Care of the Death & Dying

ØOverview: Death & Dying
ØDeath when lungs and heart cease to function
ØMultiple organ dysfunction syndrome (MODS)
ØClinical death: the short interval after the cessation of heartbeat and breathing when no evidence of brain function is present
ØFocus on death as a natural process
ØPalliative Care
ØA philosophy that provides a compassionate & supportive approach to clients & families who are living with life-threatening illnesses
ØA holistic approach that does not hasten or postpone death, but provides relief of symptoms experienced by the dying client while providing emotional & spiritual support to improve the quality of care at the end of life
ØPalliative Care
ØProvides relief from pain & other distressing symptoms
ØAffirms life & regards dying as a normal process
ØIntends neither to hasten nor postpone death
ØIntegrates the psychosocial & spiritual aspects of pt care
ØOffers a support system to help pts live as actively as possible until death
ØOffers a support system to help the family cope during the pt’s illness & in their own bereavement
ØPalliative Care
ØUses a team approach to address the needs of pts & their families, including bereavement counseling, if indicated
ØWill enhance quality of life, & may also positively influence the course of illness
ØIs applicable early in the course of illness, in conjunction w/ other therapies that are intended to prolong life (chemo or radiation tx)
ØInformed Consent & Communication
ØConfidentiality
ØAdvance Directives:
lLiving Will
lDurable Power of Attorney for Health Care
ØMedical Futility
ØDNR/DNAR Orders
ØResearch
ØInformed Consent
ØInformed consent entails right to refuse
ØIt should be given by patient or surrogate
lBut there are exceptions….
lIn the ICU, “blanket consent” covers many situations
ØDocumentation
ØCommunication
ØClear communication is part of good care
ØView self as an “educator” of patient & family (but not just raw data)
ØProvide adequate time for family to talk
ØListen for the underlying values & goals
ØGet comfortable with occasional silences
ØWhat is impact of family interests?
ØURGENT INDICATIONS FOR DISCUSSING END-OF-LIFE CARE
ØImminent death
ØTalk about wanting to die
ØInquiries about hospice or palliative care
ØRecent hospitalization for severe progressive illness
ØSevere suffering & poor prognosis
ØCommunicating w/ Pt’s Family
ØValue what the family members say.
ØAcknowledge their emotions.
ØListen.
ØUnderstand the pt as a person thru asking questions.
ØElicit questions from family members.
ROUTINE INDICATIONS
ØDiscussing prognosis
ØDiscussing tx with low probability of success
ØDiscussing hopes & fears
ØPhysician would not be surprised if the pt died in 6–12 mos
ØCommunication Bloopers
ØDo you want us to do everything?
ØShould we stop everything?
ØThere is nothing more we can do.
ØHe failed all the treatments we’ve tried.
ØWhat do you want us to do if she/he stops breathing?
ØOthers???
ØStereotyping of Patients/Families
ØGeneralizations are rarely useful.
ØIndividuals vary greatly.
ØFind a balance.
ØAvoid nick-names/jokes
lCan impact patient care
•May impact other MDs/RNs
•Patient/family overhears
ØConfidentiality
ØPatient’s reputation could be at stake.
ØEstablish to whom you are giving information.
ØRarely should patient information be withheld from the patient
ØAdvance Directives
ØOral or written expressions by an adult with decision making capacity conveying wishes related to medical care in anticipation of being unable to communicate wishes.
ØPatient, not family, can revoke at any time (document in medical record)
lVerbal or written revocation
lShould have a witness
lExplicit documentation
ØQuestions to ask to a pt about AD
ØIf you were to get so sick that you could not talk to me directly, who should I talk to help me make decisions about your care?
ØDoes this person know about this responsibility?
ØDoes he or she know what you want?
ØWhat would you want?
ØHave you written down what you want?
ØLiving Will
ØTerminal illness & patient lacks decision-making capacity.
ØAllows specific instructions: to receive or withhold/withdraw treatments
ØIt requires compliance
ØInvolvement of surrogate is not necessary.
ØDurable Power of Attorney for Health Care
ØActivated when decision making incapacity occurs
ØNames agent empowered to make medical decisions
ØApplies to any medical decision with limited exceptions
ØAllows specific instructions
ØProcedures for Handling ADs
ØInquire about existence of AD
ØSocial worker/EPIC maintains copies
ØPlace newly acquired copies of AD on chart and inform Social Worker
ØSocial Worker ( and Pastoral Care) can assist patient in completing an AD
ØDecision Makers
ØLegal guardian
ØMedical Power of Attorney
ØSpouse
ØMajority of adult children
ØParents
ØMajority of adult siblings
ØNearest adult related by blood or adoption who is reasonably available
ØPortable DNAR (DNR)
ØState-wide logo for Identification & Orders
ØProvides immunity for compliance with law
ØFor patients arriving with portable DNR, rewrite on DNAR/DNR order form
ØA DNAR/DNR is an Attending Physician’s order
ØDNR Comfort Care
ØYou will:
lSuction the airway
lAdminister oxygen
lPosition for comfort
lSplint or immobilize
lControl bleeding
lProvide pain medication
lContact other appropriate health care providers such as hospice, home health, AP/CNP
lProvide emotional support
ØDNR Comfort Care Protocol
ØYou will not:
lAdminister chest compressions
lInsert an artificial airway
lAdminister resuscitative drugs
lDefibrillate or cardiovert
lProvide respiratory assistance (other than suctioning the airway & administering oxygen)
lInitiate resuscitative IV, or initiate cardiac monitoring
ØActivation of DNAR Protocol
ØDNAR Comfort Care:
lAt time order is given
ØDNAR Comfort Care – Arrest:
lAt time of cardiac or respiratory arrest
•Cardiac arrest – absence of palpable pulse
•Respiratory arrest – absence of spontaneous respirations/presence of agonal breathing
ØDNAR - Specified
ØAppropriate for patients that might not want CPR, but would like other medical interventions
ØRaises questions about partial/limited CPR attempts
ØShould make “medical sense”
ØConsent for DNAR Orders
ØInformed consent of patient or surrogate
ØNo obligation to initiate CPR if resuscitation would be futile, i.e.,:
lIf resuscitation would not achieve its physiological objective
lwould offer no benefit to the patient
lwould violate reasonable medical standards
ØDNAR in the OR
ØPrior to any invasive procedure any existing DNAR order should be reviewed with patient or patient’s surrogate
ØChanges should be documented in the patient’s medical record with a notation indicating when & if the original DNAR order should be reinstated
ØWhen does a surgical procedure end?
ØGoals for End-of-Life Care
ØControl symptoms
ØIdentify client needs
ØPromote meaningful interactions between the client & significant others
ØFacilitate a peaceful death
ØHospice Care
ØAn interdisciplinary approach facilitates both quality of life & a “good” death for clients who are nearing the end of their lives.
ØHospice programs are often affiliated with home care agencies, providing services to families at home or in an extended care facility.
ØHospice Care Team
ØThe family
ØA physician
ØA nurse, who usually serves as a case manager and coordinates care with other disciplines
ØCounselors, including psychologists and clergy
ØA social worker
ØHome health aides
ØTrained volunteers
ØPsychosocial Assessment
ØFear
ØAnxiety
ØCultural considerations & bereavement
ØFeelings of client & significant others
ØFatigue Management
ØAspiration precautions
ØMouth care & moisture for lips
ØAltered routes of medication administration if needed—choose the least invasive route of medication administration with the most effective treatment
ØPain Management
ØPain is the symptom that dying clients fear most.
ØPain medications should be scheduled to prevent any recurrence of pain.
ØConsider alternative route of pain medication administration as needed.
ØWHO 3-Step Dosing Model For Pain Management
ØStep 1: Mild pain
lAnalgesics include aspirin, acetaminophen, & nonsteroidal anti-inflammatory drugs (NSAIDs)
•NSAIDs can cause GI bleeding
•Acetaminophen can be toxic at doses exceeding 4 gm in 24 hours, particularly in pts w/ compromised liver function.
ØStep 2: Moderate pain
lOpioids such as codeine, fentanyl, hydrocodone, hydromorphone, morphine, & oxycodone
lOpioid is combined with either acetaminophen or aspirin
ØWHO 3-Step Dosing Model For Pain Management
ØStep 3: Severe pain
lOpioid & a NSAID are combined with adjuvant drugs such as antidepressants
•Many opioids are available in sustained-release form as tablets & granules
•Fentanyl is also available in a skin patch that will last up to 72 hours
ØDyspnea Management
ØTreatment of the primary cause & relieve the psychological distress that accompanies the symptom
ØMorphine sulfate
ØDiuretics
ØBronchodilators
ØAntibiotics
ØAnticholinergics
ØSedatives
ØOxygen
ØNausea & Vomiting Management
ØAntiemetic agents
ØEspecially evident in persons with AIDS or breast, stomach, or gynecologic causes
ØRestlessness & Agitation Management
ØTreat the underlying cause.
ØAdminister sedatives.
ØConsult with a spiritual and/or bereavement counselor.
ØPhysical & Emotional Support
ØBeing realistic about the facts of death & dying
ØEncouraging reminiscence of client’s life memories & stories of events
ØPromoting spirituality including religion
ØFostering hope for clients & their families
ØAvoiding explanations of the loss
ØCommunicating with the client
ØProviding referrals to bereavement specialists
ØGRIEF AND LOSS
ØLOSS is a universal experience that occurs throughout life span; something valuable is gone
ØGRIEF is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement; total response to emotional experience related to loss
ØBEREAVEMENT= Subjective response by loved-ones
ØMOURNING= behavioral response
ØResponses to loss are strongly influenced by one’s cultural background
ØThe grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss.
ØSTAGES OF GRIEVING (Kubbler-Ross)
ØDenial- refuses to believe that the loss has occurred
ØAnger- the individual resists the loss & may “act out” feelings
ØBargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss
ØDepression- overwhelming feeling of loneliness & withdrawal from others
ØAcceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, & the interaction to other people resumed
ØLoss & Death RESPONSIBILITIES
ØProvide Relief from loneliness, fear & depression
ØHelp clients maintain sense of security
ØHelp clients accept losses
ØProvide physical comfort
ØDeath & Dying (Kozier)
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØAGE-RELATED CONCEPTS OF DEATH IN CHILDREN
ØSymptomatology of Dying
ØOne to three months prior to death:-Anorexia-Spiritual Distress
-Nausea & Vomiting-Fatigue/increased need for sleep-withdrawal from the world and from people ( h introspection / talking less)-malodorous wounds
ØOne to two weeks prior to death:- Confusion
- Picking at Clothes / Tubing
- Seeing / Talking to the Deceased
- Terminal Restlessness/Agitation
- i blood pressure- h or i pulse- skin color changes – pale or blue- h perspiration / body temp. changes- sleeping most of the time
ØDays or Hours prior to death:-Fixed stare (Eyes glassy, tearing, half or fully open) - Wavering level of consciousness
- surge of energy / restlessness or no activity- irregular breathing / periods of apnea- weak pulses / cool extremities- i urine output & incontinence- cannot be awakened
ØCare During the Last Hours
ØWhen it is apparent that death is imminent, health professionals need to alert the family and confirm the goals of care. It should be documented in the patient's chart, including the observation that the patient is dying.
ØSigns that death has occurred include:
·Lack of respiration or pulse
·Eyes open but do not move or blink; pupils dilated
·Jaw relaxed; mouth slightly open
·Bowel and bladder contents expelled
·Patient does not respond to touch or speech
ØWhen death has occurred, nurses or other clinicians need to express their sympathy to the family. It is enough to say "I am sorry for your loss."
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØSIGNS & SYMPTOMS OF IMMINENT DEATH
ØNursing Responsibilities In Death & Dying
ØNurses need to take time to analyze their own feelings about death before they can effectively help others with terminal illness
ØThe major goals for the dying clients are:
l1. To maintain PHYSIOLOGIC and
l2. PSYCHOLOGIC support
l3. To achieve a dignified & peaceful death
l4. To maintain personal control
ØThe Dying Person’s Bill of Rights
ØCreated by Amelia J. Barbus (Associate Prof. of Nursing at Wayne State University)
lI have the right to be treated as a living human being until I die.
lI have the right to maintain a sense of hopefulness however changing its focus may be.
lI have the right to be cared for by those who can maintain a sense of hopefulness, however challenging this might be.
lI have the right to express my feelings & emotions about my approaching death in my own way.
lI have the right to participate in decisions concerning my care.
ØThe Dying Person’s Bill of Rights
lI have the right to expect continuing medical & nursing attention even though "cure" goals must be changed to "comfort" goals.
lI have the right not to die alone.
lI have the right to be free from pain.
lI have the right to have my questions answered honestly.
lI have the right not to be deceived.
lI have the right to have help from & for my family in accepting my death.
lI have the right to die in peace & dignity.
ØThe Dying Person’s Bill of Rights
lI have the right to retain my individuality & not be judged for my decisions w/c may be contrary to beliefs of others.
lI have the right to discuss & enlarge my religious &/or spiritual experiences, whatever these may mean to others.
lI have the right to expect that the sanctity of the human body will be respected after death.
lI have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs & will be able to gain some satisfaction in helping me face my death.
ØPOSTMORTEM CARE
ØDeath must be certified by a physician—in a formal process called pronouncement
ØAll equipment and supplies need to be removed from the bedside and any soiled linen removed from the room.
ØAgency policy may differ on how to deal with tubes that were in place at the time of death.
ØPostmortem Care
ØLegal considerations, such as death certificate
ØDetermination of the need for an autopsy
ØTransfer of the body
ØPOSTMORTEM CARE
ØHow the body is cared for after death is influenced by religion or culture- health professionals should be aware of any preferences or limitations and comply with them.
ØPlace the body in a supine position with a pillow under the head and shoulders avoids discoloration of the face.
ØEyelids are closed; holding them closed for a few seconds helps them to remain closed.
ØIf the person wore dentures, those are inserted to give the face a more natural appearance.
ØPlacing a rolled towel under the chin will hold the mouth closed.
ØPOSTMORTEM CARE
ØThe arms are positioned either at the sides of the body or across the abdomen.
ØThe identifying wristband is left on unless it has become too tight due to fluid retention.
ØAny soiled areas of the body are washed and absorbent pads are placed under the buttocks.
ØA clean gown is placed on the body and the hair is brushed or combed.
ØAny jewelry is removed, except for a wedding band, which is taped to the finger.
ØPOSTMORTEM CARE
ØThe body is carefully covered up to the shoulders with clean bed linens.
ØAll belongings of the deceased are listed and placed in a safe storage area for the family.
ØSoft lighting is preferred and chairs are made available for family members. Clinicians need to reassure family members that they should take as much time as they need to say their last goodbyes. Only when the family leaves the room should final preparations for removal of the body be initiated.
ØPOSTMORTEM CARE
ØAfter the family has viewed the body, the care provider attaches additional ID tags, one to the ankle and another to the wrist (if the deceased person's wristband has been removed).
ØThe entire body is then wrapped in a shroud, either plastic or cotton, and another ID tag affixed to the outside of the shroud. Then the body is either picked up by the responsible mortician (undertaker) or sent to the morgue until arrangements are made with a mortician.
ØSome hospitals or other agencies close the doors to all patient rooms before transporting a body through the corridors and service elevators and require the use of service elevators rather than public elevators during this transfer.
ØAUTOPSY
ØIt contributes to medical education, aids in the characterization of newly emerging diseases, and advances the understanding of disease-related changes. It can also reveal errors in clinical diagnosis.
ØHealth professionals need to determine whether the family has any religious or cultural concerns about autopsy procedure.
ØFamilies also need to know that autopsy does not disfigure the body and would not interfere with having an open-casket service.
ØORGAN DONATION
ØIdeally, questions about organ donation are discussed with the patient in the context of advance directives. This relieves the family of making the decision during the stressful time immediately after death. Unless the patient has documented the wish to become an organ donor, the family must decide.
ØFederal law requires that only a designated representative of an organ procurement organization (OPO) or a "designated requestor" may approach the family about organ donation.
ØCARING FOR THE FAMILY DURING BEREAVEMENT
ØBegins when a loved one is diagnosed with terminal illness, initiating a period of anticipatory grieving for both patient and family.
ØAfter the patient dies, family members continue to grieve until they become resolved to live without the deceased.
ØIt may take weeks, months; for others, grieving may take a year or longer.
ØThe way in which a person will grieve depends on the personality of the grieving individual, his/her relationship with the person who died, the situation surrounding the loss, and the attachment to the person.
ØCARING FOR THE FAMILY DURING BEREAVEMENT
ØGrief reactions can be:
lPsychological & emotional: anger, guilt, anxiety, sadness, and despair
lPhysical: difficulties, appetite changes, somatic complaints, or illness
lSocial: feelings about taking care of others in the family, the desire to see or not see family or friends, or the desire to return to work
Ø3 Tasks Of Grief Work (Lindemann)
1.Freedom from ties to the deceased
2.Readjustment to the environment from which the deceased is missing
3.Formation of new relationships