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Chapter 9

Chapter 9. End-of-Life Care. Overview: Death and Dying. Concept of “good” death and “bad” death Death — cessation of integrated tissue and organ function, manifested by cessation of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction

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Chapter 9

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  1. Chapter 9 End-of-Life Care

  2. Overview: Death and Dying • Concept of “good” death and “bad” death • Death—cessation of integrated tissue and organ function, manifested by cessation of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction • Incidence of death—over 2 million deaths in the United States in 2004 • Most common cause of death—diseases of the heart, followed by cancer

  3. Advance Directives • Written document prepared by a competent individual specifying what, if any, extraordinary actions the person would want when no longer capable of decisions about personal health care • DPOA—legal document assigning decision-making power to another person to make his or her health care decisions in the event he or she becomes incapable of making decisions • Living will—legal document that instructs physicians and family members about what life-sustaining treatment a person does or does not want at some future time if he or she becomes unable to make decisions

  4. Desired Outcomes for End-of-Life Care • Identification of patient needs • Control of symptoms of distress • Promotion of meaningful interactions between the patient and family • Facilitation of a peaceful death

  5. Hospice and Palliative Care • Hospice care—interdisciplinary approach to assess and address the holistic needs of patients and families to facilitate quality of life and a peaceful death • Palliative care—a philosophy of care and an organized, structured system for delivering care for individuals with a life-threatening illness • Goal of palliative care—to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies

  6. Symptoms at End of Life • As death nears, patients often have signs and symptoms of decline in physical function, manifested as: • Weakness • Anorexia • Changes in cardiovascular function • Changes in breathing patterns • Changes in gastrointestinal function • Changes in genitourinary function

  7. Patient-Centered Collaborative Care • Assessment • Physical assessment/clinical manifestations • Coolness of extremities • Increased sleeping • Fluid and food decrease • Incontinence • Congestion and gurgling

  8. Physical Assessment/Clinical Manifestations • Breathing pattern change • Disorientation • Restlessness

  9. Psychosocial Assessment • Fear • Anxiety • Cultural considerations and bereavement • Feelings of patient and significant others

  10. Interventions: Weakness Management • Aspiration precautions • Mouth care and moisture for lips • Altered routes of medication administration if needed—choose the least invasive route of medication administration with the most effective treatment

  11. Pain Management • Pain is the symptom that dying patients fear most. • Pain medications should be scheduled to prevent any recurrence of pain. • Consider alternative route of pain medication administration as needed.

  12. Complementary and Alternative Therapies • Massage • Music therapy • Therapeutic touch • Aromatherapy

  13. Opioids Anticholinergics Bronchodilators Sedatives Corticosteroids Oxygen therapy Diuretic Antibiotics Dyspnea Management/Pharmacologic • Treat the primary cause, and relieve the psychological distress that accompanies the symptom. • Pharmacologic interventions:

  14. Dyspnea Management/Nonpharmacologic • Cool air • Wet cloths to patient’s face • Positioning of the patient to facilitate chest expansion • Frequent rest periods • Encouraging imagery and deep breathing

  15. Nausea and Vomiting Management • Antiemetic agents • Remove any source of odors • Comfortable room temperature • Dietary changes • Assess for and treat constipation

  16. Restlessness and Agitation Management • Assess for pain, urinary retention, constipation, or another reversible cause • Treat the underlying cause • Pharmacologic agents • Complementary and alternative therapies • Music therapy • Aromatherapy

  17. Seizure Management • Pharmacologic therapy

  18. Management of the Refractory Symptoms of Distress • Drug therapy • The ethical responsibility of the nurse in caring for patients near death is to follow guidelines for drug use to manage symptoms and to facilitate prompt and effective symptom management (Guideline Panel for Management of Cancer Pain, 1994)

  19. Psychosocial Management

  20. Interventions for Providing Psychosocial Support • Presence • Life review • Reminiscence • Spirituality • Religion

  21. Postmortem Care • Legal considerations, such as death certificate • Determination of the need for an autopsy • Transfer of the body

  22. Euthanasia • Withdrawing or withholding life-sustaining therapy (WWLST) • Passive euthanasia • Active euthanasia

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