Nurb Final end of life Flashcards
, research on dying in America, doing in America improving quality at and near end of life=pt value, goal, preferences
IOM- Institute of Medicine
educating nurses in all 50 states and teach as many nursing program s as possible, 3 days training
ELNEQ-
The study to understand prognosis (outcome, how long) preferences for outcome (quality of life=say they want to die and how and where they actually die) risk of treatment (ethnic issues)
A. Three major studies in the last decade paint a grim picture of the experience of dying for patients and families
means to a better end
-more than ¼ die in 7 days when entered into hospice, need to access earlier on
last acts
1-2 days, maybe a week to a few weeks, body is shutting down
Actively dying:
- 2 main fears of dying and death= don’t want be a burden or financial burden/ fear that they will be in pain
- Nothing more can be done= need to refer to hospice, fear that health care providers will abandon them
- Adjusting to changes in roles
- Drain life savings and go bankrupt
- Older adults are cared for by older parent (70 and 90 yr old)
Toll of death and dying on pt and family
providing symptom management and discussing emotional aspects of disease (focus on quality not quantity)
Post: physician order for scope of tx- are they a DNR=outpt, power of attorney
Good quality care at end of life:
- on average 78 years, more older adults living with chronic illness, technology prolonging inevitable , health care cost, lack of control over risking drug and device cost, failure to treat pain and other symptoms
Death and dying in America:
: frequent emergency room visits, increase of inpt admission, promote suffering, increase risk of depression and anxiety, promote complicated bereavement, prevent delay in hospice care
Advanced illness ad care involved
a.comfort, not a whole lot they could do for pt, cause of death was infectious disease= no vaccines, age died 50, site of death at home with family and relatively short disease trajectory
Early 1900’s:
b. cure goal, cause of death more chronic illness bc living longer, age 77.8 , die in an intuition being cared for by stranger and prolonged disease trajectory
- less than 10 percent are sudden=mi, trauma
Early and middle 1900’s:
= pancreatic cancer
trajectory
steady decline short terminal phase
- gradually going downhill short time in hospital Ex: COPD, kidney failure, congestive heart failure, and organ system failure
Slow decline and periodic crises
frail elderly, will die eventually from disease but not actively dying Ex: fall and broke hip never bounce back, Parkinson, degenerative diseases, cerebral palsy
Lingering or expected death-
- The realities of life limiting-disease
- Lack of adequate training of professionals
- Delayed access to hospice and palliative care services
Barriers to quality care at the end of life
i. Services well not well understood: counseling for family; Chaplin nurse social workers, interdisciplinary care / lack of understanding by public= Medicare does pay for some
ii. Rules and Regulations
iii. Denial of death
Delayed access to hospice and palliative care services
- concept of care delivery, physician has to say 6 months/ must have volunteer to help out it is key
a. History- use to designate waste system on the journey of pilgrimage
A. Hospice
b. - prognosis expected to die in 6 months, congress decided on the amount of time= early 1980s Florida decided Medicare would offer payment for end of life services for 18 months can’t afford to pay for so long so 6 months
- still alive at end of 6 months and revaluate= better can do alive discharge can come back in
- still met criteria renew for 6 months again
hospice
Eligibility
- Medicare Medicaid, most private health insurers/ only pay for things directly for care other things will stay being paid for by the other providers, enroll in Medicare approved program
Payment:
hospice
- Interdisciplinary care
- Medical appliances and supplies
- Drug for symptoms and pain relief
- Short term inpatient and respite care
- Homemaker/ home health aide
- Counseling
- Spiritual care
- Volunteer services
- Bereavement
hospice services
communicating with multiple health care providers, patient and family on the team=what they want, Pharmacist OT PT dietary Chaplin
interdisciplinary care hospice
- family gets a break from taking care of pt, can go to home and mow lawn or go grocery shopping, free services
Volunteer services- Respid care
hospice
- counseling after patient die, help out with grieving in the aftermath, 13 months goes through all important events that happen and anniversary date of death, can continue
Bereavement services
hospice
- emphasis on quality over quantity, strictly comfort, can still receive curative services= chemo, dialysis
- don’t have to be dying to receive must have serious life threatening illness and don’t have to be in terminal phase, time factor not a piece
a. Eligibility- anyone can get it if they have life threatening disease
b. Confusion of blending
Palliative Care
a. The patient and family as the unit of care
b. Attention to physical, psychosocial, social and spiritual needs
c. The interdisciplinary team (IDT)
d. Education and support of patient and family
e. Bereavement support
General principle of palliative care
curative for a long time, palliative a little, then barely any hospice
Palliative care: disease modifying treatment most time overlap with palliative care and hospice, will do bereavement support after death
Continuum of care:
physical well being
psychological well-being
social well- being
spiritual well-being
quality of life model
A. Addressing multiple dimensions of care to achieve quality palliative care
a. most focused on-functional ability, strength/fatigue, sleep and rest, nausea
Physical well-being:
quality of life model
: anxiety, depression, enjoyment/leisure, pain distress
quality of life model
b. Psychological well-being
c.: financial burden, caregiver burden
quality of life model
Social well-being
d. big piece when thinking about quality of life hope, meaning, suffering
quality of life model
Spiritual well-being
– where are they right now and where they would like to be, look at suffering
Meaning of “quality of life”
- what does it mean, ask what they hope for right now Ex: make it to daughter’s wedding
Maintaining hope
prevent and manage symptoms, encourage to transcend their current situation, encourage aesthetic experiences, lighteheartedness and humor appropriateness, Suggest books films and art that is uplifting and highlight the joy, encourage reminiscing, assist to focus on present and past joy, share positive hope inspiring stories, support in positive self-talk
Experimental processes:
maintaining hope
: facilitate participation in religious rituals and spiritual practices, necessary referrals to clergy and spiritual support people, assist in finding meaning in current situation and keep a journal, suggest book fill and art to explore suffering
Spiritual/transcendent processes
maintaining hope
- minimize isolation, keep open relationship, sense of self-worth, hopefulness between pt and support system, pt identify significant others and then reflect on personal characteristics and experiences that endear, communicate sense for hopefulness
Relational processes
maintaining hope
: goals without own agenda, identify available and needed resources to meet goals, assist in breaking larger goals into smaller steps, give accurate information, facilitate reality surveillance as appropriate, help identify past success, increase sense of control when possible
Rational thought processes
maintaining hope
Tools for palliative care
assessment tools and prognositcation tools
prognositication tools
2 parts forseeing and foretelling
A. Nurses can establish and impact the quality of care
B. Use of presence: therapeutic
C. Maintaining a realistic perspective: cannot be fixed
D. Nurses are the constant across all settings
E. Expand concept of healing: not for a cure what is it they hope for to provide quality across life, goes across lifespan
F. Education
Role of the nurse
palliative care
A.Quality care
B. Professional knowledge and skill: I need to know to help all
C. “doing for” and “being with”
D. nurses play a vital role in improving care
palliative care conclusion
