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Caring for the Dying Patient

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End of Life Ethics Assisted Suicide Withdrawal food/fluids Passive vs. Active Euthanasia Legalized active euthanasia in US Oregon Death ... notably pro-life and ... – PowerPoint PPT presentation

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Title: Caring for the Dying Patient


1
Caring for the Dying Patient
  • Keith Rischer RN, MA, CEN

2
Todays Objectives
  • Discuss the current ethical issues surrounding
    end of life care.
  • Identify goals of end of life care.
  • Compare contrast the emotional spiritual
    needs of the family and client who is dying.
  • Contrast early vs. late physical changes in the
    client who is dying.
  • Describe nursing goals and priorities for
    managing the client who is dying.
  • Contrast the needs of the family with the nurse
    in the client who has died.

3
End of Life Ethics
  • Assisted Suicide
  • Withdrawal food/fluids
  • Passive vs. Active Euthanasia
  • Legalized active euthanasia in US
  • Oregon Death w/Dignity Act

4
Advance Directives
  • Living will
  • Legal document instructs measure of care desired
    if incapable
  • Shortcomings
  • Life death choices over unknown set of
    circumstances
  • Some ethicists believe document is worthless
  • Durable power of attorney

5
The Cure/Care Model
D E A T H
Life Prolonging Care
Palliative/ Hospice Care
Disease Progression
6
Concerns of Dying Patient
  • Fear of physical pain and suffering
  • Symptom burden
  • Fear of unknown
  • Fear of loneliness
  • Anonymity
  • Loss of choice over destiny
  • Loss of dignity
  • Loss of consortium
  • Separation and lack of connection
  • Spiritual
  • Financial

7
Palliative Cares Place in Course of Illness
Life Prolonging Therapy
Death
Diagnosis of serious illness
Medicare Hospice Benefit
Palliative Care
8
Early Physical Changes
  • ? Appetite ?Weight loss
  • Assistance with ADLs
  • Pain (gt or lt )
  • Increased HR Potential O2 deficiency
  • Drowsiness
  • Fatigue

9
Early Emotional Changes
  • Months to Weeks
  • Hope
  • Desirable
  • Expectational
  • Withdrawal
  • Changes in mood
  • Anger, irritable, hope, denial, ect
  • World view changes gets smaller
  • Attending to business

10
Spiritual Distress
  • Signs of Spiritual Distress
  • Doubt
  • Despair
  • Guilt
  • Anger
  • Boredom
  • Isolation
  • Statements of regret
  • Statements of unresolved hurt
  • Nursing Interventions
  • Ask about their source of strength
  • Discuss sources of spiritual strength throughout
    their lives
  • Assess support system
  • Assess coping
  • Refer to clergy/chaplain
  • Ministry ex. Stephens Ministry at churches

11
Family Needs
  • Focus on dying patient without losing the present
    and future
  • The work of daily life goes on
  • Anticipatory grief
  • Increase in responsibilities (house, finances,
    work, children, and acting as a caregiver).
  • Need for support from family, community,
    spiritual faith.

12
Goals of Nursing Care for the Dying
  • Hospice
  • Improve quality of life w/terminal illness
  • Control symptoms
  • Pain
  • NV
  • Fatigue
  • SOB
  • Identify-prioritize needs
  • Promote meaningful interactions w/family and
    others
  • Facilitate peaceful death

13
Nursing CareHolistic
  • Chaplain/ Clergy visit
  • Hospice/ respite care
  • Hospice/Home Care
  • Provide CNA daily for ADL hygiene and care
  • More frequent RN visits
  • More frequent Social Worker visits
  • Talk candidly about end of life how it will
    likely be for that specific patient

14
Nursing CarePhysical Priorities
  • Pain management
  • NV management
  • Fatigue management
  • Skin care
  • Mouth care
  • Urinary care
  • Respiratory care
  • Comfort

15
Nursing Care Physical Priorities
  • Attend to any needs of patient
  • Pain
  • Long acting analgesics with medication for
    breakthrough pain
  • May need to increase doses of medication
  • Counsel pt./family on pain cycle and breakthrough
    pain
  • Nausea
  • AntiemeticsZofran
  • Foods that taste good with increased protein and
    fat
  • Ensure or supplements
  • Comfort
  • Comfortable bed
  • Chair
  • pillows

16
Why Pain?
  • Practitioners are not trained in state-of-the art
    pain management
  • Myths about addiction, dependence, and tolerance
    abound
  • The toll that unrelieved pain takes on the body
    and mind is not understood or acknowledged
  • Fear that pain intervention might cause the
    patient to die
  • Flawed assessments
  • Disconnect
  • Failure to look at non-physical sources

17
Nursing Care Physical Priorities
  • Mobility
  • Cane, walker,
  • Prevent falls
  • Falls often indicate change in status
  • Sleep
  • Sleeping more? Less? Look at medications and
    physical status. Normal to increase in sleeping.
  • Fatigue
  • Do what only matters, find what is important to
    patient
  • Hospice volunteer for family for relief

18
Nursing Care Physical Priorities
  • Neuro
  • Changes due to disease (brain mets, lack of
    oxygen?)
  • CV
  • May need fan for cool or light weight blankets
    for warmth
  • Lungs
  • Teach use of several pillows, O2 may be needed
  • Skin
  • Teach positioning, turning, and prevention of
    breakdown
  • GI
  • Use of stool softeners is a must may need
    laxatives later on
  • Urinary
  • May have incontinence (pads, diapers, last resort
    is foley)
  • Medications
  • Order what is needed for comfort

19
Changes with Weeks RemainingPhysical Changes
  • Profound weakness
  • Bedbound
  • Falling if ambulating
  • Muscle weakness
  • Potential skin breakdown
  • Increased care needed
  • VS
  • ? HR ? Pulse

20
Dyspnea Managment
  • Morphine sulfate
  • Diuretics
  • Bronchodilators
  • Antibiotics
  • Anticholinergics
  • Atropine
  • Sedatives
  • Oxygen

21
Changes with Weeks RemainingEmotional Changes
  • ? Fear, apprehension or peacefulness
  • ? withdrawal into self
  • Often sees spiritual beings
  • God previous family members who have died
    speaking out to them
  • Only allows family and loved ones in their world
  • Starts to say goodbye to loved ones
  • A sense of peace and finished business may be
    felt OR a sense that there is not enough time
    left to finish life

22
Changes with Weeks Remaining Family Needs
  • How to care for their love one
  • Focus is home care management
  • May not be able to get to PCPs office
  • May involve equipment and teaching nursing care
    for ADLs
  • O2, transfer techniques, shower chair, turning
    techniques, decubitus care, mouth care, foley
    care, ect
  • Pain relief
  • Symptom management
  • Medication management increases
  • Subq meds, rectal suppositories
  • Psychological support increases
  • Focus on quality of life vs. quantity

23
Imminent DeathNursing Care
  • Medication management
  • If unable to swallow (subq, rectal suppositories)
  • For death rattle Scopolamine patch works
  • Pain management
  • Comfort measures increase
  • Turning, mouth care, positioning of limbs,
    warm/cool measures, eye drops, ect
  • Assistance respiratory with positioning

24
Imminent DeathPhysical Changes
  • Actively Dying 48-72 hours remain
  • Confusion and disorientation
  • Metabolic changes
  • Withdraws from family going somewhere
  • Decreased consciousness
  • May refuse all fluid and food
  • Body conservation of energy for function
  • Total care ? alertness ? drowsiness
  • Metabolic changes and decreased oxygen to brain
  • ? Restlessness
  • ? BP ?HR (120-150)
  • Peripheral circulation diminishing to vital
    organs
  • Mottling of extremities

25
Imminent DeathPhysical Changes
  • Incontinence of urine and bowel
  • Increased muscle relaxation and decreased
    consciousness
  • May be incontinent around the foley catheter
  • Dependent areas become cyanotic cold
  • Skin color is pale and mottling of skin occurs
    (knees, legs, nose)
  • Slower pupil response to light, eyes fixed
    stare-even in sleep
  • Muscle becomes slack, decreased oxygen
  • Speech may be difficult and soft
  • Muscle becomes slack
  • Hearing is thought to remain present
  • Vision may be lost

26
Imminent DeathPhysical Changes
  • Cheyne-Stoke respirations
  • Metabolic and oxygen changes
  • Decreased RR
  • Death rattle
  • Profuse perspiration
  • Decreased circulation to all organs as they are
    shutting down
  • ? urinary output
  • Decreased vital organ/ kidneys shutting down
  • Body temp varies
  • May decrease or rise

27
Imminent DeathEmotional Needs
  • Sense of peacefulness in the room
  • Family and loved ones present
  • Caring feeling by loved ones
  • Its going to be OK
  • Its OK to go now
  • Your work is done
  • I love you/ I forgive you

28
Imminent Death Family Needs
  • Presence of Nurse
  • Care for patient
  • Support for patient and family
  • Educate family throughout the process to avoid
    the feeling of not knowing what next
  • Be the detail person
  • Be prepared for how family will handle death
  • Know emergency numbers for family/hospice
  • Make final arrangements
  • Mortuary pick up equipment, clean up room.

29
Imminent Death Family Needs
  • Encourage them to stay with patient
  • Touch and talk with patient
  • Be vigilant about what the patient hears, even
    though he/she cannot respond
  • Encourage active comfort measures
  • Light massage, mouth care,
  • Allow them time to privately grieve with family
  • Acknowledge the process of dying
  • Skin cooling, cyanosis, Cheyne-Stokes, urinary
    incontinence (all this is normal)

30
Pronouncement of Death
  • Cessation of blood pressure, pulse and
    respirations.
  • In hospice is pronounced by RN (or Social Worker
    in some states)
  • Blood pressure may be not be able to be palpated
    for hours before death
  • Final respirations may be gasping
  • Eyes are fixed (pupils fixed and dilated)
  • No apical pulse

31
Needs of the Family After Patients Death
  • Presence of a support system
  • Family, chaplain, nurse, social worker
  • Make sure someone is with them
  • Dont leave them alone to go home
  • No One Dies Alone at ANW
  • Vounteers who stay during last hours
  • Call family members if needed (when unexpected)
  • Allow time for the family to spend with the
    patient who died

32
Needs of the Nurse After the Patients Death
  • Support system
  • Other staff, friends, family (who can listen to
    you)
  • Physical and emotional rest
  • Attend memorial or burial service for closure
  • Final separation from family
  • Remind yourself that you made a difference

33
Near Death Experiences
  • Altered state of consciousness during brief
    cessation of VS (cardiac arrest)
  • Tunnel of light
  • Sense of being separated from body
  • Fear anxiety-torment
  • Afterwards for patient
  • More spiritual minded-less material focused
  • Less fearful of death
  • Nurses role
  • What do you remember about being unconscious?
  • Did you have a sense of being separate from your
    body while we were reviving you?
  • Avoid negative statements during code
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