Transcript Everything you wanted to know about EOL care but

Everything you wanted to
know about EOL care but
were afraid to ask!
Rita D. Anger, MS, RN, CHPN
Objectives
• Communicate effectively and compassionately
with the patient, family, and health care team
members about end-of-life issues
• Recognize symptoms (pain, dyspnea,
constipation, anxiety, fatigue,
nausea/vomiting, and altered cognition)
sometimes experienced by patients at end of
life
Objectives (cont.)
• Recognize one’s own attitudes, feelings,
values and expectations about death and the
individual
• Promote the provision of comfort care to the
dying as an active, desirable, and important
skill, and as an integral component of nursing
care
FACT
• “End-0f-Life Picture
Grows Bleaker”
• “Dying in America:
Experts Commend IOM
report, With Caveats”
• “End-of-Life
Discussions: Clinicians
Identify Important
Barriers”
Need for EOL education
• Last Acts Campaign
• Mobilized a coalition of health care &
consumer groups to improved EOL care
• American’s report card (1999): Advance
directive policies, location of death (in relation
to pts wishes), care in ICU’s at EOL, pain
among nursing home patients, state pain –
controlled policies - ALL F’s
Results?
• Thirty states have created EOL organizations
• DNR demonstration project
• End of Life Nursing Education Consortium
(ELNEC)
• Education for physicians on end of life
curriculum
• Initiative for Pediatric palliative care
ELNEC Curriculum
• Nursing care at end of life
(overview of death & dying
in America)
• Pain management
• Symptom management
• Ethical/legal issues
• Cultural considerations in
end of life care
• Communication
• Grief, loss, and
bereavement
• Achieving quality care at
end of life
• Preparation and care for
the end of life
Why educate on EOL
care?
• Nurses spend more time with patients at the
end of life than any other health care discipline
• Nurses do not feel confident in initiating EOL
Care
• All nursing students and nurses should be
prepared to provide compassionate and
effective EOL care to patients across care
settings
Communication
• Open, honest communication as death approaches
• In all communication, convey caring, nurturing,
sensitivity, and compassion
• Provide information in simple, uncomplicated terms
• Maintain presence
• Terminal illness is a family experience
• Sharing information so individuals may make informed
decisions
Barriers to
Communication
• Fear of mortality
• Fear of not knowing
• Lack of experience
• Disagreement with
decision
• Avoidance of emotion
• Insensitivity
• Lack of understanding
culture or goals
• Sense of guilt
• Personal grief issues
• Ethical concerns
Know yourself
• Listen
• Presence
• Learn communication strategies to facilitate
End-of-Life decisions
• Use words such as “death” and “dying”
• Maintain hope
IOM Report
• http://www.iom.edu/~/media/Files/Report%20Fi
les/2014/EOL/Table%20%20Core%20Components%20of%20Quality%20C
are.pdf
Advance Directives
• Living Will
• Written document
• Directs treatment in
accordance with
patient’s wishes
• Durable power of
attorney for health
care
• Designates
spokesperson to
represent patient in
decision-making
Advance Directives
• Living wills – greater
difficulties in
interpretation
• THEY CAN significantly
help families
understand
• Usefulness limited
• All 50 states have some
type of AD legislation
• No document can
guarantee pt’s wishes
be fully known
DO NOT RESUSCITATE!!
• Patients have the right to refuse resuscitative efforts.
They also have the right to revoke the DNR at ANY
time
• DNR requires specific written orders from physician
• Resuscitation effort should begin when in doubt or
when written orders are not present
• Patient does NOT need to have a living will before a
DNR order can be entered
• IT DOES NOT MEAN “DO NOT TREAT”
POLST
• http://www.healthynh.com/images/PDFfiles/ad
vancedirectives/POLST/POLST%20Overview1.pdf
NH POLST FORM
• http://www.tidyform.com/download/newhampshire-polst-form.html
Other Concerns
• Vent support
• Medically provided
nutrition & hydration
• Can be permanently
necessary
• “Sustenance of life” :
“symbolism of feeding is
intimately linked to
caring” ANA
• Withdrawal should be
viewed differently than
withdrawal of other life
sustaining therapies
(like dialysis)
• Evaluate by benefits,
burdens, efficacy and
desirability w/ regards to
goal of care
• ETHICAL DECISIONS
Artificial nutrition &
hydration
• HPNA
• “Artificial nutrition & hydration is considered
medical treatment and thus can be requested
or refused……the decision to initiate,
withhold, or withdraw ANH should be made by
the patient & family with accurate and
nonjudgmental input from the healthcare
team.”
Dying Person’s Bill of
Rights
• Right to autonomy
• Right to hear the truth
• Right to main hope as
the focus changes
• Right to be in control
• Right to express
feelings & emotions
• Right to have
spirituality respected
• Right to be free of pain
• Right not to die alone
The Dying Patient
Signs, Symptoms & Nsg Interventions
• Determining prognosis
• NO ONE CAN PREDICT EXACT TIME OF DEATH
• Affected by disease, patient’s will to live,
desire/choice to wait, completion of life
closure goals
• Signs and symptoms of the dying process only
serve as guideline
Sx/Symptoms (cont.)
• Natural slowing down
• Decreased po intake
• Usual road: sedation,
lethargy, gradual
obtundation, death
• Decreased swallow
reflex
• Confusion,
disorientation, delirium
• Weakness & fatigue
• Increased drowsiness
• Surges of energy
• Restlessness and/or
terminal agitation
• Fever, incontinence
Pain during the final
hours of life
• Assessment & management of pain is critical
• Diminished consciousness
• Rule out causes of pain
• Assess, reassess and then reassess!
OPIOIDS
• Morphine, mscontin, msir, mscr, roxanol
• Oxycontin, oxycodone, oxycodone cr,
oxycodone ir
• Dilaudid
• Fentanyl
Rule of Double Effect
• HPNA defines as
• “a bioethical concept that provides moral
justification for an action that has two foreseen
effects; one good and one bad. The key factor is
the INTENT of the person performing the act. If
the intent is good (e.g., relief of pain and
suffering) then the act is morally justifiable even if
it causes a forseeable but unintended result (e.g.,
hastening of death)”.
• DO NOT CONFUSE WITH Assisted suicide or
euthanasia!
Terminal Dyspnea
• Shortness of breath
• Awareness of difficult and uncomfortable
breathing, many pts describe as agonizing and
worse than pain
• Terminal dyspnea or AIR HUNGER, occurs in as
many as 75% of the imminently dying
• IT SHOULD BE ANTICIPATED IN ALL DYING
PATIENTS
Terminal Dyspnea
• In the dying patient, relief of dyspnea is
important, NOT THE PROLONGATION OF LIFE
• Morphine alters the perception of
breathlessness and reduces anxiety, thereby
reducing oxygen consumption (demand)
• Improves O2 supply and reduces lung
congestion
Nausea & Vomiting
• Vestibular
• Bowel obstruction
• Dysmotility of upper gut
• Infection, inflammation
• Toxins stimulating chemoreceptor trigger zone
in the brain
Treatment of N/V
• Metoclopramide (not in the case of a possible
bowel obstruction)
• Promethazine
• Prochlorperazine
• Haloperidol
• Lorazepam
Delirum/terminal
agitation
• Poorly defined
• Often confused w/ drug side effects,
confusion, dementia and/or agitation
• Emotional issues
• Spiritual issues
• Grounding
Treatment
• Haloperidol
• Has fewer anticholinergic side effects, few
active metabolites, and relatively small
likelihood of causing sedation & hypotension
compared to other antipsychotic agents
• Versed
• ABHR
Imminent Death
• Decreased urine output
• Cold & mottled
extremities
• VS changes
• Loss of ability to
swallow
• Loss of sphincter
control
• Respiratory congestion
• Pain? Physical vs
spiritual
• Breathing pattern
changes
• Burst of energy? “The
Rally”
• Restlessness
Common fears of family
• Being alone with the patient
• Pt will have a painful death
• Being alone with the patient and not knowing
how to react
• Giving the “last dose” of pain medication &
causing death
COMFORT
• The greatest gift we can give patient and family
members during this time is the ability to see their
loved one free of pain
• Comfort measures:
• Frequent repositioning & oral hygiene
• Encourage family to talk to their loved one
• EMOTIONAL SUPPORT OF FAMILY IS IMPERATIVE
What would you do to
calm their fears?
• Increase support and care to the
pt and family by:
• Collaboration with physician
• Seed increased presence
• Reassure family
• Educate family
• Spiritual comfort
• Physical comfort care
• Honor cultural beliefs
Family
• Instruct on five “tasks”
• 1. To ask forgiveness
• 2. To forgive
• 3. To say “thank you”
• 4. To say “I love you” and
• 5. To say good-bye
(Byock, 1997)
End of Life
• Labor and delivery
• Hospice
• Pediatrics
• Long term care
• Medical surgical
• Assisted living
• Mental Health
• ED
• ICU/PACU
• Home care
Young and
Old!!!!
My philosophy!
• My patients are my
teachers!
• And so…………
• Watching a peaceful death of a human being
reminds us of a falling star; one of a million
lights in a vast sky that flares up for a brief
moment only to disappear into the endless
night forever.
• Elisabeth Kubler-Ross
Further Readings
• Being Mortal by Atul Gawande
• The Conversation by Angelo Volandes
• http://kaiserhealthnews.org/news/learning-abouthospice-should-begin-long-before-you-are-sick/
• http://opinionator.blogs.nytimes.com/2015/01/31/dyingshouldnt-be-so-brutal/?_r=1
• www.choosingwisely.org
More Readings!
• http://www.healthynh.com/images/PDFfiles/ad
vancedirectives/POLST/POLST%20Overview1.pdf
• End of Life: A nurse’s guide to compassionate
care. Lippincott Williams & Wilkins (2007)
ISBN-13: 978-1-58255-660-4