E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium

1. E L N E CGeriatric CurriculumEnd-of-Life Nursing Education Consortium SESSION 10: Preparation for and Care at the Time of Death Fairfield University Quinnipiac University School of Nursing ELDER Project

2. Objectives: Upon completion of this session, the participant will be able to … • Describe typical changes and events at the time of dying. • Examine the role of the palliative care team at the time of death. • Identify self-care strategies for the health care team that promote well-being and health.

3. Dying is an Individualized Personal Experience

4. Palliative Care Team Roles at EOL • Support older adults/residents, families, and staff prior to and following the death • Coordinate care • Advocate for patients and families • Being present, bearing witness • Provide pain and symptom management • Role model self-care behaviors

5. ACTIVITY: Roles of Palliative Care Team at EOL

6. An 85-year-old client with end-stage heart disease arrives unconscious at the emergency department after sustaining her third myocardial infarction. The doctor has told the daughter that without CPR her mother could die today. The healthcare worker finds the daughter crying by the client's bedside. What should the healthcare worker do? • ask the daughter if she would like to reconsider treatment • talk to the doctor about moving the client to a more private place • stay with the daughter, using silence to give comfort • assure the daughter that she doesn't need to stay with her mother

7. Offering Support During the Death Vigil • Common fears • Being alone with resident • Not knowing when death occurs • Painful death

8. Nearing-Death Phenomena • “The Rally” • Symbolic language • Visions • Inability to let go • Saying good-bye

9. Two Roads to Death THE DIFFICULT ROAD Tremulous Confused Hallucinations Restless Mumbling Delirium NORMAL Myoclonic Jerks Sleepy Lethargic Seizures Obtunded THE USUAL ROAD Semicomatose Comatose DEAD Ferris et al., 2003

10. Frequency of Symptoms Last 48 Hours Fürst & Doyle, 2004; Lunney et al., 2002

11. Pain when Death is Imminent • Common among NH residents at EOL • Assume pain is present after ruling out other possible causes of distress!

12. Opioids at EOL • Consider routes • Oral • Rectal • Subcutaneous • There is no evidence that opioids hasten death!

13. Noisy Respirations • Noise produced by turbulent movements of secretions in upper airways; this symptom occurs in the imminently dying • Also called “death rattle” • Occurs in 23–92% ofdying patients

14. Anticholinergics • Hyoscine hydrobromide (Scopolamine) • Glycopyrrolate (Robinul) • Hyoscyamine (Levsin) • Atropine Sulfate

15. Reposition patient or resident on his side Gently suction mouth if the secretions areeasily reached Provide excellent oral care Educate and reassure family Nondrug Strategies

16. Terminal Restlessness • Occurs in the last days or hours of life • May be exhibited by thrashing, muscle twitching or jerks, fidgeting, frequent attempts to get out of bed, calling out, moaning, non-purposeful movement • Focus on providing comfort rather than treating the cause Ingham & Caraceni, 2002

17. Symptoms of Imminent Death • Decreased urine output • Cold and mottled extremities • Vital sign and breathing changes • Respiratory congestion • “Death rattle” • Delirium/confusion • Restlessness • Kehl, 2004; Matzo, 2009; Rousseau, 2002

18. Signs That Death Has Occurred • Absence of heartbeat, respirations • Pupils fixed • Pale color • Body temperature drops • Muscles, sphincters relax

19. Grief is: • the emotional response to a loss • the outward, social expression of a loss • the depression felt after a loss • the loss of a valued object or loved one

20. The best response to a client who is anticipating a loss is to: • educate them about disease progression • stress that prognosis is difficult to predict • provide therapeutic presence and practice active listening • advise the daughter to focus more on the present than the future

21. In speaking with clients and families about grief, the healthcare worker explains that grief: • is a process with predictable stages of work to be done • begins when people expect a loss or death • lasts a year or less, and then survivors should adapt to the loss • includes personal feelings that are understood by everyone

22. Care Following Death • Bathing and dressing the body • Positioning the body • Respect cultural practices • Allow for closure

23. In caring for the body after death, it is most important to: • make sure the body is sent to the morgue within an hour after death • have family members participate in the bathing and dressing the deceased • notify all family and team members regarding the patient's death • provide a clean, peaceful impression of the deceased for the family

24. The wife of a client who recently died states: "Last night I thought I heard him say ‘Good night, Honey’ just like he always did. Do you think I am going crazy?" The most helpful response is: • "You might want some extra support accepting your husband's death. I'll have the doctor make a referral to a psychologist." • "Many people see or hear the one who has died. You must miss him saying 'good night'." • "Many people believe that ghosts or spirits visit their loved ones. Do you believe in ghosts or spirits?" • "That must be frightening for you. Do you have a friend or relative who can stay with you so that you are not alone?"

25. Care Following Death (cont.) • Rigor mortis 2-4 hrs after death • Embalming • Removal of body

26. The hospice team is caring for the family of a man who died several days ago after a long illness. His wife is concerned that their 9 year old son has become withdrawn and is easily angered. Which action is most appropriate? • Refer the boy to a specialist for complicated (abnormal) grief reaction. • Suggest that the boy be excused from his usual activities. • Give opportunities for the boy to express his feelings. • Tell stories rather than facts about death to the boy.

27. Acknowledging Death • Inform staff • Inform roommate • Memory book • Recognition wall • Paying tribute

28. Lifestyle Management: Burnout Prevention for Staff • Healthy body • Healthy mind • Healthy spirit • Healthy social life

29. The healthcare team may experience feelings of anxiety and grief when caring for dying clients. To deal with these feelings it is important to: • get the assistance of team members when necessary • transfer to another unit to avoid caring for dying patients • keep an emotional distance from clients and families • schedule counseling at weekly intervals to deal with loss issues

30. Activity: Self-Care Assessment Take a moment to consider the frequency with which you do the following acts of self-care. Rate using the scale below: 4 = often 3 = sometimes 2 = rarely 1 = are you kidding? It never even crosses my mind!

31. Conclusion Family members will always remember the last days, hours, and minutes of their loved one’s life. Nurses have a unique opportunity to be invited to spend these precious moments with them and to make those moments memorable in a positive way.

32. References City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. TheEnd-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator). Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858