Palliative Care & End of Life Care

palliative care

care or treatment focusing on reducing the severity of symptoms

palliative care begins when …

during curative or restorative health care

palliative care focuses on …

reducing the severity of disease symptoms

palliative care prevents and relieves …

suffering

palliative care improves …

quality of life for pt’s with serious diseases

palliative care has shown to …

• Improves quality of life

• Decreases costs of health care

• Alleviates the burden of care

palliative care is not the same as …

hospice

palliative care is specialized medical care for people living with …

a serious illness

palliative care allows for …

curative and palliative treatment simultaneously

hospice care is provided when …

curative care is forgone

what does hospice care do?

• available 24 hours/day, 7 days/week

• provided by medically supervised professional teams and volunteers

• hospice nurses are pivotal

  • pain control, symptom management, spiritual assessment, assessment and management of family needs

hospice care admission criteria

1. Patient must desire services

2. Patient must be eligible for services

death

• Occurs when all vital organs and body systems cease to function

• Irreversible cessation of cardiovascular, respiratory, and brain function

brain death

irreversible loss of all brain functions including the brain stem that occurs when the cerebral cortex stops functioning or is destroyed

end of life

refers to the final phase of a patient’s illness, when death is imminent

period of time from diagnosis of a terminal illness to actual death varies considerably, depending on …

the patient’s diagnosis and extent of disease

3 main physical manifestations at end of life

• metabolism is decreased

• body gradually slows down until all function ends

• respiration generally ceases first

  • heart stops beating within a few minutes

sensory system manifestations at EOL

• Hearing is usually last sense to disappear

• Vision blurred, no blink reflex

• Decreased sensation in taste/smell

• Decreased perception of pain and touch

musculoskeletal manifestations at EOL

• Gradual loss of ability to move

  • trouble holding body posture and alignment

• loss of facial muscle tone

  • sagging of jaw

  • difficulty speaking

  • loss of gag reflex

  • swallowing can become more difficult

cardiovascular manifestations of EOL

• increased heart rate

  • later slowing and weakening of pulse

• irregular heart rhythm

• decreased BP

• delayed absorption of IM or SQ drugs

respiratory system manifestations of EOL

• irregular breathing that gradually slows

• cheyne-stokes respiration

• inability to cough or clear secretions

  • grunting, gurgling, or noisy congested breathing

GI manifestations of EOL

• Slowing of digestive tract and possible cessation of function

• Accumulation of gas

• Distention and nausea

• Loss of sphincter control

• Bowel movement may occur before imminent death or at the time of death

urinary system manifestations of EOL

• Gradual decrease in urinary output

• Incontinent of urine

• Unable to urinate

integumentary manifestations of EOL

• Mottling on hands, feet, arms, and legs

• Cold, clammy skin

• Cyanosis of nose, nail beds, knees

• “Waxlike” skin when very near death

bereavement

period of time following the death of a loved one

grief

• Complex and intense emotional experience that affects all aspects of life

• Priority interventions provide for patient to express feelings

• Many factors shape the manner in which a person grieves

anticipatory grief

• Caregivers of patients with chronic illness often begin to grieve long before the actual death

• Patients can also experience anticipatory grief at the end of their lives

adaptive grief

• Grief that helps accept the reality of death

• Healthy process

• Revealed in positive memories and seeing some good from the death

dysfunctional grief

• prolonged grief disorder

• recurrent and severe distressing emotions

• intrusive thoughts about the loss

• self-neglect

• denial of the loss for >6 months

cultural beliefs affect …

– Understanding of and reaction to death or loss

– Treatment decisions

what to consider with culturally competent care

– Attitudes toward death and suffering

– Preferences for information

organ and tissue donation

• Any body part or the entire body may be donated

  • decided by a person before death

  • With family permission after death

legal and ethical issues with EOL care

patients and families struggle with many decisions during the terminal illness and dying experience

• organ and tissue donations

• advance directives

• resuscitation

• mechanical ventilation

• tube feeding placement

advance care planning

a process that involves having patients think through, talk about, and document their values and goals for treatment

advance directives

the written documents of those wishes and the designated spokesperson

resuscitation

common health care practice

• pts and families have the right to decide whether CPR will be used

• physicians orders should specify:

  • full code

  • chemical code, DNI

  • no code, DNR and allow natural death

euthanaasia

• Deliberate act of hastening death

• The ANA statement on active euthanasia states that the nurse should not participate in active euthanasia

euthanasia is not the same as …

palliative sedation

palliative sedation

Use of medications to intentionally produce sedation

• Relief of intractable symptoms and distress with imminent death

• Intent is to relieve pain and suffering

main components of nursing managements with EOL care

• Relieve suffering

• Clarify misunderstanding about the use of pain medications

initial assessment phase of EOL nursing management

if patient is alert …

• Brief review of body systems to detect signs and symptoms

• Assess for discomfort, pain, nausea, or dyspnea

• assess coping abilities of patient and family

ongoing care phase of EOL nursing management

• monitor for system failure as death approaches

• attention to subtle physical changes requires vigilance

imminent death phase of EOL nursing management

in the last hours of life …

• limit to comfort measures

• more peaceful for pt and family

• transition your efforts to emotional support for pt and family as death approaches

psychosocial care communication of EOL nursing management

• communication is essential

• use empathy and active listening

  • allow patients and families time to express their feelings and thoughts

  • accept silence

• prepare family for unusual patient communication

postmortem care

• Allow family privacy and as much time as they need with deceased person

• Maintain respect for patient and family

after death is pronounced, the nurse prepares or delegates preparation of the

…

body for immediate viewing by the family

what must the nurse do to prepare body for family viewing

– Close patient’s eyes

– Replace dentures

– Wash and position body

– Arrange hair neatly

– Remove medical devices

– Put pillow under head