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

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

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

4. Basic Concepts
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

5. Grief Response
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
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
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
Anger – guilt, resentment, sadness
Bargaining – pining, searching, yearning
Depression – grieving
Acceptance - resolution

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

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

9. Influencing factors and grieving
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
Culture – major, beliefs
Spiritual belief – influences outcome of death and acceptance
Gender – woman disfigured with scar (idealization of beauty), stoic
Socioeconomic – affordability of care and funerals
Support system - acceptance, after-care
Cause of death/loss – traumatic injury, extended illness, unexpected death, suicide, drug OD

10. Death & Dying More accepted with age Develops over time
Children – temporary state
Adults – frightening
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
5 - 9
Death is final; own death avoidable; aggression & violence; wishes/unrelated actions may be responsible
9 - 12
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
Clinical – absence of apical pulse, respirations and BP
Lack of OR NO response to:
Eternal stimuli
Reflexes
Brain waves aeb flat encephalogram
Respirations or muscular movement

13. Dying Trajectories (Glaser & Strauss 1965)
Death and dying are unique
Series of graphs
Has limitations to ‘predictions’
Progression may be difficult to predict
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)
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..

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

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

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

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

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

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

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