2 EndofLife Care The American Way of Dying Not seen as a natural progression Uncomfortable with death fragmented disorganized amp inadequate guidance forced to attempt to follow changing ID: 920738
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Slide1
VN057 gerontology 8
15,
Slide2Chapter 15
2
End-of-Life Care
Slide3Slide4Slide5The American Way of Dying
Not seen as a natural progression
Uncomfortable with death
fragmented, disorganized & inadequate guidanceforced to attempt to follow changing rules & regulations set up by multi bureaucraciesGvtinsurance
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Slide6Attitudes Toward Death and
End-of-Life Planning
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Slide7Attitudes
end-of-life
care and death
planningIdeally, discussions before a health crisis variety of options-end of life decisions difficulttoo many choicesvalues, cultural & spiritual beliefs, & life experiences all affect choices Most say that they do not fear death as much as they fear how they will die
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Slide8Slide9Advance Directives
Specific end-of-life
decisions
Written- official documentsFewer issues-both providers & familyadvance directive living willdurable power of attorney for health careSpecify the type and amount of intervention desired by an individual
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Slide10Advance Directives (cont.)
Copies
to
PCP, hospital of choice, extended-care facility, power of attorney for health care, anyone else as appropriateA competent person retains the right to change his or her mind about treatment at any timeIntubation or feedingFull code to DNRDNR to full or chem codeComfort care to any of the above
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Slide11Advance Directives (cont.)
Not official or required-
Medic-alert bracelet or necklace with code status
Copy on refrigerator if person lives @ home
Slide12Caregiver Attitudes Toward
End-of-Life Care
providers see
death as a professional failure rather than the inevitable end to the human experienceCaregivers need to be able to communicate effectively –deal with grief, loss & bereavement at the end of lifepatient,family significant others
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Slide13Death among older adults is typically caused by a(n):
acute illness.
accident.
chronic and debilitating conditions.sudden, unexpected condition.
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Slide14Values Clarification Related to Death and End-of-Life Care
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Slide15Slide16Ethical Dilemmas
value systems
of
patient & caregiver are often very differentCaregivers benefit from spending time identifying their personal end of life values Understanding the value systems of others help the nurse provide quality end-of-life care, even when his or her values are not the same
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Slide17Values Clarification
Death, dying, and the end of life have different meanings for every person
Each individual must examine his or her own values
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Slide18Slide19What Is a “Good Death”?
research
to identify
specific end-of-life outcomes most valued & desired by those nearing the end of life & by their familiesCommon theme: given their choice, most people wish to be treated with respect and dignity and to die quietly and peacefully, with loved ones nearby
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Slide20Patients’ Wishes Related to
End of Life
Most dying patients have similar desires
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Slide21Where People Die
90%
indicated
a wish to die at homeless than 25% actually occur there50% occur in hospitals25%in extended-care facilitiesHospice careThe focus is palliativeproviding comfortmeeting the needs of patients & their families
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Slide22Hospice care is usually available for the last __________ of life.
month.
6 months.
1 year.2 years.
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Slide23Medicare
covers hospice
when death is expected to occur within 6 months
Not always exact timing-some lee wayNot always cancerCHFDementiaCOPDetc
Slide24Hospice Care
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Slide25Palliative Care
Focus-reduce
or
relieve symptoms without cureneither hastens nor postpones deathInterventions designed to make the best of the time left & live as active and complete a life as possible until death comes“Comfort Care”
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Slide26Palliative Care (cont.)
Individuals
choosing
palliative care usually choose to decline procedures Invasive diagnostic tests cardiopulmonary resuscitation (CPR)artificial ventilationartificial feeding, prolong the dying process
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Slide27Slide28Collaborative Assessments and Interventions for End-of-Life Care
Commitment & collaboration
of all caregivers
Disciplines must work together cooperatively & creatively positive attitude to solve any problems requires mutual respect & communication between all team members
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Slide29Communication at the End of Life
responsibility
for providing
& maintaining effective communicationnurses and assistive caregivers, who spend the most time with dying patientsNurses need to work to develop a climate that encourages open communication
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Slide30Communication at the End of Life (cont.)
demonstrate verbally and nonverbally you are
approachable
not detached or indifferentdemonstrate willingness to listen suggestions, requests, or criticisms made by the dying person or, more likely, by family
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Slide31Psychosocial Perspectives, Assessments, and Interventions
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Slide32Slide33Cultural Perspectives
cultural
beliefs influence
people think, live & interact with other people-they also affect how a person approaches deathnurse’s responsibility to assess each person to find out their preferences & viewpoints Develops trust & can plan culturally sensitive care
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Slide34Communication About Death
The Western
perspective emphasizes patient’s
“right to know” diagnosis and prognosispatient can make informed decisionsAsians & Native Americans often believe speaking about death or other bad things decreases hope and produces bad outcomes
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Slide35Decision-Making Process
Amount and type of intervention that will be
accepted
Individual/culturalfocus on helping people cope with deathfocus on living and prolonging life
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Slide36Decision-Making Process (cont.)
Significance of pain and suffering
Western
perspective focuses on freedom from pain and sufferingNon-Western cultures often see pain as a test of faith or a preparation for the afterlifesomething that is to be endured rather than avoided
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Slide37Spiritual Considerations
Determine
if there are specific
religious beliefs or practices important to the patient or their family membersAssess whether they have a preferred spiritual counselorOffer choices when availableDetermine whether the person wishes any spiritual counselor to be notified
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Slide38Spiritual Considerations (cont.)
respect
for the patient’s religious and spiritual views
Avoid imposing your own beliefs Be present, be available, and listenAvoid moving beyond your role and level of expertise unless you have specific ministerial or pastoral training in death and dying
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Slide39Depression, Anxiety, and Fear
It is one thing to know that you will die eventually;
it’s another
to realize that you have lived most of your life and that death is likely to be a reality soonIndividuals must decide whether they will give up and let fear, anxiety, or depression overwhelm them or whether they will do something to remain in control of whatever time they have remaining
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Slide40One of the most important things caregivers can do for a dying person is to:
not talk about when they will die.
allow them to be alone as much as possible.
talk to them about a “do not resuscitate” status.
spend more time with them.
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Slide41Slide42Physiologic Changes, Assessments,
and Interventions
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Slide43Pain
Biggest concern
of the dying person and
their significant othersCan interfere with the ability to maintain control, cope, and complete end-of-life tasksIncreases the likelihood of fatigue, depression, and loss of appetite
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Slide44Pain (cont.)
Interferes with the ability of the dying person to make thoughtful decisions
&
communicate effectively with loved ones at a critical timeRelief of pain begins with careful assessmentPerform assessment early & oftenpatient’s status can change dramatically in a relatively short period
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Slide45Pain (cont.)
Pain is what the patient says it
is,
but many older patients who have lived with multiple discomforts often underreport painDon’t want to be a botherAfraid of addiction to medication Medical personnelFamilypatientSelf-reported logs or journals are helpful patient and significant others more focused and attuned to subtle changes in the individual
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Slide46Fatigue and Sleepiness
May be caused by underlying disease processes, stress, anxiety, or medications
can interfere with
ability to carry out end-of-life tasks, including communicating with loved onesBecause of metabolic changes [& depression] patient may begin to sleep more and may be difficult to awaken as the end of life nears
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Slide47Cardiovascular Changes
Diminished peripheral
circulation
likely to worsen as death nearsresulting in dry, pale, or cyanotic extremitiesPeripheral pulses are often weakBlood pressure often decreased by 20 or more points from normal range and may be difficult to hearBody temperature may elevate significantly as death nears
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Slide48Respiratory Changes
Shortness of breath, difficulty breathing (dyspnea), and
Cheyne
-Stokes respirations during sleep are commonly observed in older adults as death nearsMild respiratory difficulty usually can be relieved by changing positioning, elevating the upper body, opening windows or using a fan to increase ventilation, or administering oxygen by nasal cannulaNarcotics often given for air hunger
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Slide49Gastrointestinal Changes
Loss of appetite (anorexia) and muscle wasting (cachexia) are commonly observed with advanced terminal conditions, particularly some forms of cancer
Dry mouth (xerostomia) and ulcerations of the mouth
Nausea and vomiting are not signs of impending death; rather, they are distressing symptoms of underlying problems
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Slide50Gastrointestinal Changes (cont.)
Constipation is a common and distressing problem for the terminal patient
Diarrhea is a less common problem at the end of life, but one that can have a profound effect on the quality of life
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Slide51Urinary Changes
Oliguria common-decreases in fluid intake, blood pressure, and kidney perfusion
Urinary incontinence common
Absorbent pads or indwelling catheterused to reduce need for bed changes that may disturb the dying person
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Slide52Integumentary Changes
Skin breakdown is a problem
malnourished
Lack of mobilityincontinence Interventions to prevent skin tears or pressure sores proper skin cleansing careful handling of skin frequent turning and positioning measures to reduce pressuresoft, nonconstricting, nonirritating clothing helps promote comfort and minimizes risk for skin dryness and rash
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Slide53Sensory Changes with end of life
Vision- diminishes and the visual field narrows
Hearing-acute until death
even if the person does not respondCalm, supportive, loving messages should be delivered, even when unresponsiveNegative or disturbing conversations should be avoided
,
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Slide54Changes in Cognition
Delirium-present in over 80% @ end of life
Causes
Hypotensionoxygen deprivation Apneahypoventilation, Feverneurologic changesmetabolic abnormalitiesHyperglycemia -uremia -dehydration other physiologic or emotional disturbances
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Slide55Death
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Slide56Slide57Family Members and
Significant Others
Often wish to be present at the time of death
Some can spend only limited time wish to be called only when there is a significant change in the person’s statusOthers would rather be notified only after death has occurred
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Slide58Indicators of Imminent Death
Increased sleepiness
Decreased responsiveness
Confusion in a person who has been orientedHallucinations about people (sometimes deceased family members)Increased withdrawal from visitors or other social interaction
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Slide59Indicators of Imminent Death (cont.)
Loss of interest in food and fluids
Loss of control of bowel and bladder
Altered breathing patternsshallow breathingCheyne-Stokes respirationsrattling or gurglingInvoluntary muscle movements and diminished reflexes
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Slide60After Death
family members should be allowed to sit at the bedside and say farewells or grieve as long as they need
It is appropriate for the nurse to discreetly remove oxygen, IV lines, or other medical devices
Cultural practices regarding grieving and preparation of the body should be respected and accommodated whenever possible
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Slide61Postmortem Care
Removal of soiling and application of a clean sheet or shroud according to agency policies
In most cases, the head is elevated slightly to prevent discoloration
Eyes are gently closed, dentures are inserted, and a small towel is rolled and tucked under the jaw to close the mouthPersonal belongings should be identified, listed, and bagged for return to the family
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Slide62Funeral Arrangements
Most older people have given some thought to their final resting place, and many have made specific plans, issued specific directions regarding their wishes and, in some cases, even paid for their funeral
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Slide63Bereavement
Survivors often express having ambivalent feelings regarding the death
On one hand, they feel a sense of relief that the struggle is over and that the loved one is at rest
On the other hand, they seriously grieve and miss the loved one’s presenceEven when death is anticipated, the initial feeling of shock and numbness typically occurs
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Slide64Bereavement (cont.)
reality of the loss strikes
survivors often experience s/s of depression
loss of appetiteinability to sleepavoidance of social interactionuncontrolled bouts of cryingIn normal grieving, the frequency and severity of these signs of grieving gradually decrease over time, but the loss of a loved one never goes away completely
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Slide65Kübler
-Ross model-Five
Stages of
GriefDenial — "This can't be happening to me.“Anger — "Why me? It's not fair!""Who’s to blame?“Bargaining — "I'll do anything for a few more years."hope that the individual can delay death.Depression —"I'm going to die soon so what's the point?”Acceptance — "It's going to be okay."
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