Focus on Palliative and End-of-Life Care

Focus on Palliative and End-of-Life Care
(Relates to Chapter 11, “Palliative Care at End of Life,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Palliative Care Any form of care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure Includes hospice, end-of-life care, and bereavement Palliative care originated as end-of-life (EOL) care in the 1960s. Initially this care focused on providing relief of symptoms and emotional support to the patient, family, and significant other during the terminal phase of a serious life-limiting disease. Now that phase of palliative care is called end-of-life palliative care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Palliative Care Overall goals Prevent and relieve suffering Improve quality of life for patients with serious, life-limiting illnesses Initiated after a person receives a diagnosis of a life-limiting illness Palliative care focuses on maintaining and improving quality of life for all patients and their families during any stage of a life-limiting illness, whether acute, chronic, or terminal. Patients receive palliative care services in the home as well as in long-term and acute care facilities. Patients receiving palliative care may also spend time in the intensive care unit (ICU). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Palliative Care Ideally, involves interdisciplinary team Physicians Social workers Pharmacists Nurses Chaplains Other health care professionals Many institutions have established interdisciplinary palliative and hospice care teams. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hospice Concept of care that provides compassion, concern, and support for the dying and their families Exists to provide support and care for persons in last phases of incurable diseases Hospice programs provide multidisciplinary care at the end of life with emphasis on symptom management, advance care planning, spiritual care, and family support, including bereavement. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hospice Approximately 1½ million patients receive hospice services each year. Organized under a variety of models Hospital-based, part of existing home health care agencies, free-standing, or community-based Emphasizes palliative rather than curative care Currently the median length of stay in a hospice program is 20 days. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hospice Care is provided in a variety of locations. Can be part-time, intermittent, on-call, regularly scheduled, or continuous basis Services are available 24 hours a day, 7 days a week. Hospice care is provided in a variety of locations, including the home, inpatient setting, and long-term care facilities. Inpatient hospice settings have been deinstitutionalized to make the atmosphere as relaxed and homelike as possible. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hospice Medically supervised interdisciplinary team of professionals and volunteers Hospice nurse is an integral part. Pivotal role in coordination of hospice team Educated in pain control and symptom management Hospice nurses work collaboratively with hospice physicians, pharmacists, dietitians, physical therapists, social workers, certified nursing assistants, clergy, and volunteers to provide care and support to the patient and family members. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hospice To begin hospice is a difficult decision. Lack of information about hospice care Physician may view decline as personal failure. Patients or family may see it as giving up. Some cultural/ethnic groups may underutilize hospice because of lack of awareness of hospice services, the desire to continue with potentially curative therapies, and concerns about lack of minority hospice workers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hospice Admission has two criteria: Patient must desire services. Must agree that curative care can be used to treat the terminal illness Physicians must certify that patient has 6 months or less to live. Patients in hospice programs can withdraw from the programs at any time (e.g., if their condition unexpectedly improves). For Medicare, Medicaid, and other insurances, two physicians must certify that the patient is terminally ill with less than 6 months to live. After this initial certification, only one physician (e.g., the hospice medical director) is needed to re-certify the patient. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Questions
A patient with advanced cancer is referred for hospice care. The nurse explains to the patient and the family that the goal of hospice care differs from the goal of traditional care in that hospice care 1. Provides for more complete pain control. 2. Focuses on helping the patient and family prepare for death. 3. More readily recognizes advance directives related to “right to die.” 4. Is delivered in the home and does not rely on the technology of hospitals. Answer: 2 Rationale: Hospice care provides compassion, concern, and support for the dying; emphasis of care at the end of life is on symptom management, advance care planning, spiritual care, and family support, including bereavement. Hospice care may be delivered in a variety of settings, including home, inpatient setting, and long-term care facilities. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Questions The hospice nurse identifies an abnormal grief reaction in the wife of a dying patient who says, 1. “I don’t think that I can live without my husband to take care of me.” 2. “I wonder if expressing my sadness makes my husband feel worse.” 3. “We have shared so much that it is hard to realize that I will be alone.” 4. “I don’t feel guilty about leaving him to go to lunch with my friends.” Answer: 1 Rationale: Normal reactions to loss include statements in options 2, 3, and 4. Option 1 indicates an abnormal grief reaction and possible suicidal thinking. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Death Occurs when all vital organs and body systems cease to function Irreversible cessation of cardiovascular, respiratory, and brain function Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Brain Death An irreversible loss of all brain functions, including the brainstem A clinical diagnosis that can be made in patients whose hearts continue to beat and who are maintained on mechanical ventilation in the ICU Cerebral cortex stops functioning or is irreversibly damaged. Cerebral cortex is responsible for voluntary movements and actions, as well as for cognitive functioning. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Brain Death Controversies have arisen related to an exact definition of death. Currently, legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected by the physician. Diagnosis of brain death is of particular importance when organ donation is an option. In some states and under specific circumstances, registered nurses are legally permitted to pronounce death. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

End of Life Generally refers to the final phase of a patient’s illness, when death is imminent The time from diagnosis of a terminal illness to death varies considerably, depending on the patient’s diagnosis and extent of disease. Time from diagnosis to death usually varies from a few hours to several weeks, or sometimes months. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

End of Life In some cases, it is obvious to health care providers that the patient is in this phase. In other cases, they may be uncertain whether the end is close at hand. This uncertainty adds to the difficulty of communicating clearly with patients and families. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

End-of-Life Care Term used for issues related to death and dying, as well as for services provided to address these issues Focuses on physical and psychosocial needs of the patient and the patient’s family Today, because of the “graying of America” and the increasing numbers of persons with chronic diseases, terminal illness and dying have received greater attention. Nurses spend more time with patients near the end of life than do any other health care professionals. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

EOL Care Goals Provide comfort and supportive care during dying process Improve quality of remaining life Help ensure a dignified death Provide emotional support to the family Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations EOL Care
Metabolism is decreased. Body gradually slows down until all function ends. Respiration generally ceases first. Heart stops beating within a few minutes. Trauma and disease processes can affect physical manifestations at the end of life. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Sensory System – Hearing and Touch
Hearing is usually last sense to disappear. Decreased sensation Decreased perception of pain and touch The sense of touch is decreased first in the lower extremities because of circulatory alterations. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Sensory System – Taste, Smell, & Sight
Blurring of vision Blink reflex absent Patient appears to stare. Decreased sense of taste and smell Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Integumentary System
Mottling on hands, feet, arms, and legs Cold or clammy skin Cyanosis on nose, nail beds, or knees “Waxlike” skin when very near death Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Respiratory System
Irregular breathing Cheyne-Stokes respiration Inability to cough or clear secretions Grunting, gurgling, or noisy congested breathing (“death rattle”) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Urinary System
Gradual decrease in urinary output Incontinent of urine Unable to urinate Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Gastrointestinal System
Slowing of digestive tract and possible cessation of function Accumulation of gas Distention and nausea Loss of sphincter control Bowel movement may occur before imminent death or at the time of death. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Musculoskeletal System
Gradual loss of ability to move Loss of facial muscle tone Sagging of jaw Difficulty speaking Swallowing can become more difficult. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Musculoskeletal System
Difficulty maintaining body posture and alignment Loss of gag reflex Jerking seen in patients on large amounts of opioids Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Manifestations Cardiovascular System
Decreased heart rate Later slowing and weakening of pulse Irregular rhythm Decreased blood pressure Delayed absorption of drugs Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Manifestations EOL Care
Altered decision making Anxiety about unfinished business Decreased socialization Fear of loneliness Fear of meaninglessness Fear of pain A variety of feelings and emotions affect the dying patient and the family at the end of life. Most patients and families struggle with a terminal diagnosis and the realization that there is no cure. Time may be needed to process the impending death and to formulate emotional responses. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Manifestations
Helplessness Life review Peacefulness Restlessness Saying goodbyes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Manifestations
Unusual communication Vision-like experiences Withdrawal The patient’s needs and wishes must be respected. Patients need time to ponder their thoughts and express their feelings. Response to questions time may be sluggish because of fatigue, weakness, and confusion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bereavement Bereavement is the period of time following the death of a loved one during which grief is experienced and mourning occurs. The time spent in bereavement depends on a number of factors, including how attached one was to the person who died and how much time was spent anticipating the loss. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Grief Grief is the normal process of reacting to loss or adapting to change. Dynamic process Includes both psychologic and physiologic responses following a loss Psychologic responses can include anger, guilt, anxiety, sadness, depression, and despair. Physiologic reactions can include sleeping problems, changes in appetite, physical problems, and illness. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Grief Manifested in a variety of ways Feelings Behaviors Thoughts Physical manifestations Grief is manifested in a variety of ways. Every loss is as different as each person is unique. No guidelines are available for predicting grief reactions. Individuals experience different aspects of the grieving process at different times. The individual’s cultural beliefs, religious influences or spiritual beliefs, and value system influence grief reactions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Grief Intensity of grief is driven by Individual’s personality Nature of the relationship with the dying person Concurrent life crises Coping resources Availability of support systems Cultural beliefs Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Stages of Grieving Kübler-Ross (1969) Martocchio (1985) Rando (1993) Denial Shock and disbelief Avoidance Anger/bargaining Yearning and protest Confrontation Depression Anguish, disorganization, and despair Acceptance Reorganization and restoration Accommodation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Grief Adaptive grief Healthy response Grief that assists the person in accepting the reality of death May be associated with grieving before a death actually occurs or when the reality that death is inevitable is known Indicators of adaptive grief include the ability to see some good resulting from the death and positive memories of the deceased person. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Grief Prolonged grief disorder Prolonged and intense mourning Denial of the loss for longer than 6 months Prolonged grief disorders can include symptoms such as recurrent distressing emotions and intrusive thoughts related to the loss of a loved one, severe pangs of emotion, and self-neglect. It is estimated that one in five bereaved individuals experience complicated or prolonged grief. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Grief Goals for the grief process Resolving emotions Reflecting on the dying person Expressing feelings of loss and sadness Valuing what has been shared The grieving process takes time, energy, and work. The process of resolution in normal grief may take months to years. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Grief Patient also experiences grief. Goals for grief resolution include Patient expression of feelings related to grief Acknowledgment of the impending loss Demonstration of behaviors that reflect progress in grief resolution Priority interventions for grief must focus on providing an environment that allows the patient to express feelings. Open discussion of feelings helps both the patient and the family work toward resolution of the grief process. The patient should be free to express feelings of anger, fear, or guilt. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Spiritual Needs Spiritual needs do not necessarily equate to religion. At the end of life, many patients question their beliefs about a higher power, their own journey through life, religion, and an afterlife. Some patients may choose to pursue a spiritual path. Some may not. Their individual choice needs to be respected. The patient’s and family’s preferences related to spiritual guidance or pastoral care services should be noted, and appropriate referrals made. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Spiritual Needs Deep-seated spiritual beliefs may surface for some patients when they deal with their terminal diagnosis and related issues. Spiritual distress may occur. Characteristics of spiritual distress include anger toward God or a higher being, change in behavior and mood, desire for spiritual assistance, displaced anger toward religious representatives, and display of “gallows humor.” Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Culturally Competent Care
Cultural beliefs affect a person’s understanding of and reaction to death or loss. In some cultural/ethnic groups, death and dying are private matters shared only with significant others. Often feelings are repressed or internalized. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Other cultural groups, such as African Americans and Hispanic/Latinos, may express their feelings and emotions easily. In such cultures, family members, both immediate and extended, provide support for one another. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Families with non–English-speaking members are at risk for receiving less information about their family member’s critical illness and prognosis. Cultural variations in symptom expression (e.g., pain expression) and use of health care services also exist. It is known that ethnic minority groups are often undertreated in terms of pain medications. This is critically important with regard to EOL care. Providing culturally competent care requires greater attention to assessment of nonverbal cues such as grimaces, body position, and decreased or guarded movements. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing assessment of beliefs and preferences should be made on an individual basis. Avoids stereotyping individuals with different cultural belief systems This includes assessing and documenting the patient’s cultural background, concerns, health practices, and attitudes about suffering. Open-ended questions related to the patient’s perspectives on his or her illness, as well as the patient’s expectations of care, can be used. This assessment is then used to guide the patient’s plan of care and evaluation. It can also be used to suggest or plan grief and bereavement counseling for family members. When appropriate, medical interpreter services should be accessed and used so that the patient’s wishes are known. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Legal and Ethical Issues
Outcomes related to care based on patient’s wishes Organ and tissue donations Advance directives Medical power of attorney or living wills Resuscitation Persons who are legally competent may choose organ donation. Any body part or the entire body may be donated. The decision to donate organs or to provide anatomic gifts may be made by a person before death. The decision to donate organs may be made by immediate family members after death. Some people carry donor cards. Some states allow organ donation to be marked on drivers’ licenses. The names of agencies that handle organ donation vary by state and community. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Legal Documents
Advance directives Written statements of medical care wishes Directive to physicians Patient’s desire to accept or deny treatment The first advance directive was known by laypersons as a living will. Advance care planning is focused on anticipated challenges that the patient and family will face because of illness, medical treatment, and other concerns. Most states have replaced the idea of living wills with natural death acts. Within many of these acts are specific aspects related to the individual’s wishes. Directives to physicians (DTP), durable power of attorney for health care (DPAHC), and medical power of attorney (MPOA) may be included in the natural death acts. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Common Legal Documents
Do not resuscitate (DNR) Order instructing health care providers not to attempt CPR Variety of CPR decisions A physician’s order should be written to include information concerning the patient’s or family’s wishes for the use of CPR. Several different types of CPR decisions can be made. Complete and total heroic measures, which may include CPR, drugs, and mechanical ventilation, can be referred to as a full code. A chemical code involves the use of drugs for resuscitation without the use of CPR. A “no code” or a DNR order allows the person to die with comfort measures only and without the interference of technology. A term being used to replace “no code” or DNR is the term allow natural death (AND). Some states have implemented a form called out-of-hospital DNR for use by terminally ill patients who wish to have no heroic measures used to prolong life after they leave an acute care facility. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Withholding or withdrawing treatment must be included in an advance directive. What is to be done and what is not to be done must be included in clear terms. The American Nurses Association (ANA) has a position statement on foregoing nutrition and hydration. It states that the decision to withhold artificial nutrition and hydration should be made by the patient or surrogate with the health care team. For patients who are no longer receiving artificial nutrition and hydration, it is very important that you continue to provide expert nursing care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Euthanasia is the deliberate act of hastening death. The ANA statement on active euthanasia states that the nurse should not participate in active euthanasia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Holistic Psychosocial and physical needs Focuses on Psychosocial manifestations Grieving process Physical changes associated with dying Respect, dignity, and comfort are important for the patient and for the family. In addition, nurses and other care providers must recognize their own needs when dealing with grief and dying. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Assessment
Varies with Patient condition Proximity of approaching death Limited to essential data Document specific change that brought patient into health care agency The patient’s medical diagnoses, medication profile, and allergies are recorded. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

If patient is alert Brief review of body systems to detect signs and symptoms Assess for discomfort, pain, nausea, or dyspnea. Assess coping abilities of patient and family. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Functional assessment of activities of daily living Patient’s abilities Food and fluid intake Patterns of sleep and rest Response to the stress of terminal illness Coping abilities of the patient and family should also be assessed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Frequency of assessment depends on stability, but it is done at least every 8 hours. As changes occur, assessment and documentation need to be done more frequently. For patients cared for in their homes by hospice programs, assessment may occur weekly. It is important to document both patient and family preferences for care. If the patient is in the final hours of life, the assessment may be limited to essential data. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Evaluate and monitor Circulation changes Vital signs, skin color, and temperature Respiratory status Character and pattern of respirations Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Evaluate and monitor (cont’d) Gastrointestinal/renal functioning Nutritional/fluid intake, urinary output, and bowel function Skin condition Fragile: Note breakdown Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Nursing Diagnoses: Psychosocial
Acute confusion Chronic confusion Compromised family coping Death anxiety Disturbed thought processes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Nursing Diagnoses: Physical
Acute pain Bowel incontinence Chronic pain Constipation Decreased cardiac output Diarrhea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Fatigue Imbalanced nutrition: less than body requirements Impaired bed mobility Impaired comfort Impaired gas exchange Impaired oral mucous membrane Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Impaired physical mobility Impaired skin integrity Impaired swallowing Impaired tissue integrity Impaired urinary elimination Ineffective airway clearance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ineffective breathing pattern Ineffective thermoregulation Ineffective tissue perfusion Nausea Risk for aspiration Risk for infection Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Planning
Coordination of care focus Patient’s needs Family and significant other’s needs Education, counseling, advocacy, and support Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing goals Center on patient’s abilities to express and share feelings with others Involve comfort measures and physical maintenance care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Education Ongoing information about the disease Dying process Any care provided How to cope Denial and grieving may be barriers to patient’s learning. Planning for EOL care may be particularly challenging in the ICU environment. The last hours or days of the patient experiencing brain death are frequently spent in the ICU. Some families will be approached to ask for organ donation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Anxiety
Uneasy feeling caused by a source not easily identified Frequently related to fear Management Pharmacologic or nonpharmacologic interventions Anxiety is the most common distress symptom near the end of life. Relaxation strategies such as music and imagery may be useful. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Anxiety and Depression
Causes Uncontrolled pain, psychosocial factors from disease process or impending death, altered physiologic states, drugs used in increasing doses Management Encouragement, support, and education Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Anger
The surviving family members may be angry with the dying loved one who is leaving them. Nurses are sometimes the target of the anger and must understand what is happening and not react on a personal level. There is a need to acknowledge and encourage expression of feelings, at the same time realizing how difficult it is to come to terms with grief. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Hopelessness and Powerlessness
Common emotions at the end of life You need to encourage realistic hope within the limits of the situation. Decision making about care can foster a sense of power and control for the patient. The patient and the family should be allowed to identify and to deal with what is within their control and to recognize what is beyond their control. Patient-identified goals can be encouraged to restore some sense of power. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear
Four specific fears Pain Shortness of breath Loneliness and abandonment Meaninglessness Management Coping strategies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Pain
Tendency to associate death with pain Physiologically: No indication that death is always painful Psychologically: Pain may occur based on anxieties or separations related to dying Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Pain
Terminally ill patients experiencing pain should have pain-relieving drugs available. Most patients want their pain relieved without the side effects of grogginess or sleepiness. Do not want to be deprived of ability to interact with others The patient and the family need assurance that drugs will be given promptly when needed, and that side effects of drugs can and will be managed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Shortness of Breath
The sensation of air hunger results in anxiety for the patient and family members. Current therapies involve the use of opioids, bronchodilators, and oxygen, depending on the cause of the dyspnea. Anxiety-reducing agents (e.g., anxiolytics) may help produce relaxation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Loneliness and Abandonment
Do not want to be alone Worry loved ones cannot cope and will abandon them Want someone they know and trust to stay Loved one or caregiver provides comfort and support. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Loneliness and Abandonment
High-quality nursing responses Holding hands, touching, and listening Simply providing companionship allows a sense of security. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Meaninglessness
Leads most to review their lives Intentions during life and examining actions Expressing regret Helps recognize life’s value Worth needs to be expressed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Fear of Meaninglessness
Nurse can assist patients and their families in identifying positive qualities of patient’s life. Respect and accept practices or rituals associated with patient’s life review without being judgmental. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Care Communication
Therapeutic communication is important nursing intervention. Use empathy and active listening. Allow patients and families time to express their feelings and thoughts. Patients and families may have difficulties expressing themselves emotionally. Making time to listen and interact in a sensitive way enhances the relationship among nurse, patient, and family. Listening is essential. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Silence is OK. Listening to the silence sends a message of acceptance and comfort. Frequently silence is related to the overwhelming feelings experienced at the end of life. Silence can also allow time to gather thoughts. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Patients may speak To or about family members or others who have died before them To give instructions to those who survive them To speak of projects yet to be completed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Active, careful listening allows identification of specific patterns in patient’s communication. Increased risk for inappropriate labeling of behaviors Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Physical Care Symptom management Priority is to meet physiologic and safety needs. Deserve same care as people who are expected to recover Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postmortem Care After patient is pronounced dead, the nurse prepares or delegates preparation of the body for immediate viewing by the family. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postmortem Care Considerations when preparing body Cultural customs In accordance with state law Agency policies and procedures In some cultures and in some types of death, it may be important to allow family members to prepare or assist in preparing the body. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postmortem Care Considerations when preparing body Close the patient’s eyes. Replace dentures. Wash the body as needed. Place pads under perineum. Remove tubes and dressings. Straighten body. Leave pillow to support head. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postmortem Care Unexpected or unanticipated death Preparation of the body for viewing or release to a funeral home depends on state law and agency policies and procedures. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Needs of Family Caregivers
Role of caregiver includes Working and communicating with the patient Supporting concerns Helping resolve any unfinished business Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Role of caregiver includes (cont’d) Working with family members and friends Dealing with own needs and feelings Families often face emotional, physical, and economic consequences as a result of caring for a family member. It is important to note that caregiver responsibilities often do not end when the person is admitted to a hospital or nursing home. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Recognizing signs and behaviors among family members who may be at risk for dysfunctional grief reactions is an important nursing intervention. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Risk for dysfunctional grief Dependency Negative feelings about the dying person Inability to express feelings Concurrent life crises History of depression Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Risk for dysfunctional grief (cont’d) Difficult reactions to previous losses Perceived lack of social or family support Low self-esteem Multiple previous bereavements Alcoholism Substance abuse Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Encouragement to continue their usual activities Discuss their activities and maintain some control over their lives Discuss what can and cannot change Encouragement to take care of themselves Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Special Needs of Nurses
Many nurses who care for dying patients are passionate about providing quality EOL care. Caring for dying patients is intense and emotionally charged. A bond or connection may develop between you and the patient and/or family. You need to be aware of how grief affects you personally. When you provide care for the terminally ill or for dying patients, you are not immune to feelings of loss. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Common for nurse to feel helpless and powerless when dealing with death. Feelings of sorrow, guilt, and frustration need to be expressed. Should be aware of how these feelings affect them Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Recognize and acknowledge what can and cannot be controlled. Recognize personal feelings to allow openness. Okay to cry with the patient or family during the grieving process Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study Patient admitted to ICU through ED for respiratory distress Placed on ventilator and sedated Spouse is fearful and requests all measures to prolong life. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 110

Discussion Questions How might you assess the spouse’s understanding of the situation? What complications from the disease process might he encounter? How can you minimize these? Ask her to tell the story about her husband’s disease process, including diagnosis and progression. Then ask her what her perceptions are about what is happening with her husband today. The dying process can have many physical manifestations. See Table 11-2 for specifics. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 112

Discussion Questions 3. What psychosocial issues should be addressed? 3. A variety of psychosocial factors should be considered, including, but not limited to, anxiety, depression, fear, and powerlessness. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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