End of Life

cdunbar4's version from 2017-03-28 03:08

Palliative & Hospice Care

Question Answer
palliative care focusreducing severity of disease symptoms, rather than trying to delay or reverse/cure the disease itself.
overall goalsprevent/relieve suffering; improve QOL of patients with serious, life-limiting illnesses
palliative care vs. bereavement carepalliative care extends into period of end of life (EOL) care; bereavement follows pt death
when should palliative care be initiatedafter a person gets diagnosis of life-limiting disease
examples of life-limiting diseasescancer, HF, COPD, dementia, ESRF
Hospice careeither before or at end of life; not a place, it is a concept that provides compassion, concern and support for the dying persons in the last phases of a terminal disease
Hospice provides care with emphasis onsymptom mgmt; advance care planning; spiritual care & family support
Major difference b/t hospice & palliativepalliative allows a person to receive curative & palliative tx at the same time; hospice is once person forgoes curative txs
Two criteria for admission to a hospice programpt. must desire & agree on services in writing that only hospice care be given and pts can w/draw from program at any time; pt. must be considered eligible for hospice (by PCP certifying pt has <6m to live
brain death definitionirreversible loss of all brain functions (including brainstem)
What exactly causes brain death?when the cerebral cortex stops functioning or is irreversibly destroyed
Legal and medical definition requirements of brain death (why is this of importance?)all brain function must cease; diagnosis is importance d/t organ donation options

Effects on body systems

Question Answer
Institute of Medicine's definition of end-of-lifethe period during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age, even if death is not clearly imminent.
goals for EOL care (4)(1) provide comfort and supportive care during the dying process, (2) improve the quality of the patient’s remaining life, (3) help ensure a dignified death, and (4) provide emotional support to the family.
Which of the 5 senses is usually the last sense to disappear?hearing
Sensory system manisall decreased
Sightblurred vision, sinking & glazing of eyes, blink reflex absent, eyelids remain half-open
CV EOL manis• Increased heart rate; later slowing and weakening of pulse • Irregular rhythm • Decreased blood pressure
Drug absorptiondelayed when administered IM/subQ
Respiration pattern usually seen; name and describe itCheyne-Strokes; alternating periods of apnea & deep, rapid breathing
"death rattle" inability to cough & clear secretions=grunting, gurgling, or noisy congested breathing
urinary system manis • Gradual decrease in urine output • Incontinence of urine • Inability to urinate
GI• Slowing or cessation of GI function (may be enhanced by pain-relieving drugs) • Accumulation of gas • Distention and nausea • Loss of sphincter control, producing incontinence • Bowel movement before imminent death or at time of death
Musculoskeletal system• Gradual loss of ability to move • Sagging of jaw resulting from loss of facial muscle tone • Difficulty speaking • Swallowing becoming more difficult • Difficulty maintaining body posture and alignment • Loss of gag reflex
What drug class causes a large amount of jerking at the EOL?patients who are on large amounts of opioids
Skin color, tempmottling on extremities; cold/clammy skin; cyanosis of nose, nail beds, knees
Skin appearance"waxlike" when very near death
psychosocial manis fearloneliness, meaninglessness of one's life, pain,
psychosocial manis peacefulness, restlessness, saying goodbyes, unusual communication, life review, vision-like experiences
Kubler Ross StagesDenial, Anger, Bargaining, Depression, Acceptance

Legal & Ethical issues

Question Answer
Advance DirectiveGeneral term used to describe documents that give instructions about future medical care and treatments and who should make the decisions in the event the person is unable to communicate.
Directive to physiciansWritten document specifying the patient’s wish to be allowed to die without heroic or extraordinary measures.
DNRWritten physician’s order instructing health care providers not to attempt CPR. DNR order often requested by family. Must be signed by a physician to be valid
Durable power of attorney for health careTerm used by some states to describe a document used for listing the person(s) to make health care decisions should a patient become unable to make informed decisions for self.
living willLay term used to describe any documents that give instructions about future medical care and treatments or the wish to be allowed to die without heroic or extraordinary measures should the patient be unable to communicate for self.
medical power of attorneyTerm used by some states to describe a document used for listing the person(s) to make health care decisions should a patient become unable to make informed decisions for self.
Terms being used now instead of DNR"allow natural death" or "comfort measures only"
ANA's code of ethics for nurses regarding euthanasianurses should not participate in active euthanasia since it is in direct violation of the Code for Nurses
nonmaleficence in relation to pain controlto alleviate suffering will help to prevent or reduce harm to patient
standard of care for nursing careif it falls short, it is considered negligent and unsafe & nurse can be found incompetent

Nursing Mgmt. of EOL manifestations & Special needs for EOL nurses

Question Answer
Painassess frequently, minimize irritants/contributing factors, alternative therapies, evaluate, DO NOT DELAY OR DENY pain relief measures to a terminally ill patient
Deliriumassess causes (pain, constipation, urinary retention); quiet room, well lit room; reorient person each time; stay physically close to patient & reassure in calm, soft voice; encourage family participation in care
Restlessness• Use soothing music; slow, soft touch and voice. • Limit the number of persons at the bedside.• Assess for spiritual distress as a cause of restlessness and agitation. Do not restrain patient
Weakness & Fatigue is expected• Assess the patient’s tolerance for activities. • Time nursing interventions to conserve energy. • Help the patient identify and complete valued or desired activities. • Provide support as needed to maintain positions in bed or chair. • Provide frequent rest periods.
DehydrationAssess mucous membranes; oral care; ice chips; moist cloths; lubricant to lips & oral swabs; reassure family that cessation of food is normal of dying process
Dyspnea is a subjective symptom, accompanied by fear of suffocation & anxietyAssess resp. status regularly; ↑HOB or put pt. on side; fan or AC; supplemental O2; suction PRN to remove accumulated mucus from airways
Myoclonus: mild to severe jerking or twitching d/t use of high dose of opioids Assess for initial onset, duration, and any discomfort or distress experienced by patient. • If myoclonus is distressing or becoming more severe, discuss possible drug therapy modifications with the health care provider. • Changes in opioid medication may alleviate or decrease myoclonus.
Skin breakdownassess; prevent skin breakdown; wound care protocols; perineal area clean; blankets for warmth, not heat; prevent effects of shearing forces
Bowel patterns: can be constipated or diarrheaassess function, fecal impactions; encourage movement if tolerated, fiber, fluids if they can handle it; suppositories, stool softeners, etc.
Urinary incontinenceassess urinary function; absorbent pads; follow appropriate protocol for consideration & use of indwelling/external cath
Anorexia, n/vassess contributing factors; give pt. favorite foods & antiemetics beforehand; small, frequent meals, culturally appropriate foods
Rewarding and challengingmany nurses care for dying patients because they are passionate about providing high-quality EOL care
What should these EOL nurses be aware of?How grief personally affects them; know that you are not immune to feelings of loss
Common feelings of EOL nursesfeeling helpless & powerless; feelings of sorrow, guilt & frustration
Interventions for EOL nurses to ease physical & emotional stressbe aware it is NOT in your control; be open about exchanging feelings with family; decrease stress; stay focused on things/hobbies that make you happy; have a support group
Is it ok to cry with pt/family?Yes, it may be of importance to your well-being

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