Presentation on theme: "Caring for the Dying Patient"— Presentation transcript:
1 Caring for the Dying Patient Keith Rischer RN, MA, CENDeath is part of life2.5 million die in US annaually80% >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 EuthanasiaLegalized active euthanasia in USOregon “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 itNaturalistic-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 GodWhich 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."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.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 annuallyThe 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. This controversy stretched on for seven years and included involvement by politicians and advocacy groups, notably pro-life and disability rights ones. 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 deathsEuthanasia 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 incapableShortcomingsLife & death choices over unknown set of circumstancesSome ethicists believe document is “worthless”Durable power of attorneySince 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 sufferingSymptom burdenFear of unknownFear of lonelinessAnonymityLoss of choice over destinyLoss of dignityLoss of consortiumSeparation and lack of connectionSpiritualFinancial
6 Early Physical Changes ↓ Appetite ↑Weight lossAssistance with ADLsPain (> or < )Increased HR; Potential O2 deficiencyDrowsinessFatigue
7 Early Emotional Changes Months to WeeksHopeDesirableExpectationalWithdrawalChanges in moodAnger, irritable, hope, denial, ectWorld view changes; gets smallerAttending to businessHope empowers, generates courage, motivates action, and strengthens physical and psychological function.Pattison defined 2 types of hopeDesirable: 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 occurExceptional 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 AngerBoredomIsolationStatements of regretStatements of unresolved hurtNursing InterventionsAsk about their source of strengthDiscuss sources of spiritual strength throughout their livesAssess support systemAssess copingRefer to clergy/chaplainMinistry: ex. Stephens Ministry at churchesThe 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 NeedsFocus on dying patient without losing the present and futureThe work of daily life goes onAnticipatory griefIncrease 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 HospiceImprove quality of life w/terminal illnessControl symptomsPainN&VFatigueSOBIdentify-prioritize needsPromote meaningful interactions w/family and othersFacilitate peaceful death
11 Nursing Care:Holistic Chaplain/ Clergy visitHospice/ respite careHospice/Home CareProvide CNA daily for ADL hygiene and careMore frequent RN visitsMore frequent Social Worker visitsTalk candidly about end of life= how it will likely be for that specific patient
13 Nursing Care: Physical Priorities Attend to any needs of patientPainLong acting analgesics with medication for breakthrough painMay need to increase doses of medicationCounsel pt./family on pain cycle and breakthrough painNauseaAntiemetics…ZofranFoods that taste good with increased protein and fatEnsure or supplementsComfortComfortable bedChairpillows
14 Why Pain?Practitioners are not trained in state-of-the art pain managementMyths about addiction, dependence, and tolerance aboundThe toll that unrelieved pain takes on the body and mind is not understood or acknowledgedFear that pain intervention might cause the patient to dieFlawed assessmentsDisconnectFailure to look at non-physical sources
15 Nursing Care: Physical Priorities MobilityCane, walker,Prevent fallsFalls often indicate change in statusSleepSleeping more? Less? Look at medications and physical status. Normal to increase in sleeping.FatigueDo what only matters, find what is important to patientHospice volunteer for family for relief
16 Nursing Care: Physical Priorities NeuroChanges due to disease (brain mets, lack of oxygen?)CVMay need fan for cool or light weight blankets for warmthLungsTeach use of several pillows, O2 may be neededSkinTeach positioning, turning, and prevention of breakdownGIUse of stool softeners is a must; may need laxatives later onUrinaryMay have incontinence (pads, diapers, last resort is foley)MedicationsOrder what is needed for comfortMedicationsOrder 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 weaknessBedboundFalling if ambulatingMuscle weaknessPotential skin breakdownIncreased care neededVS↑ HR ↓ Pulse
18 Dyspnea Managment Morphine sulfate Diuretics Bronchodilators AntibioticsAnticholinergicsAtropineSedativesOxygenTreatment 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 selfOften sees “spiritual beings”God; previous family members who have died speaking out to themOnly allows family and loved ones in their worldStarts to say goodbye to loved onesA 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 oneFocus is home care managementMay not be able to get to PCP’s officeMay involve equipment and teaching nursing care for ADLsO2, transfer techniques, shower chair, turning techniques, decubitus care, mouth care, foley care, ectPain reliefSymptom managementMedication management increasesSubq meds, rectal suppositoriesPsychological support increasesFocus on quality of life vs. quantity
21 Imminent Death:Nursing Care Medication managementIf unable to swallow (subq, rectal suppositories)For death rattle “Scopolamine patch” worksPain managementComfort measures increaseTurning, mouth care, positioning of limbs, warm/cool measures, eye drops, ectAssistance respiratory with positioning
22 Imminent Death:Physical Changes Actively Dying: hours remainConfusion and disorientationMetabolic changesWithdraws from family “going” somewhereDecreased consciousnessMay refuse all fluid and foodBody conservation of energy for functionTotal care ↓ alertness ↑ drowsinessMetabolic changes and decreased oxygen to brain↑ Restlessness↓ BP ↑HR ( )Peripheral circulation diminishing to vital organsMottling of extremities
23 Imminent Death:Physical Changes Incontinence of urine and bowelIncreased muscle relaxation and decreased consciousnessMay be incontinent around the foley catheterDependent areas become cyanotic & coldSkin color is pale and mottling of skin occurs (knees, legs, nose)Slower pupil response to light, & eyes fixed stare-even in sleepMuscle becomes slack, decreased oxygenSpeech may be difficult and softMuscle becomes slackHearing is thought to remain presentVision may be lost
24 Imminent Death:Physical Changes Cheyne-Stoke respirationsMetabolic and oxygen changesDecreased RRDeath rattleProfuse perspirationDecreased circulation to all organs as they are shutting down↓ urinary outputDecreased vital organ/ kidneys shutting downBody temp variesMay decrease or rise
25 Imminent Death:Emotional Needs Sense of peacefulness in the roomFamily and loved ones presentCaring feeling by loved onesIts going to be OKIts OK to go nowYour work is doneI love you/ I forgive you
26 Imminent Death: Family Needs Presence of NurseCare for patientSupport for patient and familyEducate family throughout the process to avoid the feeling of not knowing what nextBe the detail personBe prepared for how family will handle deathKnow emergency numbers for family/hospiceMake final arrangementsMortuary; pick up equipment, clean up room.
27 Imminent Death: Family Needs Encourage them to stay with patientTouch and talk with patientBe vigilant about what the patient hears, even though he/she cannot respondEncourage active comfort measuresLight massage, mouth care,Allow them time to privately grieve with familyAcknowledge the process of dyingSkin 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 deathFinal respirations may be gaspingEyes are fixed (pupils fixed and dilated)No apical pulse
29 Needs of the Family After Patient’s Death Presence of a support systemFamily, chaplain, nurse, social workerMake sure someone is with themDon’t leave them alone to go homeNo One Dies Alone at ANWVounteers who stay during last hoursCall family members if needed (when unexpected)Allow time for the family to spend with the patient who diedNo One Dies Alone at ANW
30 Needs of the Nurse After the Patient’s Death Support systemOther staff, friends, family (who can listen to you)Physical and emotional restAttend memorial or burial service for closureFinal separation from familyRemind yourself that you made a difference
31 Near Death Experiences Altered state of consciousness during brief cessation of VS (cardiac arrest)Tunnel of lightSense of being separated from bodyFear & anxiety-tormentAfterwards for patientMore spiritual minded-less material focusedLess fearful of deathNurse’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