Home Health, Hospice, and Palliative Care Flashcards
Nurses Play a Major Role in Caring for Seriously Ill
Patients and Their Families By:
Elicit goals of care
Assess, manage, and coordinate care
Listen to patients/family members
Bear witness
Communicate with all members of the
interprofessional team
Knowledgeable in evidence‐based practice
In Managing Care of the Seriously Ill, What are
the Ethical Considerations?
Need for better communication
Autonomy
Beneficence
Nonmaleficence
Justice
What Constitutes Quality Care at the End-of-
Life?
For Healthcare Teams:
For Patients:
providing symptom management and discussing
the emotional aspects of the disease.
Achieving a sense of control, attaining spiritual peace,
succeeding in having finance in order, strengthening relationships with loved ones, and believing that their life has meaning.
Overview of Caregivers: Their Commitment and The Cost
Most adults prefer to die at home, generally requiring family to provide support. Family members provide ~80% of the care
Cost of uncompensated care = $450 B/year
Millennials are contributing to the volunteer caregiver
workforce. Caregiving can increase risk of premature
death for the caregiver. Caregivers experience untoward physical, psychological, social, and spiritual angst
What is Palliative Care?
Beneficial at any stage of a serious illness, palliative care
is an interdisciplinary care delivery system designed to
anticipate, prevent, and manage physical, psychological,
social, and spiritual suffering to optimize quality of life
for patients, their families and caregivers. Palliative care
can be delivered in any care setting through the collaboration of many types of care providers.
Barriers to Quality Care at the End of Life
Failure to acknowledge the limits of medicine
Workforce that is too small to meet demands
Lack of training for healthcare providers
Hospice/palliative care services are poorly understood
Lack of research
Lack of payment models linked to quality measures
Rules and regulations
Denial of death
Four principles of survival prediction:
- It is a process
- Evolves over the disease trajectory
- Accuracy varies by definition, population, and time
- Exact time of death cannot be predicted accurately
Karnofsky –
ECOG poor predictors, multiple
symptoms, biological markers (e.g. albumin)
Which of the following patients could
benefit from palliative care?
A. 64‐year‐old with congestive heart failure,
hypertension and diabetes
B. 32‐year‐old with acute myelogenous
leukemia
C. 57‐year‐old with newly diagnosed
amyotrophic lateral sclerosis
D. 76‐year‐old with Parkinson’s disease
Domains of Palliative Care
Structure and processes of care
Physical aspects of care
Psychological and psychiatric aspects
Social aspects of care
Spiritual, religious, and existential aspects of care
Cultural aspects of care
Care of the patient nearing the end of life
Ethical and legal aspects of care
The 6 C’s:
Comprehensive assessment
Care coordination
Care transitions
Caregiver needs
Communication
Cultural inclusion
Role of the Nurse in Improving Palliative Care
Some things cannot be “fixed”
Use of therapeutic presence
Maintaining a realistic perspective
Pain review
UNPLEASANT SENSORY/EMOTIONAL EXPERIENCE
* CAN HAVE DESTRUCTIVE EFFECTS
* CAN WARN OF POTENTIAL INJURY
* A MULTIDIMENSIONAL EXPERIENCE
CAN SIGNIFICANTLY INTERFERE WITH A PERSON’S QUALITY OF LIFE,
AFFECTING NEARLY EVERY ASPECT OF LIFE.
* FOR INSTANCE, SEVERE BACK PAIN CAN AFFECT A PATIENT’S JOB PERFORMANCE, ENGAGEMENT IN SOCIAL ACTIVITIES, SEXUAL INTIMACY, SLEEP AND REST, ABILITY TO EXERCISE, AND ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING. THESE FACTORS, IN TURN, CAN
AFFECT THE INTENSITY OF THE PATIENT’S PAIN, AS WELL AS THE PATIENT’S RESPONSE TO PAIN.
* CAN CAUSE SLEEP LOSS, IRRITABILITY, COGNITIVE IMPAIRMENT, FUNCTIONAL IMPAIRMENT, AND IMMOBILITY, AND THUS IT CAN BE DESTRUCTIVE TO THE PATIENT AND FAMILY.
Deep somatic pain
ORIGINATES IN THE LIGAMENTS, TENDONS, NERVES,
BLOOD VESSELS, AND BONES. DEEP SOMATIC PAIN IS MORE LOCALIZED AND CAN BE DESCRIBED AS ACHY OR TENDER. A FRACTURE OR SPRAIN, ARTHRITIS, AND BONE CANCER CAN CAUSE DEEP SOMATIC PAIN.
Visceral pain
CAUSED BY THE STIMULATION OF DEEP INTERNAL PAIN
RECEPTORS. ABDOMINAL CAVITY, CRANIUM, OR THORAX. VISCERAL PAIN IS NOT WELL LOCALIZED AND CAN BE DESCRIBED AS TIGHT, PRESSURE, OR CRAMPY PAIN.
Factors that influence pain
- EMOTIONS
- PAST EXPERIENCE WITH PAIN
- DEVELOPMENTAL STAGE
- SOCIOCULTURAL FACTORS
- COMMUNICATION SKILLS
- COGNITIVE IMPAIRMENT
Assessing pain
OBTAINING A COMPLETE PAIN HISTORY (E.G.,
ONSET, LOCATION, AGGRAVATING/ALLEVIATING
FACTORS)
OBSERVING NONVERBAL SIGNS OF PAIN
− ELEVATED PULSE/BLOOD PRESSURE
− CRYING, MOANING
− GRIMACING
* PAIN SCALE
* ASSESS BEFORE AND AFTER PAIN MEDICATION
DEFINITION OF PALLIATIVE CARE
SPECIALIZED HEALTHCARE AIMED AT PROVIDING
PATIENTS RELIEF FROM PAIN AND OTHER
SYMPTOMS OF A SERIOUS ILLNESS REGARDLESS OF
THE DIAGNOSIS OR STAGE OF DISEASE
Palliative care cont.
PALLIATIVE CARE IS SPECIALIZED MEDICAL CARE FOR
PEOPLE LIVING WITH A SERIOUS ILLNESS, SUCH AS
CANCER OR HEART FAILURE.
* PATIENTS IN PALLIATIVE CARE MAY RECEIVE MEDICAL
CARE FOR THEIR SYMPTOMS, OR PALLIATIVE CARE,
ALONG WITH TREATMENT INTENDED TO CURE THEIR
SERIOUS ILLNESS. PALLIATIVE CARE IS MEANT TO
ENHANCE A PERSON’S CURRENT CARE BY FOCUSING ON
QUALITY OF LIFE FOR THEM AND THEIR FAMILY.
Hospice
HOSPICE CARE FOCUSES ON THE CARE, COMFORT, AND
QUALITY OF LIFE OF A PERSON WITH A SERIOUS ILLNESS
WHO IS APPROACHING THE END OF LIFE.
Actual loss
includes the death of a loved one (or relationship),
theft, deterioration, destruction, and natural disaster. The loss can be identified by others, not just by the person experiencing it (e.g., hair loss during chemotherapy).
Perceived loss
is internal; it is identified only by the person
experiencing it (e.g., a woman with a sexually transmitted infection may perceive loss of her purity).
Physical loss includes
1) injuries (e.g., limb amputation), 2) organ removal (e.g., hysterectomy), and 3) loss of function (e.g., paralysis).
Psychological (internal)
losses are commonly seen in the areas of sexuality, control, fairness, meaning, and trust. Loss of youth, limbs, body disfigurement, or body functions can negatively impact one’s perception of self. The effect is loss of hope, faith, or dreams.
External losses
are actual losses of objects with sentimental or monetary value (e.g., jewelry, a home).
Grief:
Physical, psychological, and spiritual
responses to a loss
Mourning:
Action associated with grief
Bereavement:
Mourning and adjustment time following a loss
Stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
Factors affecting grief
Significance of the loss, support system, unresolved conflict, circumstances of the loss, previous loss, spiritual/cultural beliefs and practices, timeliness of death, developmental stage of the bereaved
Types of grief
Uncomplicated
Complicated
* Chronic
* Masked
* Delayed
Disenfranchised
Anticipatory
Higher-brain death:
The brainstem can still be functioning, so both respiratory and cardiac activity may continue even though the person does not make purposive responses to external stimuli, cephalic reflexes are absent, and the
electroencephalogram shows no activity.
Coma-
Prolonged deep state of unconsciousness lasting
days or even years, pt. cannot be aroused and may or may not have decreased brainstem reflexes (alive, unable to move)
Persistent vegetative state –
follows coma, loss of higher cerebral functions. Does not purposefully respond to stimuli, unaware of the environment, and has no cognition or affective mental functions. Individuals in such a state have lost their thinking abilities and awareness of their surroundings, but retain non-cognitive function and normal sleep patterns. Even though those in a persistent vegetative state lose their higher brain functions, other key functions such as breathing and circulation remain relatively intact. Spontaneous movements may occur, and the eyes may open in response to external stimuli.
1 to 3 months prior to death:
The dying person begins to withdraw from
the world and people. Sleep increases; it becomes difficult for the body to digest food, especially meats; and appetite and food intake decrease. Liquids are preferred. Anorexia may be protective. The resulting ketosis can diminish pain and increase the person’s sense of well-being.
1 to 2 weeks prior to death:
A host of physical changes indicate the body is beginning to lose its ability to maintain itself.
Days to hours prior to death:
Often a surge of energy brings mental clarity and a desire to eat and talk with family members. However, as death approaches, patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume.
Final hours
Many patients become restless and agitated. This response may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, or unresolved emotional or spiritual issues. Near to the time of death, some people unexpectedly become more coherent and energized for a time. Others become less communicative, quiet, and withdrawn. Fatigue is common.
Moments prior
The dying person does not respond to touch or sound and cannot be awakened. Typically, there is a short series of long-spaced breaths before breathing ceases
entirely and the heart stops beating.
Hospice care is based on two key premises:
1) the quality of life is as important as the length
of life
2) those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families. Thus, hospice providers consider helping family members an essential part of
their role.
Legal and ethical dilemmas
Advance directives, do not resuscitate (DNR)/allow naturaldeath (AND), assisted suicide, euthanasia, autopsy, organ donation
Assessment for Terminally Ill Client and Family
Knowledge base, history of loss, coping abilities and support systems, meaning of the loss/illness, depression or grief, physical assessment, cultural and spiritual assessment
Facilitating greif
Expressing feelings
Recalling memories
Finding meaning
Bibliotherapy
Helping family of dying patient
Have family help with care, if able, encourage questions, provide follow-up for referrals as needed, encourage visit to chapel or to talk with clergy, provide anticipatory guidance, acknowledge feelings of family, explore coping mechanisms, remind family members and significant others to take care of themselves, teach what to expect and provide reassurance, ask directly if family wants to be present at time of death. At the moment of death, do not intrude.
Care of dying person
Meeting physiological, psychological, spiritual, and cultural needs
Postmortem care
Includes care of the patient’s body after death and fulfilling any legal obligations, such as arranging
transportation to the morgue or funeral home
and determining the disposition of the patient’s belongings
Helping families after death
Provide emotional support immediately
after the death, provide grief education, help children deal with loss
Preparing for Death
Everyone dies
Advance care planning
Advance directive—
Recognizing the transition to active dying
Care for the dying
Post death care
Death is individualized
There is no typical death
Patient preferences
Nurses advocate for choices
Setting of death
Support
Psychological and emotional considerations
What are the Cultural and Ethical Implications
of Withholding Nutrition & Fluids?
In most cultures, food is used for not only
nutritional purposes, but also social engagement
When a patient is no longer interested/able to
eat/drink, this can cause great angst to the family
Maintain three ethical principles: autonomy, beneficence, nonmaleficence
When should dialysis be discontinued?
When burdens outweigh benefits and/or dialysis is no longer prolonging life or only prolonging death
Hastened Death Request
Statement made by patient for progressive incurable illness for those who’s judgment not impaired. Intervention to cause death more immediately than
if illness took its natural course:
assisted suicide/dying
stopping eating and drinking
sx of death
Confusion, disorientation, delirium vs. unconsciousness, weakness and fatigue vs.surge of energy, drowsiness, sleeping vs. restlessness/agitation, fever, bowel changes, incontinence, decreased intake
most common sx in final days/hrs
Dyspnea, pain, noisy breathing/respiratory congestion
Symptoms of Imminent Death
Decreased urine output, cold and mottled extremities, vital sign and breathing changes, delirium / confusion, restlessness
