1. Chapter 29 Caring for older adults at the end of life

2. Introduction
Many illnesses that once were fatal are now chronic conditions
Increased emphasis on providing supportive care during chronic and life-limiting illness and end of life
Care at the end of life

3. Perspectives on end-of-life care
When does end-of-life care begin?
Death is the cessation of all biological functions
End of life: gradual process associated with cumulative effects of chronic illness and interacting conditions, rather than a single cause
Within the end-of-life phase is another: the terminal phase – actively dying
Three trajectories
Expected death
Mixed death
Unexpected death

4. Perspectives on end-of-life care—(cont.)
Views of death and dying in Western culture
Western culture tends to deny or ignore death
Social gerontology identified four contemporary values about ageing and death
Focus on holistic view of end-of-life care due to baby boomer generation
Older adults’ perspective on death and dying
Older adults are more aware and accepting of inevitability of death
Good death viewed as ageing well

5. Perspectives on end-of-life care—(cont.)
Culturally diverse perspectives on death and dying
Cultural perspective exerts strong influence
Perceptions of good death
Acceptance of hospice and palliative care
Lines of communication about pending death and end- of-life decisions
Expectations about medical interventions
Place where death occurs
Practices and rituals
Decisions about autopsy or organ donation

6. Perspectives on end-of-life care—(cont.)
Trends in providing end-of-life care
Medicalisation of end-of-life care: focuses on prolonging life through the use of medical technology rather than interventions for comfort and quality of life
“Rehumanising” of end-of-life care: recognises and respects the process of death and dying as important
Dignified death: one of acceptance and reverence
A sacred passage, time of honoring, time for goodness, time for compassion, peace, dignity and gentle release

7. Hospice and palliative care
Hospice and palliative care: interdisciplinary approach to care that holistically addresses the needs of people with life-limiting conditions along with their families and others who care for and about them
Hospice care: philosophy of care that seeks to support dignified dying for the person and their family and carers when the person usually has a short life expectancy of months
Palliative care can be provided throughout a continuum of illness for people with serious illnesses

8. Hospice and palliative care (cont.)
Palliative care: patient and family-centred care optimising quality of life by anticipating, preventing and treating suffering; method that improves quality of life of older adults and their families facing the issues associated with life-threatening illness, through prevention and relief of suffering by means of early identification, assessment, treatment of pain and other physical, psychosocial and spiritual difficulties
Scope of palliative care: broad; addresses physical, intellectual, emotional, social and spiritual needs; and facilitates older adult’s choice, autonomy and access to information

9. Promoting Wellness at the end of life
Wellness at the end of life connected to a “good death”
Dignified death = dignified care
Treated as individual and with respect
Maintain independence with basic needs met
Involved in decision making
Safe, private environment
Good communication
Absence of anxiety

10. Nursing skills and interventions for end of life
Nursing skills for quality end of life
Aggressive and comprehensive symptom management
Open and honest communication about prognosis, treatment and the dying process
Ongoing discussion of the person’s goals of care
Psychological and spiritual support for the person and family
Bereavement services

11. Nursing skills and interventions for end of life (cont.)
Communication: critical for all involved
Importance magnified due to complexity and uncertainty of situation
Offering spiritual support: essential
Listen reflectively to both the patient and the family with a compassionate presence
Demonstrate empathy and ability to journey with others in their suffering
Offer sensitivity

12. Nursing skills and interventions for end of life (cont.)
Managing physical symptoms
Fatigue (asthenia)
Constipation
Dyspnoea
Nausea and vomiting
Dehydration
Anorexia and cachexia
Providing emotional support and caring for oneself

13. Nursing skills and interventions for end of life (cont.)
Five symptoms associated with the actively dying phase:
dyspnoea, nausea and vomiting, pain, respiratory tract secretions (death rattles) and terminal restlessness/agitation
The Liverpool Care Pathway for the Dying Patient (LCP) is an example of a pathway used during the actively dying phase to assist with the delivery of quality end-of-life care
Medication administration during this phase is usually via a subcutaneous infusion
Complementary and alternative medicine can be administered

14. Question Is the following statement true or false?
Older adults have expressed a desire to die in the hospital rather than at home or a nursing home.

15. Answer
False
More than 80% of older adults have expressed a desire to die at home with their loved ones and avoid hospitalisation as their preference at the end of life. Frequently their wishes are not followed.

16. Question Is the following statement true or false?
Including family members in their loved one’s dying process ultimately has a positive impact on the experience.

17. Answer
True
Beneficial aspects of end-of-life care are nursing interventions that include families as well as the patient, as nurses assist patients and families with end-of-life tasks and teach families about the signs of imminent death and management of the dying process.