8.1 End of Life Care Flashcards
1
Q
Care of Dying
A
- Technologies applied in advanced illness make the process of dying anything but peaceful
- Technological Imperative practice - Every available means to extend life must be tried
- Hippocratic oath - Do not harm. Prohibits physicians from administering deadly drugs
- Living Will - Medical decisions left to family members
2
Q
Brain Death
A
- Irreversible unconsciousness with complete loss of brain function (heart may still beat)
- Accepted criteria for establishing time of death
- Fixed and dilated pupils (irreversible cessation of brain)
- Lack of eye movement
- Absence of respiratory reflexes (apnea)
- Unresponsiveness to pain stimuli
- Evidence that patient had a disease that could cause brain death
FINAL DETERMINATION OF BRAIN DEATH Lack of electrical activity in the brain taken by 2 EEG’s 12 and 24 hours apart - Must rule out hypothermia or drug toxicities (mimics brain death)
- Spinal reflexes and CNS function can still persist
3
Q
Nurse Role in End of Life Care
A
- Knowledge of palliative care and end of life principles are essential to nursing
4
Q
National Consensus Project for Quality Palliative Care
2013
A
- 8 domains of human approach to care of dying
- Structure, physical aspects, psychological aspects, social aspects, spiritual aspects, ethical cultural aspects, end of life care.
5
Q
Focus on dying
A
- Motivated by an aging population
- Publicity and prevalence surrounding life-threatening illness
- Increased likelihood of prolonged period of chronic illness prior to death
6
Q
Care of dying should include..
A
- Timely access to end of life care
- Comprehensive coverage for palliative services
- Improved communication between provider
- Emphasis on advanced care end-of-life planning
- Professional education and development
- Stronger public education and engagement
7
Q
Technology
A
- End of life has shifted from communicable diseases to chronic degenerative diseases
- People are surviving disease because of technology
- Death has been shifted from home setting to hospital
- Great number of deaths occur in ICU
- Causes death to be anything but peaceful
8
Q
Glasser and Strauss
4 Contexts related to dying
A
4 contexts related to dying
Closed awareness - Patient is unaware of dying but everyone else knows
Suspected awareness - Patient suspects what others know and attempts to find out
Mutual Pretense - Everyone knows but pretends otherwise
Open awareness - Everyone knows and openly acknowledges
9
Q
Assisted Suicide
A
- Providing another person a means to end their life
10
Q
Oregon Death with Dignity Act (1994)
A
- Washington state followed in 2008
- Legalized assisted suicide
11
Q
DNR (Do not Resuscitate)
A
- Physician Order
- Has different levels from doing nothing to doing partial care
12
Q
Advanced Directives
A
- Written documents of the patients preferences
13
Q
Living Will
A
- Patients treatment preferences
14
Q
Proxy
A
- Authorize someone to represent them if they cannot represent themselves
- Authorizes only for medical services
15
Q
Durable Power of Attourney
A
- Authorizes individual to make decisions on behalf of the patient when they are not able to
- Includes everything
16
Q
Palliative Care
A
- Comprehensive symptom management
- Psychosocial care, spiritual support needed to enhance quality of life
- Treating suffering
- Started off as hospice care, end of life care but evolved to be all under palliative care
- It can occur in any setting
- Death must be accepted for hospice care
- Pain and symptoms of terminal illness must be managed
- Family must also be cared for as a single unit
- Home care of dying is necessary
17
Q
Bereavement Care
A
- Provided care to family after death
18
Q
Hospice
A
- Concept of care. Doesn’t matter where the patient is, its the concept of care
- Not fully integrated into mainstream health because of difficulty of making terminal prognosis, especially in non-cancer patients
- Strong association of hospice with death because there can be treatments even in late stages of illness
- Least likely is also financial pressure for providers to continue care.
19
Q
Hospice Care
A
- All covered under Medicare/Medicaid 4 levels of hospice care - Routine Home Care - Inpatient Respite Care - Continuous Care - General Inpatient Care
20
Q
Routine Home Care
A
- All services provided and included in the daily rate of hospice care
21
Q
Inpatient/Respite Care
A
- Patient admitted for a 5 day inpatient care
- Provided to relieve caregivers and give them 5 days of rest.
22
Q
Continuous Care
A
- Care of medical crisis until it is resolved
- Example is development of seizures while in hospice care. They need continuous care until issue is resolved.
23
Q
General Inpatient Care
A
- Symptoms management that cannot be managed or provided in the home or patient needs to be admitted
24
Q
Who Uses Hospice?
A
- Dementia, Heart Disease, Lung Disease
- Used to only be for cancer patients but not anymore
25
Communication about Death
- Must be culturally aware and sensitive to approaches
| - Set aside our own assumptions and attitudes such as open disclosure about terminal illness varies among cultures.
26
Culture Differences
- Some cultures believe direct contact about terminal illness is harmful
- If you are not sure about culture then just ask
27
Advanced Directives
- Written legal documents sanctioned in every state through the "Patient Self Determination Act of 1991"
- Allows competent people to document preferences regarding use of medical treatment
"If I cannot eat on my own do not give me a feeding tube"
28
Proxy Directive
- Authorization of a person to make medical decisions for you when you cannot speak for yourself
- Underuse of these documents show society remains uncomfortable with death
29
Determination Act 1991
- Requires healthcare institutes to provide information on advanced directives to adult patients upon admission
30
Living Will
- Written statement of patients medical desires or medical directive
31
HIPPA Violations
- When discussing with family members related to end of life it must be with the next of kin (closest living blood relative including spouse and adopted relative)
32
Communicating Bad News
- Involves medical team (nurse and physician)
- Create the right setting with quietness. No pagers or phones
- Should be able to sit at eye level
33
Nursing Interventions
- The most important one is listening empathetically
- Effective listening involves avoiding distractions, noise, impulse to give advice, responses like "I know how you feel"
- Its okay to have silence, resist impulse to fill in empty spaces in communication
- Allow patient/family time to answer questions with "do you want to think about this?"
- Do not try to solve the families problems
- Assess their preferences and practices
34
Spiritual Care
- Features of religion but not the same
- Meaning and purpose of life to that person
- Beliefs, faiths, attitudes towards death.
35
FICA(H) Tool
```
- Used to address spiritual issues if you are not sure with what to ask or uncomfortable
F - Faiths and beliefs
I - Importance and Influence
C - Community
A - Address and Care
(H) - Hope
```
36
Supporting Hope
- Persists in every stage of illness in some form
- Listen attentively and encourage to share feelings
- Provide accurate information
- Encourage and support control over their circumstance, choices and environment
- Assist patients in exploring ways to find meaning in their lives whenever possible
- Have patients share uplifting memories
37
Supporting Hope
- Facilitate effective communication with families
- Make referrals to psychological or spiritual counseling when requested
- Assist with development of support groups
- Less determined to fix and more willing to listen
38
Management of Physiologic
- Bronchodilators for COPD
- Pain is preventable or treatable in most patients
- Nurses role to prevent and manage pain
- You can still provide care for DNR's. Just do not resuscitate when they stop breathing or heart fails
39
Dyspnea
- Most prevalent symptom at end of life
- Challenging to manage because meds used to treat it can also slow breathing to the point of not breathing
(Pain meds, blood transfusions, bronchodilators)
40
Nutrition/Hydration
- Agents can be used to stimulate appetite
- Artificial nutrition and hydration (comes with risks and doesn't always contribute to end of life comfort)
- Tube feedings can result in diarrhea and dehydration
41
Diagnostic Tests
- No change in treatment based on diagnostic results means no reason to do it
-
42
Death Vigil
- Withdrawal
- Sleep more
- More drowsy
- Preceded by increased intervals of respiration
- Weak and irregular pulse
- Drop in BP
- Mottling (blue/pale skin and even coolness)
43
Death
- Permanent cessation of respiratory and circulatory function
- Absence of heart and lung sounds
- Encourage family to spend time with loved ones, maintain privacy, honor cultural rituals
44
T-Coroners Case / Medical Examiner Case
- Examples is someone who had surgery in the last 24 hours or had suspicious death
- Maybe need for autopsy
-
45
Grief
- Personal feelings that accompany anticipated loss
46
Mourning
- Family/Group and cultural expressions of grief and associated behaviors
47
Bereavement
- Period of time in which mourning or loss takes place
48
Assessment of Grief/Mourning/Bereavement
- Assess feelings, coping skills, offering professional referrals
- Promote healthy personal habits (diet/exercise/stress reduction/sleep habits/guard against detrimental effects of stress)
