Caring for the Dying Patient

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Caring for the Dying Patient

• Keith Rischer RN, MA, CEN

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Todays Objectives

• Discuss the current ethical issues surrounding
  end of life care.
• Identify goals of end of life care.
• Compare contrast the emotional spiritual
  needs of the family and client who is dying.
• Contrast early vs. late physical changes in the
  client who is dying.
• Describe nursing goals and priorities for
  managing the client who is dying.
• Contrast the needs of the family with the nurse
  in the client who has died.

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End of Life Ethics

• Assisted Suicide
• Withdrawal food/fluids
• Passive vs. Active Euthanasia
• Legalized active euthanasia in US
• Oregon Death w/Dignity Act

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Advance Directives

• Living will
• Legal document instructs measure of care desired
  if incapable
• Shortcomings
• Life death choices over unknown set of
  circumstances
• Some ethicists believe document is worthless
• Durable power of attorney

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The Cure/Care Model
D E A T H
Life Prolonging Care
Palliative/ Hospice Care
Disease Progression
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Concerns of Dying Patient

• Fear of physical pain and suffering
• Symptom burden
• Fear of unknown
• Fear of loneliness
• Anonymity
• Loss of choice over destiny
• Loss of dignity
• Loss of consortium
• Separation and lack of connection
• Spiritual
• Financial

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Palliative Cares Place in Course of Illness
Life Prolonging Therapy
Death
Diagnosis of serious illness
Medicare Hospice Benefit
Palliative Care
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Early Physical Changes

• ? Appetite ?Weight loss
• Assistance with ADLs
• Pain (gt or lt )
• Increased HR Potential O2 deficiency
• Drowsiness
• Fatigue

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Early Emotional Changes

• Months to Weeks
• Hope
• Desirable
• Expectational
• Withdrawal
• Changes in mood
• Anger, irritable, hope, denial, ect
• World view changes gets smaller
• Attending to business

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Spiritual Distress

• Signs of Spiritual Distress
• Doubt
• Despair
• Guilt
• Anger
• Boredom
• Isolation
• Statements of regret
• Statements of unresolved hurt

• Nursing Interventions
• Ask about their source of strength
• Discuss sources of spiritual strength throughout
  their lives
• Assess support system
• Assess coping
• Refer to clergy/chaplain
• Ministry ex. Stephens Ministry at churches

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Family Needs

• Focus on dying patient without losing the present
  and future
• The work of daily life goes on
• Anticipatory grief
• Increase in responsibilities (house, finances,
  work, children, and acting as a caregiver).
• Need for support from family, community,
  spiritual faith.

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Goals of Nursing Care for the Dying

• Hospice
• Improve quality of life w/terminal illness
• Control symptoms
• Pain
• NV
• Fatigue
• SOB
• Identify-prioritize needs
• Promote meaningful interactions w/family and
  others
• Facilitate peaceful death

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Nursing CareHolistic

• Chaplain/ Clergy visit
• Hospice/ respite care
• Hospice/Home Care
• Provide CNA daily for ADL hygiene and care
• More frequent RN visits
• More frequent Social Worker visits
• Talk candidly about end of life how it will
  likely be for that specific patient

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Nursing CarePhysical Priorities

• Pain management
• NV management
• Fatigue management
• Skin care
• Mouth care
• Urinary care
• Respiratory care
• Comfort

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Nursing Care Physical Priorities

• Attend to any needs of patient
• Pain
• Long acting analgesics with medication for
  breakthrough pain
• May need to increase doses of medication
• Counsel pt./family on pain cycle and breakthrough
  pain
• Nausea
• AntiemeticsZofran
• Foods that taste good with increased protein and
  fat
• Ensure or supplements
• Comfort
• Comfortable bed
• Chair
• pillows

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Why Pain?

• Practitioners are not trained in state-of-the art
  pain management
• Myths about addiction, dependence, and tolerance
  abound
• The toll that unrelieved pain takes on the body
  and mind is not understood or acknowledged
• Fear that pain intervention might cause the
  patient to die
• Flawed assessments
• Disconnect
• Failure to look at non-physical sources

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Nursing Care Physical Priorities

• Mobility
• Cane, walker,
• Prevent falls
• Falls often indicate change in status
• Sleep
• Sleeping more? Less? Look at medications and
  physical status. Normal to increase in sleeping.
• Fatigue
• Do what only matters, find what is important to
  patient
• Hospice volunteer for family for relief

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Nursing Care Physical Priorities

• Neuro
• Changes due to disease (brain mets, lack of
  oxygen?)
• CV
• May need fan for cool or light weight blankets
  for warmth
• Lungs
• Teach use of several pillows, O2 may be needed
• Skin
• Teach positioning, turning, and prevention of
  breakdown
• GI
• Use of stool softeners is a must may need
  laxatives later on
• Urinary
• May have incontinence (pads, diapers, last resort
  is foley)
• Medications
• Order what is needed for comfort

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Changes with Weeks RemainingPhysical Changes

• Profound weakness
• Bedbound
• Falling if ambulating
• Muscle weakness
• Potential skin breakdown
• Increased care needed
• VS
• ? HR ? Pulse

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Dyspnea Managment

• Morphine sulfate
• Diuretics
• Bronchodilators
• Antibiotics
• Anticholinergics
• Atropine
• Sedatives
• Oxygen

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Changes with Weeks RemainingEmotional Changes

• ? Fear, apprehension or peacefulness
• ? withdrawal into self
• Often sees spiritual beings
• God previous family members who have died
  speaking out to them
• Only allows family and loved ones in their world
• Starts to say goodbye to loved ones
• A sense of peace and finished business may be
  felt OR a sense that there is not enough time
  left to finish life

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Changes with Weeks Remaining Family Needs

• How to care for their love one
• Focus is home care management
• May not be able to get to PCPs office
• May involve equipment and teaching nursing care
  for ADLs
• O2, transfer techniques, shower chair, turning
  techniques, decubitus care, mouth care, foley
  care, ect
• Pain relief
• Symptom management
• Medication management increases
• Subq meds, rectal suppositories
• Psychological support increases
• Focus on quality of life vs. quantity

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Imminent DeathNursing Care

• Medication management
• If unable to swallow (subq, rectal suppositories)
• For death rattle Scopolamine patch works
• Pain management
• Comfort measures increase
• Turning, mouth care, positioning of limbs,
  warm/cool measures, eye drops, ect
• Assistance respiratory with positioning

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Imminent DeathPhysical Changes

• Actively Dying 48-72 hours remain
• Confusion and disorientation
• Metabolic changes
• Withdraws from family going somewhere
• Decreased consciousness
• May refuse all fluid and food
• Body conservation of energy for function
• Total care ? alertness ? drowsiness
• Metabolic changes and decreased oxygen to brain
• ? Restlessness
• ? BP ?HR (120-150)
• Peripheral circulation diminishing to vital
  organs
• Mottling of extremities

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Imminent DeathPhysical Changes

• Incontinence of urine and bowel
• Increased muscle relaxation and decreased
  consciousness
• May be incontinent around the foley catheter
• Dependent areas become cyanotic cold
• Skin color is pale and mottling of skin occurs
  (knees, legs, nose)
• Slower pupil response to light, eyes fixed
  stare-even in sleep
• Muscle becomes slack, decreased oxygen
• Speech may be difficult and soft
• Muscle becomes slack
• Hearing is thought to remain present
• Vision may be lost

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Imminent DeathPhysical Changes

• Cheyne-Stoke respirations
• Metabolic and oxygen changes
• Decreased RR
• Death rattle
• Profuse perspiration
• Decreased circulation to all organs as they are
  shutting down
• ? urinary output
• Decreased vital organ/ kidneys shutting down
• Body temp varies
• May decrease or rise

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Imminent DeathEmotional Needs

• Sense of peacefulness in the room
• Family and loved ones present
• Caring feeling by loved ones
• Its going to be OK
• Its OK to go now
• Your work is done
• I love you/ I forgive you

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Imminent Death Family Needs

• Presence of Nurse
• Care for patient
• Support for patient and family
• Educate family throughout the process to avoid
  the feeling of not knowing what next
• Be the detail person
• Be prepared for how family will handle death
• Know emergency numbers for family/hospice
• Make final arrangements
• Mortuary pick up equipment, clean up room.

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Imminent Death Family Needs

• Encourage them to stay with patient
• Touch and talk with patient
• Be vigilant about what the patient hears, even
  though he/she cannot respond
• Encourage active comfort measures
• Light massage, mouth care,
• Allow them time to privately grieve with family
• Acknowledge the process of dying
• Skin cooling, cyanosis, Cheyne-Stokes, urinary
  incontinence (all this is normal)

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Pronouncement of Death

• Cessation of blood pressure, pulse and
  respirations.
• In hospice is pronounced by RN (or Social Worker
  in some states)
• Blood pressure may be not be able to be palpated
  for hours before death
• Final respirations may be gasping
• Eyes are fixed (pupils fixed and dilated)
• No apical pulse

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Needs of the Family After Patients Death

• Presence of a support system
• Family, chaplain, nurse, social worker
• Make sure someone is with them
• Dont leave them alone to go home
• No One Dies Alone at ANW
• Vounteers who stay during last hours
• Call family members if needed (when unexpected)
• Allow time for the family to spend with the
  patient who died

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Needs of the Nurse After the Patients Death

• Support system
• Other staff, friends, family (who can listen to
  you)
• Physical and emotional rest
• Attend memorial or burial service for closure
• Final separation from family
• Remind yourself that you made a difference

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Near Death Experiences

• Altered state of consciousness during brief
  cessation of VS (cardiac arrest)
• Tunnel of light
• Sense of being separated from body
• Fear anxiety-torment
• Afterwards for patient
• More spiritual minded-less material focused
• Less fearful of death
• Nurses role
• What do you remember about being unconscious?
• Did you have a sense of being separate from your
  body while we were reviving you?
• Avoid negative statements during code