1. 3-D Approach to end of life care By: Joseph Ramsubhag, RN 1

2. Presentation Objective Identifying & Meeting the Needs of Patient/family 2 Psychosocial Physical Spiritual

3. Criteria for End of Life Care 3 TX FailureToo WeakRefuses TX Unable to Stop the Trajectory of the Terminal Illness The train has left the station

4. Treatment Goals Physical Comfort Physical Comfort Palliating distressful symptoms Palliating distressful symptoms Emotional Comfort Emotional Comfort Terminating Personal relationships in a positive way Terminating Personal relationships in a positive way Preparing family for death Preparing family for death Offering bereavement services after death Offering bereavement services after death Spiritual Comfort Spiritual Comfort Finding Meaning and significance at the level of spirit Finding Meaning and significance at the level of spirit 4

5. Accomplishing Unfinished Business Patients unfinished business may not be that of the familys Patients unfinished business may not be that of the familys Family members or others assisting pt. Family members or others assisting pt. Taking over the dying pt.s Roles Taking over the dying pt.s Roles A husband does not cease to be a husband when he is dying….vice versa…. A husband does not cease to be a husband when he is dying….vice versa…. The pt.s role & responsibilities do not ceased to exit when they are dying The pt.s role & responsibilities do not ceased to exit when they are dying Family can assist pt. taking over roles Family can assist pt. taking over roles Rembrandts Return of Prodigal Son 5

6. Finishing Unfinished Business Physically Taking care of financial business Wills, power of attorneys Telling your story Completing books, videos, or music Writing letters to loved ones Advanced directives Do not resuscitate Funeral arrangements Preferential religious practices/customs 6

7. Taking Care of Emotional Unfinished Business For all those who are close and important to the patient (pt.): Thank each other for the journey Give unconditional love and forgiveness to the pt. More importantly, ask the same for yourself Allow your loved one to make their journey and for them to be able to say goodbye (Tasks of the Dying by Dr. Ira Byock) == 7

8. Taking Care of Spiritual Unfinished Business Accomplishing unfinished goals according to patients philosophy Accomplishing unfinished goals according to patients philosophy Most people's philosophy is tied in with their religion Most people's philosophy is tied in with their religion Examples: Catholic pt. will want anointing of the sick, the Buddhist pt. visit from the monk, or pt. who is close to nature wanting to be in nature Examples: Catholic pt. will want anointing of the sick, the Buddhist pt. visit from the monk, or pt. who is close to nature wanting to be in nature 8

9. Stages of Grief Experienced by Both Patient and Family 9 Dr. E. KÜBLER-ROSS Denial Anger Depression Bargaining Acceptance

10. Family Dynamics Importance of advanced directives done by patient Importance of advanced directives done by patient Death of a loved one is hard, but it can be healing event Death of a loved one is hard, but it can be healing event It is important for healthcare staff to identify where patients and family are in the grieving process It is important for healthcare staff to identify where patients and family are in the grieving process The heavy stress of a dying loved one widens the cracks in the family dynamics The heavy stress of a dying loved one widens the cracks in the family dynamics 10

11. Physical Signs & Symptoms of Impending Death Delirium Delirium Insomnia, restlessness (unable to find a comfortable position), and frightful visual hallucinations Insomnia, restlessness (unable to find a comfortable position), and frightful visual hallucinations This is high-risk area for falls This is high-risk area for falls Anorexia Anorexia Food doesnt taste the same Food doesnt taste the same Dysphagia Dysphagia Moving from meat & rice to soups & puddings, then to only liquids Moving from meat & rice to soups & puddings, then to only liquids Pocketing of food noticeable Pocketing of food noticeable GI system is winding down GI system is winding down Tube fed pts. will have increased residuals & increased lung secretions Tube fed pts. will have increased residuals & increased lung secretions 11

12. Physical Signs & Symptoms of Impending Death Vital Signs: BP, O2 Sat., HR, Resp. Vital Signs: BP, O2 Sat., HR, Resp. Change in respiratory system Change in respiratory system Labored, cheyne stoking, & argonal breathing Labored, cheyne stoking, & argonal breathing Breathing with all accessory muscles Breathing with all accessory muscles Change in thermoregulation: fever, diaphoresis, & chills (parts of body hot & parts cold) Change in thermoregulation: fever, diaphoresis, & chills (parts of body hot & parts cold) 12

13. Physical Signs & Symptoms of Impending Death Changes in Elimination Excretion Changes in Elimination Excretion Urinary retention, constipation, & bowel & bladder incontinence Urinary retention, constipation, & bowel & bladder incontinence Decreased urine output, color changes from light yellow to a tea color, apple juice color or coco cola colored (hematuria) Decreased urine output, color changes from light yellow to a tea color, apple juice color or coco cola colored (hematuria) Changes in Respiratory Status Changes in Respiratory Status Rhonchi, wheezing, rales, coughing, congestion (gurgling & rattling, sounds) Rhonchi, wheezing, rales, coughing, congestion (gurgling & rattling, sounds) Increasing fatigue & sleep Increasing fatigue & sleep Decreased LOC Decreased LOC 13

14. Emotional & Mental Signs Pt. is first to know they are dying: Pt. is first to know they are dying: I am dying or I want to go home I am dying or I want to go home Pt. is self-absorbed and pensive: Pt. is self-absorbed and pensive: Detaching from surroundings, including family Detaching from surroundings, including family In order to leave, you have to disconnect In order to leave, you have to disconnect Staring into space, looking at you but looking through you Staring into space, looking at you but looking through you Reaching or grabbing invisible things from the air or from their body Reaching or grabbing invisible things from the air or from their body 14 Wherever your heart is, there is where you will be. In order to leave, you have to detach

15. Mental & Spiritual Signs Pts. Often See & Speak to the Deceased Pts. Often See & Speak to the Deceased Maybe deceased relatives or even pets Maybe deceased relatives or even pets Gives hope to patient Gives hope to patient Pt. moving from physical to metaphysical realm Pt. moving from physical to metaphysical realm Confusion frequently occurs as a result Confusion frequently occurs as a result Pts. Experience Surge of Energy Pts. Experience Surge of Energy Commonly mistaken for the pt. getting better Commonly mistaken for the pt. getting better Taking one day at a time may be expedient Taking one day at a time may be expedient May be for the transition from this world to the other May be for the transition from this world to the other 15 The mountain tops are shorter and the valleys, deeper

16. Final Gift Pts. sometimes choose the people in whose presence they want to die. Pts. sometimes choose the people in whose presence they want to die. If you are not there when your loved on passes, dont beat up on yourself If you are not there when your loved on passes, dont beat up on yourself This may be their final gift to you. This may be their final gift to you. When a pt. dies they discard their physical body made from the dust of the earth and they put on their spiritual body made from light When a pt. dies they discard their physical body made from the dust of the earth and they put on their spiritual body made from light 16

17. References Byock, I. (1997). Dying Well. New York, NY: Riverhead Trade. Byock, I. (1997). Dying Well. New York, NY: Riverhead Trade. Coyle, N. & Ferrell, B.R. (2010). Oxford Textbook of Palliative Nursing. (3 rd ed). New York, NY: Oxford University Press. Coyle, N. & Ferrell, B.R. (2010). Oxford Textbook of Palliative Nursing. (3 rd ed). New York, NY: Oxford University Press. Hallenbeck, J.L. (2003). Palliative Care Perspectives. New York, NY: Oxford University Press. Hallenbeck, J.L. (2003). Palliative Care Perspectives. New York, NY: Oxford University Press. Kubler-Ross, E. (1997). On Death and Dying. N ew York, NY: Scribner. Kubler-Ross, E. (1997). On Death and Dying. N ew York, NY: Scribner. Matzo, M.l. & Witt, D. (2009). Palliative Care Nursing: Quality Care to the End of Life. (3 rd ed.). New York, NY: Springer Publishing Company. Matzo, M.l. & Witt, D. (2009). Palliative Care Nursing: Quality Care to the End of Life. (3 rd ed.). New York, NY: Springer Publishing Company. Myss, C. (2003). Sacred Contracts: Awakening Your Divine Potential. Carlsbad, CA: Three Rivers Press. Myss, C. (2003). Sacred Contracts: Awakening Your Divine Potential. Carlsbad, CA: Three Rivers Press. Patt, R. (1993). Cancer Pain. Philadelphia, PA: Lippincott Williams & Wilkins. Patt, R. (1993). Cancer Pain. Philadelphia, PA: Lippincott Williams & Wilkins. 17

18. Presentation dedicated to Mrs. Lucile Ramsubhag 18 Email Address : josephramsubhag@yahoo.com Office (281)894-6499 Cell (832)353-7787