Module 8: Final Hours

1. Module 8:Final Hours

2. The Nurse, Dying and Death • Nurses provide support to Veterans, families, staff • Interpersonal competence • Being present • “Bearing witness” • Interdisciplinary care

3. Dying is an Individualized Personal Experience for the Veteran • There is no typical death • Less likely to be fearful of dying alone vs. non-Veterans • Nurses advocate for choices • Setting of death • Support

4. Open, Honest Communication • Convey caring, sensitivity, compassion • Recognize their helplessness • Provide information in simple terms • Veteran awareness of dying • Maintain presence

5. What About Artificial Nutrition and Hydration at End of Life? • “Starving to death” • Enteral feeding does not reduce risk of aspiration or mortality • Hydration does not decrease dry mouth • Patients who fasted to end their lives experienced peaceful death Gabriel et al., 2010; HPNA, 2003a

6. What About CPR? • Discuss futility when death is expected • Poor outcome of CPR predictors • Advanced terminal illnesses • Dementia • Poor functional status

7. Honoring Veterans:Dignity Conserving Care • The A, B, C, & D of dignity conserving care • Attitude • Behavior • Compassion • Dialogue Chochinov, 2007

8. The Dying Older Veteran • Do not assume that a dying older Veteran has addressed his/her mortality • Positive influences facing mortality • Negative influences facing mortality

9. Two Roads to Death Ferris et al., 2003

10. Psychological and Emotional Considerations • Fear of the dying process • Fear of abandonment • Fear of unknown • Nearing death awareness • Withdrawal Berry & Griffie, 2010

11. Spiritual Considerations • Many veterans/family members may have an increased focus on spiritual issues • Role of culture? • Role of “religion?” • Integration of spirituality and healthcare

12. Frequency of Symptoms Last 48 hrs Harlos, 2010

13. Physical Symptoms Vary • Confusion, disorientation, delirium VERSUS unconsciousness • Weakness and fatigue VERSUS surge of energy • Drowsiness, sleeping VERSUS restlessness/agitation • Others

14. Pain During the Final Hours of Life • Assessment and management is critical • Watch for behavioral cues • Rule out other potential causes of distress

15. Administering Opioids During Final Hours of a Veterans’ Life • Dosing is based on appropriate assessment and reassessment • Dose may be decreased • Consider other routes (i.e. oral, rectal, subcutaneous) • Accumulation of metabolites

16. Myoclonus • Assess associated multiple etiologies • Review current drug regimens • Benzodiazepines can be helpful • Can lead to seizures

17. Intractable Pain at the End of Life • Pain may be intractable even with aggressive treatment • Palliative sedation may be the only alternative • Veteran, family, and staff support HPNA, 2004; Rousseau, 2004

18. VHA: The Ethics of Palliative Sedation at the End of Life • First Consider the Following: • All possible etiologies and treatments • Education of veteran/family regarding goals and outcomes • Informed consent • Interdisciplinary team approach Brender et al., 2005; deGraeff & Dean, 2007; NEC, 2006

19. Palliative Sedation at the End of Life (cont) • Treatment • Lorazepam • Midazolam • Ketamine • Propofol

20. Decreased urine output Cold/mottled extremities Vital sign and breathing changes Respiratory congestion “Death rattle” Delirium/confusion Restlessness Berry & Griffie, 2010; Matzo & Hill, 2010 Symptoms of Imminent Death

21. Management of Imminent Death • Elevate head of bed • Begin anticholinergic drugs prn • Reduce or withhold IV fluids/enteral feedings • Deactivate implantable cardioverter defibrillator Matzo & Hill, 2010

22. The Death Vigil • Family presence • Common fears • Being alone with Veteran • Painful death • Time of death • Giving “last dose”

23. Nursing Interventions: Support • Collaboration with physician and other team members • Reassurance and education • Role model comforting • Physical comforting • Spiritual care • Honor culture

24. Spiritual/Cultural Considerations • Death rites • Rituals

25. Signs That Death Has Occurred • Absence of heartbeat and respirations • Pupils fixed • Color • Body temperature drops • Muscles, sphincters relax

26. When Death Has Occurred • Communicating the death • Open, honest communication with family • Preparation of family is part of process

27. Care Following the Death • Prepare the family • Care after death • Honor culture • Bereavement support • Plans for burial, embalming • Removal of the body • Assist with phone calls/notifications, etc

28. Organ/Tissue Transplantation • Regulations • Talking to the family • What can be donated?

29. Honors Available to Deceased Veterans • Presidential Memorial Certificate • Military funeral honors • Burial flag • Possible burial allowance • Burial at sea

30. Death of a Parent or Grandparent… Remember the Children • Developmental stage of young child • Communicate openly and honestly • Need time to ask questions • Remember the grandparents Davies & Steele, 2010

31. Family Members Will Always Remember “The Final Hours” • Nurses have a unique opportunity to be invited to spend these precious moments with Veterans and their families and to make those moments memorable in such a positive way. • We only get one chance to do this well

32. Respect the Dying Veteran and the Family/Comrades They Leave Behind

33. Conclusion