Wk 1 End of Life Care

Question 1

What are the practice standards of a critical care nurse?

Answer 1

1. Evaluate quality & effectiveness of nursing practice
2. Reflect on standards, laws, and regulations
3. Acquire & maintains current knowledge
4. Interact and contribute to peers
5. Serve as patient advocate
6. Collaborate with health care team
7. Use clinical inquiry & integrates research into practice
8. Consider factors related to safety, effectiveness, and cost

Question 2

AACN Synergy Model:

What are the characteristics of a critical care patient?

Answer 2

a. Resiliency
b. Vulnerability (Nurses are in charge so advocate for the pt bc they are vulnerable)
c. Stability
d. Complexity
e. Resource availability
f. Participation in care
g. Participation in decision making
h. Predictability

Question 3

What are bundles of care?

Answer 3

Bundles are evidenced-based practice-interventions done as a whole to improve outcomes

VAP, Sepsis, CVC (Central venous catheters aka “Central lines”) are common bundles

Question 4

What is SBAR?

Answer 4

1. Situation-Presently going on with the patient
2. Background-What brought them in, History
3. Assessment-Pertinent body system assessment, don’t forget vitals!
4. Recommendation-Nurses do recommend! Interventions, treatments

Question 5

What is CUS?

Answer 5

1. I’m Concerned
2. I’m Uncomfortable or I am unsure of the situation
3. This isn’t Safe or I want to ensure the safety of the patient

Question 6

What are common patient stressors in the critical care environment?

Answer 6

• Loss of privacy
• Artificial lighting
• Noise
• Lack of meaningful stimuli
• Pain (Tubes and lines may not be painful but they can be uncomfortable)

How might the environment be modified?
• Pain: look for nonverbal cues such as HR, RR, etc
• Encourage comfort measures such as hand holding by family, etc

Question 7

What strategies can be implemented to address patient stressors in the critical care setting?

Answer 7

Talk to the patient!!

Also screening for PTSD

Question 8

___ situations provide greatest risk for communication breakdown

Answer 8

Handoff

Question 9

Family wishes and concerns:

How can critical illness affect the whole family?

Answer 9

1. Emotional distress
2. Financial bankruptcy
3. Family influences the patient’s recovery

Often medical personnel is annoyed by family, but they are important for patient recovery and also for past medical hx of patient

Question 10

Family wishes and concerns:

Assessment of the family includes?

Answer 10

STRUCTURAL
• Internal structure (immediate, decision-makers)
• Designating a spokesperson - Be aware of HIPAA. Be careful of who is who. In ICU, there is always a health care proxy. Get the paperwork and a phone number in case of an emergency! Only give the PIN to 1 or 2 family members

DEVELOPMENTAL
• Stages, tasks, and attachments
• Different stages of development, thinking, reasoning, maturity level

FUNCTIONAL
• Interaction with one another

Question 11

How can the nurse aid in communication with the family?

Answer 11

• Don’t forget to listen, acknowledge and express empathy to the family.
• It is okay if you do not know the answers to the family’s questions.
• Don’t ever tell a new diagnosis! Leave to the physician.

Question 12

What are some nursing interventions for the patient and their family?

Answer 12

1. Remaining near the patient
2. Receiving assurance
3. Receiving information
4. Being comfortable
5. Having support available
6. Facilitate visitation
7. Provide accurate and realistic information
8. Encourage family involvement in patient care
9. Consider family presence during procedures
10. Consider family environment and support

Question 13

Most of the ethical issues faced in the critical care setting are related to one of these 4 areas:

Answer 13

1. Informed consent and confidentiality
2. Withholding or withdrawal of treatment
3. Organ and tissue transplantation
4. Distribution of health care resources

Warning signs to recognize an ethical dilemma:

1. Emotionally charged situations
2. Significant change in patient’s condition
3. Confusion about facts
4. Hesitancy about what is “right”
5. Deviation from customary practice
6. Need for secrecy regarding proposed actions

Question 14

What are the roles of a nurse r/t ethical dilemmas?

Answer 14

ADVOCACY
is primary nursing role
• Autonomy - Right of self-determination concerning medical care
(Alert & Oriented or Confused?)
• Duty to prevent harm, remove harm, and promote the good of another person
• Nonmaleficence - Not to intentionally inflict harm

JUSTICE
Fair distribution of health care resources

VERACITY
Truthfulness

FIDELITY
Be faithful to commitment

CONFIDENTIALITY
Respect for right to control information

Question 15

When can a patient implement their autonomy? not implement their autonomy?

Answer 15

autonomy = alert and oriented

no autonomy = confused and/or sedated

Question 16

What is required for informed consent?

Answer 16

• Competence: ability to understand
• Voluntariness: consent without coercion
• Disclosure of information

Full disclosure includes:

a. Diagnosis
b. Proposed treatment
c. Probable outcome
d. Benefits and risks
e. Alternative treatments
f. Prognosis if treatment not provided

Nurses may provide additional patient education, but obtaining consent is the physician’s obligation. Also, nurses may witness the consent once the physician has obtained the patient’s consent.

Question 17

What is a Health Care Surrogate?

Answer 17

• Legally designated by the patient as part of advance directive
• The surrogate will make decisions if the patient becomes incapacitated

Question 18

What is a proxy?

Answer 18

• provided by the hospital
• Similar to a health care surrogate, however usually the health care surrogate is designated by the patient.
• The hospital may initiate this if there is no health care surrogate in place or the papers are not readily available.
• Authorized by the state statute

Question 19

Withholding care means?

Answer 19

Not initiating life-sustaining therapies in a terminally ill or persistently vegetative patient

Commonly Withheld Therapies

1. Vasopressors
2. Antibiotics
3. Blood and blood products
4. Nutritional support (ethical dilemma)
5. Possible deactivation of implanted devices (ICDs)-place magnet taped down

Question 20

Withdrawing care means?

Answer 20

weaning or removing; i. Discontinuation of life-sustaining therapies in a terminally ill or persistently vegetative patient

Example: Ventilator Withdrawal
• Most common withdrawal intervention
• Called “terminal weaning”
• can be titration of ventilator to minimal levels;
• removal of the ventilator but not the airway or endotracheal tube.
• Titrate pain medications and sedation during this process
a. Relieves tachypnea, dyspnea, and use of accessory muscles
b. Can give morphine or Ativan beforehand to help with the uncomfortableness and SOB
c. Suction and anticholinergics for secretions beforehand as well

Question 21

The nurse must ensure that the decision to withdraw is made separately from the decision to ___.

Answer 21

donate organs.

Question 22

What is medical futility?

Answer 22

A clinical situation where life-sustaining therapies or interventions will not provide a foreseeable possibility of improvement in the patient’s health condition.

There is mounting evidence that high-intensity or aggressive care near the end of life is associated with a decreased quality of life and little to no improvement in the duration of life.

The identification of the dying patient is often based on the health care providers’ opinions and interpretations of patient responses and results. This makes the determination of the appropriate intensity of care for patients near the end of life extremely difficult.

Question 23

Nursing interventions r/t communication and conflict resolution for End of Life care:

Answer 23

1. Provide clear, ongoing, honest communication
2. Allow time for family members to express themselves
3. Agree on a treatment plan
4. Emphasize that patient will not be abandoned
5. Facilitate continuity of care

Question 24

What is palliative care?

Answer 24

• Care designed to relieve symptoms that negatively affect patient or family
• Should be implemented with ALL patients, not just the dying. It has expanded beyond the scope of hospice, where it was introduced.

Elements of Palliative Care
1. Early identification of end-of-life patients
2. Pain management as “fifth vital sign”
3. Pharmacological and nonpharmacological interventions to:
• Relieve pain
• Control anxiety
• Control other distressing symptoms

Question 25

What is hospice care?

Answer 25

* Care that emphasizes comfort rather than cure * Views dying as a normal process * Terminal Illness, 6 months to live (Common in oncology) * It is a Philosophy of care, not a location * Appropriate when aggressive interventions are withdrawn * Quality end-of-life care

Question 26

What are common symptoms at End of Life? | What are nursing interventions for these?

Answer 26

Common Symptoms at End of Life 1. Pain 2. Anxiety 3. Hunger (Check for swallowing reflex before feeding) 4. Thirst 5. Dyspnea (Ativan can be given for SOB) 6. Diarrhea 7. Nausea 8. Confusion (Reorientation first and then antipsychotics) 9. Agitation 10. Sleep disturbance Nursing Interventions 1. Ongoing assessment of response to therapy and comfort 2. Pharmacological and nonpharmacological symptom management a. IV benzodiazepines (Ativan) for anxiety i. IV doses are smaller than oral (first pass effect) b. IV Morphine for dyspnea and pain c. Atropine (anticholinergic) for drool and secretions 3. Repositioning 4. Good hygiene 5. Skin care 6. Creation of a peaceful environment 7. Empathy 8. Addressing family visitation 9. Family Communication 10. Chaplain, Pastoral Care

Question 27

What are ethical principles r/t withdrawal and withholding of treatment?

Answer 27

• Death is a product of the underlying disease. • The Goal is to relieve suffering, not hasten death • Withholding life-sustaining treatment is moral equivalent of withdrawing treatment • Any treatment may be withheld or withdrawn with patient and family consent • Any dose of analgesic or anxiolytic medication may reasonably be used to control pain and relieve suffering • Life-sustaining treatment should not be withdrawn from patients on paralytic agents Example: If ventilator withdrawn and paralytic agent still effective, then the paralytic will cause death. OOOps! So make sure correct process is followed and it’s the disease causing the death • Cultural and religious perspectives may affect patient and family decision making

Question 28

What are nursing interventions during withdrawal or withholding of treatment?

Answer 28

• Provide anticipatory guidance to patient and family • Anticipate distressing symptoms and medicate to relieve symptoms • Titrate therapy to relieve emotional and physical distress For instance, the nurse can call to request different doses (opioid naïve needs less, etc).

Question 29

When should a nurse call the Organ procurement organization? Think about early identification of donors.

Answer 29

RN calls transplant coordinator if glascow coma scale <5 so they can contact family

Question 30

What are the requirements for a living donor?

Answer 30

1. Overall good health 2. Free of diabetes, cancer, heart disease, kidney disease 3. Compatible blood type 4. BMI - becoming a criterion to ensure best outcomes for the donor. Long-term outcomes are better when the donor source is a living relative.

Question 31

How is brain death confirmed?

Answer 31

performed by a neurologist. Criteria are defined as: • absent cerebral and brain stem functions associated with a non-survivable head injury. (no cranial reflexes) • coma or unresponsiveness • apnea (no breathing when off the ventilator) EEG and perfusion scan, neurology consult and cranial assessment (cranial nerves)

Question 32

How is cardiac death confirmed?

Answer 32

* 2 registered nurses * no lung, no heart sounds * telemetry - print 2 leads with asystole Donation after cardiac death (DCD) 1. No recovery from illness expected 2. Does not meet brain death criteria 3. Dependent on life-sustaining measures

Question 33

What are the 3 organ rejection types?

Answer 33

1. HYPERACUTE Occurs in 24 hours, blood vessels are rapidly destroyed, patient already had preexisting antibodies, usually rare. Organ does have to be removed. 2. ACUTE within 6 months, patient’s own lymphocytes responding and antibodies, usually reversible, additional immunosuppressives, steroids. 3. CHRONIC months to years and irreversible, repeated episodes of acute rejection, T & B cells mediated. Scarring, coronary artery disease, lung injury, fibrosis of kidneys, treatment is supportive.

Question 34

Transplant criteria and postoperative care: LUNG

Answer 34

Candidate criteria • Failed medical/surgical therapies • Expected survival < 24 months LAS score • Estimates chance of first-year survival • Candidates with higher LAS scores have higher priority. Donor criteria • Younger than 55 years • Fewer than 20 pack-years of smoking history • No active pulmonary disease, infection or aspiration, clear chest radiograph, no significant chest trauma ``` Postoperative care/monitoring • Respiratory status (Rejection indications: crackles, SOB) • Hemodynamic status • Fluid and electrolyte balance • Pain control • Early ambulation ``` Immunosuppression Triple therapy: a calcineurin inhibitor (tacrolimus/aka Prograf), corticosteroid (Prednosone), and antimetabolite (mycophenolate/ aka CellCept).

Question 35

Transplant criteria and postoperative care: KIDNEY

Answer 35

Candidate criteria • Dialysis dependent • Glomerular filtration rate < 20 mL/min not on dialysis • Point system ranks candidates based on ABO typing; time on waitlist; HLA Donor criteria • Living or deceased • Paired exchange ``` Postoperative nursing care/monitoring • Respiratory status • Hemodynamic status • Fluid balance • Electrolyte balance • Weight ``` Immunosuppression - Triple therapy consisting of a calcineurin inhibitor, corticosteroid, and antimetabolite. Additional Notes: • A kidney received from a deceased donor may take time to begin to fully function. Once the kidney starts to function, polyuria, oliguria, or anuria may result. Because of the extreme diuresis that can result, fluid replacement therapy is a priority. • Dialysis may be necessary during the postoperative period and is not indicative of rejection. Delayed renal function may be due to acute tubular necrosis (ATN), which may result from prolonged cold ischemia time (time outside the body).

Question 36

Transplant criteria and postoperative care: HEART

Answer 36

``` Candidate criteria • Advanced heart failure unresponsive to medical therapy • Medical urgency criteria Status 1A – most urgent (in ICU) Status 1B Status 2 – least urgent Status 3 = at home ``` Donor criteria • May be over the age of 55 years • CAD history, structural abnormalities, left ventricular function ``` Postoperative nursing care/monitoring • Respiratory status • Hemodynamic status: CO/CI, SVR, PVR • Chest cavity may remain open • Chest tube drainage ``` Immunosuppression- Triple therapy consisting of calcineurin inhibitor, corticosteroid, and antimetabolite Additional Notes: Dysrhythmias are not uncommon during the immediate postoperative period due to warm and cold ischemia times. A decrease in cardiac output or stroke volume must be reported to the physician so that supportive therapy can be instituted.

Question 37

Nursing Management for Organ Transplantation:

Answer 37

Follow facility protocol of when to call the OPO for patient organ donation. Postoperative: 1. Assess for any organ rejection types and symptoms, signs of infection, fluid and electrolyte balance, serum immunosuppressant med levels, oxygen requirements, and report. Educate/reinforce 1. taking immunosuppressants as prescribed; report side effects. 2. to report any organ rejection symptoms. 3. to follow up with appointments.