Care at the End of Life

LEARNING OUTCOME 1
Describe the role of the nurse in providing quality end-of-life care for older persons and their families.
Nurses Unique Qualifications to Provide End-of-Life Care
Holistic view

Comprehensive

Effective

Compassionate

Cost effective

Nurses Involvement in End-of-Life Care

Spend the most time with patients and their family members at the end-of- life than any
other member of the healthcare team
Provide education, support, and guidance throughout the dying process
Advocate for improved quality of life for the person with serious illness
Attend to physical, emotional, psychosocial, and spiritual needs of the patient
Nurses Who Help the Patient Die Comfortably and With Dignity Provide the Following Benefits
of Good Nursing Care:
Attend to pain and symptom control
Relieve psychosocial distress
Coordinate care across settings with high-quality communication between healthcare
providers
Prepare the patient and family for death
Clarify and communicate goals of treatment and values
Provide support and education during the decision-making process, including the benefits
and burdens of treatment
Nurses Who Care for the Dying

Are well educated

Have appropriate supports in the clinical setting
Develop close collaborative partnerships with hospice and palliative care service providers
Must be confident in their clinical skills
Are aware of the ethical, spiritual, and legal issues they may confront while providing endof-life care

Nurses Need to be Aware of Personal Feelings About Death

Improves ability to meet holistic needs of the patient and family
Clarifies ones own beliefs and values
Meaning of Hope Shifts
From striving for cure to achieving relief from pain and suffering
No right or correct way to die: It's everybody's right to live independent and die with
dignity
Table 11-1
Questions and Critical Thinking in Preparation to Care for Dying Patients
LEARNING OUTCOME 2
Recognize changes in demographics, economics, and service delivery that require improved nursing
interventions at the end of life.
Changing Statistics
Primary cause of death

10 leading causes of death account for 80% of all deaths in the Philippines

Heart disease
Malignant neoplasms
Cerebrovascular disease
Chronic lower respiratory disease
Accidents
Diabetes mellitus

Changing Statistics
Primary cause of death

10 leading causes of death account for 80% of all deaths in the Philippines

Influenza
Pneumonia
Alzheimers disease
Renal disease
Septicemia

Changing Statistics
Demographic trends

 Today, more deaths occur at home

The average life span is 77.9 years compared to only 50 in 1900
the average life expectancy in the Philippines is 68.76
Social trends

Today, caregivers are more likely to be professionals rather than family members

Exact Cause of Death Difficult to Determine in the Older Person

Multiple comorbid conditions (is either the presence of one or more disorders (or diseases)
in addition to a primary disease or disorder)
Acute injury added
Unexpected pathology
Most Filipinos Prefer to Die at Home

50% die in hospitals

25% die in long-term-care facilities
20% die at home or the home of a loved one
5% die in other settings

Survey Results of Healthcare System Care of Dying People

Excellent: 3%
Very good: 8%
Good: 31%
Fair: 33%
Poor: 25%

Barriers to Quality End-of-Life Care

Failure of healthcare providers to acknowledge the limits of medical technology

Lack of communication among decision makers
Disagreement regarding the goals of care
Failure to implement a timely advance care plan
Lack of training about effective means of controlling pain and symptoms
Unwillingness to be honest about a poor prognosis
Discomfort telling bad news
Lack of understanding about the valuable contributions to be made by referral and
collaboration with comprehensive hospice or palliative care services

LEARNING OUTCOME 3
Describe how pain and presence of adverse symptoms affect the dying process.

Nurses Role in Pain Treatment

Initial and ongoing assessment of levels of pain
Administration of pain medication
Evaluation of effectiveness of pain medication
How Nurses Can Alleviate the Distress Associated with Untreated Pain
Ongoing assessment of levels of pain
Administration of pain medication
Evaluation of the effectiveness of the pain management plan
Negative Outcomes of Pain

Potential to hasten death

Associated with needless suffering at the end of life
People in pain do not eat or drink well
Inability to engage in meaningful conversations with others
Isolation in order to save energy and cope with the pain sensation

Reasons for Undertreatment of Pain

Patients inability to communicate due to
Delirium
Dementia
Aphasia (speechless)
Motor weakness
Language barriers
Causes of Inadequate Care at End of Life
Disparity in access to treatment
Insensitivity to cultural differences

Attitudes about death

Attitudes about end-of-life care

African-Americans prefer aggressive life-sustaining treatments

Mexican-Americans, Korean-Americans, and Euro-Americans prefer less aggressive

treatment

Causes of Inadequate Care at End of Life

Mistrust of the healthcare system
Pain is subjective and self-report is considered accurate

Pain characteristics in Cognitively-Impaired Older Persons

Moaning or groaning at rest or with movement
Failure to eat, drink, or respond to presence of others
Grimacing or strained facial expressions
Pain Mannerisms in Cognitively-Impaired Older Persons

Guarding or not moving body parts

Resisting care or noncooperation with therapeutic interventions
Rapid heartbeat, diaphoresis, change in vital signs
Pain Treatment Based on Accurate Pain Assessment
Systematic
Ongoing

Patient Questions Regarding Usual Reactions to Pain

Do you usually seek medical help when you believe something is wrong with you?
Where does it hurt the most?
How bad is the pain (may use the facility pain indicator such as smiley face or rate the pain
on a scale of 1 to 10)
How would you describe the pain (sharp, dull, shooting)?
Patient Questions Regarding Usual Reactions to Pain
Is the pain accompanied by other troublesome symptoms such as nausea, diarrhea, and so
on?
What makes the pain go away?
Are you able to sleep when you are having the pain?
Does the pain interfere with your other activities?
What do you think is causing the pain?
What have you done to alleviate the pain in the past?
Pain During the Dying Process
Acute

Sudden onset

Usually associated with single cause or event

Chronic

Associated with long-term illness

Always present

Varies in intensity

Tolerance to pain develops

Associated factors
> Depression
>Poor self-care
>Decreased quality of life

Neuropathic pain

Nerves are damaged

Burning, electrical, or tingling sensations

Deep and severe

Nociceptive pain

Tissue inflammation or damaged tissues

Cardiac ischemia

Unrelieved pain during the dying process

Hastens death
Increases physiological stress
Diminishes immuno-competency
Decreases mobility
Increases myocardial oxygen requirements

Causes psychological distress to the patient and family

Suffering
Spiritual distress

LEARNING OUTCOME 4
Identify the diverse settings for end-of-life care and the role of the nurse in each setting.
Palliative Care

 Philosophy of care
Highly structured system for care delivery
Emphasis of Supportive Care During the Dying and Bereavement Process
Quality of life
Living a full life up until moment of death
Palliative Care Settings

Hospitals
Outpatient clinics
Long-term-care facilities
Home

Hospice Care
Focuses on the whole person

Mind

Body

Spirit

Support and care

Patients

Family and caregivers

Continues after death of a loved one

Multidisciplinary team of professional caregivers

Nurse
> Manages pain and controls symptoms
>Assesses patient and family abilities to cope
>Identifies available resources for patient care
>Recognizes patient wishes
>Assures that support systems are in place

Multidisciplinary team of professional caregivers

Physician
Pharmacist
Social workers
Others

Last phase (6 months) of incurable disease

Live as fully and comfortably as possible
Hospice Settings

Freestanding
Hospital
Home health agencies with home care hospice
Home
Nursing home or other long-term-care settings

LEARNING OUTCOME 5
Explore pharmacological and alternative methods of treating pain.
Administer Pain Medication Routinely
Prevent breakthrough pain and suffering

Long-acting drugs provide consistent relief

Chronic pain

Short-acting or immediate release agents for prn use

Acute pain

Anticipate and Treat Adverse Effects of Pain Medication

Nausea
Constipation
Pain Control at the End of Life
Non-opioids for mild to moderate pain

Acetaminophen
NSAIDs
Opioids
Codeine
Morphine
Hydromorphine

 Fentanyl
Methadone
Oxycodone
NOTE: Do not use meperidine or propoxyphene with older persons
Adjuvant analgesics

Enhance effectiveness of other drug classes

Muscle relaxants
Corticosteroids
Anticonvulsants
Antidepressants
Topical
Useful for treatment with lower doses and less side effects

Routes of Administration
Oral
For patient who can swallow
Requires higher dosage
Oral mucosa or sublingual
For patients with difficulty swallowing
May require more frequent administration
Rectal
For patients with difficulty swallowing or problems with nausea and vomiting
Patient needs to be able to reposition easily
Routes of Administration
Transdermal

Delivers 72 hours of pain medication

Topical

For pain as a result of herpes, arthritis, or local invasive procedures

Parenteral

For patients who cannot swallow

 Epidural or intrathecal

Use if unable to achieve pain control by other methods

Multiple Approaches to Manage Adverse Reactions to Pain Medication

Identify when pain is most severe

Initiate constipation treatment at time opioids are started
Keep patient warm
Encourage music listening
Visit with spiritual advisor
Provide comfort measures

Back rub

Position change

Warm milk

Alternative Pain Management Approaches

Acupuncture
Massage therapy
Reiki therapy: a combination of all other alternative therapeutic methods
Chiropractors: is a health care discipline and profession that emphasizes diagnosis,
treatment and prevention of mechanical disorders of the musculoskeletal system, especially
the spine
Herbal medications
Adverse Effects of Analgesic Medications

Constipation
Respiratory depression
Nausea and vomiting
Myoclonus: is brief, involuntary twitching of a muscle or a group of muscles
Pruritis

LEARNING OUTCOME 6
Identify the signs of approaching death.
Body Changes Indicating Impending Death
Circulation
Mottling of lower extremities

 Mottling is sometimes used to describe uneven discolored patches on the skin of humans as
a result of cutaneous ischemia (lowered blood flow to the surfaces of the skin).
Pulmonary
Death rattle: s a medical term that describes the sound produced by someone who is near
death when saliva accumulates in the throat
Cheyne-Stokes respirations: is an abnormal pattern of breathing characterized by
progressively deeper and sometimes faster breathing, followed by a gradual decrease that
results in a temporary stop in breathing called an apnea
Skin
Clammy
Dusky, gray coloration
Eyes
Discolored
Deeper set
Bruised appearance
>Discuss the Death Process and Reassure Those Present
>Support family decisions to be present or to leave
>Reinforce that the dying process is as individualized as process of living
LEARNING OUTCOME 7
Describe appropriate nursing interventions when caring for the dying.
Core Principles for End-of-Life Care

Respect the dignity of patients, families, and caregivers

Display sensitivity and respect for patient and family wishes
Use appropriate interventions to accomplish patient goals
Alleviate pain and symptoms
Assess, manage, and refer psychological, social, and spiritual problems
Offer continuity and collaboration with others
Provide access to palliative care and hospice services
Respect the rights of patients and families to refuse treatments
Promote and support evidence-based clinical practice research

Mucosal and Conjunctival Care

Provide oral hygiene several times a day

 Ice chips to relieve the feeling of dry mouth can be used as long as the swallowing reflex is
present
Soothing ointments or petroleum jelly may be used on the lips
Lack of dentures makes speech and swallowing difficult
Disease processes contribute to halitosis and thrush
Artificial tears: are lubricant eye drops used to treat the dryness and irritation associated
with deficient tear production
Ophthalmic saline solutions
Opened eyes become easily irritated
Halitosis: is a term used to describe noticeably unpleasant odors exhaled in breathing
Anorexia and Dehydration
Patients may choose to stop eating and drinking
Anorexia may result in ketosis, leading to a peaceful state of mind and decreased pain
Initiation of parenteral or enteral nutrition neither improves symptom control nor lengthens
life
Skin Care
Monitor skin changes

Edema

Bruising

Dryness

Venous pooling

Avoid shearing forces

Reposition frequently
Gentle massage or lotion application may be provided by the family
Incontinence Care

Bowel and bladder incontinence frequently occurs at the end of life

Provide protective pads
Apply barrier cream
Encourage change of position
Discourage the use of indwelling catheters

Terminal Delirium
Can be distressing to family or caregivers

Presents as confusion, restlessness, and/or agitation, with or without day-night reversal

Visual, auditory, and olfactory hallucinations may occur during this time
Is often irreversible and may vary from patient to patient
Management techniques include identifying underlying cause, reducing stimuli and anxiety,
and discontinuing all nonessential medications

Neurologic Changes
Distressing for the family

Remind them that the patient may still be able to hear

Encourage the family to let go

Give the patient permission to die

Type and Level of Care at the End of Life

Comfort measure only (CMO)

Advance directives
Use of feeding tubes
Euthanasia is illegal
Euthanasia refers to the practice of ending a life in a manner which relieves pain and
suffering

LEARNING OUTCOME 8
Describe postmortem care.
Pronouncement of Death
Absence of carotid pulses
Pupils are fixed and dilated
Absent heart sounds
Absent breath sounds
Postmortem Care

Needs to be done promptly, quietly, efficiently, and with dignity

Straighten limbs before death, if possible
Place head on pillow
After pronouncement

Glove

Remove tubes

Replace soiled dressings

Pad anal area

Gently wash body to remove discharge, if appropriate

Place body on back with head and shoulders elevated

Grasp eyelashes and gently pull lids down

Insert dentures

Place clean gown on body and cover with clean sheet

Follow Policies and Procedures of the Institution

Note time of death and chart
Notify attending physician

Chart any special directions

Notify family members

Allow time with loved one

Gather eyeglasses and other belongings

Prepare necessary paperwork for body removal
Call funeral home (or other appropriate personnel) for body transport
Note on chart

What personal artifacts were released with the body

What belonging were released

Who received the belongings

Tag or provide body identification as per policy

LEARNING OUTCOME 9
Discuss family support during the grief and bereavement period.
Alleviate Patient and Family Fears and Anxieties
Prior to death

Maintain hope for the patient and family

After death

Relief statements

Rationalizations

Educate about mourning and bereavement

Expressions of Grief
First phase: numb shock: the feeling of distress and disbelief that you have when
something bad happens accidentally; "his mother's death left him in a daze"; "he was numb
with shock"
Second phase: emotional turmoil or depression
Third phase: reorganization or resolution
Caring for the Caregiver

What have I done to meet my own needs today?

Have I laughed today?
Did I eat properly, rest enough, exercise, and play today?
How have I felt today?
Do I have something to look forward to?