Med surge chapter 16 death and dying

Assessing Spirituality

A four-step spiritual assessment process using the acronym FICA involves asking the following questions (Puchalski & Romer, 2000) : Faith and belief: Do you consider yourself to be a spiritual or religious person? What is your faith or belief? What gives your life meaning? Importance and Influence: What importance does faith have in your life? Have your beliefs influenced the way you take care of yourself and your illness? What role do your beliefs play in regaining your health? Community: Are you a part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you? Address in care: How would you like me to address these issues in your health care? (Hinkle 402) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Methods of stating end of life preferences

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 verbally communicate their wishes. The documents are generally completed in advance of serious illness but may be completed after a diagnosis of serious illness if the signer is still of sound mind. The most common types are the durable power of attorney for health care and the living will. Do Not Resuscitate: A medical order to withhold cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. In some settings, the term "allow natural death" (AND) is used in place of do not resuscitate (DNR). Durable power of attorney for health care: a legal document through which the signer appoints and authorizes another individual to make medical decisions on their behalf when he or she is no longer able to speak for himself or herself. This is also known as a health care power of attorney, medical power of attorney, or a proxy directive. Living will: a type of advance directive in which the individual documents treatment preferences. It provides instructions for care in the event that the signer is terminally ill and not able to communicate their wishes directly and often is accompanied by a durable power of attorney for health care. This is also known as a medical directive or treatment directive. Physician orders for life-sustaining treatment (POLST): a form that translates patient preferences expressed in advance directives to medical "orders" that are transferable across settings and readily available to all health care providers, including emergency medical personnel. The POLST form is a brightly colored form that specifies preferences related to CPR and use of IV medications or fluids, antibiotics, artificial nutrition, and other medical interventions. The form is signed by the patient or surrogate and the physician, advanced practice nurse, or physician assistant. The use of the POLST is subject to state laws and regulations. Numerous states have endorsed the POLST or a similar form. (Hinkle 397) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Difference between hospice and palliative care

All hospice care is palliative care; however, not all palliative care is hospice care. The difference is that hospice care is an application of palliative care delivered at the end of life. Hospice care focuses on quality of life, and by necessity, it usually includes realistic emotional, social, spiritual, and financial preparation for death. (Hinkle 391) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

sociocultural context

Although terminal illness, a progressive, irreversible illness that despite cure-focused medical treatment will result in the patient's death, is experienced uniquely by each person, it is also shaped by the broader social and cultural contexts in which it occurs. The approach in the United States to serious illness has been described as "death denying"—that is, the health care system has been built on management of acute illness and the use of technology to cure (when opossible) and to extend life. As a result, life-threatening illness, life-sustaining treatment decisions, dying, and death occur in a social environment in which illness is largely considered an enemy. Many common expressions reflect this dominant sociocultural view. For example, people talk about the "war" against cancer or "fighting" illness, and when patients choose not to pursue the most aggressive course of medical treatment available, many health care providers and indeed patients and families perceive this as "giving up." A care/cure dichotomy has persisted in which health care providers may view cure as the ultimate good and care as second best, a good only when cure is no longer possible. In such a model, alleviating suffering is not as valued as curing disease. Patients who cannot be cured feel distanced from the health care team, and when curative treatments have failed, they may feel that they too have failed. Patients and families may fear that any shift from curative goals to comfort-focused care will result in no care or lower-quality care, and that the clinicians on whom they have come to rely will abandon them if they withdraw from a focus on cure. The statement in late-stage illness that exemplifies this care versus cure dichotomy is "nothing more can be done." This all-too-frequently used statement communicates the belief of many clinicians that there is nothing of value to offer patients beyond cure; however, in a care-focused perspective, there is always more that can be done. This expanded notion of healing implies that healing can take place throughout life. There are many opportunities for physical, spiritual, emotional, and social healing, even as body systems begin to fail at the end of life. (Hinkle 388-389) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nutrition management end of life

Anorexia and cachexia differ from starvation (simple food deprivation) in several important ways. Appetite is lost early in the process, the body becomes catabolic in a dysfunctional way, and supplementation by gastric feeding (tube feeding) or parenteral nutrition in advanced disease does not replenish lean body mass that has been lost. Anorexia Although causes of anorexia may be controlled for a period of time, progressive anorexia is an expected and natural part of the dying process. Anorexia may be related to or exacerbated by situational variables (e.g., the ability to have meals with the family vs. eating alone in the "sick room"), progression of the disease, treatment of the disease, or psychological distress. The patient and the family should be instructed in strategies to manage the variables associated with anorexia (see Table 16-2). Use of Pharmacologic Agents to Stimulate Appetite Several pharmacologic agents are commonly used to stimulate appetite in patients with anorexia, although only progestational agents (e.g., megestrol acetate [Megace]) and glucocorticoids (e.g., dexamethasone [Dexpak]) have been found to stimulate appetite when examined in well-controlled research studies (Bondly & Jatoi, 2015). However, these agents have not been found to improve survival or quality in life in patients approaching end of life (Arensmeyer, 2012). Dexamethasone initially increases appetite and may provide short-term weight gain in some patients. It should be considered for those patients whose life expectancy is limited because the beneficial effects may be limited to the first few weeks of therapy and side effects increase over time (Del Fabbro, 2015). Therapy may need to be discontinued in patients with a longer life expectancy; after 3 to 4 weeks, corticosteroids interfere with the synthesis of muscle protein. Megestrol acetate produces temporary weight gain of primarily fatty tissue, with little effect on protein balance. This agent carries risk of serious side effects, including thromboembolism, and risk increases with prolonged use (Del Fabbro, 2015). Dronabinol is a psychoactive compound found in cannabis that may be helpful in reducing nausea and vomiting, appetite loss, pain, and anxiety, thereby improving food and fluid intake in some patients. However, in most patients, it is not as effective as other agents for appetite stimulation. Although dronabinol may have beneficial effects on appetite in patients with advanced cancer, it has not been shown to be more effective than megestrol. In addition, it possesses undesirable central nervous system side effects (Del Fabbro, 2015). Cachexia Cachexia refers to severe lean muscle loss with or without fat loss that cannot be reversed by traditional nutritional interventions (Fearon, Strasser, Anker, et al., 2011). Although anorexia may exacerbate cachexia, it is not the primary cause. Cachexia is associated with anabolic and catabolic changes in metabolism that relate to activity of neurohormones and proinflammatory cytokines, resulting in profound protein loss. These processes appear to be similar at the end stages of both cancer and some noncancerous illnesses, such as AIDS (Del Fabbro, 2015). However, the pathophysiology of cachexia in terminal illness is not well understood. In terminal illness, the severity of tissue wasting is greater than would be expected from reduced food intake alone, and typically increasing appetite or food intake does not reverse cachexia. At one time, it was believed that patients with cancer with rapidly growing tumors developed cachexia because the tumor created an excessive nutritional demand and diverted nutrients from the rest of the body. Research links cytokines produced by the body in response to a tumor to a complex inflammatory-immune response present in patients whose tumors have metastasized, leading to anorexia, weight loss, and altered metabolism. An increase in cytokines occurs not only in cancer but also in AIDS and many other chronic diseases (Del Fabbro, 2015). Artificial Nutrition and Hydration Along with breathing, eating and drinking are essential to survival throughout life. Near the end of life, the body's nutritional needs change, and the desire for food and fluid may diminish. People may no longer be able to use, eliminate, or store nutrients and fluids adequately. Eating and sharing meals are important social activities in families and communities, and food preparation and enjoyment are linked to happy memories, strong emotions, and hope for survival. For patients with serious illness, food preparation and mealtimes often become battlegrounds in which well-meaning family members argue, plead, and cajole to encourage ill people to eat. Seriously ill patients often lose their appetites entirely, develop strong aversions to foods that they have enjoyed in the past, or crave a particular food to the exclusion of all other foods. Although nutritional supplementation may be an important part of the treatment plan in early or chronic illness, unintended weight loss and dehydration are expected characteristics of progressive illness. As illness progresses, patients, families, and clinicians may believe that without artificial nutrition and hydration, terminally ill patients will "starve," causing profound suffering and hastened death. However, starvation should not be viewed as the failure to insert tubes for nutritional supplementation or hydration of terminally ill patients with irreversible progression of disease. Research has demonstrated that terminally ill patients with cancer who were hydrated did not have improved biochemical parameters and exhibited lower serum albumin levels, leading to fluid retention. The use of artificial nutrition and hydration (tube and intravenous [IV] fluids and feeding) carries considerable risks and generally does not contribute to comfort at the end of life (Casarett, Kapo, & Kaplan, 2005). Similarly, survival is not increased when terminally ill patients with advanced dementia receive enteral feeding, and no data support an association between tube feeding and improved quality of life in these patients (Mitchell, Black, Ersek, et al., 2012). Furthermore, in patients who are close to death, symptoms associated with dehydration such as dry mouth, confusion, and diminished alertness are common and typically do not respond to artificial nutrition (Danis, Arnold, & Savarese, 2015). Dry mouth can generally be managed through nursing measures such as mouth care and environmental changes with medications to diminish confusion. As the patient approaches the end of life, the family and the health care providers should offer the patient what he or she prefers and can most easily tolerate. The nurse should instruct the family how to separate feeding from caring and how to demonstrate love, sharing, and caring by being with the loved one in other ways. Preoccupation with appetite, feeding, and weight loss diverts energy and time that the patient and the family could use in other meaningful activities. In addition to those given in Table 16-2, the following are the tips to promote nutrition for terminally ill patients: Offer small portions of favorite foods. Be aware that cool foods may be better tolerated than hot foods. Offer cheese, eggs, peanut butter, mild fish, chicken, or turkey. Meat (especially beef) may taste bitter and unpleasant. Add milk shakes, meal replacement drinks, or other liquid supplements. Place nutritious foods at the bedside (fruit juices, milk shakes in insulated drink containers with straws). Schedule meals when family members can be present to provide company and stimulation. Offer ice chips made from frozen fruit juices. Allow the patient to refuse foods and fluids. (Hinkle 405-406) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Assessing patient and family goals palliative care

Awareness of diagnosis, illness stage, and prognosis: "Tell me your understanding of your illness right now." Values: "Tell me what is most important to you as you are thinking about the treatment options available to you/your loved one." Preferences: "You've said that being comfortable and pain free is most important to you right now. Where would you like to receive care (home, hospital, long-term care facility, doctor's office), and how can I help?" Expected/desired outcomes: "What are your hopes and expectations for this (diagnostic test [e.g., CT scan] or treatment)?" Benefits and burdens: "Is there a point at which you would say that the testing or treatment is outweighed by the burdens it is causing you (e.g., getting from home to the hospital, pain, nausea, fatigue, interference with other important activities)?" (Hinkle 401) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Clinicians attitude toward death

Clinicians' attitudes toward the terminally ill and dying remain the greatest barrier to improving care at the end of life. Kübler-Ross illuminated the concerns of the seriously ill and dying in her seminal work, On Death and Dying, first published in 1969. At that time, it was common for patients to be kept uninformed about life-threatening diagnoses, particularly cancer, and for physicians and nurses to avoid open discussion of death and dying with their patients. Kübler-Ross's work revealed that, given open discussion, adequate time, and some help in working through the process, patients could reach a stage of acceptance in which they were neither angry nor depressed about their fate (see later discussion). Clinicians' reluctance to discuss disease and death openly with patients stems from their own anxieties about death as well as misconceptions about what and how much patients want to know about their illnesses. In an early study of care of the dying in hospital settings, sociologists Glaser and Strauss (1965) discovered that health care professionals in hospital settings avoided direct communication about dying in the hope that the patient would discover it on their own. They identified four "awareness contexts": Closed awareness: The patient is unaware of their terminal state, whereas others are aware. Closed awareness may be characterized as a conspiracy between the family and the health care professionals to guard the "secret," fearing that the patient may not be able to cope with full disclosure about their status and the patient's acceptance of others' accounts of their "future biography" as long as the others give him or her no reason to be suspicious. Suspected awareness: The patient suspects what others know and attempts to find out details about their condition. Suspected awareness may be triggered by inconsistencies in the family's and the clinician's communication and behavior, discrepancies between clinicians' accounts of the seriousness of the patient's illness, or a decline in the patient's condition or other environmental cues. Mutual pretense awareness: The patient, the family, and the health care professionals are aware that the patient is dying, but all pretend otherwise. Open awareness: The patient, the family, and the health care professionals are aware that the patient is dying and openly acknowledge that reality. Glaser and Strauss (1965) also identified a pattern of clinician behavior in which those clinicians who feared or were uncomfortable discussing death developed and substituted "personal mythologies" for appraisals of what level of disclosure their patients actually wanted. For example, clinicians avoided direct communication with patients about the seriousness of their illness based on their beliefs that (1) patients already knew the truth or would ask if they wanted to know, or (2) patients would subsequently lose all hope, give up, or be psychologically harmed by disclosure. Although Glaser and Strauss's findings were published decades ago, their observations remain valid today. The growth of palliative and hospice care programs has led to greater numbers of health care providers becoming comfortable with and skilled in assessing patients' and families' information needs and disclosing honest information about the seriousness of illness (Bernacki & Block, 2014). However, in many settings, clinicians still avoid the topic of death in the hope that patients will ask or find out on their own. Despite progress on many health care fronts, many who work with seriously ill and dying patients recognize a persistent conspiracy of silence about dying. How to communicate truthfully with patients and encourage patient autonomy (the right of the individual to make choices) in a way that acknowledges where they are on the continuum of acceptance is a challenge. Despite continued reluctance of health care providers to engage in open discussion about end-of-life issues, patients want information about their illness and end-of-life choices and are not harmed by open discussion about death (The Conversation Project, 2013; Hoff & Hermeren, 2014). Timing of sensitive discussion takes experience, but speaking the truth can be a relief to patients and families, enhancing their autonomy by making way for truly informed consent as the basis for decision making. (See later section for detailed discussion of communication skills.) (Hinkle 389) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing interventions when communicating bad news

Communicating about a life-threatening diagnosis or disease progression is best accomplished in any setting by the interdisciplinary team: A physician, nurse, social worker, and chaplain should be present whenever possible to provide information, facilitate discussion, and address concerns. Most important, the presence of the team conveys caring and respect for the patient and the family. If the patient wishes to have family present for the discussion, arrangements should be made to have the discussion at a time that is best for everyone. Creating the right setting is particularly important. A quiet area with a minimum of disturbances should be used. All clinicians present should turn off pagers, cell phones, and other communication devices for the duration of the meeting and should allow sufficient time for the patient and the family to absorb and respond to the news. Finally, the space in which the meeting takes place should be conducive to seating all participants at eye level. It is difficult enough for the patient and the family to be the recipients of bad news without having an array of clinicians standing uncomfortably over them at the foot of the patient's bed (see Chart 16-5). After the initial discussion of a life-threatening illness or progression of a disease, the patient and the family will probably have many questions and may need to be reminded of factual information. Coping with news about a serious diagnosis or poor prognosis is an ongoing process. The nurse should be sensitive to these ongoing needs and may need to repeat previously provided information or simply be present while the patient and the family react emotionally. The most important intervention the nurse can provide is listening empathetically. Seriously ill patients and their families need time and support to cope with the changes brought about by serious illness and the prospect of impending death. The nurse who is able to listen without judging and without trying to solve the patient's and family's problems provides an invaluable intervention. Keys to effective listening include the following: Resist the impulse to fill the "empty space" in communication with talk. Allow the patient and the family sufficient time to reflect and respond after asking a question. Prompt gently: "Do you need more time to think about this?" Avoid distractions (noise, interruptions). Avoid the impulse to give advice. Avoid canned responses: "I know just how you feel." Ask questions. Assess understanding—your own and the patient's—by restating, summarizing, and reviewing. (See the Nursing Research Profile in Chart 16-6.) (Hinkle 398) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

COMFORT communicating palliative care

Communication (C) Narrative clinical practice: Elicit and be fully present for the patient's and family's story. Verbal clarity: Use compassionate, nonambiguous language. Nonverbal immediacy: Use eye contact, body position, and self-awareness to show attentiveness. Orientation (O) Support health literacy. Acknowledge vulnerability. Express cultural sensitivity. Mindfulness (M) Stay in the moment: Avoid scripted responses. Avoid prejudgment: Do not have expectations that this patient and family will or should respond as others have in the past. Adapt to rapid changes: Be ready to shift to new topics and concerns that are revealed. Family (F) Think of the family as a "second-order" patient: The family and the patient comprise the unit of care. Know that the family is a bridge to the patient: You must gain the family's trust to work effectively. Use family meetings (patient included) to clarify goals for treatment. Openings (O) Address essential transitions in care or status. Seek a higher level of understanding of the disease process. Engage spiritual concerns. Relating (R) Prioritize the turning point in illness. Understand that communication should be nonlinear: The patient and the family may need to revisit topics multiple times and on multiple occasions. Know that the patient's and family's acceptance must drive communication. Team (T) The interdisciplinary team includes members trained in various aspects of palliative care. Assure the patient and the family that they will not be abandoned. Ensure continuity of care across settings: Goals and plans should be clearly communicated to other providers. Adapted with permission from Wittenberg-Lyles, E., Goldsmith, J., & Ragan, S. L. (2010). The COMFORT initiative: Palliative nursing and the centrality of communication. Journal of Hospice and Palliative Nursing, 12(5), 282-292. (Hinkle 398) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing management of dyspnea

Dyspnea, an uncomfortable awareness of breathing, is one of the most prevalent symptoms at the end of life and can be challenging to manage (Kamal et al., 2012). A highly subjective symptom, dyspnea often is not associated with visible signs of distress, such as tachypnea, diaphoresis, or cyanosis. Although the underlying cause of the dyspnea can be identified and treated in some cases, the burdens of additional diagnostic evaluation and treatment aimed at the physiologic problem may outweigh the benefits. The treatment of dyspnea varies depending on the underlying cause, the patient's general physical condition, and imminence of death. For example, a blood transfusion may provide temporary symptom relief for a patient with anemia earlier in the disease process; however, as the patient approaches the end of life, the benefits are typically short-lived or absent. Nursing Assessment As with assessment of pain, reports of dyspnea by patients must be believed. As is true for physical pain, the meaning of dyspnea to an individual patient may increase their suffering. For example, the patient may interpret increasing dyspnea as a sign that death is approaching. For some patients, sensations of breathlessness may invoke frightening images of drowning or suffocation, and the resulting cycle of fear and anxiety may increase the sensation of breathlessness. Therefore, the nurse should conduct a careful assessment of the psychosocial and spiritual components of the dyspnea. Physical assessment parameters include symptom intensity, distress, and interference with activities; auscultation of lung sounds; assessment of fluid balance, including measurement of dependent edema (circumference of lower extremities) and abdominal girth; temperature; skin color; sputum quantity and character; and cough. To determine the intensity of dyspnea and its interference with daily activities, the patient can be asked to report the severity of the dyspnea using a scale of 0 to 10, where 0 is no dyspnea and 10 is the worst imaginable dyspnea. The nurse should assess the patient's baseline rating before treatment and should elicit subsequent measurements taken during exacerbation of the symptom, periodically during treatment, and whenever the treatment plan changes; these parameters provide ongoing objective evidence for the efficacy of the treatment plan. In addition, physical assessment findings may assist in locating the source of the dyspnea and selecting nursing interventions to relieve the symptom. The components of the assessment change as the patient's condition changes. For example, when the patient who has been on daily weights can no longer get out of bed, the goal of comfort may outweigh the benefit of continued weights. Like other symptoms at the end of life, dyspnea can be managed effectively in the absence of assessment and diagnostic data (e.g., arterial blood gases) that are standard when a patient's illness or symptom is acute and considered reversible. A numeric rating scale similar to one that is used for assessing pain can provide objective evidence of the severity of the patient's dyspnea. Nursing Management Nursing management of dyspnea at the end of life is directed toward administering medical treatment for the underlying pathology, monitoring the patient's response to treatment, helping the patient and the family manage anxiety (which exacerbates dyspnea), altering the perception of the symptom, and conserving energy (see Chart 16-10). Pharmacologic intervention is aimed at modifying lung physiology and improving performance as well as altering the perception of the symptom. Bronchodilators and corticosteroids are used to treat underlying obstructive pathology, thereby improving overall lung function. Low doses of opioids effectively relieve dyspnea, although the mechanism of relief is not entirely clear. Although dyspnea in terminal illness is typically not associated with diminished blood oxygen saturation, low-flow oxygen often provides psychological comfort to both patients and families, particularly in the home setting. (Hinkle 403-404) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Answering difficult questions

For example, a seriously ill patient might ask the nurse, "Am I dying?" The nurse should avoid making unhelpful responses that dismiss the patient's real concerns or defer the issue to another care provider. Nursing assessment and intervention are always possible, even when a need for further discussion with a physician is clearly indicated. Whenever possible, discussions in response to a patient's concerns should occur when the patient expresses a need, although that may be the least convenient time for the nurse. Creating an uninterrupted space of just 5 minutes can do much to identify the source of the concern, allay anxieties, and plan for follow-up. In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind"). The nurse then needs to listen intently, ask additional questions for clarification, and provide reassurance only when it is realistic. In this example, the nurse might quickly ascertain that the patient's question emanates from a need for specific information—about diagnosis and prognosis from the physician, about the physiology of the dying process from the nurse, or perhaps about financial implications for the family from the social worker. The chaplain may also be called to talk with the patient about existential concerns. (Hinkle 399) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Hospice in the United states

Hospice in the United States is not a place but a concept of care in which the end of life is viewed as a developmental stage. The hospice movement in the United States is based on the belief that meaningful living is achievable during terminal illness and that it is best supported in the home, free of technologic interventions to prolong physiologic dying (Hinkle 393) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nurses role in physician assisted suicide

In its 2010 position statement on Registered Nurses' Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life, the ANA acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. The ANA position statement further stresses the important role of the nurse in supporting effective symptom management, contributing to the creation of environments for care that honor the patient's and family's wishes, as well as identifying their concerns and fears (ANA, 2010). In its position statement on Euthanasia, Assisted Suicide and Aid in Dying, the ANA clearly prohibits nurses' participation in assisted suicide and euthanasia (Hinkle 390) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Technology and end of life care

In the 20th century, chronic, degenerative diseases replaced communicable diseases as the major causes of death. In the earlier part of the 20th century, most deaths occurred at home and most families had direct experience with death, providing care to family members at the end of life and then mourning their losses. As the place of death shifted from home to hospitals, families became increasingly distanced from the death experience. The application of technology to prolong life raises numerous ethical issues. One major question is: Because we can prolong life through increasingly sophisticated technology, does it necessarily follow that we must do so? In the latter half of the 20th century, a "technologic imperative" practice pattern among health care professionals emerged, along with an expectation among patients and families that every available means to extend life must be tried. By the early 1970s, when hospice care was just beginning in the United States, technology had become an expected companion of the critically and terminally ill. In the 21st century, technological intervention at the end of life continues to have profound implications, affecting how clinicians care for the dying, how family and friends participate in care, how patients and families understand and choose among end-of-life care options, how families prepare for terminal illness and death, and how they heal after the death of a loved one. (Hinkle 388) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Pain management end of life care

In the final stages of illnesses such as cancer, heart disease, COPD, and renal disease, pain and other symptoms are common. Pain results from the diseases as well as the modalities used to treat them. The Worldwide Palliative Care Alliance and World Health Organization (2014) called attention to the continuing, worldwide high prevalence of pain at the end of life and the inadequate supply of opioids, particularly in developing nations. Pain at the end of life is preventable or treatable in most cases: it is every nurse's role to ensure that pain is assessed, prevented where possible, and managed. Chapter 12 presents the importance of pain assessment, assessment principles for pain that include identifying the effect of the pain on the patient's life, and the importance of believing the patient's report of the pain and its effect. Although the means to relieve pain have existed for many years, the continued, pervasive undertreatment of pain has been well documented (Reynolds, Drew, & Dunwoody, 2013). Poorly managed pain affects the psychological, emotional, social, and financial well-being of patients. Despite studies demonstrating the negative effects of inadequate pain management, practice has been slow to change. Every clinician should be able to assess and oversee the basic management of pain (IOM, 2014b). Patients who are receiving an established regimen of analgesics should continue to receive those medications as they approach the end of life. Inability to communicate pain should not be equated with the absence of pain (McGuire, Reifsnyder, Soeken, et al., 2011). Although most pain can be managed effectively using the oral route, as the end of life nears, patients may be less able to swallow oral medications due to somnolence or nausea. Patients who have been receiving opioids should continue to receive equianalgesic doses via rectal or sublingual routes. Concentrated morphine solution can be effectively delivered by the sublingual route, because the small liquid volume is well tolerated even if swallowing is not possible. As long as the patient continues to receive opioids, a regimen to combat constipation must be implemented. If the patient cannot swallow laxatives or stool softeners, rectal suppositories or enemas may be necessary. The nurse should educate the family about continuation of comfort measures as the patient approaches the end of life, how to administer analgesics via alternative routes, and how to assess for pain when the patient cannot verbally report pain intensity. Because the analgesics given orally or rectally are short acting and typically scheduled as frequently as every 3 to 4 hours around the clock, there is always a strong possibility that a patient approaching the end of life will die in close proximity to the time of analgesic administration. If the patient is at home, family members administering analgesics should be prepared for this possibility. They need reassurance that they did not "cause" the death of the patient by administering a dose of analgesic medication (Hinkle 403) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Palliative care

a multidisciplinary approach to specialized medical and nursing care for people with life-limiting illnesses. It focuses on providing relief from the symptoms, pain, physical stress, and mental stress at any stage of illness.

Palliative care in a hospital

Many patients will continue to opt for hospital care or will by default find themselves in hospital settings at the end of life. Increasingly, hospitals are conducting system-wide assessments of end-of-life care practices and outcomes and are developing innovative models for delivering high-quality, person-centered care to patients approaching the end of life. A growing body of evidence supports the role of palliative care that is delivered concurrently with standard medical treatment. For example, in a landmark study of referral to palliative care for patients newly diagnosed with metastatic non-small cell lung cancer (a disease with very poor prognosis), researchers found that those patients randomized to the palliative care plus standard oncology care arm of the trial not only showed improved quality of life and mood but also had longer median survival than those who received standard oncology care alone (Temel, Greer, Muzikansky, et al., 2010). This study underscores the value of palliative care and undercuts one of the principal objections to palliative care, which equates it with "giving up." (Hinkle 392) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing issues and communication for terminally ill patients

Nurses are responsible for educating patients and their caregivers and for supporting them as they adapt to life with the illness. Nurses can assist patients and families with life review, values clarification, treatment decision making, and end-of-life goals. The only way to do this effectively is to try to appreciate and understand the illness from the patient's perspective. Nurses should be both culturally aware and sensitive in their approaches to communication with patients and families about death. Attitudes toward open disclosure about terminal illness vary widely among different cultures, and direct communication with patients about such matters may be viewed as harmful (Sarafis, Tsounis, Malliarou, et al., 2014). To provide effective patient- and family-centered care at the end of life, nurses must be willing to set aside their own assumptions and attitudes so that they can discover what type and amount of disclosure is most meaningful to each patient and family within their unique belief systems (see Table 16-1). (Hinkle 395) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Home hospice services

Nursing care provided by or under the supervision of a registered nurse, available 24 hours a day Medical social services Physician's services Counseling services, including dietary counseling Home health aide/homemaker Physical/occupational/speech therapists Volunteers Bereavement follow-up (for up to 13 months after the death of the patient) Medical supplies for the palliation of the terminal illness Medical equipment for the palliation of the terminal illness Medications for the palliation of the terminal illness (Hinkle 394) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

True

Palliative care is broader than hospice carw

Situations for patients who are dying

Patient and family awareness of prognosis is a key factor in acceptance of and planning for death. Even patients and families who have received clear and honest information may not fully accept the situation. For patients who have been informed about terminal illness, their understanding of treatment goals and prognosis is dynamic and may sometimes require reinforcement. Another concern is that patients' and their caregivers' understanding of treatment goals and prognosis can differ dramatically. In a study of patients receiving palliative radiation therapy for metastases, researchers found that 25% of patients believed that radiation therapy would cure the cancer and prolong their lives (Mitera, Zhang, Sahgal, et al., 2012). Such misunderstandings can complicate both delivery of effective care and informed consent for care. Patients with noncancer diagnoses, such as heart failure, COPD, kidney injury, dementia, or neurodegenerative diseases such as amyotrophic lateral sclerosis, frequently do not receive adequate information and support to fully understand their prognosis, yet they often desire clear and honest information. For example, they may have troublesome symptoms and reduced quality of life paralleling or exceeding that of patients with cancer. Patients may want but are unlikely to receive clear information about disease progression, advance care planning, and prognosis. Research is needed to examine the complex interactions between patients' misconceptions about advanced illness, their underlying psychological states, and barriers to clinicians' explanations of treatment expectations and prognosis. (Hinkle 390) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Signs of impending death

Signs of Approaching Death The person shows less interest in eating and drinking. For many patients, refusal of food is an indication that they are ready to die. Fluid intake may be limited to that which will keep their mouths from feeling too dry. What you can do: Offer, but do not force, fluids and medication. Sometimes pain or other symptoms that have required medication in the past may no longer be present. For most patients, pain medications are still needed, and they can be provided by concentrated oral solutions placed under the tongue or by rectal suppository. Urinary output may decrease in amount and frequency. What you can do: No response is needed unless the patient expresses a desire to urinate and cannot. Call the hospice nurse for advice if you are not sure. As the body weakens, the patient will sleep more and begin to detach from the environment. He or she may refuse your attempts to provide comfort. What you can do: Allow your loved one to sleep. You may wish to sit with him or her, play soft music, or hold hands. Your loved one's withdrawal is normal and is not a rejection of your love. Mental confusion may become apparent. This occurs because less oxygen is available to supply the brain. The patient may report strange dreams or visions. What you can do: As he or she awakens from sleep, remind him or her of the day and time, where he or she is, and who is present. This is best done in a casual, conversational way. Vision and hearing may become somewhat impaired, and speech may be difficult to understand. What you can do: Speak clearly but no more loudly than necessary. Keep the room as light as the patient wishes, even at night. Carry on all conversations as if they can be heard, because hearing may be the last of the senses to cease functioning. Many patients are able to talk until minutes before death and are reassured by the exchange of a few words with a loved one. Secretions may collect in the back of the throat and rattle or gurgle as the patient breathes through the mouth. He or she may try to cough, and their mouth may become dry and encrusted with secretions. What you can do: If the patient is trying to cough up secretions and is experiencing choking or vomiting, call the hospice nurse for assistance. Secretions may drain from the mouth if you place the patient on their side and provide support with pillows. Cleansing the mouth with moistened mouth swabs will help relieve the dryness that occurs with mouth breathing. Offer water in small amounts to keep the mouth moist. A straw with one finger placed over the end can be used to transfer sips of water to the patient's mouth. Breathing may become irregular with periods of no breathing (apnea). The patient may be working very hard to breathe and may make a moaning sound with each breath. As the time of death nears, the breathing remains irregular and may become more shallow and mechanical. What you can do: Raising the head of the bed may help the patient to breathe more easily. The moaning sound does not mean that the patient is in pain or other distress; it is the sound of air passing over very relaxed vocal cords. As the oxygen supply to the brain decreases, the patient may become restless. It is not unusual to pull at the bed linens, to have visual hallucinations, or even to try to get out of bed at this point. What you can do: Reassure the patient in a calm voice that you are there. Prevent him or her from falling by trying to get out of bed. Soft music or a back rub may be soothing. The patient may feel hot one moment and cold the next as the body loses its ability to control temperature. As circulation slows, the arms and legs may become cool and bluish. The underside of the body may darken. It may be difficult to feel a pulse at the wrist. What you can do: Provide and remove blankets as needed. Avoid using electrical blankets, which may cause burns because the patient cannot tell you if he or she is too warm. Sponge the patient's head with a cool cloth if this provides comfort. Loss of bladder and bowel control may occur around the time of death. What you can do: Protect the mattress with waterproof padding, and change the padding as needed to keep the patient comfortable. As people approach death, many times they report seeing gardens, libraries, or family or friends who have died. They may ask you to pack their bags and find tickets or a passport. Sometimes they may become insistent and attempt to do these chores themselves. They may try getting out of bed (even if they have been confined to bed for a long time) so that they can "leave." What you can do: Reassure the patient that it is all right; he or she can "go" without getting out of bed. Stay close, share stories, and be present. (Hinkle 408) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Eligibility of Hospice Care

The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and the family comprise the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means. Hospice care hinges on the competent patient's full or "open" awareness of dying; it embraces realism about death and helps patients and families understand the dying process so that they can live each moment as fully as possible. Approximately 30% of hospice programs have developed inpatient facilities or residences (NHPCO, 2014) where terminally ill patients without family support and those who desire inpatient care may receive hospice services. (Hinkle 393) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Goals of hospice

The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and the family comprise the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means. Hospice care hinges on the competent patient's full or "open" awareness of dying; it embraces realism about death and helps patients and families understand the dying process so that they can live each moment as fully as possible. Approximately 30% of hospice programs have developed inpatient facilities or residences (NHPCO, 2014) where terminally ill patients without family support and those who desire inpatient care may receive hospice services. (Hinkle 393) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Goal of palliative care

characterized by interdisciplinary communication and coordination across the trajectory of serious illness, emphasizing management of psychological, social, and spiritual problems in addition to control of pain and other physical symptoms. As the definition suggests, palliative care does not begin when cure-focused treatment ends but instead is offered "concurrently with or independent of curative or life-prolonging care" (NCP, 2013, p. 9). The goal of palliative care is to improve the patient's and family's quality of life, and indeed many aspects of this type of comprehensive, comfort-focused approach to care are applicable earlier in the process of life-threatening disease and in conjunction with cure-focused treatment. (Hinkle 391) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Denial in nursing

denial can be a useful coping mechanism that enables the patient to gain temporary emotional distance from a situation that is too painful to contemplate fully (Benkel, Wijk, & Molander, 2010). Denial may become a barrier to care if patients or families refuse to acknowledge a diagnosis or refuse to hear about treatment options. Nurses must accept patients regardless of the degree to which they are in denial about their illness and work with other health care providers to present a consistent message. (Hinkle 389-390) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.