communication in End of Life Care Flashcards
loss
- Actual or potential situation in which something that is valued is
- Changed –> Ex: body change
- No longer available –> Ex: loved one has died
- Gone
sources of loss
- Aspect of self
- Physical or mental capacities
- External objects
- Money, home, pets
- Familiar environment
- Loved ones
types of loss
- Situational
- Death of child
- Loss of function
- Developmental
- Empty nest
- Retirement
- can never be prepared for how we feel
death and dying – late 1800s
- Care = easing of symptoms
- Most deaths occurred at home
- Most die within days of onset of illness
death and dying – mid 1900s
- Emphasis on disease prevention
- Life saving & life prolonging techniques (CPR)
- Death often equated with medical failure
- abx = 1960s
- went from easing to curing
death and dying – 2000s
- Americans living longer
- Period of time living with progressive illness prolonged
- Families changing
- Medicalization of care at EOL
- Decreasing disparity between the way people die & how they want to die
learning of impending death
- Denial
- Protective: need the time to absorb it
- Anger
- Most expressed to those safest & closest
- Bargaining: if you just let me stay alive till my daughter gets married then i’ll do whatever. 2nd opinion
- Depression: mourning what they will lose and what they have lost
- Acceptance
what do patients value?
- Patient concerns
- Receiving adequate pain & symptom management
- Avoiding inappropriate prolongation of dying
- Achieving a sense of control
- Relieving burden
- Strengthening relationships with loved ones
what do patients value?
- Goals may shift as EOL nears
- Discuss & continue to discuss
- Greatest risk for non-discussion of dying
- Slow decline from chronic disease
- Metastatic cancer
- Chronic renal failure on dialysis
- ICU patient with underlying disease
- 60-90% of those with life threatening conditions have not discussed EOL care with clinicians
advanced directives
- General term used to describe documents that give instructions about future medical care and treatments and may indicate who should make decisions
types of advanced directives
- DNR—Do not resuscitate (physician has to write the order)
- No CPR in event of cardiac or respiratory arrest
- Living Will: only has power if the ppl that need it know where it is
- Specific instructions about what care patient wants and does not want
- Durable power of attorney for health care –> someone so cog impaired they can’t make their own decisions
- Appoints someone to manage health care treatments when patient is
unable to do so
- Appoints someone to manage health care treatments when patient is
- default = do everything possible unless you have a living will
general principles of palliative care
- Total care of patients whose disease is not
responsive to curative treatment - Patient & family unit of care
- Meet patient/ family’s goals & values
- Attend to physical, psychological, social & spiritual needs
- Education of patient & family
- Bereavement support
what does palliative care help with?
- helps the pt and family know what options they have and what happens if they stop treatment
the hospice concept
- Based on medieval concept of hospitality in which community assisted traveler at dangerous points along a journey
- Community—interprofessional team
- Traveler—dying patient & family
medicare
- Part A eligible
- Must be certified by 2 physicians as having < 6 months to live
- Must wave further treatment for disease (no more treatment to curve me. moving towards comfort)
- Certified for two 90 periods
true or false. many insurance plans also offer hospice coverage
true
hospice providers
- Medicare certified
- In-home, in-patient, nursing home
- Care, including medications, paid for (may
have $5 copay for meds)- In patient room and board may not be covered
- Can change provider once each benefit period
- don’t provide 24 hr nursing care –> will come to help but won’t stay
hospice provides
- physicians’ services,
- nursing care (intermittent with 24-hour on call),
- medical appliances and supplies related to the terminal illness,
- outpatient drugs for symptom management and pain relief,
- short-term acute inpatient care, including respite care,
- home health aide and homemaker services,
- physical therapy, occupational therapy and speech/language pathology services,
- medical social services
- counseling, including dietary and spiritual counseling
hospice does not cover
- Treatment for the terminal illness which is not for symptom management and pain control;
- Care given by another healthcare provider that was not arranged for by
the patient’s hospice; and - Care from another provider which duplicates care the hospice is required to provide.
key contribution of hospice
- Helps patient and family re-establish control
- Extensive assessment at intake
- In 2018, mean total days in hospice for all Medicare
patients was 77.9- 26.3% of all hospice patients spend 7 days or less in the program before death
communication for “shifting lanes”
- Patients/families need help with shifting lanes
- Anticipate road blocks
- Ability to look ahead & estimate whether planned care goal is still achievable
- Perceptions of change in condition
- Presentation of unrealistic expectations
- Discussions about treatment complications or decisions
- Gaining consensus
- Complicated by
- Prognostic uncertainty
- Fear of causing distress
- Navigating patient readiness
- Clinician feeling unprepared
- Complicated by
- Family conference
- Overall goal—family satisfaction with decisions
- Health care team conference
- Shifting gently
- Instill confidence about HC teams ability to provide support
- Break bad news “well”
Breaking Bad News: SPIKES
- Setting
- Privacy, comfort
- Perception
- What does patient/ family know?
- Invitation
- How much does patient/ family want to know?
- Knowledge
- Give info in small, understandable chunks
- Never say there is nothing more we can do
- Ask family to summarize
- Emotion
- Respond with empathy—expect anger, fear, denial, guilt
- NURSE
- Name emotion—you sound angry
- Understand
- Respect
- Support
- Explore—tell me more
- Support
- plan for future
An 82 year old man has been told by his nurse practitioner that it is no longer safe for him to drive a car. Which statement by the patient would indicate beginning positive adaptation to this loss?
A. “I told my son that I would stop driving, but I
am not going to yet.”
B. “I always knew this day would come, but I hoped it wouldn’t be now.”
C. “What does he know? I am a better driver than he’ll ever be.”
D. “Well, at least I have friends and family who can take me places.” (CORRECT)
A dying patient is withdrawing, crying, making comments regarding the regret she will feel at not getting to see her grandchildren grow. Your best action is to
- Hold her hand and allow her to express her feelings
The nurse is caring for a 15-year-old client who is
dying. The client tells the nurse, “I know I am not
going home again. I think it is harder for my parents than me. Will you talk to them for me?” Which of the following is the best response by the nurse?
- “Yes, I will talk to your parents, but you need to
talk to them also. I will help you with that.”
Which of the following is a characteristic of palliative care?
A. It only involves care of the client.
B. It provides grief support for family only while the client is alive.
C. It bears no resemblance to hospice care.
D. It is a clinical approach designed to improve quality of life (CORRECT)
Which comments made by a patient show an understanding of the teaching on palliative care completed by the nurse?
(Select all that apply.)
a) “Even though I’m continuing treatment, palliative care can help manage my symptoms and improve my quality of life.”
b) “Hospice is a type of palliative care.”
d) “Children are able to receive palliative care.”
Which interventions will the nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.)
b) Allow the patient to determine timing and scheduling of interventions.
c) Allow patients to have visitors at any time
e) Encourage the patient to eat when hungry –> eat whenever THEY feel like it
