1. Nursing Management: End-of-life Palliative care, Comfort Care, Hospice

2. End-of-Life: What is it?
Final stage of life when death is imminent
Unpredictable
May last minutes, hours, or weeks
End-of-life care refers of physical, psychosocial, and spiritual care provided to patients and their families
Care addresses issues related to death and dying

3. Goals of End-of-Life Care
Prevent or relieve suffering
Provide comfort and support
Maintain human dignity
Respect patient’s wishes and desires
Improve quality of life
Provide emotional support
(National Caregivers Library, 2015)
(Death and Dying, n.d.)

4. Care Interrelationships
Patient
Hospice Care
Palliative Care
End of life Care
Comfort
Dignity
Quality of Life
Support

5. Palliative Care
Focus on improving quality of life for patients & families.
Provided during any stage of a life-limiting illness; acute, chronic, or terminal.
Palliative Care

6. Palliative Care Programs Include:
Relief of physical suffering
Care of emotional needs
Bereavement support
Curative and life-prolonging treatments
Interdisciplinary teams including physicians, nurses, social workers, pharmacists, and physical and occupational therapists

7. Hospice Care Reserved for terminally ill
Life expectancy of six months or less
Patients no longer seeking cure or life-prolonging treatments
Comfort care at end of life
Provides a palliative approach to care.
(Hospice, n.d.)

8. Palliative Care Programs vs Hospice
Hospice Care
Focus on comfort care
Curative or life-prolonging
No time restrictions
Do not have to be terminal
Care teams oversee care
Administered in hospitals, extended care facilities, and nursing homes
Bereavement support
Focus on comfort care
Does not include curative or life- prolonging measures
Life-limiting illness with prognosis of six months or less
Reliance on family and visiting nurses and care is usually provided in the home
Bereavement support

9. Pathophysiology of Dying
As a person enters the final stage of the dying process, the body begins the final process of shutting down, which will end when all the physical systems cease to function.
(Dying, n.d.)

10. Clinical Manifestations
Sensory – decreased sensation & perception - loss of blink reflex – glazing appearance of eyes – hearing is the last sense to leave
Cardiovascular – increased HR followed by decreased HR, BP, and irregular heart rhythm
Respiratory – increased rate followed by decreased rate and depth - Cheyne-Stokes - audible congestion
Renal – oliguria progressing to anuria – urine dark amber, brown, or reddish color - incontinence possible

11. Clinical Manifestations cont.
Gastrointestinal – abdominal distension, gas, anorexia, & nausea
Muscular Skeletal – decreased movement, tone, difficulty speaking & swallowing - loss of gag reflex
Integumentary - mottling of extremities - cyanosis of nose, finger tips, nail beds & toes – cold and clammy – “waxy” appearance

12. Assessment: Subjective
Varies depending on presenting symptoms, underlying illness, and nearness to death and may need to be obtained from someone other than the patient
Review medical record and advance directives if available
Cultural issues
Personal desires, wishes, and choices regarding death and dying

13. Assessment: Objective
Vital signs (if appropriate)
General appearance
Level of consciousness
Affect
Level of comfort

14. Physiological: ABCD Labored breathing Mottling of extremities
Coolness and cyanosis of the tips of fingers, toes, and nose
Edema in Extremities
Decreased urinary output
(Dying. n.d.)

15. Physiological Assessment Cont…
Mental confusion
Pain and discomfort
Excessive fatigue and sleeping
Increasing physical weakness
Inability to perform self-care activities

16. Psychological Social withdrawal Isolation – loneliness Fear & Anxiety
Grieving & Sorrow
Spiritual unrest
Saying “good byes”
(Death and Dying, n.d.)

17. Nursing Diagnosis: Comfort Care
Pain
Analgesics (narcotics)
Anxiolytics
Impaired comfort
Position of comfort
Elevate head
Social withdrawal
Soft voice
Gentle touch
Social isolation
Allow to sleep
Acceptance

18. Interventions: Physical
Pain and discomfort - position of comfort, cover with a light but warm blanket, anxiolytics, analgesics, eye lubricants
Anorexia – follow patient cues, offer ice chips and sips of water, dab a moistened warm cloth around mouth, apply lip balm
Labored breathing – elevate head – do not suction
Fatigue and drowsiness – permit sleep, avoid quick movements and loud startling noises

19. Interventions: Psychosocial
Respect sacred space
Allow to be
Gentle touch if culturally acceptable
Allow to sleep
Encourage family to be present if culturally acceptable
Answer questions honestly
Display empathy and compassion

20. Evaluation Pain control Comfort Psychosocial support Peace
(Death and Dying, n.d.)