1. Chapter 44 End-of-Life Care All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

2. End-of-Life Care   End-of-life care describes the support and care given during the time surrounding death.   End-of-life care may involve days, weeks, or months.   Sometimes death is sudden, but often it is expected.   Your feelings about death affect the care you give.   You must understand the dying process. Then you can approach the dying person with caring, kindness, and respect. 2 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

3. Terminal Illness   An illness or injury for which there is no reasonable expectation of recovery is a terminal illness.   Hope and the will to live strongly influence living and dying.   Types of care   Palliative care involves relieving or reducing the intensity of uncomfortable symptoms without producing a cure.   Hospice care focuses on the physical, emotional, social, and spiritual needs of dying persons and their families. The goal is to improve the dying person’s quality of life. 3 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

4. Attitudes About Death   Experiences, culture, religion, and age influence attitudes about death.   Attitudes about death often change as a person grows older and with changing circumstances.   Practices and attitudes about death differ among cultures. 4 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

5. Culture, Spiritual Belief, and Age   Culture and spiritual needs   Practices and attitudes about death differ among cultures.   Attitudes about death are closely related to religion.   Reincarnation is the belief that the spirit or soul is reborn in another human body or in another form of life.   Many religions practice rites and rituals during the dying process and at the time of death.   Age affects a person’s attitudes and feelings about death. 5 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

6. The Stages of Dying   Dr. Elisabeth Kübler-Ross described five stages of dying.   Denial is the first stage.   Anger is the second stage.   Bargaining is the third stage.   Depression is the fourth stage.   Acceptance of death is the last stage.   Dying persons do not always pass through all five stages.   A person may never get beyond a certain stage.   Some move back and forth between stages. 6 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

7. Comfort Needs   End-of-life care involves addressing physical, mental, emotional, and spiritual needs.   Comfort goals are to:   Prevent or relieve suffering to the extent possible   Respect and follow end-of-life wishes   Dying persons may want to see a spiritual leader.   Provide privacy during prayer and spiritual moments.   Be courteous to the spiritual leader.   Handle the person’s religious objects with care and respect. 7 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

8. Physical Needs   Dying may take a few minutes, hours, days, or weeks.   To the extent possible, independence is allowed.   Every effort is made to promote physical and psychological comfort. The person is allowed to die in peace and dignity. 8 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

9. Physical Needs (Cont’d)   Pain   Skin care, personal and oral hygiene, back massages, and good alignment promote comfort.   Frequent position changes and supportive devices promote comfort.   Breathing problems   Vision, hearing, and speech   Vision blurs and gradually fails.   Hearing is one of the last functions lost.   Speech becomes difficult. 9 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

10. Physical Needs (Cont’d)   Mouth, nose, and skin   Oral hygiene promotes comfort.   Crusting and irritation of the nostrils can occur.   Circulation fails and body temperature rises as death nears.   Nutrition   Elimination   Urinary and fecal incontinence may occur.   Constipation and urinary retention are common. 10 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

11. The Room   The person’s room   The person’s room should be comfortable, pleasant, well lit, and well ventilated.   Unnecessary equipment is removed.   Equipment upsetting to look at is kept out of the person’s sight if possible.   The person and family arrange the room as they wish. 11 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

12. Mental and Emotional Needs   Mental and emotional needs are very personal.   Some persons have specific fears and concerns, such as:   Severe pain   When and how death will occur   What will happen to loved ones   Dying alone   The doctor may order medications for anxiety or depression.   Simple measures may soothe the person. 12 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

13. The Family   This is a difficult time for the family.   The family usually is allowed to stay as long as they wish.   You must respect the right to privacy.   You cannot neglect care because the family is present.   The family goes through stages like the dying person.   They need support, understanding, courtesy, and respect.   A spiritual leader may provide comfort. 13 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

14. Legal Issues   The Patient Self-Determination Act and OBRA:   Give persons the right to accept or refuse medical treatment.   Give the right to make advance directives.   Nursing centers must inform all persons of the right to advance directives on admission.   Living wills   Durable power of attorney for health care   “Do Not Resuscitate” (DNR) orders   Even if you do not agree with care and resuscitation decisions, you must follow the person’s or family’s wishes and the doctor’s orders. 14 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

15. Signs of Death   Signs that death is near may occur rapidly or slowly.   Movement, muscle tone, and sensation are lost.   Peristalsis and other gastro-intestinal functions slow down.   Body temperature rises.   Circulation fails.   The respiratory system fails.   Pain decreases as the person loses consciousness.   The signs of death include no pulse, no respirations, and no blood pressure.   A doctor pronounces the person dead. 15 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

16. Care of the Body After Death   Care of the body after death is called post-mortem care.   It begins when the doctor pronounces the person dead.   It is done to maintain a good appearance of the body.   The right to privacy and the right to be treated with dignity and respect apply after death.   Within 2 to 4 hours after death, rigor mortis develops.   An autopsy is the examination of the body after death to determine the cause of death. 16 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

17. Care for the Caregiver   Nursing assistants and staff grow close to the people they care for.   When death takes a person you are close to, it can be a very sad time.   Sometimes just talking can be helpful.   Healing comes with time.   It is also important to consider the feelings of other residents.   Some nursing centers may have a chapel where a memorial service takes place. 17 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

18. Quality of Life   Quality of life is important to dying persons and their families.   A person has the right to die in peace, with dignity.   The dying person has these rights under OBRA:   To privacy before and after death   To visit others in private   To confidentiality before and after death   To be free from abuse, mistreatment, and neglect   To be free from restraint   To have personal possessions   To a safe and home-like setting   To personal choice 18 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.