Care at the End of Life

1. 11 Lecture Note PowerPoint Presentation Care at the End of Life

2. LEARNING OUTCOME 1 Describe the role of the nurse in providing quality end-of-life care for older persons and their families.

3. Nurses’ Unique Qualifications to Provide End-of-Life Care • Holistic view • Comprehensive • Effective • Compassionate • Cost effective

4. Nurses’ Involvement in End-of-Life Care • Spend the most time with patients and their family members at the end-of- life than any other member of the healthcare team • Provide education, support, and guidance throughout the dying process

5. Nurses’ Involvement in End-of-Life Care • Advocate for improved quality of life for the person with serious illness • Attend to physical, emotional, psychosocial, and spiritual needs of the patient

6. Nurses Who Help the Patient Die Comfortably and With Dignity Provide the Following Benefits of Good Nursing Care: • Attend to pain and symptom control • Relieve psychosocial distress • Coordinate care across settings with high-quality communication between healthcare providers • Prepare the patient and family for death

7. Nurses Who Help the Patient Die Comfortably and With Dignity Provide the Following Benefits of Good Nursing Care: • Clarify and communicate goals of treatment and values • Provide support and education during the decision-making process, including the benefits and burdens of treatment

8. Nurses Who Care for the Dying • Are well educated • Have appropriate supports in the clinical setting • Develop close collaborative partnerships with hospice and palliative care service providers

9. Nurses Who Care for the Dying • Must be confident in their clinical skills • Are aware of the ethical, spiritual, and legal issues they may confront while providing end-of-life care

10. Nurses Need to be Aware of Personal Feelings About Death • Improves ability to meet holistic needs of the patient and family • Clarifies one’s own beliefs and values

11. Meaning of Hope Shifts • From striving for cure to achieving relief from pain and suffering • No “right” or “correct” way to die: It's everybody's right to live independent and die with dignity

12. Table 11-1Questions and Critical Thinking in Preparation to Care for Dying Patients

13. LEARNING OUTCOME 2 Recognize changes in demographics, economics, and service delivery that require improved nursing interventions at the end of life.

14. Changing Statistics • Primary cause of death • 10 leading causes of death account for 80% of all deaths in the United States • Heart disease • Malignant neoplasms • Cerebrovascular disease • Chronic lower respiratory disease • Accidents • Diabetes mellitus

15. Changing Statistics • Primary cause of death • 10 leading causes of death account for 80% of all deaths in the United States • Influenza • Pneumonia • Alzheimer’s disease • Renal disease • Septicemia

16. Changing Statistics • Demographic trends • Today, more deaths occur at home • The average life span is 77.9 years compared to only 50 in 1900 • the average life expectancy in Jordan is 73.1 • Social trends • Today, caregivers are more likely to be professionals rather than family members

17. Exact Cause of Death Difficult to Determine in the Older Person • Multiple comorbid conditions (is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder) • Acute injury added • Unexpected pathology

18. Most Americans Prefer to Die at Home • 50% die in hospitals • 25% die in long-term-care facilities • 20% die at home or the home of a loved one • 5% die in other settings

19. Survey Results of Healthcare System Care of Dying People • Excellent: 3% • Very good: 8% • Good: 31% • Fair: 33% • Poor: 25%

20. Barriers to Quality End-of-Life Care • Failure of healthcare providers to acknowledge the limits of medical technology • Lack of communication among decision makers • Disagreement regarding the goals of care • Failure to implement a timely advance care plan

21. Barriers to Quality End-of-Life Care • Lack of training about effective means of controlling pain and symptoms • Unwillingness to be honest about a poor prognosis • Discomfort telling bad news • Lack of understanding about the valuable contributions to be made by referral and collaboration with comprehensive hospice or palliative care services

22. LEARNING OUTCOME 3 Describe how pain and presence of adverse symptoms affect the dying process.

23. Nurse’s Role in Pain Treatment • Initial and ongoing assessment of levels of pain • Administration of pain medication • Evaluation of effectiveness of pain medication

24. How Nurses Can Alleviate the Distress Associated with Untreated Pain • Ongoing assessment of levels of pain • Administration of pain medication • Evaluation of the effectiveness of the pain management plan

25. Negative Outcomes of Pain • Potential to hasten death • Associated with needless suffering at the end of life • People in pain do not eat or drink well • Inability to engage in meaningful conversations with others • Isolation in order to save energy and cope with the pain sensation

26. Reasons for Undertreatment of Pain • Patient’s inability to communicate due to • Delirium • Dementia • Aphasia (speechless) • Motor weakness • Language barriers

27. Causes of Inadequate Care at End of Life • Disparity in access to treatment • Insensitivity to cultural differences • Attitudes about death • Attitudes about end-of-life care • African-Americans prefer aggressive life-sustaining treatments • Mexican-Americans, Korean-Americans, and Euro-Americans prefer less aggressive treatment

28. Causes of Inadequate Care at End of Life • Mistrust of the healthcare system • Pain is subjective and self-report is considered accurate

29. Pain characteristics in Cognitively-Impaired Older Persons • Moaning or groaning at rest or with movement • Failure to eat, drink, or respond to presence of others • Grimacing or strained facial expressions

30. Pain Mannerisms in Cognitively-Impaired Older Persons • Guarding or not moving body parts • Resisting care or noncooperation with therapeutic interventions • Rapid heartbeat, diaphoresis, change in vital signs

31. Pain Treatment Based on Accurate Pain Assessment • Systematic • Ongoing

32. Patient Questions Regarding Usual Reactions to Pain • Do you usually seek medical help when you believe something is wrong with you? • Where does it hurt the most? • How bad is the pain (may use the facility pain indicator such as smiley face or rate the pain on a scale of 1 to 10) • How would you describe the pain (sharp, dull, shooting)?

33. Patient Questions Regarding Usual Reactions to Pain • Is the pain accompanied by other troublesome symptoms such as nausea, diarrhea, and so on? • What makes the pain go away? • Are you able to sleep when you are having the pain?

34. Patient Questions Regarding Usual Reactions to Pain • Does the pain interfere with your other activities? • What do you think is causing the pain? • What have you done to alleviate the pain in the past?

35. Pain During the Dying Process • Acute • Sudden onset • Usually associated with single cause or event

36. Pain During the Dying Process • Chronic • Associated with long-term illness • Always present • Varies in intensity • Tolerance to pain develops • Associated factors • Depression • Poor self-care • Decreased quality of life

37. Pain During the Dying Process • Neuropathic pain • Nerves are damaged • Burning, electrical, or tingling sensations • Deep and severe • Nociceptive pain • Tissue inflammation or damaged tissues • Cardiac ischemia

38. Pain During the Dying Process • Unrelieved pain during the dying process • Hastens death • Increases physiological stress • Diminishes immuno-competency • Decreases mobility • Increases myocardial oxygen requirements • Causes psychological distress to the patient and family • Suffering • Spiritual distress

39. LEARNING OUTCOME 4 Identify the diverse settings for end-of-life care and the role of the nurse in each setting.

40. Palliative Care • Philosophy of care • Highly structured system for care delivery

41. Emphasis of Supportive Care During the Dying and Bereavement Process • Quality of life • Living a full life up until moment of death

42. Palliative Care Settings • Hospitals • Outpatient clinics • Long-term-care facilities • Home

43. Hospice Care • Focuses on the whole person • Mind • Body • Spirit • Support and care • Patients • Family and caregivers • Continues after death of a loved one

44. Hospice Care • Multidisciplinary team of professional caregivers • Nurse • Manages pain and controls symptoms • Assesses patient and family abilities to cope • Identifies available resources for patient care • Recognizes patient wishes • Assures that support systems are in place

45. Hospice Care • Multidisciplinary team of professional caregivers • Physician • Pharmacist • Social workers • Others • Last phase (6 months) of incurable disease • Live as fully and comfortably as possible

46. Hospice Settings • Freestanding • Hospital • Home health agencies with home care hospice • Home • Nursing home or other long-term-care settings

47. LEARNING OUTCOME 5 Explore pharmacological and alternative methods of treating pain.

48. Administer Pain Medication Routinely • Prevent breakthrough pain and suffering • Long-acting drugs provide consistent relief • Chronic pain • Short-acting or immediate release agents for prn use • Acute pain

49. Anticipate and Treat Adverse Effects of Pain Medication • Nausea • Constipation

50. Pain Control at the End of Life • Non-opioids for mild to moderate pain • Acetaminophen • NSAIDs