End of Life/Palliative Care Flashcards
End of Life generally refers to the final phase as
pt’s illness when death is imminent
Institute of Medicine defines End of Life as a period when an individual
copes with declininng health from terminal illness
- frailties with advanced age, even if not imminent
Death is when the patient no longer has
a heartbeat or brain activity
Palliative Care
- treating symptoms for comfort through effective pain and symptom management
- can actively be getting treatment but give them a better quality of life
- decrease economic costs of care
- alleviate burden of caregiver
Pallative Care does/does not hasten or postpone death
does not
Palliative care extends as far as
the bereavement period AFTER the patient’s death
In EOL care, what takes precedence over respiratory?
pain management (not worried about respiratory depression at this stage)
Palliative Care should be started
ASAP
In EOL Care, what is most important quality or quantity?
quality
Palliative Care involves who
physicians, nurses, social workers (paper work), chaplains, and other health care professionals
T/F: Palliative Care extends to the patient and their family.
True
Hospice Care
- can not be getting any curative treatment for admitting dx
- help pt die pain-free and with dignity
- Best Quality of Life
- at least 6 months to death
T/F: Hospice Care can stop or start at any time.
True
If a hospice patient develops a fracture while tripping over a rug, what happens when they enter the ER?
a) The ER tells them to turn around and won’t treat them
b) The patient comes out of hospice care and becomes a regular patient.
c) The patient is never seen by the doctor because of their hospice status.
d) The ambulance drops them off at the nearest bus station for her to walk back and shake it off.
b) The patient comes out of hospice care and becomes a regular patient
Hospice Care’s emphasis on
symptom management
advance care planning
spiritual care
family support
What is the criteria needed for hospice care?
1) pt desires the services and agrees in writing that hospice can only treat the terminal illness
2) pt must be considered eligible for hospice (usually 2 physicians signing off ion terminal and 6 months to live
If a patient is on hospice care, can they receive care for other health problems not related to the admit terminal illness.
Yes
If a patient has cancer and is actively getting chemo and radiation therapy, can they be considered for hospice?
no - active treatment
T/F: Hospice patients are guaranteed death.
False - possible not guaranteed. Patients may live longer and will still be covered as long as they show a decline each benefit period.
Hospice patients need complete control over
pain
Hospice is a ________ not a place
concept - can occur in homes, hospice centers, inpatients, hospice units, acute/long term facilities, rehab
T/F: Patients and their families can NOT revoke hospice care at any time.
False, they can.
- Hospice can also discharge patient at any time if not showing decline or if patient begins to show improvement.
Acute care facilities in hospice provide
for pts whose symptoms cannot be managed in the home environment
Rehab Centers in hospice care
those not seeking treatment for admitting dx (broken hip)
What are the 4 levels of hospice care
Routine - check-in, meds, weight, diet, bath at no charge
Inpatient respite care - caregiver family gets a break
Continuous care - provided for medical crisis
Gen inpatient care - hospitals
What is respite care?
letting the caregiver get a break for about 5 days from taking care of the patient (trip or sleep)
Difference between home health and continuous care from hospice?
Home health - visit counts
Continuous - no visit counts and depends on needs
Hospice nurses are more educated in
pain control
symptom management
spiritual assessments and cultural competence
management of family needs
works with an interprofessional team
If you have a patient who is non-verbal and not arousing, but whose vital signs are changing (B/P and pulse rise), show what?
What will the hospice nurse do?
In pain so give pain medication
Closed awareness
pt does not know if they are dying but the family knows
- conspiracy between the family and health professionals to guard the “secret”, fearing that the patient may not be able to cope with full disclosure about his or her status.
Suspected awareness
pt thinks they have an illness and attempts to find out details, but the family still won’t tell them
-May be triggered by inconsistencies in the family’s and the clinician’s communication and behavior.
Mutual pretense awareness
everyone is aware pt is dying but pretends and doesn’t talk about it
Open awareness
everyone knows and accepts what is going on
- openly acknowledge reality
Legal documents are needed for understanding the patient’s wishes
DNR orders
Advance Directives
- Living will
- Power of attorney
Assisted Suicide/ Euthanasia
Organ and tissue donation
DNR order is
written medical order
- documents the pt’s wishes regarding resuscitation and the patient’s desire to avoid CPR
DNR options
Full CPR
No compression
no intubation and mechanical ventilation
no chemical treatment/drug therapy
medication only
no electrical cardiac conversion
no IV hydration
no enteral nutritional support.
What term is replacing DNR?
Allow Natural Death
When can a DNR be suspended?
operative or invasive procedures during the intraop and immediate post-op period
Code status should be _____________ and ____________ clearly to all involved in the care of the pt
documented and communicated
Advance Directives
written documents that provide information about the patient’s wishes and designated spokesperson
Living wills
an individual can tell the physician exactly what treatment is or is not desired.
Copies of forms can be obtained from the internet and local medical associations but are not required.
Are you able to give a verbal directive from a patient?
Yes, as long as given to the physicians with 2 witnesses
Then documented
Who determines the decisions if the patient is not able to communicate?
A surrogate or medical power of attorney
As the disease progresses, can the patient re-assess their advance directives?
yes
Euthanasia is the
the deliberate act of hastening death
- ANA prohibits nurses from participating bc direct violation of ethics
Physician-assisted suicide is the
making lethal means available to the pt for use at a time when the pt is ready at their own choice
- voluntary active euthanasia - physician carries out a request by IV for a lethal substance
When donating organs and tissues what is needed at the time of donation?
family permission and physican must be notified immediately
For the donation to occur the body needs to be
brain dead (cerebral cortex stops functioning or irreversibly destroyed
including coma, unresponsive, absence of brainstem reflexes, and apnea
Who is well-known for euthanasia?
Dr. Klavorkian
Can a long lost relative make decisions for a dying patient even if they have a DNR?
yes, but medical power of attorney can override
What company in Lubbock deals with organ donations?
Lifegift
What are the different options of codes?
organ and tissue donation
advance directives
resuscitation
mechanical ventilation
tube feeding placement
Barriers to improving EOL Care
cure (may happen but not guarantee work)
- can’t receive curative care or life-prolonging treatments
financial criteria (most insurance pay)
reimbursement issues
cultural, and social issues (language, edu., socioeconomic disadvantaged)
discomfort with addressing issues of death (pt, family, HCP)
- personal failure by a physician
psychological, coping responses to death, dying, denial
What is the median length of stay in a hospice program?
21 days (3/4 over 65, 80% white) - 1/2 of pts in the US die in hospice
How do you communicate with a pt and family while they are in hospice care?
- Reflect on own experiences
- Use normal terms: not jargon
- Respect Cultural background
- Talking may not be convenient for nurse
- Be fully present
- Allow agenda regarding depth
What are ways to communicate and break the ice with a family and patient on hospice? Select all that apply.
“Tell me how you and your family talk about sensitive or serious matters.”
“How are decisions made in your family?”
“How would you like us to help you with the physical effects of your illness?”
“What rituals or practices are important to you regarding funerals or burial?”
All the above
When communicating resist impulse to
fill the empty space
When communicating allow the patient to _________ ______ _________ _________
sufficient time to reflect/respond
If the patient has been silent for a long time, what can you do?
prompt gently and ask questions to assess understanding
What should the nurse avoid when talking to the patient?
avoid distractions, impulse to give advice and canned responses
The nurse during hospice care can or can not cry with the patient.
can shows humanity
Psychosocial Manifestations in communication
Altered decision making
Anxiety over unfinished business
Decreased socialization
Fear of loneliness
Fear of meaninglessness
Fear of pain
Helplessness
Life review
Peacefulness
Restlessness
Saying goodbyes
Unusual communication
Vision-like experiences (hallucinations/delusions)
Withdrawal
Responding with sensitivity
- make time for them
- open-ended questions
- seek clarification
- realistic reassurance (direct discussion and validation of emotions) - aware of nonverbal
- grief process
- preferences
When responding to difficult questions, how should the nurse respond?
don’t lie/ honesty
If the patient is dying and asks about their illness or if they are dying, what should the nurse say
honesty and add on
“This must be difficult for you, tell me what is on your mind” or “What do you understand about your illness at this point?”
What is the best way of communicating with patients?
Avoid multitasking
directly face the patient at eye level
avoid distracting mannerisms
maintain an open posture
lean forward
maintain appropriate eye contact
be sensitive to and aware of cultural differences in nonverbal behavior
develop self-awareness about one’s own nonverbal behaviors and what they communicate to others.
Culturally competent care
- variations in symptom expression (grimaces, positioning, guarded mvmt
- cultures may not accept resources (seen as a weakness)
suggest bereavement counseling - avoid stereotypes and bias
- rituals of dying (beliefs and variations in death/dying)
accommodate diet, cultural beliefs/practices
If the patient speaks a different language, the nurse needs to
use a medical interpreter
Palliative/Hospice Care in relation to the African American community
AA value toughness in tough times
rely on God
use hospice less often
easily express emotions
Palliative/Hospice Care in relation to the Hispanic community
Spouses and daughters involved in decisions
Strong kinship and the family as a whole provide support for each other
easily express emotions
Palliative/Hospice Care in relation to the Filipino American community
the family decides on terminal dx, life support, and withholding tx
Palliative/Hospice Care in relation to the Jewish American community
- spirit should be left alone when it leaves the body
constant vigil, the body is never left alone
expect all body tissues to be buried with the individual
Palliative/Hospice Care in relation to the Puerto Rican community
- liss and touch the body after death to say goodbye
Spiritual Care includes
religion
care of dying pt
maintaining hope (comfort and next steps
Spiritual Assessment mnemonic
Faith/Belief
Importance/Influence
Community
Address in Care
What are signs of a dying person secure in their faith about the future?
decrease despair at EOL
give away material possessions
focus on values for the other life
order in physical decline
existential meaning in a broader cosmic context
Spiritual distress signs
Anger toward God or a higher being
Change in behavior and mood
Desire for spiritual assistance
Displaced anger toward clergy
What is the priority of physical care in a palliative patient?
symptom management and comfort
physiologic and safety needs priority
same care as people recovering
dignified death with emotional support to the family
Physical care of palliative patients consists of
oxygen
nutrition
pain relief
mobility
elimination
skincare (difficult due to maintaining near EOL)
Signs of pain in nonverbal or unconscious persons is
increased breathing
increased HR
possible grimacing
Uncontrolled pain can hasten
death
What is the maximum L via NC a COPD pt can be on?
6
What physiological symptom is common in COPD and Lung Cancer Pts?
What would be given to them because of the anxiety from the symptom?
Chronic dyspnea
- benzodiazepines
Physiological responses/symptoms
In palliative pts
pain
dyspnea
nausea
weakness
anxiety
Signs of approaching death
refusal of food and fluids
urinary output decreases (possible incontinence)
weakness, sleep, confusion, restlessness
impaired vision/hearing (hallucinations)
thick secretions (throat)
Cheyene - Stokes respirations
CV changes
Develop mottling, Kennedy terminal ulcer
Third-spacing
When the patient is approaching death, which is the priority I&Os or sleep?
sleep
When the patient is having hallucinations and LOC, what should the nurse do?
Let them set the pace with confusion and clarity moments
When the patient has thick secretions, what are some nursing interventions? Select all that apply.
Raise HOB
Turn on their sides
Oral Care
Suctioning
Raise HOB
Turn on their sides
Oral Care
What is a “death rattle”?
gurgling, grunting, or noisy congested breathing
Cheyne-Stokes breathing
pattern of alternating periods of apnea and deep, rapid breathing
Kennedy Terminal Ulcer
decreased circulation to skin
- horseshoe-shaped purple area on boney prominences
- indicates death within 24-48 hours
- can be better if feed patient IV or tube feedings
Pulses in the feet may no longer be palpable within __ to __ weeks of death.
1 to 2
Radial pulses may no longer be palpable within __ to __ hours of death.
24 to 48
What does mottling look like?
general location, temp and texture, color,
hands, feet, arms, legs extremities
cold and clammy skin
cyanosis of the nose, nail beds, and knees
–“waxlike” skin very near death**
Third-spacing
retaining fluid as kidneys shut down
- weep through pores
Third-spacing nursing intervention
place pads under arms and body prn
What can happen to the patient’s bowels before death?
Bowel sounds?
If unexpected?
release days/weeks before death
absent sounds
bowels could clear just after death
loss of sphincter tone
What are the last senses to go?
hearing and touch
Is it okay to give the patient permission to die and let them know it will be okay?
Yes
Nursing Management: Assessment for End of Life
- manage symptoms of the disease
- monitor for system failure
- if alert, then review systems, discomfort, pain, nausea, or dyspnea
- coping abilities of patient and family (respect, dignity, and comfort)
- a vigilance to subtle physical changes
If you could only pick 2 assessments for your palliative patient what would you assess?
Respiratory
Cardiac
Pain
LOC
Blood glucose
Respiratory and pain
During nursing management, what planning should be done?
goals involve comfort and safety measures
patient’s emotional and physical needs
advocate for their wishes
During nursing implementation, what emotions are involved in psychosocial and physical care?
anxiety and depression (meds, support, relaxation techniques)
anger (allow them to express feelings)
hopeless and powerless (give them control over care)
fear ( of pain, SOB, loneliness, abandonment, meaninglessness)
communication (empathy and active listening)
post mortem care
Anxiety is frequently related to but not easily identified
fear
What is a normal response to grief?
anger
- usually at nurse (not personal)
- not forced to accept loss
- encourage the expression of feelings
What can the nurse allow the patient to do despite hopeless and powerless emotions?
decision making
Empathy
identification with and understanding of another’s situation, feelings, and motives
Silence during communication is seen as
message of acceptance and comfort
Is a family conference good communication?
yes
Postmortem care consists of
prepare the body for immediate viewing by the family
considerate of cultures, laws, and policies
close pt’s eyes
replace dentures
wash as needed
remove tubes/dressings
leave pillow
never refer to them as “the body”
= family can help prepare in certain cultures
After preparing the body in post mortem care, what needs to happen next?
- pronoucement of death
- allow privacy and as much time
- call Medical examiner (if their case)
- security takes body to morgue
- security releases the body
Medical Examiner’s pronouces when
Death upon arrival to the hospital
Death occurs within 24 hours of admission to hospital
Result of homicide or unnatural means
Absence of a witness
Suicide or circumstances that lead to suspect suicide
Dies without having been seen by a licensed provider
Child younger than 6yo and death is not expected
What should be documented after death?
Time VS ceased
Time MD or designated nurse notified and time patient pronounced dead (ex: Patient pronounced det at 11:30AM by Dr Melaine Oblender)
Post-mortem care done
Disposition of clothing and valuables (name/relationship of family member given the valuables)
Time of removal of body to morgue and by whom
Name of the funeral home
If autopsy is to be performed
Dismissal form: Write “Deceased” across the page
Bereavement
The period following death of a loved one during which grief is experienced and mourning occurs.
The time spent in this period depends on the closeness of the loved one and how much time was spent anticipating the loss.
Grief
The normal reaction to loss
Occurs in response to the real loss of a loved one and the loss of what might have been.
Anticipatory grief
The grief experience for the caregiver of the patient with a chronic illness often begins long before the actual death event.
Not uncommon to feel somewhat of a relief when death finally comes.
Confirm that they should not feel guilty for these feelings. They are normal.
Adaptive grief
Grief that assists the person in accepting the reality of death.
This is a healthy response.
Indicators of this is the ability to see some good resulting from the death and positive memories of the deceased person.
Prolonged griwef disorder
Prolonged and intense mourning.
Can include symptoms such as recurrent and severe distressing emotions and intrusive thoughts related to the loss of a loved one, self-neglect, and denial of the loss for longer than 6 months.
These people are at risk for illness and may have work and social impairments.
Kubler-Ross Model: 5 Stages of Grief
Denial (avoidance, confusion, elation, shock, fear)
Anger (frustration, irritation, anxiety) “Why me?”
Bargaining (overwhelming, helpless, hostility, and flight)
Depression (struggling for meaning, reaching out, one’s story)
Acceptance (explore options, new plans, moving on)
In the Kubler-Ross Model, does everyone go through each step in order?
no
Grief Wheel Model
Shock: Numbness, denial, inability to think straight
Protest: where a person experiences anger, guilt, sadness, fear, and searching
Disorganization: feelings of despair, apathy, anxiety, and confusion
Reorganization: gradually returning to normalcy but feelings and experiences are different.
New normal. The challenge is to accept the new normal. Trying to go back to the “old” normal (which is not there anymore) is what causes a great deal of stress and anxiety.
