1. Chapter Eleven
End-of-Life Issues

2. End-of-Life Issues People want a “good death.”
Nurses have an essential role in providing end-of-life (EOL) care.
Need to explain options and provide referrals and resources to older adults and their families.

3. Mystery of Death
Nurses need to be prepared to be a positive influence for appropriate EOL issues.
Educated in EOL issues
Provide older adults with high quality of life and a good death.
Need to be skilled at teamwork with other caring professionals, families, and the dying person.

4. Stages of Grief Grief is the normal reaction to a catastrophic loss.
Kübler-Ross defined stages of grief.
Stages of grief describe normal human reactions to death.
Stages include denial, anger, bargaining, depression, and acceptance.
Person can move from one stage to another and then up or down the stages.

5. Stages of Grief (cont’d)
Denial
Person is unable to accept loss.
May show signs of shock, praying that it is not true; may seem “dazed”
Survivor may not realize what happens in the next few days
Anger
Demonstrates awareness of loss and its consequences
Person needs be able to vent anger in a safe environment.

6. Stages of Grief (cont’d)
Bargaining
Making bargains with God or a supernatural power
The thinking is that if one trades something of value, then the person will get better.
Family needs to be supportive during this stage.

7. Stages of Grief (cont’d)
Depression
The individual does not accept the loss but accepts the fact that nothing can change it.
May not have desire or energy to do anything including ADLs
Assess for suicidal thinking.
Acceptance
Person accepts death and feels a sense of relief.
Able to go on with life’s activities
Happens at different times for all

8. Anger Denial Depression Acceptance Bargaining
Which of the stages of grief is observed by the patient saying that he or she will begin going to church more if he or she is okay?
Anger
Denial
Depression
Acceptance
Bargaining

9. Answer
E. Bargaining

10. In which of the stages of grief is the patient able to move on with daily activities?
Anger
Denial
Depression
Acceptance
Bargaining

11. Answer
D. Acceptance

12. Qualities for a Nurse Providing EOL Care
Tolerance and empathy
With tolerance person(s) will show compassion and endurance
Empathy is ability to identify with the client by being sympathetic and understanding
Gain an understanding of people and their differences.
Provide an environment that meets the physical, emotional, social, and spiritual needs of each dying person.

13. Qualities for a Nurse Providing EOL Care (cont’d)
Be flexible with dying client
Sense of humor
Assists in relieving, reducing, and soothing the symptoms of a disease
Know the personality and mood of the older adult in your care before using humor.
Communication
Strong communication allows for open discussions about death.

14. Qualities for a Nurse Providing EOL Care (cont’d)
Good listening skills
Must be fully present and attentive to the other person.
Taking time to listen
Asking appropriate questions
Not interrupting
Speak in a voice that the older person can hear.

15. Which quality of the nurse should be used to help increase open discussions?
Tolerance and empathy
Good listening skills
Sense of humor
Communication

16. Answer
D. Communication

17. Which of these skills should be used when the mood is right?
Tolerance and empathy
Good listening skills
Sense of humor
Communication

18. Answer
C. Sense of humor

19. Cultural Accountability
Be familiar with the cultural diversities of the older adults in your care.
Cultural needs should be addressed immediately on admission.

20. End-of-Life Decisions
Be aware of the decisions a person has made about his or her current and future medical care.
Help protect the patient’s right to make his or her own health-care choices.
Palliative care-measures that are taken to help client with terminal illness; not to treat client
Hospice care serves not only the dying patient but also the patient’s family, finding out their needs and responding to them in a culturally sensitive way. Usually client has about 6 months to live when referred. Often underused.
A quality hospice program will have an interdisciplinary team that is sensitive to cultural differences, and responds to patient and family needs. Will provide guidance and support.

21. End-of-Life Decisions (cont’d)
Advance directives
Written documents that outline patient’s wishes about life-sustaining treatments
Durable Power of Attorney
Used in cases in which an individual is incompetent
Forms need to come from a qualified attorney to ensure their legality in the state where the older adult resides.

22. End-of-Life Decisions (cont’d)
Living will
Allows individuals to share their opinions and wishes regarding their death

23. Which of the following is the written plan for end-of-life care?
Living will
Accountability
Advance directives
Durable Power of Attorney

24. Answer
C. Advance directives

25. What allows another person to make decisions if the patient is not able?
Durable Power of Attorney
Advance directives
Accountability
Living will

26. Answer
A. Durable Power of Attorney

27. Imminent Signs of Death
Bodily functions slow
Signs and symptoms
Rapid, weak pulse
Decline in blood pressure
Dyspnea and periods of apnea
Slower or no pupil response to light
Profuse perspiration even though cool to touch

28. Imminent Signs of Death (cont’d)
Signs and symptoms (cont’d)
Cold extremities-cover with blanket if needed
Bladder and bowel incontinence
Pallor and mottling of skin
Loss of hearing is the last thing to go