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End of Life Care

End of Life Care. Lisa B. Flatt, RN, MSN, CHPN. Objectives. Understand palliative care Compare and contrast settings where palliative care and end of life care occur Identify stages of grief, uncomplicated grief and mourning

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End of Life Care

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  1. End of Life Care Lisa B. Flatt, RN, MSN, CHPN

  2. Objectives • Understand palliative care • Compare and contrast settings where palliative care and end of life care occur • Identify stages of grief, uncomplicated grief and mourning • Describe legal, historical, social and cultural aspects of palliative and end of life care

  3. Definitions to know • Assisted suicide • Autonomy • Grief, Mourning & bereavement • Euthanasia • Terminal illness • Hospice • Medicare hospice benefit

  4. Basic Concepts • Loss –something/person and be actual or potential no longer with you, valued • Sources of Loss – body image, death, loss of independence, brain ability, financial, memory

  5. Grief Response • Bereavement (subjective) and Mourning (process follows bereavement, resolution of grief) • Normal grieving – essential for mental health following a loss, steps are involved, helps you move on • S/S of grieving – depression, sadness, isolation, wt loss, sleep disturbances, ETOH, SA, fatigue, N&V, HA, faint, palpitations • Variations of grief – anticipated or abbreviated • Dysfunctional grief – pathological, unresolved, extended s/s of grief, stuck in a phase

  6. Kubler-Ross’s (1969) Stages of Grief • Denial – shock, didn’t happen, numb, disbelief • Anger – guilt, resentment, sadness • Bargaining – pining, searching, yearning • Depression – grieving • Acceptance - resolution

  7. Engel’s (1964)Stages of Grief • Shock & disbelief • Developing awareness – directed anger, loss becomes real • Restitution – dealing with it all, looking more • Resolving the loss – memories, talk it out • Idealization – ‘the best at…..’ • Outcome – acceptance, moving on

  8. Sander’s (1998) Five Phases of Bereavement • Shock – confused, unreal, disbelief • Awareness of loss – conflict, stress, seperation anxiety • Conservation/Withdrawal – despair, hopeless, isolation • Healing – identity, control • Renewal – acceptance, revitalization

  9. Influencing factors and grieving • Age – younger/children, acceptance as we age, familiar, free from pain and poor quality of life • Significance of loss – how close, spouse, parents, pets, kids, relatives • Culture – major, beliefs • Spiritual belief – influences outcome of death and acceptance • Gender – woman disfigured with scar (idealization of beauty), stoic • Socioeconomic – affordability of care and funerals • Support system - acceptance, after-care • Cause of death/loss – traumatic injury, extended illness, unexpected death, suicide, drug OD

  10. Death & Dying • More accepted with age • Develops over time • Children – temporary state • Adults – frightening • Quality of life and lack of it can determine a persons perspective on death

  11. Concept of Death and Development

  12. Definitions of Death • With life support & medical interventions, in 1968 World Medical Assembly redefined • Clinical – absence of apical pulse, respirations and BP • Lack of OR NO response to: • Eternal stimuli • Reflexes • Brain waves aeb flat encephalogram • Respirations or muscular movement

  13. Dying Trajectories (Glaser & Strauss 1965) • Death and dying are unique • Series of graphs • Has limitations to ‘predictions’ • Progression may be difficult to predict • If someone knows outcome, this may affect trajectory (sense of control over dying process and illness)

  14. Types of Trajectories • Expected trajectory – short duration, steadily progressing downward (terminal cancer) • Unexpected trajectory- episodes of acute deterioration, recovery, decline then unexpected death • Lingering/Prolonged – elderly escaping cancer and MOF then die later with dementia, Alzheimers, etc..

  15. Physiologic Needs (pg 104) • Maintain airway • Pain free • Positioning/comfort • Pastoral/spiritual care • Mouth care • ADL’s, brushing hair

  16. Impending Death • Muscle tone – decreased, relaxed face, swallowing, speaking • Circulation – slows down, mottling, cold • Respirations – rapid, shallow, noisy, dry, mouth breathing, slows and irregular • Sensory impairment • Vision- blurred • Decreased smell/taste (or hypersensivity)

  17. Care Post-Mortem • When appropriate, after they are gone and family aware and in agreement • Clean, covered • Remove tubes and lines • Dignity • Teeth, eyes closed • Rigor mortis

  18. Hospice • Cecily Saunders, MD founded concept • Support and care of person & family • Goal: peaceful and dignified death • Holistic and interdisciplinary • Qualified if MD certifies within the last 6 months of life

  19. Where can hospice care occur? • Home • Facility • Hospital • ECF

  20. Define Palliative Care • Relief from symptoms of disease • Relief from pain • Support to patient and family, coping mechanisms • Interdisciplinary team • Death not imminent • Allow pt and family to live as ‘normally’ as possible

  21. The Nursing Process • Assessment/Analysis • Planning • Rationale • Factors influencing grief & dying • Implementation • Evaluation

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