3-D Approach to end of life care

1. 3-D Approach to end of life care By: Joseph Ramsubhag, RN

2. Presentation Objective Identifying & Meeting the Needs of Patient/family Spiritual

3. Criteriafor End of Life Care Unable to Stop the Trajectory of the Terminal Illness “The train has left the station”

4. Treatment Goals • Physical Comfort • Palliating distressful symptoms • Emotional Comfort • Terminating Personal relationships in a positive way • Preparing family for death • Offering bereavement services after death • Spiritual Comfort • Finding Meaning and significance at the level of spirit

5. Accomplishing Unfinished Business • Patient’s unfinished business may not be that of the family’s • Family members or others assisting pt. • Taking over the dying pt.’s Roles • A husband does not cease to be a husband when he is dying….vice versa…. • The pt.’s role & responsibilities do not ceased to exit when they are dying • Family can assist pt. taking over roles Rembrandt’s Return of Prodigal Son

6. Finishing Unfinished Business Physically • Taking care of financial business • Wills, power of attorneys • Telling your story • Completing books, videos, or music • Writing letters to loved ones • Advanced directives • Do not resuscitate • Funeral arrangements • Preferential religious practices/customs

7. Taking Care of Emotional Unfinished Business For all those who are close and important to the patient (pt.): == • Thank each other for the journey • Give unconditional love and forgiveness to the pt. • More importantly, ask the same for yourself • Allow your loved one to make their • journey and for them to be able to say • goodbye (Tasks of the Dying by Dr. Ira • Byock)

8. Taking Care of Spiritual Unfinished Business • Accomplishing unfinished goals according to patient’s philosophy • Most people's philosophy is tied in with their religion • Examples: Catholic pt. will want anointing of the sick, the Buddhist pt. visit from the monk, or pt. who is close to nature wanting to be in nature

9. Stages of Grief Experienced by Both Patient and Family Dr. E. KÜBLER-ROSS

10. Family Dynamics • Importance of advanced directives done by patient • Death of a loved one is hard, but it can be healing event • It is important for healthcare staff to identify where patients and family are in the grieving process • The heavy stress of a dying loved one widens the cracks in the family dynamics

11. Physical Signs & Symptoms of Impending Death • Delirium • Insomnia, restlessness (unable to find a comfortable position), and frightful visual hallucinations • This is high-risk area for falls • Anorexia • Food doesn’t taste the same • Dysphagia • Moving from meat & rice to soups & puddings, then to only liquids • Pocketing of food noticeable • GI system is winding down • Tube fed pts. will have increased residuals & increased lung secretions

12. Physical Signs & Symptoms of Impending Death • Vital Signs: BP, O2 Sat., HR, Resp. • Change in respiratory system • Labored, cheyne stoking, & argonal breathing • Breathing with all accessory muscles • Change in thermoregulation: fever, diaphoresis, & chills(parts of body hot & parts cold)

13. Physical Signs & Symptoms of Impending Death • Changes in Elimination Excretion • Urinary retention, constipation, & bowel & bladder incontinence • Decreased urine output, color changes from light yellow to a tea color, apple juice color or coco cola colored (hematuria) • Changes in Respiratory Status • Rhonchi, wheezing, rales, coughing, congestion (gurgling & rattling, sounds) • Increasing fatigue & sleep • Decreased LOC

14. Emotional & Mental Signs • Pt. is first to know they are dying: • “I am dying” or “I want to go home” • Pt. is self-absorbed and pensive: • Detaching from surroundings, including family • In order to leave, you have to disconnect • Staring into space, looking at you but looking through you • Reaching or grabbing invisible things from the air or from their body “Wherever your heart is, there is where you will be. In order to leave, you have to detach”

15. Mental & Spiritual Signs • Pts. Often See & Speak to the Deceased • Maybe deceased relatives or even pets • Gives hope to patient • Pt. moving from physical to metaphysical realm • Confusion frequently occurs as a result • Pts. Experience Surge of Energy • Commonly mistaken for the pt. getting better • Taking one day at a time may be expedient • May be for the transition from this world to the other • “The mountain tops are shorter and the valleys, deeper”

16. Final Gift • Pts. sometimes choose the people in whose presence they want to die. • If you are not there when your loved on passes, don’t beat up on yourself • This may be their final gift to you. • When a pt. dies they discard their physical body made from the dust of the earth and they put on their spiritual body made from light

17. References • Byock, I. (1997). Dying Well. New York, NY: Riverhead Trade. • Coyle, N. & Ferrell, B.R. (2010). Oxford Textbook of Palliative Nursing. (3rded). New York, NY: Oxford University Press. • Hallenbeck, J.L. (2003). Palliative Care Perspectives. New York, NY: Oxford University Press. • Kubler-Ross, E. (1997). On Death and Dying. New York, NY: Scribner. • Matzo, M.l. & Witt, D. (2009). Palliative Care Nursing: Quality Care to the End of Life. (3rd ed.). New York, NY: Springer Publishing Company. • Myss, C. (2003). Sacred Contracts: Awakening Your Divine Potential. Carlsbad, CA: Three Rivers Press. • Patt, R. (1993). Cancer Pain. Philadelphia, PA: Lippincott Williams & Wilkins.

18. Presentation dedicated to Mrs. Lucile Ramsubhag Email Address : josephramsubhag@yahoo.com Office (281)894-6499 Cell (832)353-7787