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End of Life Communication & Collaboration “Care of the Actively Dying” Cheryl Vahl MSN AOCN ACHPN Adapted from Clinical Review for the Hospice and Palliative.

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Presentation on theme: "End of Life Communication & Collaboration “Care of the Actively Dying” Cheryl Vahl MSN AOCN ACHPN Adapted from Clinical Review for the Hospice and Palliative."— Presentation transcript:

1 End of Life Communication & Collaboration “Care of the Actively Dying” Cheryl Vahl MSN AOCN ACHPN Adapted from Clinical Review for the Hospice and Palliative Nurse

2 3/23/2010Iowa Cancer Consortium & C- Change 2 Program Objectives Describe palliative care, hospice care, and end of life care Identify end of life symptoms and management options Identify regulatory, institutional and personal barriers impacting palliative care and end of life care Discuss the referral of patients to community palliative and end of life care and support services Describe the process of working with patients and families to define goals of care and use of advanced directives Examine ways to collaborate with hospice care providers within long-term care facility settings

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6 3/23/2010Iowa Cancer Consortium & C- Change 6 Identifying the Dying Patient Progressive, incurable, chronic medical condition –Progressive disease that no longer responds to life- prolonging treatments Heart failure or COPD Metastatic cancer Chronic aspiration pneumonia –Progressive decline in functional ability –Psychological acceptance of imminent death –CAPC: A Guide to Building a Hospital-based Palliative Care Program, 2004.

7 3/23/2010Iowa Cancer Consortium & C- Change 7 Identifying the Dying Patient Syndrome of Imminent Death –Early Stage - bedbound, loss of interest/ability to eat/drink; cognitive changes; either hypo/hyperactive delirium, or sedation –Mid Stage - further decline in mental status (obtunded); ‘death rattle’ or inability to manage oral secretions; fever –Late Stage - coma, cool extremities, altered respiratory pattern; fever –Time Course - varies from less than 24hrs to 14days; difficult to predict time course; family distress as patient ‘lingers.’ –CAPC: A Guide to Building a Hospital-based Palliative Care Program, 2004.

8 3/23/2010Iowa Cancer Consortium & C- Change 8 Ensuring Good Care Make environment comfortable Attentiveness, compassion and concern Avoid burdensome care Respect values Working as a team Encourage family to be with, touch, speak to the patient; support them as needed to do this

9 3/23/2010Iowa Cancer Consortium & C- Change 9 Self-determined Needs & Goals Assist patient in meeting end-of-life goals -Who? -What? -Where?

10 3/23/2010Iowa Cancer Consortium & C- Change 10 Cultural Influences Determine beliefs and values Respect need to “die on his or her own terms” Never impose own beliefs Avoid judging how family members cope

11 3/23/2010Iowa Cancer Consortium & C- Change 11 Family Needs Do patient’s and family’s goals conflict? Is there unfinished business? Promote patient – family communication Reassess patient goals and priorities

12 3/23/2010Iowa Cancer Consortium & C- Change 12 Assist Patients & Family in “Reframing Hope” Hope may begin with hope for a cure, but can evolve into many things as patient and family goals change There are many facets to hope. It’s the desire and the expectation that something is obtainable Caution to not to promote “false hope”

13 3/23/2010Iowa Cancer Consortium & C- Change 13 Care Environment - Physical Environment “Sacred space” Objects and views Lighting Sound Family space

14 3/23/2010Iowa Cancer Consortium & C- Change 14 Care Environment - Staff behaviors and attitudes Privacy and support Sit, listen, convey compassion, concern Importance of presence Model behavior

15 3/23/2010Iowa Cancer Consortium & C- Change 15 Symptom Management Anticipate the patient’s decline Reduce polypharmacy Change medication routes Plan to manage “Expected Symptoms” –Pain, dyspnea, delirium, secretions

16 3/23/2010Iowa Cancer Consortium & C- Change 16 Plan to support Family Offer Spiritual, Cultural, Psychosocial Support Teach the signposts of Dying Process Provide Educational materials

17 3/23/2010Iowa Cancer Consortium & C- Change 17 Physical Comfort - Pain Patient’s priority; often greatest fear Handle gently with respect Signs of discomfort in the non-verbal patient

18 3/23/2010Iowa Cancer Consortium & C- Change 18 Patient with significant pain, entering final days Assume pain will continue to be present until death Do not discontinue pain meds as mental status declines –Dose reduction may be considered in liver & renal failure (especially when there is no urine output) Use nonverbal indicators of pain to judge analgesic needs

19 3/23/2010Iowa Cancer Consortium & C- Change 19 Patient without significant pain, entering final days New severe pain due to dying process is unlikely –Discomfort from immobility can occur Trial of analgesics for suspected pain

20 3/23/2010Iowa Cancer Consortium & C- Change 20 Agitation - Delirium Types Reversible physical causes Emotional or spiritual causes Non-verbal signs of discomfort Provide calm quiet environment Minimize sleep interruptions Medications if distressed –Neuroleptics (haldol) –Benzodiazepines (ativan)

21 3/23/2010Iowa Cancer Consortium & C- Change 21 Dyspnea “I can’t get my breath” Different from Tachypnea (rapid breathing) or Apnea (pauses in breathing) Medications for perception of breathlessness –Morphine –Lorazepam (Ativan ® ) Environment –Change position –Fan

22 3/23/2010Iowa Cancer Consortium & C- Change 22 Noisy Respirations “Death rattle” Caused by relaxation of throat muscles and pooling of secretions Environment –Reposition –Minimize fluids Medications –Scopolamine patch; Atropine drops; Glycopyrrolate Avoid deep suctioning

23 3/23/2010Iowa Cancer Consortium & C- Change 23 Nutrition/Hydration Provide family support when patients stop or are unable to eat by mouth Small sips for conscious patients who express Hunger or Thirst Avoid fluid overload Tube feedings – do not initiate or continue Dehydration may provide comfort Mouth care

24 3/23/2010Iowa Cancer Consortium & C- Change 24 IV Fluids Increased discomfort due to –Repeated venipunctures –Iatrogenic infections –Worsening of edema –Increasing respiratory secretions

25 3/23/2010Iowa Cancer Consortium & C- Change 25 Elimination Management Absorbent pad/adult protection Moisture barrier Indwelling catheter Assess for underlying causes of fecal incontinence

26 3/23/2010Iowa Cancer Consortium & C- Change 26 Skin Integrity & Loss of Mobility Reposition frequently Medicate prior to movement Special mattresses prior to decline

27 3/23/2010Iowa Cancer Consortium & C- Change 27 Terminal, Palliative, or Respite Sedation? What is the “intent”? Use of sedative to provide relief of refractory and intolerable symptoms at the end of life “Time limited trial” Not euthanasia Indicated in <2% of patients

28 3/23/2010Iowa Cancer Consortium & C- Change 28 Psychosocial Support for Patient Allow control Maintain dignity Fears of unknown, abandonment, burdening Communication

29 3/23/2010Iowa Cancer Consortium & C- Change 29 Psychosocial Support for Family Listen Allow control Determine who is the decision-maker Respect preferences Address concerns

30 3/23/2010Iowa Cancer Consortium & C- Change 30 Grieving Emotional responses to loss Types –Anticipatory –Disenfranchised –Public –Normal vs. Complicated

31 3/23/2010Iowa Cancer Consortium & C- Change 31 Risk Factors for Complicated Grieving Enmeshed relationships Multiple losses Child’s loss of a parent Death of a child Substance abuse

32 3/23/2010Iowa Cancer Consortium & C- Change 32 Grief Interventions Education and preparation Keep family informed Provide information Prepare family for death Allow family to participate in caregiving Permission to take breaks or leave

33 3/23/2010Iowa Cancer Consortium & C- Change 33 Grief Coaching Encourage communication with patient Saying goodbye Provide resources for bereavement support A “good death” is sad, but hopefully will ease their grief

34 3/23/2010Iowa Cancer Consortium & C- Change 34 Spiritual Needs Suffering, meaning, and hope Cultural influences Clergy support Patient-family conflict of values/beliefs Unresolved issues/relationships

35 3/23/2010Iowa Cancer Consortium & C- Change 35 Spiritual Needs Intervention Chaplain/Clergy Goal attainment Forgiveness Permission to die

36 3/23/2010Iowa Cancer Consortium & C- Change 36 Request to Hasten Death Origin of suffering Physical or existential Who is suffering? Compassionate, non-judgmental response Elicit team for support

37 3/23/2010Iowa Cancer Consortium & C- Change 37 Other Issues of Dying Final rally Symbolic language Visions Dying alone

38 3/23/2010Iowa Cancer Consortium & C- Change 38 Signs of Imminent Death Changes in mentation Loss of eyelash reflex Changes in breathing patterns Decreased urinary output Cooling and mottling of extremities

39 3/23/2010Iowa Cancer Consortium & C- Change 39 The Death Event Signs of death Rituals and family support Post-mortem care

40 3/23/2010Iowa Cancer Consortium & C- Change 40 Professional Coping Importance of self care View of dying Personal feeling about patients who die Recognize limits

41 3/23/2010Iowa Cancer Consortium & C- Change 41 Conclusion Assist patient to meet goals Individualize the environment Anticipate symptom management Anticipate spiritual care needs Facilitate grieving Recognize importance of self care

42 3/23/2010Iowa Cancer Consortium & C- Change 42 References Bednash G, Ferrell B. End-of-life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing; Wagner B, Ersek M, Riddell S. Artificial Nutrition and Hydration Position Statement. Pittsburgh, PA: Hospice and Palliative Nurses Association; Corless IB. Bereavement. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press, 2006: Emanual L, von Gunten CF, Ferris FD, eds. The Education for Physicians on End-of-Life Care (EPEC) Curriculum. The EPEC Project, The Robert Wood Johnson, Foundation, Berry P, Griffie J. Planning for the actual death. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford University Press, 2006: Berry PH, ed. Core Curriculum for the Generalist Hospice and Palliative Nurse. Dubuque, IA: Kendall/Hunt; Martinez J, Wagner S. At the end of life: hospice and palliative care. In Groenwald SL, Hansen M, Goodman M, Yarbro M, Jones C.H. Cancer nursing: Principles and Practices (5th ed). Boston, MA: Bartlett Publishing;2000


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