Terms

Question 1

PEPSI-COLA Framework

Answer 1

P – Physical
E – Emotional
P – Personal
S – Social Support
I – Information and Communication
C – Control. Choices and advanced care plan
O – Out of Hours who do they contact ouside of working hours
L – Late or Living with Illness
A – Aftercare do they have a will? Anything to look after still?

Question 2

Medical Focus

Answer 2

Therapies to maintain Physiological systems.
Death as defeat.
Silence without discussion of dying.
Withdrawal from dying people.
Avoidance of opioids and sedative

Question 3

Palliative Care

Answer 3

• Actively seeks to reduce distress, relieve suffering and provide quality of life for dying individual and family members.
• Patient chooses level of care desired.

Question 4

Palliation

Answer 4

means lessening pain and symptoms without curing

Question 5

Rituals

Answer 5

solemn or sacred acts or ceremonies that assist people to find meaning and solace in death.

Ex. funerals, memorials wakes, celebration of life services, tributes, traditional days and processes of mourning which may include special dress and/or prayers.

Question 6

Virtue Ethics

Answer 6

defines good actions as ones that display embody virtuous character traits, like courage, loyalty, or wisdom

• Virtues are strengths of character that relate to habitual patterns of perceiving, feeling and behaving.
• Compassion, courage and the ability to speak out on behalf of the dying person and family are essential virtues that sometimes questions the authority of physicians and institutional authority.
• Compassion includes empathy which involves a deep sense of shared humanity, and a disposition to provide comfort and to relieve suffering.
• Ethical decisions require critical reflection, on-going dialogue about ethical issues in the health care setting.

Question 7

Beneficence

Answer 7

Doing good for others by:

Attentive listening.
Knowing the patient as a whole person.
Persistently trying to relieve suffering.
Caring actions.
Courage to confront our own fears and vulnerability.
Advocating on their behalf.
Appropriately using medication to relieve suffering.

Question 8

Non-maleficence

Answer 8

Avoiding causing physical or emotional harm by:

Foreseeing harm that may not be obvious.
A mandate to avoid killing and to prevent suffering.
Moral requirement to do no harm.
Creates controversy about medical decisions that may cause death.
Obligation to prolong life regardless of suffering?
Plays heavily in day to day decisions of care i.e. vigorous wound care, suctioning, turning, withdrawing blood, forcing fluids, forcing mobility and performing frequent vital signs.

Question 9

Autonomy

Answer 9

Individual liberty and self-determination are principles that are highly regarded in North American society. Honoring these principles requires:
Informed consent

Question 10

Veracity

Answer 10

Speaking the truth is fundamental to ethical relationships and involves:

Avoiding lying, deception and fraud.
Self-determination is not possible without knowing the truth
If they do not wish to be informed of their status they need to identify someone that they wish to receive the information.

Question 11

Fidelity

Answer 11

Loyalty
The establishment of a trusting nurse-patient relationship.
Usually achieved by persistence over time.
Involves being an active presence at the end of life.
Requires that all clinicians confront their own fears in order to allow themselves to develop genuine trusting relationships with those individuals approaching death.

Question 12

Utilitarian Ethics

Answer 12

• Utilitarian thinking focuses on the outcomes or consequences of a decision.
• Social utilitarian thinking relates to providing the greatest good to the highest number of individuals.
• Utilitarian thinking requires an individual or health care team to weigh the benefits of treatment against the burden of treatment as a means to making treatment decisions.
• One problem with this type of thinking is that individual persons may differ on what they consider beneficial and burdensome.
• Social utilitarianism also looks at the broader benefits and burden to society as a whole.

Question 13

Care Ethics

Answer 13

• focuses on moral decision making that occurs within the context of relationships.
• Conflicts are resolved in ways that preserve community, family and connection.
• Decisions concern the needs of care-givers in addition to the needs of the patient.
• Emphasizes that the nurse, patient and family are all a part of one community.

Question 14

Noncompliance

Answer 14

Patients may alter their health care regimen because they cannot afford it, cannot understand it , or they may find the side effects intolerable. They may find the interventions too intrusive, stigmatizing and taking control of their lives. They may be concerned about chemical dependency

Question 15

Decisional Capacity:

Answer 15

Patients must be mentally competent. Can the person understand and communicate information? Is the person able to reason and deliberate about a decision? And can the person identify personal values and goals?

Question 16

Double Effect

Answer 16

Where a proposed intervention can result in both good and harm. The act must not be wrong, the intent must not be to do harm, the secondary effect must not be the means to achieve the good effect and the good effect must out weigh the bad.

Ex. you want to relieve pain but the amount of pain relief might suppress your breathing but that’s not what you want

Question 17

Futile Interventions

Answer 17

A futile intervention is one which is incapable of achieving a positive result i.e. CPR will not restore a brain dead person to normal life and cognitive functioning. DNR orders should be written when (1) medical judgment indicates that the code would be futile, (2) the patient or substitute decision maker consents to the DNR order and (3) the quality of life after resuscitation will be poor (Zerwekh, p. 197).

Question 18

Withholding treatment

Answer 18

means not starting an intervention that is believed to be futile.
* It is important to remember that the patient is dying from disease not from the withholding of treatment.

Question 19

Euthanasia

Answer 19

Is translated as “good death” or “mercy killing” in which another person kills the person with merciful intent.

Question 20

Assisted Suicide

Answer 20

involves the patient killing him or herself with the assistance of a physician prescribing lethal medication.

Question 21

Voluntary Active Euthanasia

Answer 21

Interventions administered with the intention to end the patients life. Voluntary means that the patient has asked for this intervention.

Question 22

Non-voluntary Euthanasia

Answer 22

The patient is incapable of making a decision and patients are killed against their prior expressed wishes.

Question 23

Active Euthanasia

Answer 23

Involves the commission of an act with the intent to kill.
killing a patient by active means, for example, injecting a patient with a lethal dose of a drug

Passive euthanasia: intentionally letting a patient die by withholding artificial life support such as a ventilator or feeding tube.

Question 24

permanent vegetative states

Answer 24

are unconscious with most brain functions gone, but they may have limited reflexes maintained by the brain stem.

Question 25

Pain

Answer 25

Pain is the physical dimension of complex psychic distress or human misery called “suffering” (Zerwekh).

Question 26

Suffering

Answer 26

Encompasses the physical, psychological, spiritual and social aspects of distress often experienced by people who approach the end of life.

Question 27

Enduring

Answer 27

suppressing emotional response when the integrity of self is threatened.

Question 28

Emoting

Answer 28

confronting the meaning of the suffering – crying, screaming, moaning and talking about feelings.

Question 29

Nociceptive Pain

Answer 29

• physiologic (physical) pain
•visceral or somatic
• occurs when nociceptors are stimulated in response to trauma, inflammation, tissue damage, or surgery.
• sharp, burning, aching, cramping, or stabbing
• Nociceptors are receptors that sense when there is tissue injury or damage
• They pick up changes in the chemical, thermal or mechanical environment of the tissues that are a result of injury and the body’s inflammatory response to that injury
• The chemicals produced by the inflammatory response and injury stimulates the nerve endings
• This information is converted into electrical impulses that carry messages to the brain via the nervous system.

Question 30

Neuropathic Pain

Answer 30

• Originates from nerve injury.
• Pain continues even after the painful stimuli is gone.
• Sensations may include numbness, tingling, burning, aching, crushing, stabbing, or shooting.

• Refers to the pain that results from neurological damage
• Symptoms include; stabbing, tingling, pins and needles, burning and shooting pain
• It can result in hypersensitization of areas of the skin where even a slight touch or brush against something can cause an intensely painful feeling
• This can result from peripheral and/or central nerve involvement
• It is complex, difficult to diagnose and difficult to treat
• In identifying the different types of pain our patients suffer it allows us to combine pain management strategies to achieve a relief of suffering for them

Question 31

Bone and Cancer Pain

Answer 31

The term ‘cancer pain’ covers a number of different elements
The most common and the most unique types of pain we see is metastatic bone pain
This can be a combination of nociceptive pain and neurological pain
The most common physiology for this type of pain is destruction of bone tissue as a result of disease and tumour growth that can press on nerve endings
This is managed by treating the disease, or halting or slowing down the metatastic process in the bone through a combination of anti-cancer therapies such as chemo and radiation therapy
The use of biophosphonates can strengthen bone tissue
Bone pain can be challenging to manage

Question 32

PQRST

Answer 32

Provokes/precipitating factors - What starts the pain? Where does it come from? What makes it feel better or worse?

Quality of pain –What does the pain feel like? Is it intermittent or constant? How would you describe it?

Region and radiation – Does the pain stay in one place or does it radiate from its origin? This can indicate whether there is neuropathic pain involved

Severity or associated symptoms – Rate the pain on a score of 1-10. What is your pain right now? What has it been today? What has it been like this week?

Temporal factors/timing – When did you first feel this pain? When does it come on – any particular time of day, week or year?

Question 33

PAINAD

Answer 33

Pain Assessment in Advanced Dementia Scale
can’t communication (ex. For dementia) breathing, groaning, facial expressions, are they restless can they be comforted/reassured, are they trying to hit you?

Question 34

Wrong Baker Faces:

Answer 34

visual images using facial expressions from 0-10 severe

Question 35

Non Opiods

Answer 35

These drugs include acetaminophen (Tylenol), NSAIDS such as aspirin, ibuprofen, Motrin, Advil and the COX-2 NSAIDS like Celebrex.

Some of these drugs cause gastric side effects and toxicity levels can be reached when combined with other opioid type drugs like Oxycodone and Percodan

These medications require administration every 3-4 hours

Question 36

Opioid Analgesics

Answer 36

any drug that has actions similar to morphine
producing analgesia , reducing anxiety, and increasing the person’s sense of well being
They reduce the perception of pain and the resulting suffering

Question 37

Opiophobia

Answer 37

Fear of Addiction and Pseudo-addiction
Addiction is characterized by a compulsive use of a drug to regulate one’s mood, not to relieve pain
Fear of sanctioning for prescribing large quantities of opioids

Question 38

Breakthrough pain

Answer 38

temporary increase in pain that rises above the baseline that is normally managed by around the clock pain management
Can occur as a result of activity or just before the next long-acting dose is due to be administered

Question 39

Corticosteroids

Answer 39

TLDR: anti-inflammatory, reduce edema, help bone pain

Decadron and prednisone are often used for their anti-inflammatory effects
They inhibit synthesis of prostaglandins and diminish edema
They reduce malignant bone pain, control symptoms of expanding tumours especially those that cause spinal cord compression

Question 40

Anxiolytics

Answer 40

Provides relief of anxiety which often aggravates pain at the End-of Life
Common drugs include diazepam, alprazolam, lorazepam and midazolam, Buspar for acute anxiety and Ambien is often used to induce sleep
Sedation is the most common side effect and lowered BP and respirations can occur at high doses

Question 41

Antidepressants

Answer 41

TLDR: TCAs reduce neuropathic pain & help sleep

The older tricyclic antidepressants such as amitriptyline, desipramine and nortriptyline inhibit the reuptake of norepinephrine and serotonin therefore provide a pronounced reduction in neuropathic pain, which is the burning, and shooting pain associated with nerve involvement
These drugs take weeks to reduce depression but only days to reduce pain
These drugs are also useful to promote sleep

Question 42

Anticonvulsants

Answer 42

TLDR: good for neuropathic pain, SE: sleepy, dizzy, hepatic toxicity, agranulocytosis

Neuropathic or nerve pain can also be relieved with adjuvant anticonvulsants like gabapentin, sleepiness and dizziness can occur
Older agents such as Dilantin, Tegretol and Depakote help but are associated with more severe side effects such as hepatic toxicity and agranulocytosis
Carbamazepine (Tegretol) is highly effective but is associated with bone marrow depression that limits its use in patients with cancer.

Question 43

Muscle Relaxants

Answer 43

Benzodiazepines are commonly ordered for muscle spasms
Serious CNS and sedative side effects means these drugs are reserved short-term use for acute muscle spasms and/or injury

Question 44

Bisphosphates

Answer 44

Fosamax, Didronel and Aredia decrease the pain of bony metastases and prevent pathological fractures by diminishing bone reabsorption

Question 45

Anesthetics

Answer 45

Local anesthetics can be injected to block spinal, peripheral and sympathetic nerves – anesthetics and steroids can be injected into the spinal space or nerve roots

Question 46

The Edmonton Symptom Assessment System

Answer 46

EQ useful tool for cancer pts. that documents severity of pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, sense of well-being and shortness of breath

Question 47

Gentle hydration

Answer 47

approximately 1 liter of fluid daily maintains hydration without causing fluid overload.

Question 48

Hypercalcemia

Answer 48

artificial hydration is indicated with elevated levels of serum calcium which is commonly seen with squamous cell carcinoma, lung, breast and multiple myeloma. Without treatment individuals become anorexic, nauseated and cognitively impaired. Rehydration with saline is required.

Question 49

Cultural Safety

Answer 49

Ethnocentrism causes us to view the world through our own cultural lens and can lead us to believe that other cultural beliefs and values are wrong.

We can actively develop our ability to provide culturally safe care by approaching people from different cultures with different beliefs and values from a place of curiosity and a willingness to learn from people who are different from us.

Question 50

Acculturation

Answer 50

involves identifying with one’s traditional cultural while at the same time learning about the mainstream or dominant culture to survive

“assimilating tot he dominate culture”

Question 51

FICA

Answer 51

mnemonic to remember and ask about the following concerns:

Faith – Does faith play a significant role in your life? What gives your life meaning?

Influence – How do your religious or spiritual beliefs influence how you think about this illness, how you live your life and what you believe about dying?

Community – Who are the community members that are important to you? Is it important that they are here to support you at this time?

Address – Do you have any spiritual concerns or unfinished emotional business that you would like to address? Is there anyone you would like to speak to about this?

Question 52

Loss

Answer 52

Loss occurs when something or someone is missing. Death and dying losses include; loss of health and normal physiological functioning, decreased energy, loss of work or roles within the home, loss of relationships, loss of hope for the future and life itself.

Question 53

Bereavement

Answer 53

The experience of loss of a person to whom one has a significant attachment. Bereavement is the loss itself, whereas grief is the intense emotional response to that loss.

Question 54

Grief

Answer 54

A universal human response when security is shattered by a loss. The grief process involves letting go of life and entering a place of unknowing.

Question 55

Mourning

Answer 55

The outward expression of grief in public with other people and may include such things as funerals, wakes and memorials

Question 56

Healthy Grief

Answer 56

Attachment theory is considered to be the best predictor of healthy or unhealthy grieving. Adults who had secure comforting bonds with their parents in childhood have the healthiest adult relationships and healthy bereavement in adulthood when they lose people they love. Children whose parents had anxious, avoidant or disorganized relationships with their parents tend to have troubled adult relationships and more complicated bereavement.

Question 57

Complicated Grief

Answer 57

Grief is considered complicated when individuals
- isolate themselves from others
- have a lost sense of meaning
- are consumed by anger
- a failure to invest in life
- the person is so disturbed that functioning at work, home and in social roles is grossly impaired.

Symptoms
- preoccupation with the deceased that impairs function.
- Marked and persistent feelings of futility
- loss of meaning,
- absence of emotional responses
- feeling dazed
- difficulty acknowledging that the death has occurred
- self-destructive behavior
- persistent anger and bitterness.

Question 58

Disenfranchised Grief

Answer 58

Many deaths cannot be acknowledged or mourned openly i.e. we have no public right to grieve.
Examples include gay and lesbian partners who are not acknowledged or accepted within the dying person’s family and social circles, extramarital relationships, when healthcare providers lose patients that they became close to.
Death of pets, loss of someone with dementia, ambiguous losses i.e. person presumed dead but no body has been found.

Question 59

Anticipatory Grief

Answer 59

Is a process that occurs in response to the advanced warning of impending death in oneself or a significant loved one. The loss is recognized, the life lived and relationships are reviewed, unfinished business may or may not be worked through and there is a letting go of the life that had been known.

For survivors anticipatory grieving can often promote healthy bereavement after their loved one dies as they have had time to prepare and they often have an opportunity to support the person in achieving some control over the dying process. There is a chance to say goodbye. It can create complication if it goes on for an extended period of time.

Question 60

Chronic Sorrow

Answer 60

Chronic sorrow involves recurring grief reactions when there is a significant loss of crucial functions in oneself or another to whom the person has a deep attachment i.e. losing ones partner to Alzheimer’s disease over many years.

Other examples include people living with chronic disability and their care givers i.e. parents with developmentally challenged children, people with long-term progressive debilitating diseases; Muscular Dystrophy, ALS, Parkinson’s disease and Acquired Brain Injury.