Care at the end of life.wvamc version
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Care at the end of life.wvamc version

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  • 1. Supplemental Ethics Points
  • 2. DE Hierarchy of Decision-makers (If no POA-HC)1. The spouse, unless a petition for divorce has been filed2. An adult child3. A parent4. An adult sibling5. An adult grandchild6. An adult niece or nephew7. Disqualified if pt. has a PFA or “no contact” order8. If no one, Court of Chancery may appoint as guardian an adult who exhibits special care +concern, + who is familiar w/ patients values.
  • 3. Do we need the Principle of the Double Effect to justify giving morphine at end-of-life?– NO– “Double Effect” is when there are 2 known, expected effects, one good and one bad. (ex. Separating conjoined twins where one will die)– Morphine at end of life (at appropriate doses)  does not cause respiratory depression.  is not a meaningful factor in hastening death (many studies)– So, we do not hasten death by treating pain or shortness of breath with appropriate doses of opioids. (see handout)
  • 4. Living Wills are inadequate • Only 36% of Americans have a living will • L.W’s often not available when needed • Uncertainty about “qualifying conditions” • DNR orders based on L.W.’s are not portable
  • 5. TRADITIONAL ETHICS ETHICS OF CAREAutonomy • InterdependenceBeneficence • Preventing HarmNon- • Providing Care Maleficence • CommunicationJustice • Maintaining RelationshipsVeracity
  • 6. Feminist writers:Tong, Gilligan, Prendergast “Autonomous Man” vs. “Communal Woman”
  • 7. CARE AT THE END OF LIFE: One Chance to Do It Right Presented by: Sheila Grant, BSN, RN, CHPN
  • 8. DISCLOSURES• I am employed by Heartland Hospice, IV, and Homecare as a Nurse-Liaison.
  • 9. OBJECTIVES1—Describe the concept “Convergence of Symptoms”.2—Identify 7 common symptoms of the active phase of dying.3—Identify strategies for controlling each of those symptoms.4—Describe ‘terminal agitation”, its possible causes, and options for treatment.5—Explain the principles of communicating bad news.
  • 10. Most People Die Aftera prolonged illness Withgradual deterioration Withan active dying phase at the end of life
  • 11. MOST CLINICIANS Have little or no formal training in managing the dying process.
  • 12. Most FamiliesHave even less experience or knowledge of the dying process.
  • 13. FAMILIES WILL REMEMBERA “good death”OR a “difficultdeath”.A difficult deathmay lead toanger,depression, orcomplicatedgrief
  • 14. CARE PROVIDED DURING THE LAST DAYS  Affects not just the patient, but families and everyone involved in a patient’s care.THERE IS NO SECOND CHANCE TO GET IT RIGHT
  • 15. ofSymptoms No matter what disease the person is dying from, the symptoms begin to look the same in the final stage. The failure of one organ system affects all the others. [“multi-system organ failure”] In the final stage, you will treat the symptoms (for comfort), NOT the disease (for cure).
  • 16. Concerns in the last hours of life Pain Shortness of Breath Secretions Feeding and hydration Changes in Consciousness Circulatory dysfunction Delirium
  • 17. PAINYou may need to change the route and dose of pain medicine, due to increased pain, inability to swallow, or decreased metabolism.
  • 18. LIQUID MORPHINE (Roxanol) Often used in the last few days or when patient is unable to swallow pills. Partially absorbed by mucous membranes in the mouth. Begins to relieve pain/SOB in about 15-20 minutes.
  • 19. PAIN MEDICINE IS BEST GIVENATC, not PRN If allowed to wear off, pain becomes harder to treat, requiring higher doses.
  • 20. P.O Narcotics Peak in 1 hour Half-life is 4 hours
  • 21. Respiratory Depression + Opioids Normal adult Resp. Rate = 12-20 [count for 60 sec.] Respiratory depression ONLY occurs with the first few doses of an opioid and with new increases in dose. Tolerance to Resp. Dep. occurs quickly. (stable dose w/RR>12—OK to give dose)[Source: EPEC Pain Module]
  • 22. Fact: Morphine Toxicity Occurs in this sequence:1. Drowsiness2. Confusion3. Loss of consciousness ONLY after these will you see:4. Respiratory drive significantly compromised* If patient is AWAKE and COMPLAINING—OK to give pain medicine.
  • 23. GOAL is steady pain relief—don’tskip doses without a good reason.When judging whether to hold dose, consider: New or recently increased dose? Is patient difficult to arouse? Is Resp. rate < 12 ? If yes, hold the dose. If no, give the dose.
  • 24. HOSPICE NURSES  Are expert in managing opioids for pain relief  Have access to Hospice Medical Director  Can be a resource
  • 25. *FENTANYL PATCH—NOT recommended at end-of-life  Pt’s. may not have enough SQ fat stores to absorb the drug.  Poor absorption due to changes in circulation and metabolism.  Rapid titration often necessary as pain levels and LOC change at the end of life. Patch takes about 18 hours to reach peak levels.
  • 26. DYSPNEA—SOB  Increased respiratory rate  Then, decreased rate  Apnea  Cheyne-Stokes breathing  Agonal breaths
  • 27. CHEYNE-STOKES BREATHING
  • 28. If Patient Is Actively Dying w/ SOB Avoid using an O2 mask (comfort) Nasal Canula O2 may help Fan may help, blowing air toward pt’s. face Morphine is drug of choice for “air hunger” Lorazepam, if anxiety is present
  • 29. SECRETIONS  Due to oral and tracheal secretions  Gurgling (“death rattle”)  No sign that this bothers the patient  DEFINITELY bothers those listening  Suctioning is NOT recommended
  • 30. TO DRY UP EXCESS SECRETIONS,GIVE:• Hyoscyamine (Levsin) or Atropine drops• Transdermal Scopolomine (Scop patch)• Also, try repositioning the patient*All 3 equally effective in a recent comparative study, but Scopolamine takes 24 hrs. to reach steady state.
  • 31. Decreased P.O. Intake Decreased appetite, weight loss, wasting, weakness Decreased fluid intake, dehydration, hypotension, dry mouth
  • 32. Decreased P.O. intake is normal at end-of life. Doesn’t bother patients. They DO complain of dry mouth. Treat with frequent mouth care. Educate families regarding decreased P.O. intake— Normal at end-of-life.
  • 33. CHANGES IN CONSCIOUSNESS Drowsiness Difficulty Awakening Unresponsive to stimuli
  • 34. CIRCULATORY DYSFUNCTION Cardiac – Tachycardia – Hyper/Hypotension – Peripheral cooling and cyanosis/mottling Renal – Dark Urine (tea-colored) – Oliguria (<400 ml./day)/ Anuria  EDUCATE FAMILY—Normal / No treatment needed
  • 35. DELIRIUM—treat w/benzos, haldol, etc.Symptoms: – Confusion, day/night reversal – Agitation – Purposeless, restless movements – Moaning – Acute onset
  • 36. Terminal Agitation Checklist Medication review (polypharm., toxicity, side effects?) Hx/ of substance abuse? Retention or urine/stool? Signs of fever or sepsis ? Dyspnea ? Assess pain/suffering
  • 37. Non-Physical Causes of T.A. Fear/Anxiety…… IDT can offer support, treat cautiously w/anxiolytics, consider music tx., therapeutic touch Environment…… Reduce stimuli, involve familiar faces @ bedside, consider Severe mental aromatx. anguish…………. If recovery is impossible and  death is near, consider terminal sedation
  • 38. TWO ROADS TO DEATH  The usual road--easy – Sleepy – Lethargic – Semi-comatose – Death
  • 39. The DIFFICULT ROAD  Restless  Confused  Hallucinations  Delirium  Myoclonic jerks, seizures  Comatose  Death
  • 40. PROGNOSIS AT END-OF-LIFE  Very difficult to be precise  Betterto give a general estimate (“days to weeks”)  Always remind patients & families of the unpredictability of the dying process.
  • 41. Unconscious Patients Near Death  May still hear, even if they can’t respond.  Advise caregivers and family members to talk to the patient as if he/she were conscious.
  • 42. WHEN DEATH OCCURS Heart stops beating Breathing stops Pupils become fixed and dilated Skin color becomes pale and waxen Body temperature cools Urine and stool may be released Eyes may remain open Jaw may fall open Observers may hear trickling of internal fluids, even after death.
  • 43. FAMILY MEMBERS OR CAREGIVERS May want to spend time with the body after the death A peaceful environment may facilitate grieving, so. . . Staff should take time to position the body, remove tubes, disconnect machinery, and clean up any mess
  • 44. LOVED ONESMay benefit from a recounting of events leading up to the death.Staff may be able to help families understand and “frame” the events.Families may need time alone with the body, or to observe customs & traditions.
  • 45. Communicating the Bad News1—Get the setting right2—Provide a “warning shot”3—Tell the news4—Respond to emotions with empathy5—Conclude with a plan
  • 46. Remember . . .We have only ONE CHANCE to get it right.
  • 47. Your Expertise Can Provide a Smooth Passage for the Patient and Family
  • 48. HOSPICE can HELP by offering Expert symptom control Education and support for your staff Psycho-social support for pt. and family Spiritual care Volunteer services Bereavement care for 13 months or longer Coverage for medications and equipment
  • 49. QUESTIONS/STORIES?