End Of Life In The Critical Care Setting Flashcards by Elizabeth Gausin

What is still important at the end of life?

Human touch

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If a pt comes in with delirium .. what do we assess?

Assess for cause ( can be reversible)
Assess for pain, constipation , urinary retention

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If pt can’t talk how can we assess for pain?

Vitals
Facial expression
Restlessness
Moving , fidgeting

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Psychological signs of EOL

Delirium
Anxiety & fear
Life review
Visions- air picking
Withdrawal
Waiting for approval
Saying good bye

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Cardiovascular and respiratory signs of EOL

Tachy then Brady , irregular
Dyspnea
Weak pulse
Decrease BP
Delayed absorption of drugs
Cheyne strokes
Terminal secretions, gurgling
Cold feet ( lack of pulses in pedal about 3 days before death & radial sometimes day before)

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If a pt is full code and they stop breathing - what do we do?

CPR, ventilation

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Which drug route of administration especially have delayed absorption

IM or SUB Q

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Most pt do have a peripheral line or picc .. what do we do if they dont have it?

Use a butterfly and place in the subq .. and put in morphine if needed for pain but Becareful because they have delayed absorption

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Cheyne stokes

Stop breathing for a minute then take a deep breath

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Interventions for terminal secretions , gurgling

Don’t sunction
Opt for anticholinergic- Benadryl ( if they can take oral ) , Claritin ,

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Drugs given for terminal secretions or gurgling

Anticholinergics such as Benadryl (diphenhydramine), zertec , Claritin

Diphenhydramine can be given PO if they take it or IV
IM too but be careful with absorption

Sit them up and turn them on their side

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What intervention can we do if a pt is in the middle of a Cheyne stoke to see if they are gone or just need to be stimulataed?

Sternal rub

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Last thing to go as far as sensory

Hearing

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Sensory issues as far as site

Blurred vision, blink reflex absent , eyelids stay half open

Can put something easy over eyes to close them
Teach the family this can happen

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Other sensory issues in EOL

Taste and smell -decreased
Touch -decreased

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Even though touch is decreased what do we encourage

Human touch

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Pain in EOL

Facial grimacing
Restless, tense
Attempts to sit up
Pulls at lines
Muscle rigidity or tension
Moaning
Crying , sobbing

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In EOL the skin is cold , clammy and mottling.. what causes this

Perfusion issues

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In the musculoskeletal system in EOL care the pt has a loss of ability to move. If the pt is stable what can we do?

ROM

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What causes myoclonus

Build up of opioids due to lack of body metabolizing them.. watch for twitches when pt has morphine.. may indicate need to change medication

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Gastrointestinal changes in EOL

Hypoactive /absent BS
Distention
Constipation
N&V ( if eating)
Bowel incontinence

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Genitourinary changes in EOL

Oliguria
Anuria
Incontinence

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Pulses in EOL

Weaker typically in bottom
So get Doppler to hear pulses and assess if feet are cold..

3 days before death no pulses in foot and typically one day before death no radial pulses but that depends on

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Brain death

No function to the brain due to stroke, trauma, herniation or sudden cardiac arrest

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What does the brain stem control

Breathing Body tempt Digestion Alertness Sleeping Swallowing

When they determine brain death.. what day is that considered ?

The day of death

So when a trauma occurs that leads to brain death .. what happens

Leads to increase ICP causing brain herniation , effecting the brain stem

Criteria for brain death

GCS -<8 (coma or unresponsive) A sense of brain stem reflexes Apnea

The brain stem reflexes that are absent is brain death

No cortisol brain function Pupillary responses absent (noreaction) Gag reflex absent

Apnea in brain death

Can be slow and shallow but can’t sustain life on its own Increase Paco2 and decrease paO2

Process of assessing apnea for brain death

Pt is on a ventilator Pre oxygenate For 30 min Get them in normal level ( paco2 &pao2) Shut off ventilator Take ABG If paco2 is up and o2 is down they are considered apnic

Criteria prior to brain death diagnosis

Normothermic 98.6-100.5(cool them down or warm them up) SBP WNL (above 90) Free from sedation or paralytic Metabolic issues excluded as a factor

Why is it important for pt to be off sedation or paralytic before brain death diagnosis

To make sure that they really are comatose on their own and without drugs

Why is it important to rule out metabolic issues like DKA before a brain death diagnosis

Someone with DKA can be comatose as well so we should make sure they dont need insulin or something

Test to determine brain stem function

Vestibulo ocular reflex Oculocephalic reflex

Vestibulo-ocular reflex

They shoot water into the ear and the eyes move to the side of the water injection - which shows present. Or positive reflex Absent reflex - eyes stay fixed midline

Oculocephalic reflex

Doll eyes Head rotates one way eyes rotate the opposite ( positive , normal ) Absent- eyes stay fixed and midline

Vestibulo-ocular reflex And Oculocephalic reflex is done by who

A physician

What must be cleared before test to determine brain stem function

C -spine

Who can donate organs ?

Living relative Living unrelated Deceased unrelated - most common

Organs that can be donated

Heart , lungs, kidneys, pancreas, liver, intestines .

What is important to keep in mind when you have a pt on a ventilator who is an organ donor

They remain full code.. so we do CPR and must stay on ventilator until surgery.. maintain hemodynamics Normothermic

How can we assist with tissue perfusion for a pt on life gift

Fluid and vasopressor

Tissues that can be donated

Corneas, skin, heart valves, bone, blood vessels, connective tissue

Important to remember for tissue donation

Can be donated after cardiac death Does not need to be on ventilator

Factors that play a part organ and tissue donation

Geography ( organ) Body size Blood type Medical urgency Transplant team evaluate the med history of the donor

What factors do NOT play part in tissue and organ donation?

Race, gender, or financial status

Test used to assess organ function

Check kidney function Type and cross match Leparcopic (lungs) Check tissue perfusion

Opiates

Help with pain and comfort in EOL

Antipsychotic used

Haldol ( haloperidol) Used if pt is restless

Antimetic used in EOL

Ondansetron

Antipyretic used in EOL

Acetaminophen

Why are benzo used in EOL

For anxiety

When is blood transfusion d/c

During the withdrawal of life sustaining treatments

Respiratory devices d/c in withdrawing life sustaining treatments

Ventilator CPAP Bipap

How do you stop the shock with a implanted defib

Place a magnet over it

Nutrition d/c when withdrawing life sustaining treatments

Enteral and tpn

Why is CRRT and telemetry removed when withdrawing life sustaining treatments

It removes waste and potassium making it life sustaining Telemetry - may want to shock if pt goes into a fib or vtach

WOC

Withdraw of care

What is imporant to document as well

Notes Summary of day Pt and family understanding Pt level of comfort Meds Life sustaining treatment withdrawn of scare Time of pt death

Example of notes about med admin and pain level of pt

Pt was restless and fidgety , had a grimace on there face so i went ahead and medicated them..

Example of documenting with drawn of care in notes

Pt taken off ventilator at 11:05 PM Pt had 5 minutes of slow and shallow breathing Time of pt death( you can’t pronounce death w/o proper training) * paint a picture of it

Advance directive

Your voice when you can’t talk Allows someone your wishes if you can not talk or speak for yourself

Allow natural death (AND)

Palliative team coming in and withdrawing care and allowing the pt to die naturally Can be on comfort measures like pain meds But wont be on any large dose of profofol

Do not resuscitate

Can still do anything except if they go into cardiac or respiratory arrest ( so no vent or cpr) No advance life saving efforts

Euthanasia

Physician assisted suicide Nurse code of ethics prevents us from causing death to pt

ED is not out pt t or f

False

If someone comes in through ED and does not have out of hospital DNR presented what happens

They will perform CPR

In the community what happens if pt does not present DNR

Have to perform CPR

Ethical issues

Principles violated No family present Pt cannot communicate words Families want to continue futile care