2. OBJECTIVE
1. Discuss personal and societal attitudes related to death and end-of-
life planning.
2. Identify factors that are likely to influence end-of-life decision
making.
3. Explore caregiver attitudes toward end-of-life care.
4. Discuss the importance of effective communication at the end of life.
3. OBJECTIVE
5. Identify cultural and spiritual considerations related to end-of-life
care.
6. Describe nursing assessments and interventions appropriate to end-
of-life care.
7. Discuss the role of the nurse when interacting with the bereaved.
8. Describe the stages of grief
4. INTRODUCTION
• In the 17th century death was acknowledge by a solemn ringing of
church bells.
• Death was feared, but it was perceived as inevitable part of life.
• People died at home receiving care from family members.
• People of all ages were exposed to the realities of death.
• Cultures around the world developed grieving rituals to held the
deceased person’s family process and mange the experience of loss.
5. INTRODUCTION
• End-of-life experiences are very different today.
• Advancement of science and technology have led to increase of life
expectancy over the last 100 years.
• Almost 80% of deaths occur among people over age 65.
• With increasing life expectancy, death is becoming increasingly
associated with advance age and progression of chronic/debilitating
conditions.
6. CAUSES OF DEATH IN ADULTS
• Disease of the heart
• Malignancy neoplasms
• Cardiovascular diseases
• Chronic obstructive pulmonary diseases
• Pneumonia and influenza
• Diabetes melllitus
• Alzheimer disease
• Nephritis, nephrotic syndrome, nephrosis
• Accidents
• Septicemia
7. ATTITUDE TOWARD DEATH AND END-OF-
LIFE PLANNING
• Health professionals often made the decision about end-of-life care
• “We have done everything possible”
• The primary role of health professionals if to help consumers make informed decisions.
• End-of-life shifted from purely medical focus to wholistic – giving considerations to
consumer’s personal values, cultural and spiritual beliefs, and life experiences.
• Older adults and families prefer treatment modalities to prolong life, receive treatment.
• Prefer a comfortable death in the presence of loved once.
8. • Family members, nurses, and other care givers must be able to communicate about
end of life to provide good care for older people nearing end of their lives.
• Discussions regarding end-of-life care and planning of death should occur before a
health crisis .
• Able to make decisions according to personal values.
• Most death are not traumatic to older adults than young people.
• Most older adults express their death wishes.
9. ADVANCE DIRECTIVES
• Special end of life decisions
• A written statement of a person’s wishes regarding medical
treatment, often including a living will, made to ensure those wishes
are carried out should the person be unable to communicate to a
doctor.
• Physician’s order for life sustaining treatment (POLST).
• Copies of advance directives should be given to primary care
providers.
10. INFORMATION NEEDED BEFORE DECIDING
EOL
• The amount of time a treatment will add to life
• The quality of life with this treatment
• The amount of pain, disability, or risk involved with the treatment
• The amount of time involved in the treatment
• The cost of treatment (whether it is covered by insurance)
• The need for and availability of caregivers
• The availability, benefits, and risk of other treatment options.
11. VALUES RELATED TO EOL
• Beliefs, attitudes, and values regarding the experience of death and
end of life care vary.
• This is influenced by age, gender, culture, religious background and
life experiences.
• Ethical dilemmas relating to end of life care occurs when the value
system of the patient and of the caregiver differ.
• Understanding the value system of others can help the nurse provide
quality end-of-life care, even when the nurse does not share the same
values.
13. SUMMARY OF PATIENT’S WISH
• Be able to issue advance directives to ensure their wishes are respected
• Be afforded dignity, respect, and privacy
• Know when death is coming and what to expect
• Have access to information and options related to care
• Retain control of decision-making regarding care
• Have control over symptom and pain relief
• Have access to emotional, cultural, and spiritual support
• Retain control regarding who may be present at the end of life
• Know possible options (e.g., hospital, home care, and hospice) and have a choice regarding where and how death will occur
• Have time to say goodbye to significant others
• Leave life when ready to go without unnecessary or pointless interventions
14. WHERE DO PEOPLE DIE
• 90% wish to die at home
• Approximately half of deaths occur in hospitals and other health care facilities
• Hospital focuses on curative and restorative care and may not be suitable for end of
life care.
• Hospice care focuses on humane, dignified, and compassionate care of the dying
persons and their loved ones.
15. PALLIATIVE CARE
• World Health Organization, palliative care focuses on reducing or
relieving the symptoms of a disease without attempting to provide a
cure; it neither hastens or postpones death.
• Interventions are designed to optimize the patient’s ability to live as
active and complete a life as possible until death comes.
• Medical treatment and nursing care focus on actions that enable the
dying person to have the highest quality of life for whatever time
remains.
16. SPIRITUAL NEEDS OF A DYING PERSON
• Determine whether or not any specific religious beliefs or practices are
important to the person or his or her family members.
• Assess whether or not the patient has a preferred spiritual counselor.
• Offer choices when available.
• Determine whether or not the person wishes any spiritual counselor to
be notified.
17. SPIRITUAL NEEDS OF A DYING PERSON
• Demonstrate respect for the patient’s religious spiritual views.
• Do not impose your own beliefs on the patient.
• Be present, be available, and listen.
• Keep the patient’s relevant religious symbols readily available and treat them with
respect.
• Avoid moving beyond role and level of expertise unless you have specific ministerial
or pastoral training in death and dying.
18. DEPRESSION, ANXIETY AND FEAR
How to cope with emotional distress:
1. Encourage the dying person and his/her loved once to participate in creative and
pleasurable activities – art, poetry, writing
2. Physical activity can help reduce both physical and emotional tension.
3. Relaxation classes or support groups – help decrease social isolation
4. Allow to verbalize their anger and help them ways to move forward to cope with
the future.
19. DEATH
1. Discuss the family’s wishes early, so that appropriate notification of family,
clergy, and others can take place.
2. Record and communicate instructions on who to call, how they can be
reached, and whether there are any limitations regarding time of day.
3. Offer family members the opportunity to participate in the care of the dying
person. Families often want to be helpful. Educate them and provide them with
opportunities to participate in the care.
20. DEATH
4. Allow family members to express their emotions and provide them with
support. Some family members may be hesitant and may need permission to
express their emotions, although others might be very demonstrative when it
comes to grief. Ensure they feel comfortable and supported.
5. Provide frequent updates on the condition of the dying person, and be
available to answer questions. Families often need assurance that the person is
comfortable. Provide comfort measures and be sensitive to the needs of the
family members.
21. INDICATORS OF IMMINENT DEATH
1. Increased sleepiness
2. Decreased responsiveness
3. Confusion in a person who has been oriented
4. Hallucinations about people (sometimes deceased family members)
5. Increased withdrawal from visitors or other social interaction
6. Loss of interest in food and fluids
7. Loss of control of bowel and bladder in a person who has been continent
8. Altered breathing patterns such as shallow breathing, Cheyne-Stokes respirations, and rattling or
gurgling respirations
9. Involuntary muscle movements and diminished reflexes
22. • Death may be sudden and quick, slow or gradual.
• Some experience physiologic changes that result to relatively quick
death.
• Some bodily functions shuts down system by system, heart rate slows,
respiration fades, individual slowly slips away.
23. SIGNS OF DEATH
• Absence of heartbeat and spontaneous respiration
• Open eyes without blink
• Nonreactive pupils
• Flaccid jaw with slightly open mouth
• Lack of response to touch, speech, or painful stimuli
• Legal pronouncement of death is made by the physician
24. POST MORTEM CARE
• Remove soiled sheets and apply clean ones
• Head should be elevated to prevent discoloration
• Gently close the eyes
• Insert dentures
• Position a small town to close the mouth
• Note the time of death
25. BEREAVEMENT
• Encourage the grieving person to take time to cry and express his
feelings
• Listen to the grieving person and talk about the love one
• Review and reminiscence about good times
• Recommend support groups
• Collaborate with other health team members to provide support and
initiate referral to a grief counselor.
26. KUBLER-ROSS STAGES OF GRIEF
• DENIAL Numbness protects the survivor from the intensity of the
loss. This typically decreases as the individual acknowledges the
reality and permanence of the loss.
• ANGER Feeling of anger are often directed at the deceases of at a
deity because the survivor feels abandoned. Anger is one method for
dealing with the feeling of helplessness and powerlessness. Anger
tends to decrease over time
27. KUBLER-ROSS STAGES OF GRIEF
• BARGAINING Survivors try to identify whether they could have dome something
different to prevent the loss. Some may make resolutions to change their behavior
or lifestyle based on these reflections. Remorse and guilt that they did not do
enough are common and can slow the grief process.
• DEPRESSION Feelings of emptiness, loneliness, and isolation are common after the
loss of a loved one. Frequent crying spells, inability to sleep, inability to concentrate
or make decisions, and loss of appetite are typical. Some survivors describe their
lives as colorless and meaningless. Many people try to hide their feelings and suffer
needlessly. Support from family, friends, nurses, physicians, and bereavement
groups can help the survivor work through feelings of depression. Antidepressant
medications are sometimes used on a short-term basis.
28. KUBLER-ROSS STAGES OF GRIEF
• ACCEPTANCE There is no set time limit for grief over the loss of a
loved one. Acceptance and healing occur slowly as the person works
through his or her feelings and reestablishes a meaning and pattern
to life.
29. POINTERS TO REVIEW
• Care pf aging skin and mucous membrane, oral mucous
• Elimination
• Activity and exercise
• Sleep and rest
• Medications of older adults
• End-of-Life Care
