Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

“Good” death and “bad” death Death—cessation of integrated tissue and organ function, manifested by cessation of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction Most common cause of death—heart diseases, followed by cancer

Research shows European Americans (whites) have more positive attitude toward death Non-European American groups more family-centered, expect family to make best possible decisions about patient’s death

Hospice—Interdisciplinary approach assesses/addresses holistic needs of patients and families to facilitate quality of life and peaceful death Palliative—Philosophy of care, organized/structured system delivering care for individuals with life-threatening illness

Cool extremities Increased sleeping Fluid and food intake decrease Incontinence Congestion, gurgling Changes in breathing pattern Disorientation Restlessness

Withdrawal Vision-like experiences Letting go Saying goodbye

Drug therapy Ethical responsibility of nurse in caring for patients near death – follow guidelines for drug use to manage symptoms, facilitate prompt and effective symptom management

Presence Life review Reminiscence Spirituality Religion

Needs and preferences met Control of symptoms of distress Meaningful interactions between patient and family Peaceful death

Most people prefer to die at home Advance directive Durable power of attorney (DPOA) Living will

By law, health care providers must initiate CPR for a person who is not breathing or pulseless unless DNR exists Can be written in advance (portable DNR) Major problems: ◦ Unclear variations ◦ Can be perceived by family members to mean that they have been given permission to end patient’s life

Someone else is appointed (health care proxy) to make patient’s health care decisions

Assess symptoms of distress in collaboration with family members ◦ Pain ◦ Discomfort

Fear Anxiety Cultural considerations and bereavement Feelings of patient/significant others

Aspiration precautions Mouth care, moisture for lips Altered routes of medication administration if needed—choose least invasive route with most effective treatment

Pain is symptom dying patients fear most Schedule pain medications to prevent recurrence of pain Consider alternative administration route of pain medication as needed

Massage Music therapy Therapeutic touch Aromatherapy

◦ Opioids ◦ Anticholinergics ◦ Bronchodilators ◦ Sedatives ◦ Corticosteroids ◦ Oxygen therapy ◦ Diuretics ◦ Antibiotics   Treat primary cause, relieve psychological distress that accompanies symptoms

Cool air Wet cloths to the face Positioning to facilitate chest expansion Frequent rest periods Encouraging imagery and deep breathing

Antiemetic agents ◦ Prochlorperazine (Compazine) ◦ Dexamethasone (Decadron, Deronil) ◦ Metoclopramide (Reglan, Maxeran) Remove any source of odors Comfortable room temperature

Assess for pain, urinary retention, constipation, other reversible cause Treat underlying cause Pharmacologic agents (haloperidol [Haldol, Peridol]) Complementary and alternative therapies (music, aromatherapy)

Pharmacologic therapy ◦ Benzodiazepines ◦ Barbiturates (phenobarbital)

Withdrawing or withholding life-sustaining therapy (WWLST) ◦ Passive ◦ Active

Legal considerations (e.g., death certificate) Determination of need for autopsy Transfer of body

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25

An older patient with end-stage heart failure is admitted with severe dyspnea and chronic pain. The patient expresses frustration and a sense of hopelessness with his illness. The nurse should advocate for the patient by requesting which type of consult services? A. Hospice care B. Palliative care C. Rehabilitation D. Pastoral/clergy

The home hospice nurse is evaluating a patient who is dying of end-stage chronic obstructive pulmonary disease (COPD). The patient indicates that she is not in pain but wants something “to help my breathing.” There is a list of standing orders for the hospice program. Which prescribed action by the nurse would be most helpful for this patient? A. Administer morphine solution (20 mg/1 mL solution) 0.25 to 0.5 mL sublingually every 2 hours as needed. B. Administer lorazepam elixir 1 mg orally, and instruct the family to give 0.5 mg or 1 mg every 4 hours. C. Provide 50% oxygen via facemask. D. Administer prochlorperazine 25 mg suppository every 8 hours as needed.

True or False: Discontinuing a mechanical ventilator from a patient who sustained an irreversible anoxic brain injury after a severe automobile accident is a form of active euthanasia. A.True B.False