End of Life Flashcards
“Hand of God” ICU
the idea to place warm water and possibly solidifier in gloves so that unconscious patients would have something familiar – human touch. In a time when ICU nurses do not have time to sit with patients and hold their hand, we still recognize the need for human touch even in end of life.
Sudden death with unexpected cause includes
-MI, trauma like a car crash or act of violence
Death that occurs rapidly & generally unexpectedly
-Suicide
-MVC or other accident
-heart attack
-brain hemorrhage
-undiagnosed advanced terminal illness
Unanticipated /unexplained death
to the family
Family have no time to prepare for their loss, comes as shock.
Family may suffer from “complicated grief” - an ongoing, heightened state ofmourning.
- unable to say goodbye
Anticipated Death by
: Age, Lengthy illness (i.e. cancer), multiple co-morbidities, life Support
Steady decline deaths
: short terminal illness (cancer diagnosed in late stages)
Steady decline for the family
Family has more time to process and anticipate death but can still have complicated grief.
Slow decline pts
: chronic illness with parodic crises & eventually death
- CHF, COPD, AIDS, cirrhosis, diabetic, renal failure
Slow decline for the family
Periodic acute exacerbation, high symptom burden, prognostication is challenging.
Caregivers may need additional support.
Family has more time to process and anticipate death.
Progressive deterioration deaths
prolonged & gradual physical & cognitive decline
Frailty, one who declines due to age, autoimmune disorders, or Alzheimer’s
Increasing fatigue, weight loss, decreased food & fluid intake
Progressive deterioration on the family
Caregivers may need additional support.
Decisions regarding placement in long term care may be difficult.
End of Life S/S
Psychological
Delirium
- Reversible – assess for causes
- Assess for pain, constipation, urinary retention
Anxiety and/or Fear
Life review
Vision like experiences
Withdrawal
Waiting for approval
Saying goodbye
EOL Delirium
reversible
Assess causes (pain, constipation, urinary retention)
Provide quiet environment.
Administer sedatives or benzodiazepines as ordered.
End of Life S/S
CVPV
Tachy - brady, irregular
Dyspnea
Weak pulse
Decreased BP
Delayed absorption of drugs given IM or SQ
Cheyne Stokes
Terminal secretions, gurgling
EOL - related Dyspnea intervention
Assess respiratory status.
Elevate HOB, position patient on side.
TEACH and encourage pursed-lip breathing, if able.
Suction cautiously in the terminal phase.
End of Life S/S
Sensory
- Hearing
Hearing – last to go
End of Life S/S
Sensory
- Sight
Sight – blurred vision, blink reflex absent, eyelids stay half open
End of Life S/S
Sensory
- Taste
Taste & Smell – decreased
End of Life S/S
Sensory
- Touch
Touch – decreased
End of Life S/S
Pain
Facial grimacing
Restless, tense
Attempts to sit up
Pulls at lines
Muscle rigidity or tension
Moaning
Crying, sobbing
Consider what other routes if PO is not an option?
Rectal
Subcutaneous
Injection (IV or IM)
EOL -related Pain
- nurse should
Assess and reassess.’
If the patient did not previously have pain, but now appears to be in pain, or seems to have changes in pain, be sure to rule out other potential causes of distress such as:
Constipation
Delirium
Decubitus ulcer(s) (check bony prominences)
End of Life S/S
GI
Hypoactive/absent BS
Distention, constipation
Nausea, Vomiting
Bowel incontinence
What can you do if the EOL pt has anorexia, N/V?
Assess for causes and provide antiemetics.
offer culturally appropriate foods if they want to eat.
TEACH family that appetite naturally decreases at EOL
DO NOT force feed the patient
EOL bowel patterns
Assess for causes.
Encourage movement as tolerated.
Administer stool softeners or laxatives
EOL Dehydration
Assess mucous membranes.
Use moist cloths or ice chips.
TEACH family that thirst is rate in the last days of life
End of Life S/S
GU
Oliguria
Anuria
Incontinence
What should be done for urinary incontinence in the EOL?
Assess urinary function.
Use absorbent pads.
Is an indwelling catheter beneficial?
End of Life S/S
Skin
Cold, clammy
Mottling
Kennedy Ulcer
Kennedy Ulcer
no perfusion will pool
- not blanchable and looks like a bruise
can change shape
What should the nurse do for skin care in the EOL
manage and prevent skin breakdown
End of Life S/S
Musculoskeletal
Loss of ability to move
Myoclonus (opioid related)
Myoclonus
jerking/twitching associated with high doses of opioids.
- usually given fentanyl for fast half-life
Myoclonus occurs what should the nurse do
Assess for onset and duration.
Notify HCP.
Brain Death
Clinical Diagnosis where irreversible loss of all brain functions, including brainstem. Cerebral cortex stops functioning or is irreversibly destroyed.
Brain stem controls
breathing
body temp
digestion
alertness
sleep
swallowing
Brain death criteria
- Coma or unresponsiveness
=GCS <8
= no response to noxious stimuli - Absence of brainstem reflexes
= No cortical brain function
~ fixed and dilated pupils (no pupils response)
~ absent cranial nerve reflexes > 4 hours
~ Gag reflex absent - Apnea (PaCO2 high, low PaO2
= preoxy. with 100% O2 for 30 minutes
= Normal PaO2, PaO2, pH
(manipulate vent to achieve parameters)
Brain death must have what prior to a diagnosis?
- Normothermic (>96.8F or 36C)
- SBP WNL >90 (permit vasopressors)
- Free from sedation or paralytics
- Metabolic issues excluded as a factor
- Apnea Testing
gold standard for Cerebral blood flow documentation
4 vessel angiography
- no blood flow above carotid = brain death
Apnea Testing
Preoxygenate with 100% O2 for 30 minutes
Normal PaCO2, PaO2, pH
Manipulate ventilator to achieve parameters
In a 4 vessel angiography, what shows brain death?
absence of intracerebral filling above carotids
What tests are used to determine brainstem function?
Vestibulo-ocular Reflex
Oculocephalic Reflex
Vestibulo-ocular Reflex
- positive/present
= Good
Eyes move toward the side of the ice water injection
Vestibulo-ocular Reflex
- absent
No brainstem function
Eyes stay fixed midline
Vestibulo-ocular Reflex is used to
cold ice water directly into the ear
Reflex Testing for Brainstem function can only be performed by
physicians
What needs to be cleared before the brainstem function tests?
C-spine
Oculocephalic Reflex
“Dolls eyes”
Oculocephalic Reflex
- normal
Eyes to move opposite of head movement
- head to the right and eyes go left
Oculocephalic Reflex
- absent
Eyes stay fixed midline
- eyes stay when the head is tilted
Paired Organs
Living relative
Living unrelated
Deceased unrelated – most common
Organs available for donation
Heart, lungs, kidneys, pancreas, liver, intestines
Must remain on ventilator until in surgical suite
Maintain hemodynamics
Tissue perfusion - May need fluid and/or vasopressors
Normothermia
Full Code
NEED to be on a ventilator
Tissues available for donation
Corneas, skin, heart valves, bone, blood vessels, connective tissue
Donation after cardiac death
Does not need to be on ventilator
What factors are considered in organ donations
Geography distance between donor and recipient
Body size
Blood type
Medical urgency
Transplant teams evaluate the medical history of the donors
DOES NOT include race, gender, or financial status
Withdrawing Life-sustaining Tx
-Medications-
Opiates
Antipsychotics
Antiemetics
Anticholinergics
Antipyretics
Benzodiazepines
Discontinue blood transfusions
EOL Medications
Antipsychotics
– decrease delirium: haloperidol or risperidone.
Injection, sublingual, rectal
EOL Medications
Opiates
– decrease pain & decrease respiration: tramadol, morphine, fentanyl, or oxycodone.
Injection, sublingual, or subcutaneous
Monitor for constipation – may need to add stool softener or laxatives.
Withdrawing Life-sustaining Tx
-Respiratory Assistive Devices-
Discontinue mechanical ventilator, CPAP, BiPAP
Withdrawing Life-sustaining Tx
-Implanted Defibs and Pacemakers-
Magnet for defibrillators or call for it to be turned off
- Pacemakers are okay as they only send a signal and not a shock
Withdrawing Life-sustaining Tx
-Nutrition-
Discontinue enteral feeding tubes
- benefits with providers/family of withholding food in the days immediately prior to death to prevent unnecessary suffering
- accept decision
Why do you stop enteral feedings at EOL?
Risk of aspiration.
Malabsorption – if albumin is low & pt is third spacing the feeding will not be absorbed.
Lack Satiety - the quality or state of being fed or gratified to or beyond capacity.
Food is social, visual, smell, taste & feeling of fullness for satisfaction.
Hydration PROS
Increased ketones lead to euphoria & sleepiness.
Decrease GI fluids means less N/V & abdominal distention.
Hydration CONS
Dry mouth continues even with IVF or Tube Feed.
Must provide ice chips & oral care often.
Withdrawing Life-sustaining Tx
-Additional-
Continuous renal replacement therapy (CRRT)
Telemetry monitoring
EOL Medications
Antiemetics
– decrease nausea: ondansetron.
Injection, oral
EOL Medications
Anticholinergics
– decrease secretions: scopolamine patch, atropine, glycopyrrolate.
Topical (scopolamine),
Injection or ophthalmic (atropine)
Injection or subcutaneous (glycopyrrolate)
EOL Medications
Antipyretics
– decrease fever: acetaminophen.
Injection, rectal
EOL Medications
Benzodiazepines
– anxiety, dyspnea: lorazepam.
Injection, sublingual, rectal
EOL Medications
Blood Transfusions
D/C
Nursing Assessments/Implement/Evaluate for EOL
Assess systems and continue life sustaining treatment until family communication is complete
Decide which care will be discontinued
Educate family on the dying process & WOC
Contact charge nurse and Organ Procurement Organization
Documentation for EOL
Education
Patient’s and/or family’s understanding
Patient’s level of comfort
Medications
Life sustaining treatment withdraw of care
Time of patient’s death
Self-Care for Nurses
- recognize values, attitudes, and feelings
- develop support system at work and at home
- be self-aware (coping)
Legal and Ethics of EOL
Advance Directives
Code Status
Euthanasia
Ethical Issues
Advance Directives
Allows a designated person to communicate patient’s wishes if they are unable to communicate or consent
- instructions about future medical care and treatments and who should make the decisions in the event the person is unable to communicate
AND Code
Allow Natural Death
- promote comfort measures at the end of life.
- Written order acknowledging that comfort measures only are being provided to patient.
- May withdraw all care
DNR Code
- Written physician’s order instructing HCPs not to attempt CPR.
- Allows for life saving therapies to continue except cardiopulmonary resuscitation either physical or medicinal interventions.
- Must indicate any specific measures to be used or withheld (ie chemical code only, no compressions etc.)
- Must be signed by a physician to be valid.
If a person is out of the hospital and they do not wish to have heroic measures taken, they NEED
Out of Hospital DNR form signed by their physician
- family need to know where it is
If EMS shows up and you do not provide DNR form to them, they
MUST start CPR if the person is unconscious, not breathing, or have a pulse.
Euthanasia according to the Code of Ethics
Nurse Code of Ethics prohibits nurses from causing death of a patient.
According to the American Nurses Association (ANA), participation in assisted suicide would
violate the ANA Code of Ethics.
- even if in a state allowing it
- Nurses can listen to the patients concerns and monitor the patient, but they cannot administer medications prescribed that would end the life of a patient.
Report concerns to Hospital Ethics Committee
They determine possible courses of actions based on information
They do not make a final decision only recommendations
Autonomy
– Patient right to make their own decisions
- Advance directives if unable to themselves
Beneficence
– is it a benefit to the patient?
Non-Maleficence
– do no harm
Justice
- equality
Fidelity
– Keeping a promise
Ethics Committee does what
body of persons established by a hospital or health care institution and assigned to consider, debate, study, take action on, or report on ethical issues that arise in patient care
