1. VN057 gerontology 8

2. Chapter 15 End-of-Life Care 2

4. The American Way of Dying Not seen as a natural progression Uncomfortable with death people are faced with fragmented, disorganized & inadequate guidance forced to attempt to make sense of changing rules and regulations set up by various bureaucracies – Gvt – insurance 4

5. Attitudes Toward Death and End-of-Life Planning 5

6. Attitudes variety of options makes end-of-life decision making difficult Personal values, cultural & spiritual beliefs, & life experiences all affect choices Many older people say that they do not fear death as much as they fear how they will die Ideally, discussions regarding end-of-life care and death planning will occur before a health crisis arises 6

7. Advance Directives Specific end-of-life decisions can be expressed in advance directive documents, such as a living will or durable power of attorney for health care Specify the type and amount of intervention desired by an individual 7

8. Advance Directives (cont.) Copies to the physician, hospital of choice, extended-care facility, power of attorney for health care, and anyone else deemed appropriate A competent person retains the right to change his or her mind about treatment at any time – Intubation or feeding – Full code to DNR – DNR to full or chem code – Comfort care to any of the above 8

9. Caregiver Attitudes Toward End-of-Life Care Many health providers see death as a professional failure rather than as the inevitable end to the human experience Caregivers need to be able to communicate effectively – deal with grief, loss & bereavement at the end of life – patient, – family – significant others 9

10. Death among older adults is typically caused by a(n): A.acute illness. B.accident. C.chronic and debilitating conditions. D.sudden, unexpected condition. 10

11. Values Clarification Related to Death and End-of-Life Care 11

13. Ethical Dilemmas value systems of the patient & caregiver differ significantly Individuals would benefit from spending some time identifying their personal values related to the end of life Understanding the value systems of others can help the nurse provide quality end-of-life care, even when his or her values are not the same 13

14. Values Clarification Death, dying, and the end of life have different meanings for every person Each individual must examine his or her own values 14

16. What Is a “Good Death”? Many groups have conducted research to identify the specific end-of-life outcomes that are most valued and desired by those nearing the end of life and by their families Themes throughout all studies indicate that given their choice, most people wish to be treated with respect and dignity and to die quietly and peacefully, with loved ones nearby 16

17. Patients’ Wishes Related to End of Life Most dying patients have similar desires 17

18. Where People Die 90% of people surveyed indicated a wish to die at home, less than one-fourth of deaths actually occur there half occur in hospitals; another quarter in extended-care facilities Hospice care – The focus of hospice care is palliative, providing comfort and meeting the needs of patients and their families 18

19. Hospice care is usually available for the last __________ of life. A.month. B.6 months. C.1 year. D.2 years. 19

20. Medicare will cover hospice when death is expected to occur within 6 months – Not always exact timing – Not always cancer CHF Dementia COPD etc

21. Hospice Care 21

22. Palliative Care Focus-reducing or relieving symptoms without attempting a cure; it neither hastens nor postpones death Interventions designed to optimize ability to live as active and complete a life as possible until death comes “Comfort Care” 22

23. Palliative Care (cont.) Individuals chosing palliative care typically choose to decline procedures – Invasive diagnostic tests – cardiopulmonary resuscitation (CPR) – artificial ventilation – artificial feeding, prolong the dying process 23

24. Collaborative Assessments and Interventions for End-of-Life Care requires commitment and collaboration of all caregivers Everyone must work together cooperatively & creatively & with a positive attitude to solve any problems Problem solving requires mutual respect and prompt effective communication among all team members 24

25. Communication at the End of Life The responsibility for providing and maintaining effective communication – nurses and assistive caregivers, who spend the most time with dying patients Nurses need to work to develop a climate that encourages open communication 25

26. Communication at the End of Life (cont.) demonstrate verbally and nonverbally you are approachable and not detached or indifferent need to demonstrate willingness to listen to suggestions, requests, or criticisms made by the dying person or, more likely, by his or her family 26

27. Audience Response System Question 3 One of the most important things caregivers can do for a dying person is to: A.not talk about when they will die. B.allow them to be alone as much as possible. C.talk to them about a “do not resuscitate” status. D.spend more time with them. Copyright © 2012, 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. 27

28. Psychosocial Perspectives, Assessments, and Interventions 28

29. Cultural Perspectives A person’s cultural beliefs influence how he or she thinks, lives, and interacts with other people; the beliefs also affect how a person will approach death A part of the nurse’s responsibility is to assess each individual to determine his or her unique preferences and viewpoints so that trust can be developed and culturally sensitive care can be planned 29

30. Communication About Death The Western or European and American perspective tends to emphasize the patient’s “right to know” his or her diagnosis and prognosis so that the patient can make informed decisions Asians and Native Americans often believe that speaking about death or other bad things will decrease hope and produce bad outcomes 30

31. Decision-Making Process Amount and type of intervention that will be accepted – Some focus on helping people cope with death – Other cultures more likely to focus on living and prolonging life 31

32. Decision-Making Process (cont.) Significance of pain and suffering – The Western perspective focuses on achieving freedom from pain and suffering – Non-Western cultures are more likely to view pain as a test of faith or a preparation for the afterlife; it is something that is to be endured rather than avoided 32

33. Spiritual Considerations Determine whether any specific religious beliefs or practices are important to the patient or his or her family members Assess whether the patient has a preferred spiritual counselor Offer choices when available Determine whether the person wishes any spiritual counselor to be notified 33

34. Spiritual Considerations (cont.) Demonstrate respect for the patient’s religious and spiritual views Avoid imposing your own beliefs on the patient Be present, be available, and listen Avoid moving beyond your role and level of expertise unless you have specific ministerial or pastoral training in death and dying 34

35. Depression, Anxiety, and Fear It is one thing to know that you will die eventually; it is another to realize that you have lived most of your life and that death is likely to be a reality soon Individuals must decide whether they will give up and let fear, anxiety, or depression overwhelm them or whether they will do something to remain in control of whatever time they have remaining 35

36. Physiologic Changes, Assessments, and Interventions 36

37. Pain Often the most significant concern of the dying person and his or her significant others Can interfere with the dying person’s ability to maintain control, cope, and complete end-of- life tasks Increases the likelihood of fatigue, depression, and loss of appetite 37

38. Pain (cont.) Interferes with the ability of the dying person to make thoughtful decisions and to communicate effectively with loved ones at a critical time Relief of pain begins with careful assessment Assessment needs to be performed early and often, because the patient’s status can change dramatically in a relatively short period 38

39. Pain (cont.) Pain is what the patient says it is, but many older patients who have lived with multiple discomforts often underreport the amount of pain they are experiencing – Don’t want to be a bother – Afraid of addiction to medication Medical personnel Family patient Self-reported logs or journals are helpful because the patient and significant others are more focused and attuned to subtle changes in the individual 39

40. Fatigue and Sleepiness May be caused by underlying disease processes, stress, anxiety, or medications Fatigue can interfere with the dying person’s ability to carry out necessary end-of-life tasks, including communicating with loved ones Because of metabolic changes [& depression] patient may begin to sleep more and may be difficult to awaken as the end of life nears 40

41. Cardiovascular Changes Diminished peripheral circulation already is likely to worsen as death nears, resulting in dry, pale, or cyanotic extremities Peripheral pulses are often weak Blood pressure typically is decreased by 20 or more points from the normal range and may be difficult to auscultate Body temperature may elevate significantly as death nears 41

42. Respiratory Changes Shortness of breath, difficulty breathing (dyspnea), and Cheyne-Stokes respirations during sleep are commonly observed in older adults as death nears Mild respiratory difficulty usually can be relieved by changing positioning, elevating the upper body, opening windows or using a fan to increase ventilation, or administering oxygen by nasal cannula – Narcotics often given for air hunger 42

43. Gastrointestinal Changes Loss of appetite (anorexia) and muscle wasting (cachexia) are commonly observed with advanced terminal conditions, particularly some forms of cancer Dry mouth (xerostomia) and ulcerations of the mouth Nausea and vomiting are not signs of impending death; rather, they are distressing symptoms of underlying problems 43

44. Gastrointestinal Changes (cont.) Constipation is a common and distressing problem for the terminal patient Diarrhea is a less common problem at the end of life, but one that can have a profound effect on the quality of life 44

45. Urinary Changes Oliguria common-decreases in fluid intake, blood pressure, and kidney perfusion Urinary incontinence common Absorbent pads or indwelling catheter – used to reduce need for bed changes that may disturb the dying person 45

46. Integumentary Changes Skin breakdown is a problem – malnourished – Lack of mobility – incontinence Interventions to prevent skin tears or pressure sores proper skin cleansing – careful handling of skin – frequent turning and positioning – measures to reduce pressure soft, nonconstricting, nonirritating clothing helps promote comfort and minimizes risk for skin dryness and rash 46

47. Sensory Changes with end of life Vision- diminishes and the visual field narrows Hearing-acute until death – even if the person does not respond – Calm, supportive, loving messages should be delivered, even when unresponsive – Negative or disturbing conversations should be avoided, 47

48. Changes in Cognition Delirium-present in over 80% @ end of life – Causes Hypotension oxygen deprivation – Apnea – hypoventilation, Fever neurologic changes metabolic abnormalities – Hyperglycemia -uremia -dehydration other physiologic or emotional disturbances 48

49. Death 49

51. Family Members and Significant Others Often wish to be present at the time of death Some can spend only limited time – wish to be called only when there is a significant change in the person’s status – Others would rather be notified only after death has occurred 51

52. Indicators of Imminent Death Increased sleepiness Decreased responsiveness Confusion in a person who has been oriented Hallucinations about people (sometimes deceased family members) Increased withdrawal from visitors or other social interaction 52

53. Indicators of Imminent Death (cont.) Loss of interest in food and fluids Loss of control of bowel and bladder Altered breathing patterns – shallow breathing – Cheyne-Stokes respirations – rattling or gurgling Involuntary muscle movements and diminished reflexes 53

54. After Death family members should be allowed to sit at the bedside and say farewells or grieve as long as they need It is appropriate for the nurse to discreetly remove oxygen, IV lines, or other medical devices Cultural practices regarding grieving and preparation of the body should be respected and accommodated whenever possible 54

55. Postmortem Care Removal of soiling and application of a clean sheet or shroud according to agency policies In most cases, the head is elevated slightly to prevent discoloration Eyes are gently closed, dentures are inserted, and a small towel is rolled and tucked under the jaw to close the mouth Personal belongings should be identified, listed, and bagged for return to the family 55

56. Funeral Arrangements Most older people have given some thought to their final resting place, and many have made specific plans, issued specific directions regarding their wishes and, in some cases, even paid for their funeral 56

57. Bereavement Survivors often express having ambivalent feelings regarding the death – On one hand, they feel a sense of relief that the struggle is over and that the loved one is at rest – On the other hand, they seriously grieve and miss the loved one’s presence Even when death is anticipated, the initial feeling of shock and numbness typically occurs 57

58. Bereavement (cont.) reality of the loss strikes survivors often experience s/s of depression – loss of appetite – inability to sleep – avoidance of social interaction – uncontrolled bouts of crying In normal grieving, the frequency and severity of these signs of grieving gradually decrease over time, but the loss of a loved one never goes away completely 58

60. Chapter 16 Sexuality and Aging 60

62. Factors that Affect Sexuality of Older Adults 62

63. Normal Changes in Women changes in the reproductive system related to decreased levels of progesterone and estrogen 63

64. Changes in Women The good – More relaxed about sexuality Experience/assertiveness No pregnancy worries Less life stress

65. Changes in Women (cont.) The not so good Increased STD risk – Tissue thinning – No pregnancy worry=no condom discomfort or pain during intercourse – Irritation of the external genitals – Thinning and dryness of the vaginal walls – Alteration in vaginal flora increased risk for vaginal yeast infections 65

66. Erectile Dysfunction in Men orgasm takes longer to achieve and has a shorter duration than at a younger age Ejaculation less forceful-smaller volume of seminal fluid is released Loss of erection occurs quickly after orgasm The time between orgasms increases, and orgasm may not occur with every episode of sexual intercourse 66

67. Illness and Decreased Sexual Function Many disease processes & medications interfere with normal sexual function  – Some medications enhance sexual function, even some that aren’t designed to do so Incontinence does not interfere with sexual relations but may cause some people to avoid sex because of the risk of embarrassment 67

68. Illness and Decreased Sexual Function (cont.) Joint pain resulting from arthritis can interfere with sexual activity Cardiac problems can interfere with normal sexual activity-more from fear than from actual danger – Circulation problems affect ALL organs….. 68

69. Illness and Decreased Sexual Function (cont.) Stroke need not prevent sexual activity Neither hysterectomy nor mastectomy changes sexual functioning – BUT.. They often cause body image problems Depression- can decrease sexual interest & lead to decreased response to intimacy – Many antidepressants cause sexual side effects 69

70. Alcohol and Medications Excessive alcohol intake – delayed orgasm in women – loss of the ability to achieve or maintain erection in men Digitalis, tranquilizers, diuretics, antihypertensives, antihistamines, antidepressants, and even some medications used to treat GERD are likely to cause sexual problems for men and women 70

71. Loss of Partner Single older women experience more of a problem than single older men By age 85, there are 100 single women for every 39 single men 71

72. Loss of Partner (cont.) 72

73. Marriage and Older Adults 73

74. Marriage many different responses- particularly from families Pensions, insurance benefits, and other financial concerns may be contingent on the person’s remaining single Some choose to live together without marrying – can be a difficult decision for them and their families 74

75. Caregivers and the Sexuality of Older Adults 75

77. Caregivers Young people often uncomfortable with the thought of sexual activity health care professionals may be unaware of or uncomfortable about addressing the sexual needs of older adults Fear, shame, or embarrassment causes many older people to hide their sexual interests and activity, even from health care professionals 77

78. Sexual Health and Sexual Orientation 78

79. Sexual Health Older adults often are not considered when sexually transmitted diseases are discussed, yet 10% of acquired immunodeficiency syndrome (AIDS) cases occur in people older than 50 years All sexually active individuals, no matter what their age, should use safe sex practices The risk for sexually transmitted disease does not disappear with age 79

81. Sexual Orientation People may be more comfortable expressing sexual orientation as they age Health care providers must be careful to recognize the sexual needs and concerns of older lesbian, gay, and transgendered people 81

82. Privacy and Personal Rights of Older Adults Obtaining adequate privacy may be difficult even for married couples who reside in the same institution, particularly if regular medical or nursing care is necessary Touching, hand-holding, and cuddling are encouraged A closed door must be respected when privacy for intimacy is desired 82

83. Touch and Affection 83

84. Touch and affection are human needs, even when sexual expression isn’t possible