end of life care

recognize difference between palliative care vs. hospice vs. comfort measures

palliative: family-centered approach that attends to physiological, psychological, spiritual, and existential aspects of serious illness

• done at any time of illness

• continue life-prolonging/curative therapies

hospice: coordinated interdisciplinary care and services for terminally ill patients and their families

• done when prognosis is 6 months or less

• majority of life-prolonging tx is forgo

expected physiological changes and nursing interventions

loss of interest in eating/drinking (body is not interested)

• decreased blood pressure, irregular pulses → offer fluids

• decrease in urine output/incontinence → turn on side and change pad PRN

• nausea and vomiting → ondansetron

mental status changes

• lethargic

• awake, hallucinating, disoriented → reorient

lose ability to thermoregulate

• can be either really hot/cold → remove/provide blanket and acetaminophen

vision/hearing impaired, speech difficulty

• hard to understand → carry on conversation (unless near the end, titrate amount of speaking)

collection of secretions (secretions building up in throat due to brain limiting signals), can exhibit “death rattle”

• drooling → reposition patient, moisten mouth, oral suctioning (never deep), glycopyrrolate or atropine ophthalmic drops to decrease

irregular breathing with apnea

• “cat-gasping” for air → hob elevated and opioid (morphine)

• anxiety → lorazepam (ativan)

restless

• pain → assess (grimacing? uncomfortable?)

• provide reassurance with calm voice

• fall preventions in place

• agitated → haloperidol

differences in end-of-life preferences

advance directive: for anyone 18yrs or older, requires witness/notorization

• instructions for future treatment

• appoints someone as health care representative

• two types:

  • living will

  • durable power of attorney

physican order for life-sustaining treatment form: person with serious illness at any age

• provides medical orders for current treatment

• guides emergency medical personnel when available

• multiple types of care decisions

  • full code

  • dnr or and (do not resuscitate; allow natural death)

  • dni (do not intubate)

  • comfort measure only

nursing interventions during end-of-life news delivered

• involve interdisciplinary team

• coordinate time/place (know when/how to deliver)

• repeat information previously provided

• be present with active listening

• ask family or patient to sit

• listen empathetically

Kubler-Ross’ 5 stages of grief

people may not go through all stages

1. denial: isolation, unable to handle news, expected → be clear on what is happening with loved one

2. anger: trying to work through pain of grief → work w/ team

3. bargaining

4. depression

5. acceptance

associated tasks with grieving

• accepting the reality of loss

• working though the pain of grief

• adjusting to enviornment that has changed → prepare home for what it will be before and after loved one is gone

• emotional relocation → ilicit help from others, find what trigger may be

• recognize dysfunctional grief

  • worsen/persists overtime

  • daily functioning is impaired

dimensions of grieving and nursing interventions

cognitive: processing loss, confused, shock, difficulty concentrating

→ provide clear, simple info, allow time for decision making

emotional: flucuate emotions (sad, angry, sorrow, guilt, regret)

→ validate emotions w/o judgement, encourage expression, be present/listen, emotions can surface

spiritual: may question faith, meaning in loss, turning to spiritual practices

→ offer chaplin, dont impose on personal beliefs

behavioral: clinging to routine, changes in activites of daily living

→ assess for maladaptive behavior and risk taking

physiological: loved ones may feel fatigue, have sleep disturbances, insomnia, appetite changes

apply the nursing process to end-of-life care

assess

• the 5 dimensions of grieving

• perception of the loss

• support in place

• current coping behaviors

diagnose

• grieving

• any caregiver role strain

• risk for spiritual distress

• risk for moral distress

plan

• patient or family will participate in..

implement

• interventions done

evaluate

ethical considerations in place

• technology and end-of-life care

  • even though we are able to prolong life, it is really necessary or ethical to?

• active euthanasia vs. passive euthanasia

  • directly causing death vs. withholding/drawing tx

• assisted suicide

  • legal in certain states

  • supporters: terminally ill should be able to make decision

  • opponants: greater access to symptom management/psychosocial support

  • ANA: violation of code of ethics

    • nurses can support symptom management, contribute to environment

nurse’s role in post-mortum care

• elevate head of the bed

• clean patient for family to visit

• tag patient’s body

• prepare for transport