Chapter 040 Hospice Care

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Chapter 040 Hospice Care

  1. 1. EDITED BY BRENDA HOLMES MSN/ED, RN Chapter 40 Hospice Care
  2. 2. History of Hospice <ul><li>The concept originated in Europe, where hospices were resting places for travelers. </li></ul><ul><li>Monks and nuns believed that service to one’s neighbor was a sign of love and dedication to God. </li></ul><ul><li>They were places of refuge for the poor, the sick, and travelers on religious journeys. </li></ul><ul><li>They provided food, shelter, and care to ill guests until they were strong enough to continue their journey or they died. </li></ul>
  3. 3. History of Hospice <ul><li>The idea of hospice was renewed in the 1960s in London, when Dame Cicely Saunders, a nurse and physician, realized that a different kind of care was needed for the terminally ill. </li></ul><ul><li>She then devoted her life to improving pain management and symptom control for people who were dying. </li></ul><ul><li>The philosophy of hospice migrated to the United States in the early 1970s, with the first hospice program opening in Connecticut in 1971. </li></ul>
  4. 4. Palliative versus Curative Care <ul><li>Hospice care is appropriate when active treatment is no longer effective and supportive measures are needed to assist the terminally ill patient through the dying process. </li></ul><ul><li>It offers the patient a supported and safe passage from life to death in a way that preserves dignity and important relationships. </li></ul><ul><li>Death and dying become realities affecting the family roles, lifestyle patterns, and future goals of the patient and family. </li></ul>
  5. 5. Figure 40-1 Family members are an important part of hospice. (From Harkreader, H., Hogan, M.A. [2004]. Fundamentals of nursing: caring and clinical judgment . [2 nd ed.]. Philadelphia: Saunders.)
  6. 6. Palliative versus Curative Care <ul><li>Curative treatment is aggressive care in which the goal and intent are to cure the disease and to prolong life at all cost. </li></ul><ul><li>Palliative care is not curative in nature but is designed to relieve pain and distress and to control symptoms of the disease. </li></ul><ul><li>Quality, and not quantity, of life is emphasized with hospice care. </li></ul><ul><li>Palliative care is not giving up hope; it is full of hope of a good, fulfilling life. </li></ul>
  7. 7. Criteria for Admission <ul><li>The attending physician must certify that the patient’s illness is terminal and that the patient has a prognosis of 6 months or less to live. </li></ul><ul><li>The patient must be willing to forego any further curative treatment and be willing to seek only palliative care. </li></ul><ul><li>The patient and caregiver must understand and agree that the care will be planned according to comfort and that life-support measures may not necessarily be performed. </li></ul><ul><li>The patient and caregiver must understand the prognosis and be willing to participate in the planning of the care. </li></ul>
  8. 8. Goals of Hospice <ul><li>Controlling or alleviating the patient’s symptoms </li></ul><ul><li>Allowing the patient and caregiver to be involved in the decisions regarding the plan of care </li></ul><ul><li>Encouraging the patient and caregiver to live life to the fullest </li></ul><ul><li>Providing continuous support to maintain patient/family confidences and reassurances to achieve these goals </li></ul><ul><li>Educating and supporting the primary caregiver in the home setting that the patient chooses </li></ul>
  9. 9. Interdisciplinary Team <ul><li>Multiprofessional health team works together in caring for the terminally ill patient. </li></ul><ul><li>They develop and supervise the plan of care in conjunction with all of those involved with the care. </li></ul><ul><li>The interdisciplinary team considers all aspects of the family unit, providing support to both the dying patient and to the caregiver. </li></ul><ul><li>The family is included in all decisions and care planning. </li></ul>
  10. 10. Interdisciplinary Team <ul><li>Medical Director </li></ul><ul><ul><li>A doctor of medicine or osteopathy </li></ul></ul><ul><ul><li>Assumes overall responsibility for the medical component of the hospice patient’s care program </li></ul></ul><ul><ul><li>Acts as a consultant for the attending physician </li></ul></ul><ul><ul><li>Is a mediator between the interdisciplinary team and the attending physician </li></ul></ul>
  11. 11. Interdisciplinary Team <ul><li>Nurse Coordinator </li></ul><ul><ul><li>Registered nurse who coordinates the implementation of the plan of care for each patient </li></ul></ul><ul><ul><li>May perform the initial assessment, admit the patient to the hospice program, and develop the plan of care along with the interdisciplinary team </li></ul></ul><ul><ul><li>Ensures the plan of care is being followed, coordinates the assignments of the hospice nurses and aides, facilitates meetings, and determines the methods of payments </li></ul></ul>
  12. 12. Interdisciplinary Team <ul><li>Social Worker </li></ul><ul><ul><li>Evaluates and assess the psychosocial needs of the patient </li></ul></ul><ul><ul><li>Assists with community resources and filing insurance papers </li></ul></ul><ul><ul><li>Supports the patient and caregiver with emotional and grief issues </li></ul></ul><ul><ul><li>Assists with counseling when communication difficulties are present </li></ul></ul>
  13. 13. Interdisciplinary Team <ul><li>Spiritual Coordinator </li></ul><ul><ul><li>Must have a seminary degree but can be affiliated with any church </li></ul></ul><ul><ul><li>Is the liaison between the spiritual community and the interdisciplinary team </li></ul></ul><ul><ul><li>Assists with the spiritual assessment of the patient and, in keeping with the patients’ and families’ beliefs, develops the plan of care regarding spiritual matters </li></ul></ul><ul><ul><li>Assists the patient and caregiver to cope with fears and uncertainty </li></ul></ul><ul><ul><li>Assists with funeral planning and performing funeral services </li></ul></ul>
  14. 14. Interdisciplinary Team <ul><li>Volunteer Coordinator </li></ul><ul><ul><li>Must have experience in volunteer work </li></ul></ul><ul><ul><li>Assess the needs of the patient and caregiver for volunteer services </li></ul></ul><ul><ul><li>Provides companionship, caregiver relief through respite care, and emotional support </li></ul></ul><ul><ul><li>Volunteers may read to the patient, sit with the patient or do grocery shopping or yard work. </li></ul></ul>
  15. 15. Interdisciplinary Team <ul><li>Bereavement Coordinator </li></ul><ul><ul><li>Professional who has experience in dealing with grief issues </li></ul></ul><ul><ul><li>Assesses the patient and caregiver at admission to the hospice program and identifies risk factors that may be of concern following the death of the patient </li></ul></ul><ul><ul><li>Follows the plan of care for the bereaved caregiver for at least a year following the death </li></ul></ul><ul><ul><li>May also provide counseling or refer to other counseling resources </li></ul></ul>
  16. 16. Interdisciplinary Team <ul><li>Hospice Pharmacist </li></ul><ul><ul><li>Must be a licensed pharmacist and available for consultation on the drugs the hospice patient may be taking </li></ul></ul><ul><ul><li>Evaluates for drug-drug or drug-food interactions, appropriate drug doses, and correct administration times and routes </li></ul></ul>
  17. 17. Interdisciplinary Team <ul><li>Dietitian Consultant </li></ul><ul><ul><li>Licensed medical nutritional therapists (LMNTs) are available for consultations and for diet counseling. </li></ul></ul><ul><ul><li>Nutritional assessment is done at admission by the hospice nurse; if nutritional problems are noted, the patient may be referred to the LMNT. </li></ul></ul><ul><ul><li>LMNTs assist with educating the caregiver regarding nutritional issues in end-stage disease. </li></ul></ul>
  18. 18. Interdisciplinary Team <ul><li>Hospice Aide </li></ul><ul><ul><li>Certified nurse assistant who is supervised by the hospice nurse </li></ul></ul><ul><ul><li>Follows the plan of care developed by the interdisciplinary team </li></ul></ul><ul><ul><li>Assists the patient with bathing and personal care </li></ul></ul><ul><ul><li>May also assist the patient/caregiver with light housekeeping services </li></ul></ul>
  19. 19. Interdisciplinary Team <ul><li>Other Service Providers </li></ul><ul><ul><li>Physical therapist </li></ul></ul><ul><ul><li>Speech-language pathologist </li></ul></ul><ul><ul><li>Occupation therapist </li></ul></ul><ul><ul><li>Not for rehabilitative services but to assist with improving the quality of life and care for the patient and caregiver </li></ul></ul>
  20. 20. Palliative Care <ul><li>Pain </li></ul><ul><ul><li>The most dreaded and feared symptom </li></ul></ul><ul><ul><li>Priority for symptoms management </li></ul></ul><ul><ul><li>Can be excruciating, constant, and terrifying </li></ul></ul><ul><ul><li>Pain assessment </li></ul></ul><ul><ul><ul><li>Evaluation of the factors that alleviate or exacerbate a patient’s pain </li></ul></ul></ul><ul><ul><ul><li>Should be ongoing </li></ul></ul></ul>
  21. 21. Palliative Care <ul><li>Pain (continued) </li></ul><ul><ul><li>Somatic pain </li></ul></ul><ul><ul><ul><li>Arises from the musculoskeletal system </li></ul></ul></ul><ul><ul><ul><li>Described as aching, stabbing, or throbbing </li></ul></ul></ul><ul><ul><ul><li>Nonsteroidal antiinflammatory drugs, nonopioid drugs, or opioid drugs used </li></ul></ul></ul><ul><ul><li>Visceral pain </li></ul></ul><ul><ul><ul><li>Originates from the internal organs </li></ul></ul></ul><ul><ul><ul><li>Described as cramping, pressure, dull, or squeezing </li></ul></ul></ul><ul><ul><ul><li>Anticholinergic medications alone or as adjuvants </li></ul></ul></ul>
  22. 22. Palliative Care <ul><li>Pain (continued) </li></ul><ul><ul><li>Neuropathic pain </li></ul></ul><ul><ul><ul><li>Initiated from the nerves and nervous system </li></ul></ul></ul><ul><ul><ul><li>Tingling, burning, or shooting pains </li></ul></ul></ul><ul><ul><ul><li>Anticonvulsants may be given as an adjuvant to assist with pain control. </li></ul></ul></ul><ul><ul><li>Routes </li></ul></ul><ul><ul><ul><li>Oral, sublingual, subcutaneous, parenteral, rectal, or topical </li></ul></ul></ul>
  23. 23. Palliative Care <ul><li>Pain (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>The nurse’s role is to focus on the effectiveness of the plan to ensure that the symptoms are being well controlled. </li></ul></ul></ul><ul><ul><ul><li>The nurse must consistently assess and reassess the pain and symptoms to ensure that they are managed. </li></ul></ul></ul><ul><ul><ul><li>Educate the patient and caregiver in the appropriate administration, scheduling, and effects of the medication. </li></ul></ul></ul>
  24. 24. Palliative Care <ul><li>Nausea and Vomiting </li></ul><ul><ul><li>Must be assessed as to their cause, with the cause being removed if at all possible. </li></ul></ul><ul><ul><li>Nausea can result from chemotherapy side effects, obstruction, tumor, uncontrolled pain, constipation, and even food smells. </li></ul></ul><ul><ul><li>Sometimes drugs used to control pain cause nausea; it is recommended that antiemetics be given with the narcotic analgesic. </li></ul></ul>
  25. 25. Palliative Care <ul><li>Nausea and Vomiting (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>Educate the patient and caregiver regarding the cause or prevention of nausea and vomiting. </li></ul></ul></ul><ul><ul><ul><li>Encourage the patient to take the antiemetics 30 minutes before meals and at bedtime. </li></ul></ul></ul><ul><ul><ul><li>Eating slowly and in a pleasant atmosphere is a good way to control nausea. </li></ul></ul></ul><ul><ul><ul><li>Patients should not be forced to eat or drink if they have no desire. </li></ul></ul></ul>
  26. 26. Palliative Care <ul><li>Constipation </li></ul><ul><ul><li>This is one of the most common problems of the terminally ill patient. </li></ul></ul><ul><ul><li>Factors that contribute to constipation are poor dietary intake, poor fluid intake, use of opioids for pain control, and decrease in physical activity. </li></ul></ul><ul><ul><li>A rectal exam may be necessary to check for an impaction along with manual removal of stool. </li></ul></ul><ul><ul><li>Fleet enema helps soften and dissolve a hard impaction. </li></ul></ul>
  27. 27. Palliative Care <ul><li>Constipation (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>Educate the patient and caregiver on the following </li></ul></ul></ul><ul><ul><ul><ul><li>A decrease in oral intake will also decrease the amount of stool expelled. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Even though a patient does not have oral intake, bowel movements may still be possible. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Opioids can cause constipation, so laxatives must be given. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Comfort is the all-important factor. </li></ul></ul></ul></ul>
  28. 28. Palliative Care <ul><li>Anorexia and Malnutrition </li></ul><ul><ul><li>Poor appetite may be caused by nausea, vomiting, constipation, dysphagia, stomatitis, tumor invasion, general deterioration of the body, depression, or infections. </li></ul></ul><ul><ul><li>Odors of food cooking, inability to tolerate sweet foods, or a bitter taste in the mouth also contributes to the problem. </li></ul></ul><ul><ul><li>Cachexia is malnutrition marked by weakness and emaciation. </li></ul></ul>
  29. 29. Palliative Care <ul><li>Anorexia and Malnutrition (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>Nutritional assessments must be completed routinely and applied to the hospice plan of care. </li></ul></ul></ul><ul><ul><ul><li>Assess and treat causes such as nausea and vomiting. </li></ul></ul></ul><ul><ul><ul><li>If related to infection or stomatitis, good oral hygiene is important. </li></ul></ul></ul><ul><ul><ul><li>If the odor of food causes anorexia, the patient should not be in the kitchen during meal preparation. </li></ul></ul></ul><ul><ul><ul><li>High-protein supplements are helpful. </li></ul></ul></ul>
  30. 30. Palliative Care <ul><li>Dyspnea or Air Hunger </li></ul><ul><ul><li>Dyspnea can be caused by a variety of conditions such as heart failure, dysrhythmias, infection, ascites, or tumor growth. </li></ul></ul><ul><ul><li>Air hunger may be caused by tumor pressure, fluid and electrolyte imbalance, or anemia. </li></ul></ul><ul><ul><li>It may be relieved by oxygen, morphine, or bronchodilators. </li></ul></ul><ul><ul><li>Often 24 to 48 hours before death, the patient exhibits the “death rattle,” which is an accumulation of mucus and fluids in the posterior pharynx. </li></ul></ul>
  31. 31. Palliative Care <ul><li>Dyspnea or Air Hunger (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>Main focus is on relieving anxiety and supporting the patient and caregiver. </li></ul></ul></ul><ul><ul><ul><li>Educate on positioning, use of a fan to circulate air, use of morphine to decrease respiratory effort, use of tranquilizers to ease anxiety, and maintaining good oral hygiene. </li></ul></ul></ul><ul><ul><ul><li>Suctioning should occur only if the patient is choking and unable to recover. </li></ul></ul></ul>
  32. 32. Palliative Care <ul><li>Psychosocial and Spiritual Issues </li></ul><ul><ul><li>Concerns must always be respected, and the patient’s wishes are met if at all possible. </li></ul></ul><ul><ul><li>Patients may question their faiths and beliefs or may look to find support that they have never had when they are confronted with a terminal illness. </li></ul></ul><ul><ul><li>Symptoms such as depression, the need to suffer, bitterness, anger, hallucinations, or dreams of fire may be indicative of unmet spiritual needs. </li></ul></ul>
  33. 33. Palliative Care <ul><li>Psychosocial and Spiritual Issues (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>The spiritual coordinator or the nurse does the spiritual assessment and must be nonjudgmental and accepting of the patient's and caregiver’s spiritual beliefs. </li></ul></ul></ul><ul><ul><ul><li>The social worker may assist in relationships between the patient and caregiver and provide counseling to resolve conflict. </li></ul></ul></ul>
  34. 34. Palliative Care <ul><li>Other Common Signs and Symptoms </li></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Risk for skin impairment </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Sleeplessness and insomnia </li></ul></ul>
  35. 35. Palliative Care <ul><li>Other Common Signs and Symptoms (continued) </li></ul><ul><ul><li>Nursing Interventions and Patient Teaching </li></ul></ul><ul><ul><ul><li>Teach the basics of good skin care. </li></ul></ul></ul><ul><ul><ul><li>Cleanliness promoted by bathing can be refreshing as well as therapeutic. </li></ul></ul></ul><ul><ul><ul><li>Inspect skin frequently and keep it dry and clean. </li></ul></ul></ul><ul><ul><ul><li>Egg-crate mattress and elbow protectors can cushion bony areas. </li></ul></ul></ul><ul><ul><ul><li>Provide information regarding home safety. </li></ul></ul></ul><ul><ul><ul><li>Listen and provide emotional support. </li></ul></ul></ul>
  36. 36. Patient and Caregiver Teaching <ul><li>The approach taken in all matters affecting the patient and caregiver is as honest and straightforward as possible. </li></ul><ul><li>It is thought that the fear of the unknown is always greater than the fear of the known. </li></ul><ul><li>Educating the caregiver in symptom management, hands-on care of the patient, caring for body functions, and teaching regarding the signs and symptoms of approaching death are important to relieve fears. </li></ul>
  37. 37. Bereavement Period <ul><li>Hospice care does not conclude once the patient dies but usually continues for at least 1 year with bereavement support. </li></ul><ul><li>Even though the family feels they have prepared for the death, facing the future without the person who died is difficult. </li></ul><ul><li>The hospice staff also go through a grieving period for each patient who dies. </li></ul><ul><li>Each hospice provides support to their staff with support meetings and time to vent their feelings and to heal. </li></ul>
  38. 38. Ethical Issues in Hospice Care <ul><li>Ethical issuess when dealing with hospice patients include withholding or withdrawing nutritional support, the right to refuse treatment, and do not resuscitate (DNR) orders. </li></ul><ul><li>It is hoped that the patient’s wishes are made known in advance, such as a living will or an advance directive, or that a durable power of attorney has been appointed. </li></ul><ul><li>It is imperative that the nurse be aware of the organization’s ethics policies and procedures so that any questions and concerns may be addressed appropriately and correctly. </li></ul>
  39. 39. Key Points <ul><li>Hospice is a philosophy of care that provides support to patients with a terminal illness (an advanced stage of a disease with no known cure and poor prognosis and their families) </li></ul><ul><li>Hospice is from the Latin word hospitium meaning hospitality and lodging. </li></ul><ul><li>Hospice care is appropriate when active treatment is no longer effective and supportive measures are needed to assist the terminally ill patient through the dying process. </li></ul>
  40. 40. Key Points (cont’) <ul><li>The Hospice Medicare Benefit covers all expenses for palliative care related to the terminal illness, including professional staff visits, medication, equipment, and respite and acute care. </li></ul><ul><li>Quality not quantity of life is emphasized with hospice care </li></ul><ul><li>Palliative care is appropriate when cure is not possible but care is still needed. This becomes the goal of hospice care </li></ul><ul><li>The goal of palliative care is to control pain and other symptoms for prevention of distress </li></ul>
  41. 41. Key Points <ul><li>Hospice care </li></ul><ul><ul><li>Consists of a blending of professionals and nonprofessionals to meet the total needs of the patient and family </li></ul></ul><ul><ul><li>Delivered by an interdisciplinary team because no individual or profession can meet all the needs of terminally ill patient and families all the time </li></ul></ul><ul><ul><li>Considers all aspect of the lives of patients and their families. Stresses and concerns may arise in many ways when families are faced with a terminal illness </li></ul></ul><ul><ul><li>Available 24 hours/day, 7 days/week because needs may arise at any time </li></ul></ul><ul><ul><li>For the family continues into the bereavement period. Needs of the family continue after patient dies. </li></ul></ul>
  42. 42. Key Points <ul><li>Admission to a hospice program is the decision of a patient and family, because not all people need or desire hospice care </li></ul><ul><li>A hospice care program considers the patient and family together as the unit of care because families experience much stress and pain during the terminal illness of one of their members </li></ul><ul><li>Family participation in caregiving is an important part of the palliative care. </li></ul><ul><li>Hospice care is respectful of all patient and family belief systems, seeking resources to meet the physical. </li></ul>

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