EndofLife Care Chapter 55 z Copyright 2017 Elsevier

End-of-Life Care Chapter 55 z Copyright © 2017, Elsevier, Inc. All rights reserved.

2 z End-of-Life Care § End-of-life care describes the support and care given during the time surrounding death. § Death may be sudden or expected. § Some people gradually fail. § End-of-life care may involve days, weeks, or months. Copyright © 2017, Elsevier, Inc. All rights reserved. § According to the National Institute on Aging, most people die in hospitals or nursing centers. § Hospice care is becoming a common option. § You must understand the dying process. § Then you can approach the dying person with caring, kindness, and respect.

3 z Terminal Illness § Terminal illness is an illness or injury from which the person will not likely recover. § Many illnesses and diseases have no cure. § The body cannot function after some injuries. § Recovery is not expected. § The disease or injury ends in death. Copyright © 2017, Elsevier, Inc. All rights reserved. § Doctors cannot predict the time of death. § Hope and the will to live strongly influence living and dying.

4 z Terminal Illness (Cont. ) § Persons with terminal illnesses can choose palliative care or hospice care. § Palliative care—focuses on relief of symptoms. The illness is also treated. § Care is for a long-term illness that will cause death. § Settings include hospitals, nursing centers, and the person’s Copyright © 2017, Elsevier, Inc. All rights reserved. home. § Hospice care—focuses on the physical, emotional, social, and spiritual needs of dying persons and their families. Hospice care is not concerned with cure or life-saving measures. § Often, the person has less than 6 months to live. § Hospitals, nursing centers, and home care agencies offer hospice care, or a hospice may be a separate agency.

5 z Attitudes About Death (Cont. ) § Spiritual needs relate to the human spirit and to religion and religious beliefs. § Attitudes about death are closely related to religion. § Some believe in an afterlife; others do not. § There also are religious beliefs about the body’s form after Copyright © 2017, Elsevier, Inc. All rights reserved. death. § Some believe the body keeps its physical form § Others believe only the spirit or soul is present in the afterlife. § Reincarnation is the belief that the spirit or soul is reborn in another human body or in another form of life.

6 z Attitudes About Death (Cont. ) § Age § Adults fear: § Pain and suffering § Dying alone § The invasion of privacy Copyright © 2017, Elsevier, Inc. All rights reserved. § Loneliness and separation from loved ones § Adults worry about the care and support of those left behind. § Adults often resent death because it affects plans, hopes, dreams, and ambitions.

7 z The Stages of Dying § Dr. Elisabeth Kübler-Ross described five stages of dying. § Stage 1: Denial § § Stage 2: Anger § § Copyright © 2017, Elsevier, Inc. All rights reserved. The person thinks, “Yes, me” and is very sad. Stage 5: Acceptance § § The person now says, “Yes, me, but. . . ” Stage 4: Depression § § The person thinks “Why me? ” Stage 3: Bargaining § § “No, not me” is a common response. The person is calm and at peace. Dying persons do not always pass through all five stages. Some move back and forth between stages.

8 z Comfort Needs § Comfort involves physical, mental and emotional, and spiritual needs. § Comfort goals are to: § Prevent or relieve suffering to the extent possible § Respect and follow end-of-life wishes Copyright © 2017, Elsevier, Inc. All rights reserved. § You need to listen and use touch. § Some people may want to see a spiritual leader. § Some want to take part in religious practices. § Provide privacy during prayer and spiritual moments. § Be courteous to the spiritual leader. § Handle religious objects with care and respect.

9 z Comfort Needs (Cont. ) § Physical needs § Dying may take a few minutes, hours, days, or weeks. § To the extent possible, independence is allowed. Copyright © 2017, Elsevier, Inc. All rights reserved. § As the person weakens, basic needs are met. § Every effort is made to promote physical and psychological comfort. § The person is allowed to die in peace and with dignity.

10 z Comfort Needs (Cont. ) § Pain § Some dying person do not have pain. Others may have severe pain. § Pain management is important. § The following promote comfort: § Good skin care Copyright © 2017, Elsevier, Inc. All rights reserved. § Personal and oral hygiene § Back massages § Good alignment § Frequent position changes § Supportive devices

11 z Comfort Needs (Cont. ) § Breathing problems § Shortness of breath and difficulty breathing (dyspnea) are common end-of-life problems. § Semi-Fowler’s position and oxygen are helpful. Copyright © 2017, Elsevier, Inc. All rights reserved. § Noisy breathing—called the death rattle—is common as death nears. § This is due to mucus collecting in the airway. These may help: the side-lying position; suctioning by the nurse; and drugs to reduce the amount of mucus.

12 z Comfort Needs (Cont. ) § Vision, hearing, and speech § Vision blurs and gradually fails. § Secretions may collect in the eye corners. § Good eye care is needed. § Hearing is one of the last functions lost. Copyright © 2017, Elsevier, Inc. All rights reserved. § Always assume that the person can hear. § Speech becomes harder. § It may be hard to understand the person. § Sometimes, the person cannot speak.

13 z Comfort Needs (Cont. ) § Mouth, nose, and skin § Oral hygiene promotes comfort. § Oral hygiene is needed if mucus collects in the mouth and the person cannot swallow. § Crusting and irritation of the nostrils can occur. § Nasal secretions, an oxygen canula, and a naso Copyright © 2017, Elsevier, Inc. All rights reserved. -gastric tube are common causes. § Circulation fails and body temperature rises as death nears. § The skin is cool, pale, and mottled (blotchy). § Perspiration increases. § Skin care, bathing, and preventing pressure ulcers are necessary.

14 z Comfort Needs (Cont. ) § Nutrition § Nausea, vomiting, and loss of appetite are common at the end of life. § As death nears, loss of appetite is common. § The person may choose not to eat or drink. Copyright © 2017, Elsevier, Inc. All rights reserved. § Elimination § Urinary and fecal incontinence may occur. § Constipation and urinary retention are common. § Enemas and catheters may be needed.

15 z Comfort Needs (Cont. ) § The person’s room: § Provide a comfortable and pleasant room. § Remove unnecessary equipment. Copyright © 2017, Elsevier, Inc. All rights reserved. § The person and family arrange the room as they wish. § This helps meet love, belonging, and esteem needs. § The room should reflect the person’s choices.

16 z Comfort Needs (Cont. ) § Mental and emotional needs are very personal. § Some persons are anxious or depressed. § Others have specific fears and concerns. Examples include: Copyright © 2017, Elsevier, Inc. All rights reserved. § Severe pain § When and how death will occur § What will happen to loved ones § Dying alone

17 z The Family § This is a hard time for the family. § Show you care by being available, courteous, and considerate. § Family members usually can stay as long as they Copyright © 2017, Elsevier, Inc. All rights reserved. wish. § Respect the right to privacy. § However, do not neglect care because the family is present. § The family goes through stages like the dying person. § They need support, understanding, courtesy, and respect. § A spiritual leader may provide comfort.

18 z Legal Issues § Consent is needed for any treatment. § When able, the person makes care decisions. § Some people make end-of-life wishes known. Copyright © 2017, Elsevier, Inc. All rights reserved. § The Patient Self-Determination Act and OBRA give persons the right to: § Accept or refuse treatment § Make advance directives § An advance directive is a document stating a person’s wishes about health care when that person cannot make his or her own decisions.

19 z Legal Issues (Cont. ) § A living will is a document about measures that support or maintain life when death is likely. § A living will may instruct doctors: § Not to start measures that prolong dying § To remove measures that prolong dying § Durable power of attorney for health care gives the power to Copyright © 2017, Elsevier, Inc. All rights reserved. make health care decisions to another person (Health Care Proxy). § After consulting with the person and family, doctors often write “Do Not Resuscitate” (DNR) or “No Code” orders for terminally ill persons. § This means that the person will not be resuscitated.

20 z Signs of Death § In the weeks before death, the following may occur: § Restlessness and agitation § Shortness of breath § Depression § Anxiety § Drowsiness § Confusion Copyright © 2017, Elsevier, Inc. All rights reserved. § Constipation or incontinence § Nausea § Loss of appetite § Healing problems § Swelling in the hands, feet, or other body areas § Pauses in breathing

21 z Signs of Death (Cont. ) § As death nears, the following signs may occur fast or slowly: § Movement, muscle tone, and sensation are lost. § Peristalsis and other gastrointestinal functions slow down. § Body temperature rises. § Circulation fails. Copyright © 2017, Elsevier, Inc. All rights reserved. § The respiratory system fails. § Pain decreases as the person loses consciousness. § The signs of death include no pulse, no respirations, and no blood pressure. § The pupils are fixed and dilated. § A doctor determines that death has occurred.

22 z Care of the Body After Death § Care of the body after death is called post-mortem care. § A nurse gives post-mortem care. Copyright © 2017, Elsevier, Inc. All rights reserved. § You may be asked to assist. § Post-mortem care begins when the doctor pronounces the person dead. § Post-mortem care is done to maintain a good appearance of the body.

23 z Care of the Body After Death (Cont. ) § The right to privacy and the right to be treated with dignity and respect apply after death. § Within 2 to 4 hours after death, rigor mortis (the stiffness or rigidity of skeletal muscles that occurs after death) develops. § The body is positioned in normal alignment before rigor Copyright © 2017, Elsevier, Inc. All rights reserved. mortis sets in. § When an autopsy is done, post-mortem care is not done. § An autopsy is the examination of the body after death. § Follow agency procedures for an autopsy.