End of Life Care

Assessing the patient & family perspective in palliative care

Awareness of diagnosis, illness stage, + prognosis Values Preferences Expected/desired outcomes Benefits + burdens

Knowledge check: What barrier to end-of-life care does a dying client demonstrate with the statement, "I don't need hospice. Hospice is for people who are dying." A. anger B. bargaining C. denial D. acceptance

C. denial

Symptom management at end-of-life

*the patient's goals should guide management* Symptoms are caused by: - the disease itself - treatment of the disease - a coexisting disease unrelated to the disease Most challenging s/s: - pain - nutrition & hydration - changes in LOC - dyspnea and secretions

Kubler-Ross stages of grief (5)

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Progressively ill patients need 3 types of experiences

1. Know what is happening to them & be able to talk about it to someone that will truly listen 2. Be allowed to experience the pain of "feeling bad" instead of having to hide their feelings to protect others 3. Participate in decisions affecting how they will live their final days & how they will die

Knowledge Check: A patient with end-stage COPD is admitted to a hospice facility and asks the admitting nurse, "how long will I be allowed to stay here?" What is the best response by the nurse? A. "You will be able to stay only for 1 month and then you will be discharged" B. "When your stay reaches 6 months, you will be recertified for a continued stay" C. "You will be able to stay for 2 months before being discharged" D. "There is no time limit for your stay. You can stay until you die"

Correct Answer: B

Knowledge check: Which of the following nursing interventions is appropriate with regard to pain control in the dying client? A. explain that narcotics cause addiction B. give pain meds on a routine schedule C. explain that oxygen will eventually be used D. explain that morphine will be avoided bc of its sedative effects

Correct answer: B. give pain medications on a routine schedule

Knowledge Check: The client has been diagnosed with terminal COPD. The client and client's family have not yet agreed on the final arrangements and are discussing options. How can the nurse best intervene in these final decisions? A. persuade the client to follow their family's preference for end-of-life care B. remind the family that the client needs to focus energy on recovery C. ask the family members about coordinating spiritual care for the client D. respect the client's autonomy and right to determine how to spend the rest of their life

Correct answer: D

Full code

Do everything All patients are assumed full code unless otherwise specified

Body changes immediately after death

Dusky or bluish skin Cool + waxy appearance Blood darkens and pools in dependent areas Urine and stool may be evacuated

What are the 3 code status options?

Full code DNRCC-A DNRCC

Grief, mourning, and bereavement

Grief: personal feelings that accompany an anticipated or actual loss Mourning: individual, family, group, & cultural expressions of grief and associated behaviors Bereavement: the period of time during which mourning takes place

Things to remember for culturally sensitive care

Historical mistrust of the healthcare system & unequal access Lack of education or knowledge about end of life care treatment options Language barriers Institutional practices and laws governing informed consent are rooted in Western notion of autonomous decision making Hospital chaplains are great resources

Can you do CPR if code is DNRCC-A?

No

Can you start an airway if code is DNRCC?

No

Can you start an IV on a DNRCC patient?

Yes if it's for comfort care, like pain meds. Not if it's for resuscitative measures.

Can a patient revoke their DNR status?

Yes they can revoke the DNR order and request cpr at any time

Can the patient have cardiac monitoring on if they are DNRCC?

Yes, pre-existing monitoring can be left on. But new cardiac monitoring cannot be started

Non-modifiable factors that influence dying

age gender personality cultural attitude previous experiences types of disease & course expected actual cause of death for the bereaved

3 time periods of terminal care

pre-death period death event bereavement

Goal of palliative care

preventing + relieving suffering

Modifiable factors that influence dying

previous & current relationship with healthcare providers medical management of the illness treatment effects & projected prognosis meaning that the dying person invests into the experience resources for support

DNRCC-Arrest

Allows everything *before* arrest, but not during or after an arrest (cardiac or respiratory) Do everything up until arrest (including things that can prevent an arrest)

Living will

An advance directive where the individual documents treatment preferences & instructions for care that should be followed when the signer is terminally ill and unable to communicate their wishes verbally

Knowledge check: Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? SATA A. maintaining client comfort B. arranging plans for after death C. supporting family members D. providing personal care E. completing a head-to-toe assessment

A, C, D

True or False: The family should be kicked out of the room immediately after the patient dies.

False, allow them to stick around

True or False: family members are encouraged to act impulsively in the bereavement stage

False, they are encouraged not to act impulsively or make rash decisions. Have them take time to think things through

True or false: only a nurse is required to be present to start a DNR order

False. DNR orders must be written and signed by a physician or CNP

True or false: DNRCC is the same as "do not treat"

False. DNRCC can still provide comfort care measures

True or false: "DNR" tattoos on the chest count as valid form of DNR identification

False. The official DNR form, a DNR wallet card, or a necklace/bracelet with the state of Ohio DNR logo *and* the patient's name are acceptable forms

Health Care Power of Attorney

Legal document where the signer appoints & authorizes another individual to make medical decisions when the pt cannot express their wishes

DNRCC

Make the patient comfortable comfort care only, no extra measures before, during, or after arrest

True of false: hospice care is palliative care

True

True or False: the living will takes precedent over the healthcare power of attorney

True. Living will > HCPOA

What counts as CPR in a DNR case?

chest compressions insertion of artificial airway administration of resuscitative drugs defibrillation or cardioversion starting a resuscitative IV line starting cardiac monitoring

Anorexia-cachexia syndrome

disturbances in carb, protein, and fat metabolism endocrine dysfunction & anemia severe energy loss wasting away, ↓ interest in food, ↓ energy needs

Advance directives

written documents that allow the individual of sound mind to document preferences regarding end of life care that should be followed when the signer is terminally ill and unable to communicate their wishes verbally