NRSG 310 Final

Good death

Described in terms of peacefulness, symptom control, frank conversations, acceptance and openness to physical and emotional support

Bad death

Described in terms of conflict with family, lack of acceptance, rejection of physical and emotional support, physical and emotional distress

4 death work competencies

Knowledge competence, practice competence, work-environment competence and self competence (personal resources, existential resources, emotional coping)

Living well and dying well

A dynamic and constantly changing journey of living while dying and dying while living

Palliative care

An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness.

Done through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other problems

Palliative approach

Journeying with the patient who has chronic life-limiting diseases to meet their goals

Upstream approach

10 guiding principles of palliative approach

Palliative care is person- and family-centered care

Death, dying, grief and bereavement are all part of life

Caregivers are both providers and recipients of care

Palliative care is integrated and holistic

Access to palliative care is equitable

Palliative care recognizes and values the diversity of Canada and it's peoples

Palliative care services are valued, understood and adequately resourced

Palliative care is high quality and evidence based

Palliative care improves QOL

Palliative care is a shared responsibility

How to provide LGBTQ+ inclusive care

Develop self-awareness and consciously practice your skill in putting aside baggage before providing care

Wholeheartedly support colleagues who are seeking to build LGBTQ-inclusive practices

Advocate for LGBTQ-inclusive language and care options in your workplace

Acknowledge and honour the person-hood within every person you provide care to

3 triggers of nearing end of life (GSF prognostic indicator)

Would you be surprised if this patient were to due in the next few months/weeks/days?

General indicators of decline

Specific clinical indicators of decline in relation to certain conditions

Sudden death graph characteristics

Steady line, then straight drop down

Terminal illness graph characteristics

Straight line, then gradual line down

Organ failure graph characteristics

Stuttering decline (up, then down, then up, then down etc)

Frailty graph characteristics

Slow and progressive decline

Catastrophic event graph characteristics

Steady line, straight drop down, then steady decline

Transitions

Changes that occur on a continuum from wellness to death, commonly identified in hospice and palliative care practice using various palliative performance skills

Experiencing a change in health status d/t improvements or decline

100-90% PPS meaning

Diagnosis

80-70% PPS meaning

Indicates that illness is not responding well to treatment

Disease progression

60-50% PPS meaning

Disease extensive and advanced

Cure not possible

40-30% PPS meaning

Unable to provide self-care

Extensive-care giving

20-10% PPS meaning

Less alert and responsive

Death is imminent

0% PPS meaning

Death

Types of hope

Realistic, utopian, chosen and transcendent

Realistic hope

Hope for an outcome that is reasonable or probable

Utopian hope

Collectively oriented hope that collaborative action can lead to a better future for all

Critically negates the present and is driven by hope to affirm a better alternative

Chosen hope

Helps us live with a difficult present and with an uncertain future

Critical to the management of hopelessness and dispair

Transcendent hope

AKA existential hope

Describes a stance of general hopefulness not tied to a specific outcome or goal

The hope that something good can happen

Snyder's Hope Theory

Hopefullness is a life-sustaining human strength comprised of 3 different but related components (goals thinking, pathways thinking and agency thinking)

Hope does not necessarily fade in the face of adversity; in fact hope often endures despite poverty, war and famine

Goals thinking

Clear conceptualization of valuable goals

Pathways thinking

Capacity to develop specific strategies to reach goals established in goal thinking

Agency thinking

Ability to initiate and sustain the motivation for using strategies of pathways thinking

Hope engendering nurse interventions (HENI)

Prevent and manage EOL s/s

Use lightheartedness and humour appropriately

Encourage aesthetic experiences

Encourage engagement in creative and joyous endeavors

Suggest literature, movies and art that are uplifting and highlight joy in life

Encourage reminiscing

Assist pt and family to focus on present and past joys

Share positive and hope-inspiring stories

Support positive self-talk

Relational HENI

Minimize isolation

Establish and maintain open relationships

Affirm self-worth

Recognize and reinforce hope

Provide time for relationships

Foster attachment ideation

Rational thought HENI

Assist pt and family to establish, obtain and revise goals

Assist to identify available and needed resources

Assist in procuring resources and breaking big goals into smaller steps

Provide accurate information

Help pt and family identify past successes

Increase patient and family's sense of control

Spiritual/transcendent HENI

Initiate referrals to spiritual counsellors

Facilitate participation in practices

Assist the pt and family in finding meaning in the current situation

Advanced care planning

Part of good palliative and EOL care

Looking forward to preferences for care with the aim of supporting "good" decision making to enable "good death"

Why is advanced care planning important

Allows EOL wishes to be known and followed, decreases stress on loved ones, pt/family is more satisfied with care, pt will have better QOL and good death

Challenges with advanced care planning

People change

Values/beliefs change

People may feel differently in final hours

Key documents in advanced care planning

Will, Representation Agreement or TSDM list, Advanced Directives, Enduring Power of Attorney

Will

Document that leaves instructions about what you want done with your personal possessions and land after death

Names an executor, names guardians, deals with estate

Representation agreement

Name someone to make your health and personal care decisions if you become incapable

Temporary substitute decision maker (TSDM)

Contact information of people who may be approached by a health care provider when needed to make a treatment decision if the representative resigns or is unavailable

Order of approach for TSDM

Spouse, child, parent, sibling, grandparent, grandchild, other relatives, close friends, relative by marriage

Advanced directive

Legally binding document that provides written instructions, made while capable directly to HCP for health care they wish to consent to/refuse when incapable

Enduring power of attorney

Person to make decisions about financial affairs, business and property

Serious illness

A condition that carries a high risk of mortality AND

Negatively impacts a person's daily ftn or QOL OR excessively strains their caregivers

Serious illness conversation

Clinician-initiated discussion regarding:

Values and goals, prognosis, treatments and procedures

Provides foundation for making future decisions

Should be reviewed/revisited

The "spirit" of SIC

Partnership, Acceptance, Compassion, Evocation or Elicit

Sympathy

Unwanted, pity-based response to a distressing situation

Characterized by a lack of understand and self-preservation of the observer

Empathy

An affective response that acknowledges and attempts to understand the individual's suffering through emotional resonance

Compassion

Enhances the key facets of empathy while adding distinct features of being motivated by love, altruism, action and acts of kindness

A constructive response to suffering that enhances treatment outcome, fosters the dignity of the recipient and provides self-care for the giver

Existential suffering

Profound feelings of fear, loss of identity or dignity and hopelessness

Symptoms may be inconsolable by care or medication

Existential pain

Manifests in 4 domains: meaninglessness, isolation, mortality and freedom

Palliative sedation

Use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and HCPs

Possible reasons for palliative sedation

Pain, anguish, respiratory distress, agitation, delirium, confusion, fear, panic, anxiety, terror, emotional/spiritual distress

4 conditions of ethical palliative sedation

Nature of act must be good

Good effect must be intended

Bad effect must not be means to good effect

Good effect must outweigh the bad effect

Expected changes during EOL

Decreasing energy, decreased appetite and thirst, medication concerns, decreased circulation, skin breakdown, decreased bowel and bladder function, Cheyne-Stokes, death rattle, confusion, visions, unexpected rally, agonal breathing

Cheyne-Stokes

Series of short breaths and long or short pauses

Indicates death is close

Death rattle

Raspy wet respirations

Caused by a build-up of saliva or secretions at the back of the throat

Agonal breathing

Last reflexes of dying brain

Sudden drawing of a breath and twitching

Viewed as a sign of death and can happen after the heart has stopped beating

Principles of symptom management

Do not overlook symptom management when focusing on disease oriented care

Identify underlying pathophys and mechanism

Symptoms are the patient's experience of illness

HCP is obligated to relieve those symptoms

Unrelieved suffering is demoralizing and demeaning

Common symptoms of advanced disease

Pain, loss of appetite, nausea + vomiting, fatigue, dyspnea, constipation, delirium

Prevalence of pain

84% of people with advanced cancer experience pain

60% will experience pain at more than 1 site

66% will experience moderate to severe pain

Basic pain control principles help manage pain in 85% of people experiencing pain d/t cancer

Pain crisis

Acute medical crisis graded at 7/10 on pain scare or higher

Develops rapidly over a few hours

Goal is immediate control of symptoms using a dose-stacking method

Causes of pain crises

Medical crisis, possible terminal event, poor opioid titration, insufficient breakthrough dose, inaccurate equinanalgesic calculation, miscalculation with change of route

Grade 1 pain

Mild pain

Grade 2 pain

Moderate pain, limiting instrumental ADLs

Grade 3 pain

Severe pain, limiting self-care ADLs

Grade 4 pain

Life-threatening

Types of nociceptive pain

Somatic, visceral, colic

Types of neuropathic pain

Dysesthetic, lacinating, central

Step one of pain relief ladder

For mild pain

Non-opioid analgesic (acetaminophen or ASA)

Step two of pain relief ladder

Moderately severe pain

Weak opioid plus or minus adjuvants

Step three of pain relief ladder

For severe pain or when it is expected that pain will become severe

Low dose of a strong opioid and titre according to effect

Initiation of opioid analgesics clinical review points

Start low, go slow, PO, by the clock, plan for adverse effects, plan for breakthrough pain

3 most common side effects of opioids

Constipation, nausea, somnolence (feeling of being sleepy)

Components of total pain/total suffering

Psychological, social/financial, cultural, spiritual/existential, physical

Mild dyspnea

Breathing not labored, tasks without pausing, no cyanosis, can sit or lie with no SOB

Dyspnea is new or chronic, intermittent or persistent

Moderate dyspnea

Breathing is mildly difficult but not labored, pauses while talking q30sec, no cyanosis, worsens with activity

Dyspnea is new or chronic, usually persistent

Progressively severe dyspnea

Labored breathing, pauses while talking q15-30sec, +/- cyanosis, anxiety, wakes suddenly with dyspnea, cough, +/- confusion, worsens over a few days or weeks

Dyspnea is acute or chronic

Sudden severe dyspnea

Breathing is labored, pauses while talking, cyanotic, high levels of anxiety, +/- congestion; chest pain; diaphoresis and confusion

Dyspnea is sudden onset

Risk factors of delirium

Age, dementia, multiple diseases, chronic inflammation, polycharmacy, renal impairment, malnutrition, visual impairment. deafness

Precipitants of delirium

Medication, change in environment, infection, dehydration, surgery, electrolyte imbalance, stroke, hematoma, sleep deprivation

Causes of delirium

Drugs, electrolyte imbalance, liver failure, infection, respiratory problems, increased ICP, uremia, metabolic disease

Delirium onset, course and features

Rapid, fluctuates, lack of attention and concentration

Dementia onset, course, and features

Very gradual (months to years), generally stable but may have periods of behavioral problems, memory loss

Depression onset, course and features

Gradual (weeks to months), generally stable, may affect cognition

Spirituality

Propensity to make meaning through a sense of relatedness to dimensions that transcend the self in such a way that empowers and does not devalue the individual

Seeking and expressing meaning and purpose

Experience of connectedness to self, moment, others, nature and to the significant or sacred

Fundamental spiritual needs

Be loved and love in return, find meaning and purpose in life and hope for future, be true to self, transcend self

Spiritual distress

Unpleasant emotional experience of a psychological, social and spiritual nature that may interfere with the ability to cope effectively with an illness, its physical symptoms and its treatment

Risks for spiritual distress

Grief, concerns about death and afterlife, conflicted or challenged belief systems, loss of faith, concerns with meaning/purpose of life, concerns about relationships, isolation from religious community, guilt, hopelessness, conflict between beliefs and recommended treatments, unmet ritual needs

Spiritual care

Seeks to reach heart of person and gives space for unexpected development

Allows movement towards integration, integrity and wholeness (healing) even when cure isnt possible

Healing prescence

Provides ministry of presence, space to verbalize the search for meaning and affirms the whole person

4 areas of spiritual assessment

Religious practices, patient's concept of God or deity, relationships between spiritual beliefs and health, sources of hope and strength

Nursing role in spiritual care

Spiritual self-awareness, creating a safe space, connecting, empathetic listening, focusing on questions and not answers, know when to refer

5 bedside skills essential to spiritual care

Hearing: listening attentively

Sight: seeing soulfully

Speech: taming the tongue

Touch: Physical means of spiritual care

Presence: the essence of spiritual care

ABCD of dignity in care

Attitude, behaviour, compassion, dialogue

Nurse's role in MAID

Providing education, acting as independent witness, acting as proxy, acting as a witness in a telehealth assessment, aiding in provision

Nurse's responsibilities with MAID

Understand and follow BCCNM standards, complete additional education, possess knowledge to provide safe; competent and ethical care, be aware of eligibility, be aware of legal seek professional help as needed

Medical Assistance in Dying

Process that allows eligible people to receive assistance from a medical practitioner to end their life

In relation to MAID, nurses cannot

Assess or determine eligibility

Prescribe, compound, dispense, prepare or administer MAID medications

Pronounce death related to MAID

Document any aspect of the MAID procedure

Aid in the provision of MAID for a family member