End of Life Care

What are the signs of impending death?

• Difficulty talking or swallowing

• Nausea, flatus, and abdominal distension

• Urinary or bowel incontinence or constipation

• Loss of movement, reflexes, and sensation

• Decreasing body temp. w/cold or clammy skin

• Weak, slow, or irregular pulse

• Decreasing BP

• Noisy, irregular, or Cheyne-Stokes respirations

• Restlessness or agitation

• Cooling, mottling, and cyanosis of the extremities and dependent areas

• Decreased LOC or agitated delirium

What’s considered a “good death”?

Different for every patient, but overall, it allows a person to die on their own terms, relatively free of pain and with dignity.

Palliative Care

Involves taking care of the whole person — mind, body, and spirit. Goal is to give patients with life-threatening illnesses the best quality of life they can have by aggressive management of symptoms. Appropriate for those of any age and even those seeking curative therapies.

Hospice Care

Falls under the term of palliative care. It’s provided for people with limited life expectancy, less than 6 months, often in the home.

What are the indicators for a hospice referral?

• Poor performance status

• Declining cognitive status

• Advanced age

• Poor nutritional intake

• Pressure injuries

• Comorbidities

• Previous hospital admissions for acute decompensation

What are the four trajectories of illness?

Terminal illness (ex. cancer), organ failure, frailty (ex. dementia), and sudden death.

Hospice care was recognized by Medicare in _.

1983

What makes a patient eligible for hospice care

Two primary providers certify that prognosis is less than 6 months if the disease runs its usual course. And the patient and family agree with comfort as the goal of care.

What are some principles of hospice?

Death must be accepted, patient and family should be viewed as a single unit, bereavement care must be provided to family members.

Palliative performance scale (PPS)

Assesses functional status to acquire prognostic indication. Based on ambulation, activity, outward evidence of disease, self-care, intake, and LOC.

10-point increments, with 100% being fully functional and independent.

Comfort kit

Ready to administer doses of various medications that are useful to treat symptoms in advanced illness.

Nursing interventions to promote comfort

Management of: Pain, dyspnea, secretions, impaired vision or speech, incontinence, hallucinations/delirium, and anorexia.

What medications/interventions can treat pain?

Narcotics (morphine, dilaudid, fentanyl, hydrocodone, etc.), OTC (tylenol, ibuprofen), Antispasmodic/anticholinergic (Levsin/Atropine drops), Steroids, Creams, Repositioning, and alternative therapies like massages.

What medications/interventions can treat air hunger/dyspnea?

Morphine, allergy-related meds, anti-anxiety, O2 therapy, positioning, activity moderation/rest, and thoracentesis or pleurx catheter .

What medications/interventions can treat secretions?

Hyoscyamine, atropine, robinul, scopolamine, and suctioning (not favored).

What medications/interventions can treat skin care?

Positioning, incontinence care, barrier creams, wound care and pressure-relieving devices, and powders for rashes.

What medications/interventions can treat agitation/restlessness/depression?

Antianxiety (ativan,valium), antipsychotics (haldol), calm environment, distractions, bowel and bladder status, and pain management.

What medications/interventions can treat delirium?

Haldol or ativan, ensure safety, spiritual intervention, music, therapeutic touch, environmental distraction, familiar faces, and gentle reorientation and reassurance.

What medications/interventions can treat anorexia/cachexia?

Offer what they prefer and can easily tolerate, give them food that brings them joy.

Anorexia

Inadequate nutritional intake.

Cachexia

Lean muscle loss.

What qualifies for inpatient care in IPU?

• Uncontrolled pain

• Uncontrolled nausea and vomiting

• Respiratory distress

• Wound care that requires frequent dressing changes

• Unmanageable agitation

• Uncontrolled seizures

• Fractures with symptoms

• Symptom relief via IV medications.

What makes up an interdisciplinary team?

Medical social worker, CNA, chaplain, RN, physician.

The _ is the only member that is required to be assigned to a patient.

Nurse