UNIT 4: End of life Flashcards
What should we expect psycologically as a patient starts the death process
- Delirium
- Reversible: Assess for causes
- Assess for pain, constipation, urinary retention
- Anixety and/or fear
- Life review
- Vision like experiences
- Withdrawl
- Waiting for approval
- Saying goodbye
What cardio/resp changes should we expect to see in a patient undergoing the death process
- Tachy then brady, irregular
- Dyspnea
- Weak pulse
- Decreased BP
- Delayed absorption of drugs given IM or sub Q
- Cheyne stokes
- Terminal secreations, gurgling
What sensory changes should we expect to see in a patient undergoing the death process
- Hearing- last to go
- Slight- blurred vision, blink reflex absent, eyelids stay half open
- Taste and smell- decreased
- Touch- Decreased
What GI changes should we expect to see in a patient undergoing the death process
- Hypoactive/absent BS
- distention, constipation
- n/v
- bowel incontinence
What genitourinary changes might we see in patient that is dying?
- Oliguria
- Anuria
- Incontinence
What skin changes might we see in a patient dying?
- Cold, clammy
- Mottling
- Kennedy ulcer
What musculoskeltal changes might we see in a dying patient?
- Loss of ability to move
- Myoclonus (opioid related)- jerky movement
What is the criteria for brain death?
- Coma or unresponsiveness (GCS less than 8)
- Absence of brainstem reflexes
- No cortical brain function
- Pupillary responses absent
- Gag reflex absent
- Apnea
- Must have these prior to dx:
- Normothermic (96.8)
- SBP WNL (100/90)
- Free from sedation or paralytics
- Metabolic issues excluded as a factor
What are tests to determine brainstem funciton?
- Vestibulo-ocular reflex
- Oculocephalic Reflex “dolls eyes”
What should we know about the vestibulo-occular reflex?
- Positive/present reflex = good
- eyes more toward the side of the ice water injection
- Absent reflex- no brainstem funciton
- Eyes stay fixed midline
What do we need to know about oculocephalic reflex?
“dolls eyes”
- Normal response = good
- eyes to move opposite of head movement
- Absent reflex- no brainstem function
- Eyes stay fixed in midline
What are types of paired donations?
- Living relative
- Living unrelated
- Decreased unrelated- most common
4.
What organs can be donated?
- Heart, lungs, kidneys, pancreas, liver, intestines
What are some criteria for the organs to be able to donate?
- Must remain on ventilator until in surgical suite
- Maintain hemodynamics
- tissue perfusion-may need fluid and/or vasopressors
- nrmothermia
- Full code
What types of tissues can be donated?
- Corneas, skin, heart valves, bone, blood vessels, connective tissues
- Donation after cardiac death
- Does NOT have to be on a vent
What factors play a part in organ donation?
- Geogrpahy distance between donor and recipent
- Body size
- Blood type
- Medical urgency
- Transplant teams evaluate the medical hx of the donor
- DOES NOT include race, gender, or financial status
What medications might we give a patient when withdrawing life sustaining treatments.
- Opiates
- Antipsychotics
- antiemetics
- anticholinergics
- antipyretics
- benzos
- discontinue blood transfusions
What devices may we be dc when withdrawling life sustaining tx?
- Resp assistive devices
- DC mechanical vent, cpap, bipap
- Implanted defibrilator vs. pacemaker
- Magnent for defebrillator to DC it
- know which one your pt has. Pace maker will show on telemetry with spikes
- Nutrition
- DC enteral feedings and perientral feelings as well
Additional Life sustaining treatments
- CRRT: Replaces kidney funcition… life sustaining.
- Telemetry monitoring
What is our nursing managment during the time where family is deciding on if they wish to withdrawal care
- Assess systems and continue life sustaining tx until the family communciaiton is complete
- decide which care will be dc
- Educate family on the dying process and & WOC (withdrawal of care) (MODS process)
- Contact charge nurse and organ procurement organization
What should our documentaiton include during the time of the dying process
- Education
- Patients and/or familys understanding. Doc. what did you teach them, did they verbalize understanding.
- Patients level of comfort
- esp. if they are not able to verbilize pain. document what you see.
- Medications
- Life sustaining tx withdraw of care
- Document time
- Time of pts death
- When pt dies in the hospital the house supervisor fill out death certificate. certain RNs on floor can pronouce death but it has to be in the pocily otherwise its usually people above RN
Self care for nurses includes?
- Recognize values, attitudes and feelings
- Develope a support system at work
- Be self aware- what are your patterns for dealing with grief
- Develope a support system at home
What should we know about advanced directives?
- Allows a designated person to communicate patients wishes if they are unable to communicate or consent
Legal & Ethical issue: Euthasia (physican assisted suicide) what should we know
Check nurse practice act out to find out if the state allows euthanasia. Our code of ethics prohibits us from causing death to a patient. So we cannot give the lethal dose of meds but we can be present to monitor the patient.
A patient that is going to be an organ donor must remain what code status until they are ready to withdrawal care?
Full code… once they get into the OR and they are set up they will turn off vent and withdrawal care. They have 90 mins from the time they turn off the vent for the patient to either begin to breath on their own or die. Once they die they can begin to organ retrieval process
Do you need an order to withdrawal care?
Yes
What education would we give a family about withdrawing life sustaining tx?
- Make sure to explain that if they aren’t breathing on their on the vent… then they likely wont breath without the vent support
What is allow natural death code status?
Basically means withdrawal of care. Allow body to die naturally but still can provide comfort care
What is DNR?
Wont do anything if they have a cardiac aresst and need like CPR or resp sustaining care
What is Autonomy?
Pt has the right to say what they want and what they dont want
What is beneficence?
Benefiting the pt
what is Non-maleficence
not doing harm
What is justice?
being equal or fair regardless of different situations (money, race, gender)
What is fedility?
Telling the truth, keeping a promise.
What situations may cause ethical issues?
- No famlies present
- Patients cannot communicate wants
- Families want to continue futile care.
