddies C- At high risk for complicated grief because his wife died in the hospital D- Is doing poorly alone at home because he is not eating well and needs counseling

*A- Experiencing normal grief after his wife died two months ago*

You are assessing Mrs. Smith's husband's well-being during Mrs. Smith's recent hospitalization. He tells you he has had trouble with heart failure this past year and then says, "All that matters is my wife. I don't have time to go to my doctor even though my prescriptions have run out. Don't you realize how many medications I have to give my wife around the clock? I can't deal with any more medications. I will have time to take care of myself later on." Your best response is: A- "I understand. Your wife certainly requires a lot of care and it is so hard to keep track of all her medications, let alone your own." B- "I am concerned about you too. Keep in mind you can't take care of Mrs. Smith if you get sick; you need to get your prescriptions filled." C- "That is nonsense; don't you know that not taking your heart failure medications could put you in the hospital?" D- "Later on may never come if you don't take care of yourself now; you have to take better care of yourself and get your medications filled."

*B- "I am concerned about you too. Keep in mind you can't take care of Mrs. Smith if you get sick; you need to get your prescriptions filled."*

You are helping a new member of the palliative care team understand the ways the behavior of healthcare professionals can produce a communication barrier. Which statement by the team member indicates the need for additional education on communication barriers? A- "I will complete a cultural assessment in order to understand the patient's communication preferences." B- "I will keep an emotional distance in order to maintain a professional relationship with patients." C- "I may not always know the answers to questions that the patient or family may ask." D- "My lack of personal experience with death can make me reluctant to discuss death and dying."

*B- "I will keep an emotional distance in order to maintain a professional relationship with patients."*

Mr. G has just been told he has a serious illness. Which of the following statements reflects respectful communication with him about his treatment and illness? A- "We will decide which treatment options are best for you Mr. G." B- "It is important that we understand what your hopes are for your treatment of this illness." C- "Treatment will be difficult; you just have to be strong and get through it." D- "This disease is terminal and there is nothing we can do for you."

*B- "It is important that we understand what your hopes are for your treatment of this illness."*

You are caring for a 76-year-old patient who is unresponsive and close to end of life from a massive stroke. The patient has a history of breast cancer and had been experiencing severe bone pain in her left hip prior to her stroke. How do you assess her pain now that she is unresponsive? A_ Ask her anyway and see if she can nod "yes" to your question. B- Assume she continues to have pain and assess for evidence of wincing or facial grimacing. C- You don't need to assess this, as she is now unresponsive. D- Ask the family to report a pain score, using a 0-10 numeric rating scale, for her.

*B- Assume she continues to have pain and assess for evidence of wincing or facial grimacing.*

Mr. X has end-stage liver cancer and multiple organ failure. He wants to be home and comfortable. Which intervention would be most appropriate to offer him? A- Admission to the ICU to get his organ failure under control B- Hospice services C- Home care with a nursing expert in rehabilitation services D- Placement in a nursing facility for 24-hour nursing care

*B- Hospice services*

Which of the following patients should never be given an opioid medication? A- Ms. Jones a 27-year-old with a history of substance abuse B- Mr. Rich who reports severe nausea and vomiting with previous use of opioids for pain C- Mrs. Smith who reports developing a rash, hives, and shortness of breath after taking an opioid for dental work D- Mr. Hanover who is 72 and has end-stage heart failure

*C- Mrs. Smith who reports developing a rash, hives, and shortness of breath after taking an opioid for dental work*(this is a true allergic reaction)

You are caring for a 55-year-old female patient with metastatic breast cancer. During a home visit, you find the patient's 22-year-old daughter weeping at the kitchen table. The daughter explains that she just realized that her mother will not be alive when she gets married or has children of her own. Recognizing anticipatory grief in the young woman, the best first intervention is: A- Educate about signs and symptoms of disease progression. B- Foster hope by stressing that prognosis is difficult to predict. C- Provide active listening and therapeutic presence. D- Advise the daughter to focus more on the present time with her mother rather than the future.

*C- Provide active listening and therapeutic presence.*

You are entering a room to administer a medication to your patient and as you come in you find that the three family members and the patient are all crying. What should you do next? A- Leave the room and come back with the medication when everyone is feeling better. B- Apologize for intruding and let the patient know you are nearby if he needs you. C- Remain silent to give permission to talk with you, holding off on the medication initially. D- Administer the medication and then ask if everything is ok.

*C- Remain silent to give permission to talk with you, holding off on the medication initially.*

Ms. H's family is in the waiting room of the intensive care unit. Ms. H is very ill and the family has been told she will probably die during this hospital admission. You are walking by the waiting room and you see that they are all seated together, crying. What is your best response? A- Leave them alone to give them private time to do their grieving. B- Find a social worker to go into the waiting room to see if they need anything. C- Call the hospital chaplain to visit them and offer prayers. D- Go into the waiting room, sit next to them, and give them time to talk with you.

*D- Go into the waiting room, sit next to them, and give them time to talk with you.*

You are providing bereavement support to an 8-year-old child whose father just died on your unit. Which of the following statements would be appropriate for you to use? A- Use the phrase "your father has gone away" rather than "your father has died." B- Tell him he will get over the loss of his father when he gets a little older. C- Let him know his father's death was peaceful and that he "just went to sleep." D- Let him know you wish that his father had not died.

*D- Let him know you wish that his father had not died.* ("I wish" = desire but reality of limitations...and we use the word "died/death/dead")

(types of grief) described as *any loss that is not validated* or *recognized*. society may not want to acknowledge the grief, and doesn't know how to deal with the loss. Those experiencing this grief don't feel freedom to share or openly acknowledge it. (ex: ex lovers, partners of AIDS patients, mothersof stillbirths etc)

*Disenfranchised* grief

Should you tell someone going through grief of losing a loved one something like: *God needed your loved one* or *It was God's plan* ?

NO @sshole You don't know if this fits the persons spiritual beliefs (even if you know their religious affiliation) Even if it does fit, they may not get to this level of acceptance for quite some time.

Should you tell someone grieving the loss of a loved one *I know what you're going through* or *I know how you feel* or *I understand how hard this is* ?

NO mang, its *impossible* to know what someone else is going through. Each and every loss is *unique*

When speaking with a child about the death of a loved one, should you use words like "passed away" or "gone to sleep" etc?

NO, use the word *death*

Does the Death WIth Dignity Act allow euthanasia?

No!. Euthanasia is a different procedure for hastening death. In euthanasia, a *doctor injects a patient with a lethal dosage of medication*. In the Act, a *physician prescribes a lethal dose of medication* to a patient, *but the patient - not the doctor - administers the medication*. Euthanasia is illegal in every state in the union, including Oregon

-*Structure & Process* of Care -*Physical* Aspects of Care -*Psychological & Psychiatric* Aspects of Care - *Social* Aspects of Care - *Spiritual/Religious/Existential* Aspects of Care - *Cultural* Aspects of Care - *End of life Care* - *Ethical/Legal* Aspects of Care These are the 8 Domains of

Palliative Care (according to the National Consensus Project)

If a patient's doctor does not participate in the Death With Dignity Act, how can s/he get a prescription?

The patient must *find another* M.D. or D.O. licensed to practice medicine in Oregon *who is willing to participate*. The Oregon Health Authority does not recommend doctors, nor do we provide the names of participating physicians or patients due to the need to protect confidentiality.

Describe Cheyne-stokes

no breathing for period of time, then gasping, then no breathing etc. dying