Presentation is loading. Please wait.

Presentation is loading. Please wait.

Caring for the Dying Patient

Similar presentations

Presentation on theme: "Caring for the Dying Patient"— Presentation transcript:

1 Caring for the Dying Patient
Keith Rischer RN, MA, CEN Death is part of life 2.5 million die in US annaually 80% >65 yrs

2 Today’s Objectives… Discuss the current ethical issues surrounding end of life care. Identify goals of end of life care. Compare & contrast the emotional & spiritual needs of the family and client who is dying. Contrast early vs. late physical changes in the client who is dying. Describe nursing goals and priorities for managing the client who is dying. Contrast the needs of the family with the nurse in the client who has died.

3 End of Life Ethics Assisted Suicide Withdrawal food/fluids
Passive vs. Active Euthanasia Legalized active euthanasia in US Oregon “Death w/Dignity Act” Ethics-moral philosophy to determine what is right…worldview-refers to the framework of ideas and beliefs through which an individual interprets the world and interacts in it Naturalistic-Darwinian-evolution-survival of the fittest-no intrinsic value in human life-there is no God…vs. Biblical worldview-God is…human life has intrinsic value-created in the image of God Which worldview do all of these trends represent??? Asssited suicide he claims to have assisted at least 130 patients to that end. He famously said that "dying is not a crime."[citation needed] Between 1999 and 2007, Kevorkian served eipenisght years of an 11-to-20-year prison sentence for second-degree murder. He was released on June 1, 2007, on parole due to good behavior.[3] Oregon Oregon enacted the Death with Dignity Act (the Act)-upheld in 2006 which allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose.  Barbituates Rx of choice-40 deaths on average annually The Law Under the law, a capable adult Oregon resident who has been diagnosed with a terminal illness by a physician may request in writing, from his or her physician, a prescription for a lethal dose of medication for the purpose of ending the patient's life. The request must be confirmed by two witnesses, one of whom cannot be related to the patient, be entitled to any portion of the patient's estate, be the patient's physician, or be an employee of a health care facility caring for the patient. After the request is made, another physician must examine the patient's medical records and confirm the diagnosis. The patient must be determined to not suffer from a mental condition impairing judgment. If the request is authorized, the patient must wait at least fifteen days and make a second oral request before the prescription may be written. The patient has a right to rescind the request at any time. The law protects doctors from liability for participating in assisted suicide. Furthermore, no doctor is required to participate. Also, the law specifies that a patient's decision to end his or her life shall not "have an effect upon a life, health, or accident insurance or annuity policy." Withdrawal food/fluids woman who suffered brain damage and became dependent on a feeding tube. She collapsed in her home on February 25, 1990, and experienced respiratory and cardiac arrest, resulting in extensive brain damage, a diagnosis of persistent vegetative state (PVS) and 15 years of institutionalization. In 1998, Michael Schiavo, her husband and guardian, petitioned the Pinellas County Circuit Court to remove her feeding tube. Robert and Mary Schindler, her parents, opposed this, arguing she was conscious. The court determined that Terri would not wish to continue life-prolonging measures.[1] This controversy stretched on for seven years and included involvement by politicians and advocacy groups, notably pro-life and disability rights ones.[2] Before the local court's decision was carried out, on March 18, 2005, the governments of Florida and the United States had passed laws that sought, unsuccessfully, to prevent removal of Schiavo's feeding tube. Active euthanasia- Holland (or more properly, the Netherlands) is the only country in the world where euthanasia is openly practiced. It is not allowed by statute, but the law accepts a standard defence from doctors that have adhered to official guidelines. These hinge on voluntariness of the request and unrelievable-ness of the suffering. It is not a condition that the patient is terminally ill or that the suffering is physical. 1995: 2.4% Physician-Assisted suicide 1995: 1995: 19.1% Withdrawing/with-holding potentially life-prolonging treatment 1995: 20.2% Total of % out of 136,000 deaths Euthanasia in The Netherlands is "beyond effective control", according to a report which shows that one in five assisted suicides is without explicit consent. The Dutch survey, reviewed in the Journal of Medical Ethics, looked at the figures for 1995 and found that as well as 3,600 authorized cases there were 900 others in which doctors had acted without explicit consent. A follow-up survey found that the main reason for not consulting patients was that they had dementia or were otherwise not competent.

4 Advance Directives Living will Durable power of attorney
Legal document instructs measure of care desired if incapable Shortcomings Life & death choices over unknown set of circumstances Some ethicists believe document is “worthless” Durable power of attorney Since their inception, living wills have exhibited flaws: People with living wills don't always tell their relatives about them, so their wishes remain unknown. Hospitals find the wills difficult to interpret: a stated preference not to receive artificial nutrition when brain-dead may not apply if a person is comatose. And it's difficult to address all possible end-of-life situations in a living will - especially as life-sustaining technology continues to evolve. Recently, two University of Michigan researchers, writing in the bimonthly Hastings Center Report, a journal that examines issues in medical ethics, concluded that living wills are useless. "It's very hard for people to predict their preferences for an unknown health condition," said Angela Fagerlin, a research scientist and co-author of the article. In addition, "decision makers have a difficult time interpreting [living wills]," Fagerlin said.

5 Concerns of Dying Patient
Fear of physical pain and suffering Symptom burden Fear of unknown Fear of loneliness Anonymity Loss of choice over destiny Loss of dignity Loss of consortium Separation and lack of connection Spiritual Financial

6 Early Physical Changes
↓ Appetite ↑Weight loss Assistance with ADLs Pain (> or < ) Increased HR; Potential O2 deficiency Drowsiness Fatigue

7 Early Emotional Changes
Months to Weeks Hope Desirable Expectational Withdrawal Changes in mood Anger, irritable, hope, denial, ect World view changes; gets smaller Attending to business Hope empowers, generates courage, motivates action, and strengthens physical and psychological function. Pattison defined 2 types of hope Desirable: wishes are something that would be appreciated if it were to occur without the expectation that it will or must occur. Ex. the patient says “I hope I get better” when rapidly declining could comment that that would be great but what can I do now to make you more comfortable. The hope may be related to living till a child graduates, a grand daughter marries, a grandchild is born. It is desirable but may or may not occur Exceptional hope is more unrealistic; Ex the patient says “I hope to get better” meaning I hope for a miracle or a cure; this is a reflection of something not probably going to occur. This can increase stress or can be a denial that keeps a patient and family going. 7

8 Spiritual Distress Signs of Spiritual Distress Doubt Despair Guilt
Anger Boredom Isolation Statements of regret Statements of unresolved hurt Nursing Interventions Ask about their source of strength Discuss sources of spiritual strength throughout their lives Assess support system Assess coping Refer to clergy/chaplain Ministry: ex. Stephens Ministry at churches The spiritual dimensions deals with the transcendental relationship between the dying person and another; or their God or significant other. Spiritualty can be met through religious acts or through human caring relationships. This leads us to a feeling of self-love, and a connection with others. 8

9 Family Needs Focus on dying patient without losing the present and future The work of daily life goes on Anticipatory grief Increase in responsibilities (house, finances, work, children, and acting as a caregiver). Need for support from family, community, spiritual faith.

10 Goals of Nursing Care for the Dying
Hospice Improve quality of life w/terminal illness Control symptoms Pain N&V Fatigue SOB Identify-prioritize needs Promote meaningful interactions w/family and others Facilitate peaceful death

11 Nursing Care:Holistic
Chaplain/ Clergy visit Hospice/ respite care Hospice/Home Care Provide CNA daily for ADL hygiene and care More frequent RN visits More frequent Social Worker visits Talk candidly about end of life= how it will likely be for that specific patient

12 Nursing Care:Physical Priorities
Pain management N&V management Fatigue management Skin care Mouth care Urinary care Respiratory care Comfort

13 Nursing Care: Physical Priorities
Attend to any needs of patient Pain Long acting analgesics with medication for breakthrough pain May need to increase doses of medication Counsel pt./family on pain cycle and breakthrough pain Nausea Antiemetics…Zofran Foods that taste good with increased protein and fat Ensure or supplements Comfort Comfortable bed Chair pillows

14 Why Pain? Practitioners are not trained in state-of-the art pain management Myths about addiction, dependence, and tolerance abound The toll that unrelieved pain takes on the body and mind is not understood or acknowledged Fear that pain intervention might cause the patient to die Flawed assessments Disconnect Failure to look at non-physical sources

15 Nursing Care: Physical Priorities
Mobility Cane, walker, Prevent falls Falls often indicate change in status Sleep Sleeping more? Less? Look at medications and physical status. Normal to increase in sleeping. Fatigue Do what only matters, find what is important to patient Hospice volunteer for family for relief

16 Nursing Care: Physical Priorities
Neuro Changes due to disease (brain mets, lack of oxygen?) CV May need fan for cool or light weight blankets for warmth Lungs Teach use of several pillows, O2 may be needed Skin Teach positioning, turning, and prevention of breakdown GI Use of stool softeners is a must; may need laxatives later on Urinary May have incontinence (pads, diapers, last resort is foley) Medications Order what is needed for comfort Medications Order what is needed for comfort; close relationship with Doctors and Office nurses; weekly meetings if in Hospice with medical management.

17 Changes with Weeks Remaining: Physical Changes
Profound weakness Bedbound Falling if ambulating Muscle weakness Potential skin breakdown Increased care needed VS ↑ HR ↓ Pulse

18 Dyspnea Managment Morphine sulfate Diuretics Bronchodilators
Antibiotics Anticholinergics Atropine Sedatives Oxygen Treatment of the primary cause and relieve the psychological distress that accompanies the symptom

19 Changes with Weeks Remaining: Emotional Changes
↑ Fear, apprehension or peacefulness ↑ withdrawal into self Often sees “spiritual beings” God; previous family members who have died speaking out to them Only allows family and loved ones in their world Starts to say goodbye to loved ones A sense of peace and finished business may be felt OR a sense that there is not enough time left to finish life

20 Changes with Weeks Remaining: Family Needs
How to care for their love one Focus is home care management May not be able to get to PCP’s office May involve equipment and teaching nursing care for ADLs O2, transfer techniques, shower chair, turning techniques, decubitus care, mouth care, foley care, ect Pain relief Symptom management Medication management increases Subq meds, rectal suppositories Psychological support increases Focus on quality of life vs. quantity

21 Imminent Death:Nursing Care
Medication management If unable to swallow (subq, rectal suppositories) For death rattle “Scopolamine patch” works Pain management Comfort measures increase Turning, mouth care, positioning of limbs, warm/cool measures, eye drops, ect Assistance respiratory with positioning

22 Imminent Death:Physical Changes
Actively Dying: hours remain Confusion and disorientation Metabolic changes Withdraws from family “going” somewhere Decreased consciousness May refuse all fluid and food Body conservation of energy for function Total care ↓ alertness ↑ drowsiness Metabolic changes and decreased oxygen to brain ↑ Restlessness ↓ BP ↑HR ( ) Peripheral circulation diminishing to vital organs Mottling of extremities

23 Imminent Death:Physical Changes
Incontinence of urine and bowel Increased muscle relaxation and decreased consciousness May be incontinent around the foley catheter Dependent areas become cyanotic & cold Skin color is pale and mottling of skin occurs (knees, legs, nose) Slower pupil response to light, & eyes fixed stare-even in sleep Muscle becomes slack, decreased oxygen Speech may be difficult and soft Muscle becomes slack Hearing is thought to remain present Vision may be lost

24 Imminent Death:Physical Changes
Cheyne-Stoke respirations Metabolic and oxygen changes Decreased RR Death rattle Profuse perspiration Decreased circulation to all organs as they are shutting down ↓ urinary output Decreased vital organ/ kidneys shutting down Body temp varies May decrease or rise

25 Imminent Death:Emotional Needs
Sense of peacefulness in the room Family and loved ones present Caring feeling by loved ones Its going to be OK Its OK to go now Your work is done I love you/ I forgive you

26 Imminent Death: Family Needs
Presence of Nurse Care for patient Support for patient and family Educate family throughout the process to avoid the feeling of not knowing what next Be the detail person Be prepared for how family will handle death Know emergency numbers for family/hospice Make final arrangements Mortuary; pick up equipment, clean up room.

27 Imminent Death: Family Needs
Encourage them to stay with patient Touch and talk with patient Be vigilant about what the patient hears, even though he/she cannot respond Encourage active comfort measures Light massage, mouth care, Allow them time to privately grieve with family Acknowledge the process of dying Skin cooling, cyanosis, Cheyne-Stokes, urinary incontinence (all this is normal)

28 Pronouncement of Death
Cessation of blood pressure, pulse and respirations. In hospice is pronounced by RN (or Social Worker in some states) Blood pressure may be not be able to be palpated for hours before death Final respirations may be gasping Eyes are fixed (pupils fixed and dilated) No apical pulse

29 Needs of the Family After Patient’s Death
Presence of a support system Family, chaplain, nurse, social worker Make sure someone is with them Don’t leave them alone to go home No One Dies Alone at ANW Vounteers who stay during last hours Call family members if needed (when unexpected) Allow time for the family to spend with the patient who died No One Dies Alone at ANW

30 Needs of the Nurse After the Patient’s Death
Support system Other staff, friends, family (who can listen to you) Physical and emotional rest Attend memorial or burial service for closure Final separation from family Remind yourself that you made a difference

31 Near Death Experiences
Altered state of consciousness during brief cessation of VS (cardiac arrest) Tunnel of light Sense of being separated from body Fear & anxiety-torment Afterwards for patient More spiritual minded-less material focused Less fearful of death Nurse’s role “What do you remember about being unconscious?” “Did you have a sense of being separate from your body while we were reviving you?” Avoid negative statements during code

Download ppt "Caring for the Dying Patient"

Similar presentations

Ads by Google