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Carla Hunt, RN, BSN “To live in hearts we leave behind is not to die” Thomas Campbell.

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Presentation on theme: "Carla Hunt, RN, BSN “To live in hearts we leave behind is not to die” Thomas Campbell."— Presentation transcript:

1 Carla Hunt, RN, BSN “To live in hearts we leave behind is not to die” Thomas Campbell

2 Realities of Care  Rapidly aging U.S. population  Medical care has limitations and inappropriate use of advanced technology to prolong life when death is inevitable (Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Care, 1997).  Exorbitant expense is associated with futile care 2.5 million U.S. deaths have been negotiated annually while life-extending/sustaining measures were provided (Tilden & Thompson, 2009).

3 Palliative Care  Intends to improve the quality of life for patients and families faced with life-limiting illness (World Health Organization, 2012).  Provides support in chronic illness: cardiac (CHF), pulmonary (COPD), renal disease, cancer, immune suppression, HIV/AIDS, dementia, traumatic injury (McLean-Heitkemper, 2011).  Care or treatment that reduces or controls symptoms instead of seeking cure or efforts to delay death.

4 Palliative Care  Begins after the patient receives the diagnosis of life-limiting illness.  Goals: Prevent and relieve patient suffering Improve quality of life  Timeframe includes hospice, end-of-life, and bereavement.  Generally precedes hospice.  Hospice philosophies are the foundation of palliative care. McLean-Heitkemper, 2011

5 Hospice  Holistic, compassionate care for the dying and their family during terminal illness.  Hospice Medicare eligibility requires a prognosis of less than six months life expectancy.  Provides supportive care for patients in the last phase of incurable disease. Palliative focus instead of curative.  Preserves dignity and quality of life throughout the dying process.  Focuses on symptom management, advanced care planning, spiritual care, family support, and bereavement. McLean-Heitkemper 2011

6 Hospice  Addresses physical, emotional, social, and spiritual needs of patients and families.  Collaborative and coordinated care via interdisciplinary team members.  Care team includes: physicians, pharmacist, nurses, nursing assistants, chaplain, volunteers, social worker, and bereavement coordinator.  Services offered in the home, hospital, residential care center, and nursing home. McLean-Heitkemper 2011

7 End-of-Life  Generally refers to care in the final phase of illness when the patient is near death or actively dying.  EOL care may be a few hours, weeks, or months.  The timeframe from diagnosis to death varies by diagnosis and disease extensiveness.  Institute of Medicine considers EOL as the time of coping with terminal illness or advanced age even if death is not clearly imminent. McLean-Heitkemper, 2011

8 Goals of EOL Care  Comfort and supportive care for the patient and family during the dying process.  Improved quality of life for the life that remains.  Dignified and peaceful death.  Emotional support for both patient and family. McLean-Heitkemper, 2011

9 Consider for a moment…..  How would your life change if you learned you would die in the next 12 months, six months, or one month? (Sherman, Matzo, Panke, Grant, Rhome, 2003)  What would you want to do if you were diagnosed with a terminal condition?  How would you need to do to prepare?  Never loose sight of how very personal this is for the patient and family!

10 When will death occur?  Prognosis is influenced by disease, desire to live, and sometimes anticipation of special events (Sherman, Matzo, Pitorak, Ferrlll, Malloy, 2005).  Not all patients experience the same symptoms as there is no specific sequence (McLean-Heitkemper, 2011).  Death results when all vital organ function stops (cardiac, respiratory, and brain).

11 Brain Death  No brain or brainstem function.  Cerebral cortex no longer functions or is irreversibly damaged.  Clinical brain death in the ICU—heart continues to beat (intubation with mechanical ventilation).  Legal definition—brain function must cease for brain death to be pronounced and life support removed. McLean-Heitkemper 2011

12 Death Draws Near: Physical Manifestations  Slowed metabolism and impaired organ function that leads to multi-system failure and organ shut- down.  Respirations are usually the first to stop.  Heart usually stops within a few minutes of respirations. McLean-Heitkemper 2011

13 Death Draws Near: Physical Manifestations cont. Sensory:  Decreased sensation  Decreased ability to perceive pain and touch  Poor sense of taste and smell  Eyes: blurred vision, absent blink reflex, sunken, glazed over, blank stare, slit eye lids  Loss of hearing (last sense to loose)  Inability to respond McLean-Heitkemper, 2011

14 Death Draws Near: Physical Manifestations cont. Respiratory: (distress and air hunger common)  Rapid, slow, shallow, irregular breathing  Cheyne-Stokes respirations (alternating apnea and deep, rapid respirations)  Slowed respirations “terminal gasps” or “guppy breaths”  Unable to cough and clear secretions  Noisy, gurgling secretions audible without a stethoscope, “death rattle” McLean-Heitkemper, 2011

15 Death Draws Near: Physical Manifestations Cardiovascular:  Increased heart rate that begins to slow  Weak or absent pulses  Progressive decrease in blood pressure  Delayed absorption of injected medications  Irregular rhythm McLean-Heitkemper 2011

16 Death Draws Near: Physical Manifestations cont.  Urinary:  Decreasing output  Incontinent  Inability to void  Gastrointestinal: Decreased motility and peristalsis Abdominal distention, nausea, and constipation Loss of sphincter control makes incontinence common as death occurs. McLean-Heitkemper 2011

17 Death Draws Near: Physical Manifestations cont.  Musculoskeletal:  Severe weakness and inability to move  Relaxed facial tone—jaw drop, difficulty/inability to speak and/or swallow  Poor body posturing and alignment  Impaired gag reflex  Myoclonus (involuntary jerking commonly seen with high-dose opioids) McLean-Heitkemper 2011

18 Death Draws Near: Physical Manifestations cont.  Integumentary:  Cold, clammy, diaphoretic, fever  Cyanosis of nose, nail beds, ears  Mottling of hands, feet, toes, arms, legs, and knees  Skin may have wax-like appearance McLean-Heitkemper 2011

19 Death Draws Near: Psychosocial Manifestations cont.  Conflicting decisions  Anxiety regarding things left undone  Feelings of meaningless life contributions  Fear of pain or shortness of breath  Loneliness  Helplessness  Depression McLean-Heitkemper 2011

20 Death Draws Near: Psychosocial Manifestations cont.  Anticipatory grieving  Difficulty saying goodbye  Reminiscent of life’s events  Fear of loss of independence and functional decline  Recognized condition deterioration that patient correlates with approaching death  Restlessness  Inability to understand communication McLean-Heitkemper 2011

21 Confusion-Disorientation-Delirium Management  Determine etiology—Disease progression, fever, nearing death awareness, opioid effects, full bladder, hypoxia, metabolic imbalances, toxin accumulation due to liver or renal failure.  Management—Assess cause and treat, safety precautions, administer sedatives, speak truthfully regarding condition, provide spiritual and emotional support, assess for caregiver fatigue. McLean-Heitkemper 2011; Sherman et al., 2005

22 Dyspnea Management  Pharmacologic  Nonpharmacologic  Opioids (morphine)  Bronchodilators (albuterol)  Diuretics (furosemide)  Benzodiazpines (lorazepam; alprazolam)  Anxiolytics (buspirone)  Steriods (dexametasone, Solu- Medrol)  Antibiotics  Oxygen if hypoxic  Fan for air circulation, cool room temperature  Positioning, elevate head of bead  Suctioning Sherman et al., 2004

23 Gastrointestinal Management  Nausea  Antiemetics  NG if obstructed  Constipation  Stimulant (Senna)  Bulk laxatives (Metamucil)  Warm fluids (prune juice)  Diarrhea Opioids (Loperamide hydrochloride) Bulk forming agents Somatostatin (Sandostatin) Sherman et al., 2004

24 Fatigue-Weakness Management  Increased weakness Interventions include:  Assist with ADL’s  Bedrest—ROM, turning, positioning, and skin assessment.  Alter medication routes—least invasive and most effective  Aspiration precautions  Suction McLean-Heitkemper 2011; Sherman et al., 2004; Sherman et al., 2005

25 Pain Management  Patients fear that they will die in pain  Scheduled analgesia for pain control (long/short acting)  Inability to swallow—consider alternate administration routes  Interventions—massage, reposition, bracing/splinting  Alternative/ complimentary therapies  Use standardized tools for pain assessment McLean-Heitkemper 2011; Sherman et al., 2004

26 Comfort Care: Actively Dying  Simple patient directions  Oral care—sips of fluid, mouth care, lip moisturizer  Preventive skin care—manage incontinence, skin barriers.  Medications to alleviate respiratory congestion, agitation, pain, and dyspnea.  Antiemetics for discomfort associated with nausea and vomiting. Sherman et al., 2005

27 Care of the Spirit  May or may not mean religion  Spiritual support provides strength and decreases despair at EOL  Pray with patient and family  Involve pastoral services  Recognize spiritual diversity and ritualistic EOL practices McLean-Heitkemper 2011

28 Emotional Support  Provide hope, comfort, and peacefulness (Matzo, Sherman, Sheehan, Ferrell, & Penn, 2003).  Reassure the patient you will not abandon them  Ask yourself, “What would I do if this were my family member?”  Provide realistic and honest information  Prepare for emotional decline and cognitive changes  Empathetic and compassionate care ( McLean-Heitkemper, 2011)  Encourage sharing of life stories, memories, and life contributions  Live your life until you die (Cramer, 2010).

29 Communication  Communication is 7% verbal, 38% tone, and 55% body language (Cramer, 2010)  Be present, use eye contact and touch, sit at the bedside, listen more than you talk.  Communicate with open acceptance (McLean-Heitkemper, 2011)  Create an environment that feels safe to share feelings and express emotion. Silence is ok.  Nearing death awareness:  Patient may see or talk with a loved ones that have died  Patient may provide instructions for those left behind

30 Response to Loss  Grief is normal, healthy process of reacting to loss and adapting to change.  Bereavement is the time after death when grief and mourning occur  Factors that influence grief:  Personal characteristics  Relationship with the deceased  Life stressors  Coping resources  Support systems  Often begins prior to death  Powerful, affects all aspects of one’s life  Nurse may be the recipient of anger. Do not react or take it personal. McLean-Heitkemper 2011; Sherman et al., 2003

31 Grief/Bereavement: Response to loss  Poor concentration, persistent sadness, constant thoughts of the one who died  Guilt, anger, abnormal behavior  Weight loss, poor appetite  Difficulty sleeping, palpitations  Anxiety, fear, loneliness, hopelessness, powerlessness McLean-Heitkemper 2011

32 Legal and Ethical Principles in Complex EOL Care  Care determined by the patient’s wishes ( McLean-Heitkemper,2011)  Organ and tissue donations  Advance directives  Medical power of attorney or living wills  Resuscitation  The nurse must recognize how her/his personal beliefs, values, and expectations influence EOL care (Matzo et al., 2003).  Fear of death, lack of experience, not knowing what to say, unresolved grief, and disagreement with patient wishes  A nurse has an ethical responsibility to ensure everything possible is done to provide a peaceful death.

33 Organ and Tissue Donation  Any part of the entire body may be donated  Decision may be made prior to death but family must consent at time of donation  Usually retrieved within a few hours after death  Designated requestors at every hospital McLean-Heitkemper 2011

34 Legal Documents: Protect the Patient’s Wishes  Advance directives  Written statements of medical care wishes  Sometimes called a living will  Directive to physicians  Patient’s desire to accept or deny treatment  Durable power of attorney for health care  Lists the person to make health care decisions should a patient become unable to make informed decisions for self McLean-Heitkemper 2011

35 Common Legal Documents  Do not resuscitate (DNR)  Orders instructing health care providers not to perform CPR  Often requested by family  Must be signed by a physician to be valid  Purple bracelet placed on client  Push to change the term to allow natural death (AND) to more clearly describe what occurs McLean-Heitkemper 2011

36 Ethical Issues  Beneficence—To do good without causing harm.  Give effective amounts of timely pain medication.  Failure to give effective pain medication and adequate dosing neglects the principles of beneficence.  Nonmaleficence—To “do no harm”. To refrain from causing harm.  Effective pain control that alleviates suffering in the terminally ill.  Under treatment of pain may be more harmful than the presumed harmful side effects.  Secondary effects that may hasten death are ethically justified. Bernhofer, 2011

37 Postmortem Care  After patient is pronounced dead the nurse prepares or delegates preparation of the body  If death is in a semi-private room—move the other patient out  Considerations when preparing body:  Cultural and ritualistic practices  Adherence to policies and procedures  Close the patient’s eyes  Replace dentures  Wash the body as needed  Remove tubes and dressings  Straighten the body  Leave a pillow in place to support the head McLean-Heitkemper 2011

38 Postmortem Care  Immediate family viewing and saying final goodbye  Family should be allowed privacy and as much time as needed with the deceased loved one  Body may stay on the unit 2 hours McLean-Heitkemper 2011

39 Special Needs of the Nurse  Recognize what can and cannot be controlled  It is appropriate to cry with the patient and family during the grieving process  Care for the dying is emotionally challenging for everyone involved  It is common for nurse to feel helpless and powerless  Feelings of sorrow, guilt, and frustration need to be expressed McLean-Heitkemper 2011

40 Nursing Management Nursing Diagnoses: Psychosocial  Acute/ chronic confusion  Compromised family coping  Death anxiety  Disturbed thought processes  Spiritual distress  Ineffective denial  Interrupted family processes  Insomnia

41 Nursing Management Nursing Diagnoses: Psychosocial  Fear  Grieving  Hopelessness  Impaired religiosity  Impaired social interaction  Impaired verbal communication  Ineffective coping  Readiness for enhanced spiritual well-being  Risk for loneliness  Social isolation

42 Nursing Management Nursing Diagnoses: Physical  Acute/ chronic pain  Bowel incontinence  Constipation  Decreased cardiac output  Diarrhea  Impaired tissue integrity  Impaired urinary elimination  Ineffective airway clearance  Impaired physical mobility

43 Nursing Management Nursing Diagnoses: Physical  Fatigue  Imbalanced nutrition: less than body requirements  Impaired bed mobility  Impaired comfort  Impaired gas exchange  Impaired oral mucous membrane  Impaired skin integrity  Impaired swallowing

44 Nursing Management Nursing Diagnoses: Physical  Ineffective breathing pattern  Ineffective thermoregulation  Ineffective tissue perfusion  Nausea  Risk for aspiration  Risk for infection  Risk for injury  Self-care deficit  Total urinary incontinence

45 Resources  American Cancer Society (http:/  National Hospice and Palliative Care Organization (  Hospice and Palliative Nurses Association (  Oncology nursing Society (  Journal of Supportive oncology: Quality of Life/Symptom Management/Palliative care (  End of Life Nursing Education Consortium From the American Association of College of Nursing (

46 References Ackley, B.J. & Ladwig, G.B. (9 th ed). Nursing diagnosis handbook: An evidence- based guide to planning care. Mosby. American Association of Colleges of Nursing. (2004). Peaceful death: Recommended competencies and curricular guidelines for end-of-life nursing care. Retrieved from Bernhofer, E. (2011). Ethics: Ethics and pain management in hospitalized patients. The Online Journal of Issues in Nursing, 17(1). doi: 10.3912/OJN.Vol17No01EthCol01 Cramer, C. F. (2010). To live until you die: Quality of life at the end of life. Clinical Journal of Oncology Nursing, 14(1), 53-56. doi: 10.1188/10.CJON.53-56 Matzo, M. L., Sherman, D. W., Lo, K., Egan, K. A., Grant, M., & Rhome, A. (2003). Strategies for teaching loss, grief, and bereavement. Nurse Educator, 28(2), 71- 76. doi: 10.1097/00006223-200303000-00009 Matzo, M. L., Sherman, D. W., Nelson-Marten, P., Rhome, A., & Grant, M. (2004). Ethical and legal issues in end-of-life care: content of the End-of-life Nursing Education Consortium Curriculum and teaching strategies. Journal for Nurse in Staff Development, 20(2), 59-66. doi: 10.1097/00124645-20040300-00001

47 References McLean-Heitkemper, M. (2011). Palliative care at the end-of-life. In S. L. Lewis, S. Ruff- Dirksen, M. McLean-Heitkemper, L. Bucher, & I. M. Camera (Eds.), Medical- surgical nursing: Assessment and management of clinical problems (pp. 153-166). St. Louis, MO: Mosby. Sherman, D. W., Matzo, M. L., Coyne, P., Ferrell, B. R., & Penn, B. K. (2004). Teaching symptom management in end-of-life care: The didactic content and teaching strategies based on the End-of-Life Nursing Education Curriculum. Journal for Nurses in Staff Development, 20(3), 103-115. doi: 10.1097/00124645-200405000-00001 Sherman, D. W., Matzo, M. L., Panke, J., Grant, M., & Rhome, A. (2003). End-of-Life Nursing Education Consortium Curriculum: An introduction to palliative care. Nurse Educator, 28(3), 111-120. doi: 10.1097/00006223-200305000-00004 Sherman, D. W., Matzo, M. L., Pitorak, E., Ferrell, B. R., & Malloy, P. (2005). Preparation and care at the time of death: Content of the ELNEC Curriculum and teaching strategies. Journal for Nurses in Staff Development, 21(3), 93-100. doi: 10.1097/00124645-200505000-00003 Tilden, V. P., & Thompson, S. (2009). Policy issues in end-of-life care. Journal of Professional Nursing, 25(6), 363-368. doi: 10.1016/j.profnurs.2009.08.005 World Health Organization. (2012).

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