1. 15,

2. 2 End-of-Life Care

5.  Not seen as a natural progression  Uncomfortable with death  fragmented, disorganized & inadequate guidance  forced to attempt to follow changing rules & regulations set up by multi bureaucracies  Gvt  insurance 5

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7.  end-of-life care and death planning  Ideally, discussions before a health crisis  variety of options-end of life decisions difficult  too many choices  values, cultural & spiritual beliefs, & life experiences all affect choices  Most say that they do not fear death as much as they fear how they will die 7

9.  Specific end-of-life decisions  Written- official documents  Fewer issues-both providers & family  advance directive  living will  durable power of attorney for health care  Specify the type and amount of intervention desired by an individual 9

10.  Copies to  PCP, hospital of choice, extended-care facility, power of attorney for health care, anyone else as 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 10

11.  Not official or required-  Medic-alert bracelet or necklace with code status  Copy on refrigerator if person lives @ home

12.  providers see death as a professional failure rather than 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 12

13. Death among older adults is typically caused by a(n): A.acute illness. B.accident. C.chronic and debilitating conditions. D.sudden, unexpected condition. 13

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16.  value systems of patient & caregiver are often very different  Caregivers benefit from spending time identifying their personal end of life values  Understanding the value systems of others help the nurse provide quality end-of-life care, even when his or her values are not the same 16

17.  Death, dying, and the end of life have different meanings for every person  Each individual must examine his or her own values 17

19.  research to identify specific end-of-life outcomes most valued & desired by those nearing the end of life & by their families  Common theme: given their choice, most people wish to be treated with respect and dignity and to die quietly and peacefully, with loved ones nearby 19

20.  Most dying patients have similar desires 20

21.  90% indicated a wish to die at home  less than 25% actually occur there  50% occur in hospitals  25%in extended-care facilities  Hospice care  The focus is palliative  providing comfort  meeting the needs of patients & their families 21

22. Hospice care is usually available for the last __________ of life. A.month. B.6 months. C.1 year. D.2 years. 22

23.  Medicare covers hospice when death is expected to occur within 6 months  Not always exact timing-some lee way  Not always cancer  CHF  Dementia  COPD  etc

24. 24

25.  Focus-reduce or relieve symptoms without cure  neither hastens nor postpones death  Interventions designed to make the best of the time left & live as active and complete a life as possible until death comes  “Comfort Care” 25

26.  Individuals choosing palliative care usually choose to decline procedures  Invasive diagnostic tests  cardiopulmonary resuscitation (CPR)  artificial ventilation  artificial feeding,  prolong the dying process 26

28.  Commitment & collaboration of all caregivers  Disciplines must work together cooperatively & creatively  positive attitude to solve any problems  requires mutual respect & communication between all team members 28

29.  responsibility for providing & 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 29

30.  demonstrate verbally and nonverbally you are approachable  not detached or indifferent  demonstrate willingness to listen  suggestions, requests, or criticisms made by the dying person or, more likely, by family 30

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33.  cultural beliefs influence people think, live & interact with other people-they also affect how a person approaches death  nurse’s responsibility to assess each person to find out their preferences & viewpoints  Develops trust & can plan culturally sensitive care 33

34.  The Western perspective emphasizes patient’s “right to know” diagnosis and prognosis  patient can make informed decisions  Asians & Native Americans often believe speaking about death or other bad things decreases hope and produces bad outcomes 34

35.  Amount and type of intervention that will be accepted  Individual/cultural  focus on helping people cope with death  focus on living and prolonging life 35

36.  Significance of pain and suffering  Western perspective focuses on freedom from pain and suffering  Non-Western cultures often see pain as a test of faith or a preparation for the afterlife  something that is to be endured rather than avoided 36

37.  Determine if there are specific religious beliefs or practices important to the patient or their family members  Assess whether they have a preferred spiritual counselor  Offer choices when available  Determine whether the person wishes any spiritual counselor to be notified 37

38. respect for the patient’s religious and spiritual views  Avoid imposing your own beliefs  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 38

39.  It is one thing to know that you will die eventually; it’s 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 39

40. 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. 40

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43.  Biggest concern of the dying person and their significant others  Can interfere with the ability to maintain control, cope, and complete end-of-life tasks  Increases the likelihood of fatigue, depression, and loss of appetite 43

44.  Interferes with the ability of the dying person to make thoughtful decisions & communicate effectively with loved ones at a critical time  Relief of pain begins with careful assessment  Perform assessment early & often  patient’s status can change dramatically in a relatively short period 44

45.  Pain is what the patient says it is, but many older patients who have lived with multiple discomforts often underreport pain  Don’t want to be a bother  Afraid of addiction to medication  Medical personnel  Family  patient  Self-reported logs or journals are helpful  patient and significant others more focused and attuned to subtle changes in the individual 45

46.  May be caused by underlying disease processes, stress, anxiety, or medications  can interfere with ability to carry out 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 46

47.  Diminished peripheral circulation  likely to worsen as death nears  resulting in dry, pale, or cyanotic extremities  Peripheral pulses are often weak  Blood pressure often decreased by 20 or more points from normal range and may be difficult to hear  Body temperature may elevate significantly as death nears 47

48.  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 48

49.  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 49

50.  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 50

51.  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 51

52.  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 52

53.  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, 53

54.  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 54

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57.  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 57

58.  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 58

59.  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 59

60.  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 60

61.  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 61

62.  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 62

63.  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 63

64.  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 64

65.  Denial — "This can't be happening to me.“ Denial  Anger — "Why me? It's not fair!""Who’s to blame?“ Anger  Bargaining — "I'll do anything for a few more years."hope that the individual can delay death. Bargaining  Depression —"I'm going to die soon so what's the point?” Depression  Acceptance — "It's going to be okay." Acceptance