PALLIATIVE CARE END OF LIFE

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PALLIATIVE CARE END OF LIFE : 

PALLIATIVE CARE END OF LIFE LEHMAN COLLEGE NUR 409

END OF LIFE CARE : 

END OF LIFE CARE

Introduction : 

Introduction The dying process is often accompanied by: Psychological, Spiritual, Physical needs. Nurses are in the most immediate position to provide care, comfort, and counsel Compassionate and highly specialized care is required

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Rarely discussed before 1960; considered a taboo topic Patients received less than quality care Not expected to survive, isolated in hospital areas Family and faith communities or both were care providers

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Today special needs acknowledged and integrated into care Are researched by scientists and professionals Information can be found in popular and professional literature

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End of life: Used for issues related to death/dying Defined by the institute of medicine As a concluding phase of a normal life span, although life can end at any age End of life-focus on physical/psychosocial/spiritual Needs at end of life for patients/pt’s family

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GOALS Provide comfort Supportive care during dying process Improve quality of remaining life Help ensure a dignified death

The Hospice Movement : 

The Hospice Movement Began in the late 1960’s in the United Kingdom, by Dame Cicely Saunders Believed that the dying process required multiple skills of an interdisciplinary team and the provision of “patient-centered care”.

Death and Dying Process : 

Death and Dying Process Elizabeth Kubler-Ross developed theoretical framework Denial Anger Bargaining Depression Acceptance Florence Wald brought hospice movement to the US

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Most Americans still die in nursing homes or hospitals; limited use of hospice care in the US Western society is a death-denying culture; many clients and health care professionals desire life-prolonging care Clients and families often lack knowledge regarding the availability of hospice services Physicians have difficulty in determining prognoses in terms of six months or less.

Palliative Care : 

Palliative Care Combines an interdisciplinary approach to promote competent and compassionate care. Does not emphasize cure but rather provides relief of suffering by managing symptoms and maximizing quality of life. Palliative care differs from Hospice care in that it should be available and integrated into the beginning of the disease process until death.

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Palliative care provides support and care for persons facing life-limited illness across all care settings, Identifies death as normal and natural, Dying process is profoundly individualized and occurs within the dynamics of the family, Enhances the quality of life and integrates physical, psychological, social, and spiritual aspects of care

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Interdisciplinary team addresses the multidisciplinary needs of the dying clients and his/her family Palliative interventions affirm life and neither hasten nor postpone death. Appropriate palliative care and a supportive environment promote quality of life and health closure for the client and family.

Disease Trajectory : 

Disease Trajectory Identified from the onset of a life-limited diagnosis until death. Heart disease, cancer, stroke, COPD, and dementia have relatively predictable courses. Vast majority of Americans who die average 77 years, and typically suffer from a slow, progressive, variable course, with periods of remission and exacerbation. Women = 3 years; men 2 years at end of life.

Identifying appropriate cases for Palliative Care : 

Identifying appropriate cases for Palliative Care Assessment Defining the nature of clinical findings and symptoms Thorough history and physical examination, review of medications, history of diagnostic procedures (determine reversibility) Prioritization of client’s problems and situation Cost of diagnostic and therapeutic interventions and the varying differences between clients Discussing care options with client and family—informed decision making

Quality of Life : 

Quality of Life Palliative Care Offered when progressive illness is symptomatic and interferes with the quality of life Socioeconomic status, physical health, relationships with friends and family, satisfaction with self Quality of life is defined as: Personal statement of the positively or negativity of attributes that characterize life

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Persons quality of life is often linked to the experience of symptom distress and the meanings that person assigns to these physical sensations. Symptom distress and effect of life routine, ability to cope, and presence of social support Pain Fatigue, weakness Constipation Nausea, anorexia, early satiety, dry mouth Dyspnea Depression, insomnia

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Symptoms vary in frequency and intensity, and also in the distress experienced by the client. Management of symptoms includes: Pharmacological interventions Non-pharmacological interventions

Pain : 

Pain Multidimensional phenomenon Response to underlying disorder Emotional, intellectual, behavioral, sensory, and cultural dimensions Client who is unresponsive Restlessness: agitation, picking at things vocalizations: moaning, groaning, crying out Muscle tension: tense muscles, guarded movements Facial expression: frowning, grimacing, distressed Physiological indicators: tachycardia, tachypnea, diaphoresis

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Opioids are mainstay of treatment for moderate to severe pain Side effects include: decreased intestinal motility, constipation, urinary retention, nausea, vomiting, respiratory depression (rare), sedation Adjuvant analgesics NSAIDS Tricyclic antidepressants Anticonvulsants—phenytoin, gabapentin Anti-anxiety agents—benzodiazepines

Dyspnea : 

Dyspnea Subjective experience of difficulty breathing Occurs in as many as 50—70% of persons at the end of life. Client’s are unable to carry out activities of daily living—gravely affects quality of life Diseases associated with dyspnea include: Acute and chronic pulmonary disorders Heart failure Neuromuscular disorders Weakness Emotions, fear (panic)

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Assessment Use of analog scales Objective assessment Management Treatment of underlying disease Opioids, Anti-anxiety agents, benzodiazepines, Bronchodilators, Corticosteroids Oxygen therapy

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Non-pharmacological interventions Pursed-lip breathing, Breathing exercises Positioning, Fan blowing in the room Coping techniques Calming presence, relaxation therapy, massage, acupuncture

Fatigue and Weakness : 

Fatigue and Weakness Fatigue one of the most prevalent symptoms; universally associated with advanced malignancy. Distressing subjective experience, impedes functioning, and impairs quality of life Tiredness, exhaustion, diminished energy, diminished motivation, diminished capacity to pay attention, or a disturbed mood.

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Etiology: Not clearly understood May result from disease process, psychoemotional, spiritual Assessment Comprehensive assessment Important to review treatable causes of fatigue Review of medications

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Management Anemia should be treated, use of erythropoietin Counseling, education, relaxation techniques, massage Rest periods in clients’ schedules Plan most strenuous activities during times of day with the most amount of energy Medications: corticosteroids, psychostimulants (ritalin)

Sleep Disturbances : 

Sleep Disturbances Impaired sleep is common and often overlooked Occurs up to 59% of persons with advanced cancer Sleep has restorative and protective functions; impairment of sleep may lead to depression, irritability, and withdrawal

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Assessment of sleep Usual bedtime How long it takes to fall asleep Any wakefulness during the night Usual waking time Subjective feeling of being “refreshed” in the morning Frequency and length of daytime naps

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Use of sleep medications (and medications in general) Cause of any sleep problems as identified by the client Many potential causes: pain, nausea, vomiting, itching, respiratory problems, medications, psychoemotional factors, environment, lack of exercise, boredom

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Management Establish regular sleep schedule Staying out of bed during the day; no napping unless absolutely necessary Keeping active, mentally or physically Minimizing nighttime disruptions Avoiding stimulants at night (caffeine, nicotine) Relaxing bedtime routine Medications Ambien; halcion, Ativan, serax

Cachexia-Anorexia Syndrome : 

Cachexia-Anorexia Syndrome Cachexia- weight loss, wasting, loss of appetite Etiology Chemical factors—tumor burden Cytokines—tumor necrosis syndrome Metabolic abnormalities

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Decrease nutritional intake Loss of appetite 5 pound weight loss in two months or fewer than 70 calories per kilogram of body weight Psychological factors malabsorption

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Clinical manifestations Muscle loss Impaired immunity Loss of body fat Glucose intolerance Fluid retention Vitamin deficiency Fatigue and weakness

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Management Replacement of dietary supplements Megace– minimal doses Progestational agents Corticosteroids Dietary interventions involving Omega-3 fatty acids

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Combinations Cannabinoids Dietary supplements Prokinetic agents CNS stimulants (methylphenidate) Loss of appetite in the dying patient is a normal process that should not be confused with cachexia-anorexia syndrome

Depression : 

Depression Prevalence of depression in clients with cancer ranges 10—25%; prevalence increases in the presence of functional losses, advancing illness, and unmanaged symptoms. Key indicators of depression in the terminally ill: alterations in mood, feelings of hopelessness, worthlessness, or excessive guilt, and recurrent death wishes including suicidality

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Etiology: terminal prognosis potentiates anxiety and depression. Family history or personal history of depression increases the risk. Depression is thought to be the result of abnormal serotonin levels, although an exact cause is not known

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Assessment Ask about mood Ask about depression, anhedonia Management Combination of supportive psychotherapy, cognitive-behavioral techniques, and pharmacological treatment

Delirium : 

Delirium Found in 77—85% of terminally ill clients with cancer and in 57% of terminally ill clients with AIDS 25—33% of episodes of delirium are reversible. As many as 80% of clients with advanced cancer develop delirium during the last week of life. Terms used to describe delirium: acute brain failure, acute confusional state, acute secondary psychosis, sundown syndrome.

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Delirium defined: Non-specific global, cerebral dysfunction characterized by concurrent disturbances of level of consciousness attention, thinking, perception, memory, psychomotor behavior. Sudden significant decline in a previous level of functioning and is potentially a reversible process Delirium affects sleep, psychomotor activity, and emotions

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Assessment Diagnosis of delirium is based on observations: Change in cognition or consciousness Rapid onset of symptoms Disorientation Language disturbance not accounted for by pre-existing condition, or evolving dementia Develops over a short time and a tendency to fluctuate during the day

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Management Prognosis usually poor Delirium shortens survival of cancer clients makes the assessment of pain and symptoms difficult Delirium is potentially reversible Frequent causes: medications (opioids, sedatives, anticholinergics, and steroids), polypharmacy Hypoxia, Dehydration Metabolic causes Hypercalcemia,hyponatremia Sepsis Increased intracranial pressure

INDICATORS OF IMMINENT DEATH : 

INDICATORS OF IMMINENT DEATH Changes in physical, cognitive, and behavior occur as a person enters the active dying process. Cognition/orientation—not always responsive, agitated or restless, cannot subjectively respond to verbal stimuli Cardiovascular– tachycardia, irregular heart rate, lowered blood pressure, dehydration

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Pulmonary– tachypnea, dyspnea, use of accessory muscles, cheyne-stokes breathing, pooling of secretions Gastrointestinal—diminished appetite, smaller amounts of feces, incontinence Renal—diminished urine output, incontinence, concentrated urine Mobility—limited mobility, bedbound, and requires frequent position changes

SENSORY CHANGES : 

SENSORY CHANGES DECREASED OXYGENATION AND CIRCULATION TO BRAIN ALTERATION IN INTERPRETATION OF SENSORY INPUT BLURRED VISION

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DECREASED SENSE OF TASTE AND SMELL DECREASED PAIN AND TOUCH PERCEPTION BLINK REFLEX IS LOST, PT APPEARS TO STARE

Sense of touch decreases first in the lower extremities because of circulatory alterationshearing is last sense to remain intact at the end of life : 

Sense of touch decreases first in the lower extremities because of circulatory alterationshearing is last sense to remain intact at the end of life

CIRCULATORY/RESPIRATORY CHANGES : 

CIRCULATORY/RESPIRATORY CHANGES DECREASED OXYGENATION HEART RATE SLOWS BLOOD PRESSURE FALLS BODY TEMPERATURE MAY BE ELEVATED RESPIRATIONS VARY BREATH SOUNDS MAY BE WET/NOISY THE DEATH RATTLE-NOISY WET SOUND RESPIRATIONS-DUED TO MOUTH BREATHING AND ACCUMULATION OF MUCUS IN THE AIRWAYS

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CHEYNE-STOKES RESPIRATION IS AN ABNORMAL PATTERN OF BREATHING CHARACTERIZED BY ALTERNATING PERIODS OF APNEA AND DEEP, RAPID BREATHING. SEEN AS PERSON NEARS DEATH

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EXTREMITIES PALE, MOTTLED AND CYANOTIC SKIN COOL, FIRST IN FEET/LEGS LOSS OF MUSCLE TONE MUSCULAR SYSTEM WEAKENS SLUGGISH FUNCTIONAL ABILITIES FACIAL MUSCLES LOSE TONE JAW SAGS AS A RESULT

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GAG REFLEX LOST ABILITY OF URINARY SYSTEM TO FUNCTION AND PRODUCE URINE DECREASES

PHYSICAL MANIFESTATIONS OF END OF LIFE : 

PHYSICAL MANIFESTATIONS OF END OF LIFE DEATH OCCURS WHEN ALL VITAL ORGANS AND SYSTEMS CEASE TO FUNCTION

DEFINITION OF DEATH : 

DEFINITION OF DEATH Irreversible cessation of circulatory and respiratory function or the irreversible cessation of all functions of entire brain including brainstem.

BRAIN DEATH : 

BRAIN DEATH BASED ON BRAIN AND CEREBRAL DEATH BRAIN DEATH OCCURS WHEN THE CEREBRAL CORTEX STOPS FUNCTIONING CEREBRAL CORTEX-RESPONSIBLE FOR VOLUNTARY MOVEMENT AND ACTIONS AND COGNITIVE FUNCTIONING

1995 QUALITY STANDARDS SUBCOMMITTEE OF THE AMERICAN ACADEMYOF NEUROLOGY RECOMMENDED GUIDELINES FOR CLINICAL DIAGNOSIS OF BRAIN DEATH IN ADULTS : 

1995 QUALITY STANDARDS SUBCOMMITTEE OF THE AMERICAN ACADEMYOF NEUROLOGY RECOMMENDED GUIDELINES FOR CLINICAL DIAGNOSIS OF BRAIN DEATH IN ADULTS

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CRITERIA FOR BRAIN DEATH INCLUDE COMA OR UNRESPONSIVENESS ABSENCE OF BRAINSTEM REFLEXES AND APNEA CURRENTLY LEGAL AND MEDICAL STANDARDS STATE ALL BRAIN FUNCTION MUST CEASE FOR BRAIN DEATH TO BE PRONOUNCED AND LIFE SUPPORT TO BE D/C

BEREAVEMENT PROCESS : 

BEREAVEMENT PROCESS

COMMUNICATION ISSUES : 

COMMUNICATION ISSUES Can be time of emotional crisis for many clients and their families. Nurse serves as listener, counselor, advocate Most important task of nurse is to empower clients and families to participate in the final act of living; providing peace and comfort

CARE FOR CAREGIVERS : 

CARE FOR CAREGIVERS Nurses play an important role in assessing educational and support needs, providing information, support, and offering referrals, as needed. Coping tasks for families Promote acceptance versus denial Establish relationship with health care team members

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Meet the needs of the dying person: physical, emotional Maintain functional equilibrium Regulate family affect Negotiate relationships outside the family Cope with the post-death phase (healthy grieving)

SUPPORT OF GRIEVING FAMILY : 

SUPPORT OF GRIEVING FAMILY Grief is a normal and expected reaction to loss Providing bereavement care requires an understanding of the normal grieving process and the tasks of grief work. Nurses need to validate as normal the manifestations that the bereaved may be experiencing.

TASKS OF MOURNING : 

TASKS OF MOURNING Accepting the reality of the loss Experiencing the pain of the loss Adjusting to the environment in which the deceased is missing Finding a way to remember the deceased while moving forward with life.

MANIFESTATIONS OF NORMAL GRIEF : 

MANIFESTATIONS OF NORMAL GRIEF Sleep disturbances Appetite disturbances Absent-minded behavior Social withdrawal Dreams of the deceased Avoidance of reminders of the deceased Crying Carrying objects reminders Disbelief Confusion Sadness, anger, guilt, anxiety, loneliness, relief, Chest, throat tightness, muscle weakness, dry mouth, lack of energy

KUBLER ROSS STAGES OF GRIEF : 

KUBLER ROSS STAGES OF GRIEF DENIAL ANGER BARGAINING DEPRESSION ACCEPTANCE

Family Coping Tasks in Terminal Illness : 

Family Coping Tasks in Terminal Illness Promote acceptance versus denial Realistic information about the illness and treatment options. Encourage open and honest communication among family members. Establish a relationship with the health care team Explain roles of all interdisciplinary team members. Establish trust and maintain open lines of communication

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Maintain functional equilibrium (family must maintain some sense of normalcy to continue to function as a family unit). Assist family to identify and prioritize activities that must be continued; laundry, shopping Assist family to identify support persons to help with these tasks Use of respite services Meet the needs of the dying person Physical needs—pain management, skin care, rest, nutrition, safety Emotional needs—caregivers to sit and talk with their loved one.

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Regulate family affect Allow caregivers the opportunity toexpress their feelings. Give family permission to have their feelings Acknowledge that normally joyful times, such as holidays, may not feel as joyful. Negotiate relationships outside the family Give permission to take time to maintain friendships Discuss options for maintaining jobs while caring for a dying loved one

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Cope with the post-death phase (healthy grieving). Support family while they accept the finality of their loss. Discuss the functioning of the family unit without the loved one. Encourage using available bereavement supports/counseling.

INTERVENTIONS FOR THE GRIEVING PROCESS : 

INTERVENTIONS FOR THE GRIEVING PROCESS Accept the reality of the loss Listen actively Encourage gentle exploration of what the future may look like without the person who has died Encourage time with deceased Normalize feelings through personal contacts and written materials Respect the survivors’ feelings without judgemet

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Experience the pain of the loss Assist in identifying feelings or behaviors and normalize them Assist survivor with placing meaning on the death Adjust to the environment in which the deceased is missing Assist survivor in further identifying the meaning of loss in practical terms Remember the deceased with moving forward with life Listen without judgment Validate and normalize feelings Encourage attendance at grief and loss support or educational groups

BEREAVEMENT : 

BEREAVEMENT IS AN INDIVIDUAL’S RESPONSE TO THE LOSS OF A SIGNIFICANT PERSON CAN BEGIN BEFORE DEATH OCCURS CAN HELP ADAPT TO THE LOSS CAN TAKE MONTHS TO A YEAR PATHOLOGIC GRIEF-CHRONIC GRIEF WHEN INTENSITY DOES NOT WANE AFTER THE FIRST YEAR

BEREAVEMENT : 

BEREAVEMENT CONFLICTED GRIEF- WHEN THE BEREAVED PERSON HAS NOT RESOLVED AMBIVALENT FEELINGS TOWARD THE DECEASED ABSENT GRIEF-BEREAVED PERSON APPEARS TO BE COPING AND CARRYING ON AS IF NOTHING HAS HAPPENED

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GRIEF- THAT IS PROLONGED OR UNRESOLVED MAY BE CALLED MALADAPTIVE OR DYSFUNCTIONAL GRIEF, CAN BE FROM PRIOR EXPERIENCE OR WHEN THE EXPRESSION OF GRIEF IS BLOCKED IN SOME WAY GRIEF-ADAPTIVE IS HELPFUL ASSISTS THE PERSON IN ACCEPTING THE REALITY OF DEATH

VARIABLES TO END-OF-LIFE : 

VARIABLES TO END-OF-LIFE MUST BE AWARE OF CULTURAL DIFFERENCES RELIGIOUS AND FAMILIAL INFLUENCES DEATH AND DYING TEND TO BE CONSIDERED PRIVATE MATTERS SHARED ONLY WITH SIGNIFICANT OTHERS PERSONAL/INDIVIDUALCHOICE NEEDS TO BE RESPECTED

LEGAL/ETHICAL : 

LEGAL/ETHICAL THEIR WISHES –DONATE ORGANS CAN BE MADE BY IMMEDIATE FAMILY FOLLOWING DEATH DONOR CARDS

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OF 1990 (KNOWN AS PATIENT SELF DETERMINATION ACT REQUIRES ALL INSTITUTIONS THAT PARTICIPATE IN MEDICARE TO PROVIDE WRITTEN INFORMATION TO PTS CONCERNIN G THEIR RIGHT TO ACCEPT OR REFUSE TREATMENT

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The first advance directive known as living will Developed by the euthanasia education council-now known as partnership for caring

Natural Death Act : 

Natural Death Act Most states have replaced the living will with Natural Death Acts Within many of these acts are specific aspects related to the individual wishes Can tell the MD exactly what tx is or is no desired

Verbal Directive : 

Verbal Directive Can be given to MD with specific instructions in the presence of two witnesses

CPR : 

CPR Common practice in the past 30 years Patients had no choice whether or not CPR was used The ANA supports the patients right to self determination A Physician order must be written to include the information concerning the patients wishes.

CONCLUSION : 

CONCLUSION Nurses who are able to offer compassion, assess the multitude of symptoms, and participate in their management from an interdisciplinary team are vital for clients, families, and health care organizations. The nurse is the bearer of light along the path of unknown as the client and family attempt to make sense of life’s greatest mystery—death The nurse can promote a healthy and positive dying experience for all involved.

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