End of Life

Pathophysiology

Introduction to Death

• Death is manifested by the cessation of breath and pulse.

• Typical signs and symptoms of death follow a characteristic pattern.

Stages of Death

1. Early stage

2. Middle stage

3. Late stage

Types of Death

• Brain (Biological) Death:

  • Determined by the lack of activity on an electroencephalogram (EEG) or no blood flow to the brain.

  • Key indicators include:

  • Apnea

  • Lack of brainstem reflexes

  • Coma

• Clinical Death:

  • Defined as the cessation of heart and lung function while brain viability may still be present.

  • Function may be restored through cardiopulmonary resuscitation (CPR).

  • Irreversible brain damage can occur after just 4 minutes without oxygen, resulting in death as early as 4 to 6 minutes later.

Palliative Care

Overview

• Goal of Care:

  • Focus is on curative treatment and quality of life improvement.

• Interdisciplinary Team:

  • Includes nursing, physician or nurse practitioner, social worker, and clergy.

• Symptom Control:

  • Manages symptoms such as dyspnea and pain.

Hospice Care

Definitions and Goals

• Care provided to individuals who cannot be cured or who choose not to be treated.

• Patients are typically anticipated to have 6 months or fewer to live (National Institute of Aging, 2021).

• Care can be delivered at home, facilities, or nursing homes.

• Services include respite care, comfort care, and palliative sedation.

Discussion Questions

1. What differences would the nurse need to consider for a patient receiving palliative care versus hospice care?

2. What would you consider to be a priority for a patient receiving hospice care?

Cultural and Spiritual Needs

Importance

• Cultural affiliations influence how patients perceive illness and end-of-life issues.

• Essential to conduct thorough cultural and spiritual assessments and maintain therapeutic communication with patients.

Cultural Care

• Cultural Needs:

  • Views of end-of-life care.

  • Adherence to cultural rituals.

• Spiritual Needs:

  • Involvement of religious staff.

  • Use of H.O.P.E. framework for spiritual care.

H.O.P.E. Framework

• H: Hope - What gives you a sense of hope, peace, or strength?

• O: Organized - Is your religion important to you?

• P: Personal - What are your spiritual beliefs and practices?

• E: Effects on medical care - How has your illness impacted your meaning in life?

Discussion Question

• What types of resources would be beneficial for the spiritual needs of an actively dying patient?

Ethical and Legal Considerations

Ethical Principles

1. Justice

2. Nonmaleficence

3. Beneficence

4. Fidelity

Legal Considerations

• Terminal Sedation:

  • Administered to patients with a do-not-resuscitate order experiencing intolerable suffering not relieved by other treatments.

• Physician-Assisted Suicide:

  • Legal in 12 states in the United States (not legal in Texas).

  • Involves prescriptions from licensed physicians as authorized by state law; terminal diagnosis is required.

• Advanced Directives:

  • Legal documents guiding end-of-life decisions when patients cannot voice their wishes, such as living wills and medical powers of attorney.

Code Statuses

Overview

1. Full Code:

   • Full resuscitation measures applied.

2. Do Not Resuscitate (DNR):

   • No CPR or resuscitation efforts.

3. Do Not Intubate (DNI):

   • No intubation; CPR or medication interventions may still occur.

4. Medical Orders:

   • Medical Orders for Life-Sustaining Treatment (MOLST), Physician Orders for Life-Sustaining Treatment (POLST).

Discussion Question

• A family is conflicted regarding their loved one's desire regarding code status. What considerations might they take into account?

Withdrawal of Care

Guidelines

• The American Nurses Association (2016) posits no ethical, moral, or legal distinction between stopping therapy and never starting it.

• Nurses play a crucial role in supporting families and loved ones through the challenging decisions surrounding end-of-life care and withdrawal of treatments.

• Nursing Care Continuity:

  • Nursing care remains crucial even when withdrawing treatment, including the management of medically administered nutrition and hydration (MANH).

Health Care Proxy

• Crucial for patients unable to make end-of-life decisions.

• A designated proxy must be identified according to local, state, and facility regulations.

• For minors, parents or guardians hold legal authority over treatment decisions and may consider the child's preferences.

Discussion Question

• What factors should be considered for a 16-year-old patient with terminal cancer who refuses additional treatment?

Role of the Nurse in End-of-Life Care

1. Identify and address patients' symptoms.

2. Perform nursing interventions within their scope of practice.

3. Provide care that alleviates pain, promotes comfort, and supports patients and their families (American Nurses Association, 2016).

Recognizing Cues

• Observations include the patient's diagnosis, potential risks for distressing symptoms, gaps in knowledge regarding end-of-life processes, and issues surrounding the withdrawal of treatment.

Impending Death Signs

• Key indicators can include fatigue, drowsiness, confusion or terminal delirium, decreased interest in food and fluids, reduced urinary output, skin mottling, decubitus ulcer development, decreased cerebral perfusion, and Cheyne-Stokes respirations.

Nursing Interventions

Pain and Symptom Management

1. Pain Control:

   • Approaches: Pharmacological (opioids) and non-pharmacological.

2. Dyspnea Management:

   • Utilize the Respiratory Distress Observational Scale (RDOS) to assess and treat dyspnea, administer opioids according to need, and provide oxygenation.

3. Skin Care:

   • Maintain hygiene, apply lotions, reposition every two hours, and use pressure relief mattresses as needed.

4. Gastrointestinal Interventions:

   • Encourage favorite foods and small, frequent meals; never force food as anorexia is part of the dying process.

5. Hydration Considerations:

   • Address hydration needs with medications and ensure measurement of dietary fiber intake.

6. Fatigue Management:

   • Provide assistive devices and assess for underlying fatigue causes such as depression or dehydration.

Impending Death: Discussion Question

• How should a nurse respond to a family upset about a patient no longer taking food or fluids?

Self-Reflection Activity

• Discuss strategies for nurses to maintain composure while providing care to patients receiving hospice care.

• Reflect on personal feelings about caring for patients on hospice and how to best support families.

Lesson Reflection Activity

1. Address caring for patients with increased pain and inadequate vital signs.

2. Identify key roles in hospice care and how they differ from other patient care contexts.

3. List three ways nursing skills improved after this lesson and any remaining questions.

Case Study Overview

Gerry Charleston

• Patient Profile: 87-year-old female with metastatic lung cancer.

• Reports: Fatigue, dyspnea, and a desire to stop treatment.

Presenting Symptoms

• Physical Assessment: Diminished breath sounds and generalized weakness.

• Pain levels rated at 9 out of 10 in the right arm, alongside a history of anorexia and chronic conditions.

• Vital statistics include temperature, heart rate, respiration rates, blood pressure, and oxygen saturation levels.

Hospice Care Implementation

• Following admission to hospice, patient reported pain level decreased significantly while vital signs showed stability.

Postmortem Care Procedures

Steps for Care

1. Utilize nonsterile gloves and personal protective equipment (PPE) as needed.

2. Wash the deceased body, comb hair, and dress in a clean gown.

3. Provide family participation options and privacy for viewing.

4. Remove medical tubes as per agency policy.

5. Return the belongings of the deceased appropriately.

Postmortem Kit Contents

• Items include identification tag, ties, chin strap, gauze, bags for personal items, and a body bag/shroud.