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End of Life Care Lisa B. Flatt, RN, MSN, CHPN. Objectives Understand palliative care Understand palliative care Compare and contrast settings where palliative.

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Presentation on theme: "End of Life Care Lisa B. Flatt, RN, MSN, CHPN. Objectives Understand palliative care Understand palliative care Compare and contrast settings where palliative."— Presentation transcript:

1 End of Life Care Lisa B. Flatt, RN, MSN, CHPN

2 Objectives Understand palliative care Understand palliative care Compare and contrast settings where palliative care and end of life care occur Compare and contrast settings where palliative care and end of life care occur Identify stages of grief, uncomplicated grief and mourning Identify stages of grief, uncomplicated grief and mourning Describe legal, historical, social and cultural aspects of palliative and end of life care Describe legal, historical, social and cultural aspects of palliative and end of life care

3 Definitions to know Assisted suicide Assisted suicide Autonomy Autonomy Grief, Mourning & bereavement Grief, Mourning & bereavement Euthanasia Euthanasia Terminal illness Terminal illness Hospice Hospice Medicare hospice benefit Medicare hospice benefit

4 Basic Concepts Loss –something/person and be actual or potential no longer with you, valued Loss –something/person and be actual or potential no longer with you, valued Sources of Loss – body image, death, loss of independence, brain ability, financial, memory Sources of Loss – body image, death, loss of independence, brain ability, financial, memory

5 Grief Response Bereavement (subjective) and Mourning (process follows bereavement, resolution of grief) Bereavement (subjective) and Mourning (process follows bereavement, resolution of grief) Normal grieving – essential for mental health following a loss, steps are involved, helps you move on Normal grieving – essential for mental health following a loss, steps are involved, helps you move on S/S of grieving – depression, sadness, isolation, wt loss, sleep disturbances, ETOH, SA, fatigue, N&V, HA, faint, palpitations S/S of grieving – depression, sadness, isolation, wt loss, sleep disturbances, ETOH, SA, fatigue, N&V, HA, faint, palpitations Variations of grief – anticipated or abbreviated Variations of grief – anticipated or abbreviated Dysfunctional grief – pathological, unresolved, extended s/s of grief, stuck in a phase Dysfunctional grief – pathological, unresolved, extended s/s of grief, stuck in a phase

6 Kubler-Ross’s (1969) Stages of Grief Denial – shock, didn’t happen, numb, disbelief Denial – shock, didn’t happen, numb, disbelief Anger – guilt, resentment, sadness Anger – guilt, resentment, sadness Bargaining – pining, searching, yearning Bargaining – pining, searching, yearning Depression – grieving Depression – grieving Acceptance - resolution Acceptance - resolution

7 Engel’s (1964)Stages of Grief Shock & disbelief Shock & disbelief Developing awareness – directed anger, loss becomes real Developing awareness – directed anger, loss becomes real Restitution – dealing with it all, looking more Restitution – dealing with it all, looking more Resolving the loss – memories, talk it out Resolving the loss – memories, talk it out Idealization – ‘the best at…..’ Idealization – ‘the best at…..’ Outcome – acceptance, moving on Outcome – acceptance, moving on

8 Sander’s (1998) Five Phases of Bereavement Shock – confused, unreal, disbelief Shock – confused, unreal, disbelief Awareness of loss – conflict, stress, seperation anxiety Awareness of loss – conflict, stress, seperation anxiety Conservation/Withdrawal – despair, hopeless, isolation Conservation/Withdrawal – despair, hopeless, isolation Healing – identity, control Healing – identity, control Renewal – acceptance, revitalization Renewal – acceptance, revitalization

9 Influencing factors and grieving Age – younger/children, acceptance as we age, familiar, free from pain and poor quality of life Age – younger/children, acceptance as we age, familiar, free from pain and poor quality of life Significance of loss – how close, spouse, parents, pets, kids, relatives Significance of loss – how close, spouse, parents, pets, kids, relatives Culture – major, beliefs Culture – major, beliefs Spiritual belief – influences outcome of death and acceptance Spiritual belief – influences outcome of death and acceptance Gender – woman disfigured with scar (idealization of beauty), stoic Gender – woman disfigured with scar (idealization of beauty), stoic Socioeconomic – affordability of care and funerals Socioeconomic – affordability of care and funerals Support system - acceptance, after-care Support system - acceptance, after-care Cause of death/loss – traumatic injury, extended illness, unexpected death, suicide, drug OD Cause of death/loss – traumatic injury, extended illness, unexpected death, suicide, drug OD

10 Death & Dying More accepted with age More accepted with age Develops over time Develops over time Children – temporary state Children – temporary state Adults – frightening Adults – frightening Quality of life and lack of it can determine a persons perspective on death Quality of life and lack of it can determine a persons perspective on death

11 Concept of Death and Development Age Attitudes and Beliefs 0 to 5 Reversible; Sleep; Temporary ‘trip’’; immobility & inactivity are part of death; separation forms basis for undstg later Death is final; own death avoidable; aggression & violence; wishes/unrelated actions may be responsible Inevitable end of life; understanding mortality = interest in fear of death or interest in afterlife 12 – 18 Fear lingering death; doesn’t think much about; views in religious/philosophic ways; emotionally difficult to accept; fantasize it can be defied (acting out in reckless behaviors) 18 – 45 Attitude is influences: religious and culture belief system 45 – 65 Accepting of own mortality; peaks of death anxiety; emotional well being = decrease of death anxiety; death of parents and peers occurs 65 + Fear of prolonged illness, death of family and peers; multiple meanings = reunion, free from pain

12 Definitions of Death With life support & medical interventions, in 1968 World Medical Assembly redefined With life support & medical interventions, in 1968 World Medical Assembly redefined Clinical – absence of apical pulse, respirations and BP Clinical – absence of apical pulse, respirations and BP Lack of OR NO response to: Lack of OR NO response to: Eternal stimuli Eternal stimuli Reflexes Reflexes Brain waves aeb flat encephalogram Brain waves aeb flat encephalogram Respirations or muscular movement Respirations or muscular movement

13 Dying Trajectories (Glaser & Strauss 1965) Death and dying are unique Death and dying are unique Series of graphs Series of graphs Has limitations to ‘predictions’ Has limitations to ‘predictions’ Progression may be difficult to predict Progression may be difficult to predict If someone knows outcome, this may affect trajectory (sense of control over dying process and illness) If someone knows outcome, this may affect trajectory (sense of control over dying process and illness)

14 Types of Trajectories Expected trajectory – short duration, steadily progressing downward (terminal cancer) Expected trajectory – short duration, steadily progressing downward (terminal cancer) Unexpected trajectory- episodes of acute deterioration, recovery, decline then unexpected death Unexpected trajectory- episodes of acute deterioration, recovery, decline then unexpected death Lingering/Prolonged – elderly escaping cancer and MOF then die later with dementia, Alzheimers, etc.. Lingering/Prolonged – elderly escaping cancer and MOF then die later with dementia, Alzheimers, etc..

15 Physiologic Needs (pg 104) Maintain airway Maintain airway Pain free Pain free Positioning/comfort Positioning/comfort Pastoral/spiritual care Pastoral/spiritual care Mouth care Mouth care ADL’s, brushing hair ADL’s, brushing hair

16 Impending Death Muscle tone – decreased, relaxed face, swallowing, speaking Muscle tone – decreased, relaxed face, swallowing, speaking Circulation – slows down, mottling, cold Circulation – slows down, mottling, cold Respirations – rapid, shallow, noisy, dry, mouth breathing, slows and irregular Respirations – rapid, shallow, noisy, dry, mouth breathing, slows and irregular Sensory impairment Sensory impairment Vision- blurred Vision- blurred Decreased smell/taste (or hypersensivity) Decreased smell/taste (or hypersensivity)

17 Care Post-Mortem When appropriate, after they are gone and family aware and in agreement When appropriate, after they are gone and family aware and in agreement Clean, covered Clean, covered Remove tubes and lines Remove tubes and lines Dignity Dignity Teeth, eyes closed Teeth, eyes closed Rigor mortis Rigor mortis

18 Hospice Cecily Saunders, MD founded concept Cecily Saunders, MD founded concept Support and care of person & family Support and care of person & family Goal: peaceful and dignified death Goal: peaceful and dignified death Holistic and interdisciplinary Holistic and interdisciplinary Qualified if MD certifies within the last 6 months of life Qualified if MD certifies within the last 6 months of life

19 Where can hospice care occur? Home Home Facility Facility Hospital Hospital ECF ECF

20 Define Palliative Care Relief from symptoms of disease Relief from symptoms of disease Relief from pain Relief from pain Support to patient and family, coping mechanisms Support to patient and family, coping mechanisms Interdisciplinary team Interdisciplinary team Death not imminent Death not imminent Allow pt and family to live as ‘normally’ as possible Allow pt and family to live as ‘normally’ as possible

21 The Nursing Process Assessment/Analysis Assessment/Analysis Planning Planning Rationale Rationale Factors influencing grief & dying Factors influencing grief & dying Implementation Implementation Evaluation Evaluation


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