Death And Dying


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Powerpoints for Fennison lecture to appear on test #1.

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  • As Woody Allen says, “I don’t mind dying, I just don’t want to be around when it happens.” Poets love it: a. Now I am about to take my voyage, a great leap in the dark – Hobbs – an adventure b. Each person is born to one possession which out values all others; his last breathe – Twain – philosophical c. The silence of that dreamless sleep, I now envy to much to sleep – Byron – embraced. Attitudes: May have no experience as grandparents live longer. Death often become impersonal and an unusual event. Tend to confront it on an intellectual level only. Prolonging life: New medical methods make this possible. This practice is entangled in a web of ethical, religious, legal, and morel problems. Hospice starting to be used more and more and not only for patients dying of cancer. Whether patient remains in the home, hospital or in inpatient hospice center, the doctors and nurses are there to help the patient and the family through the dying process. Common fears: change in body image; losing control of bodily functions; not being told the facts ; losing control of decision-making in regards to quality of life ( to minimize this sense of powerlessness, allow patient to be involves in decision concerning his/her care ) ; being abandoned by love ones and dying alone ; Fear of pain; (tendency to associate death with pain – “ on pain of death ”); the fear of meaninglessness ( need to look at the positive aspects of his/her life ) Healthcare Professionals – Need to do a self-assessment & plan necessary interventions How do you feel about death. Is it affected by culture? Be honest about own feelings Examine how you see own death. Share feelings about death with others to help self-understanding. Learn to listen: Not all questions require answer. Ask patient what he/she thinks or feels about his question: “Am I going to die?”
  • Death And Dying

    1. 1. DEATH AND DYING Attitudes about death & dying -- Present generation (you) may be unaware of feelings -- Prolonging life -- Common fears -- Behaviors of healthcare professionals Definitions : -- The concepts of death and dying were rarely studied before the 1960’s -- Death is an inevitable, unequivocal, universal experience. -- Physiologically it is a cessation of all vital functions -- Emotionally it is looked at as one of life’s mysteries
    2. 2. Interventions : a. Do not interfere unless it becomes destructive b. Do not support denial; conversations should include reality c. Continue to teach and encourage self- care and activities Coping Mechanisms (Elizabeth Kubler-Ross) <ul><li>Denial </li></ul>After the initial shock has worn off, the next stage is usually one of classic denial, where they pretend that the news has not been given. They effectively close their eyes to any evidence and pretend that nothing has happened. “ No, not me”
    3. 3. Interventions : a. Give them space, allowing them to rail and bellow. The more the storm blows, the sooner it will blow itself out. b. Try not to respond in “kind ” c. When anger becomes destructive, it must be address directly. Remind person of appropriate and inappropriate behavior <ul><li>Anger </li></ul>This stage often occurs in an explosion of emotion, where the bottled-up feelings of the previous stages are expulsed in a huge outpouring of grief. Whoever is in the way is likely to be blamed . “ Why me”
    4. 4. <ul><li>Bargaining </li></ul>“ Yes me, but” The patient attempts to negotiate a postponement, usually with God and is generally kept a secret Interventions : a. Spend time with patient b. Discuss importance of valued objects and people <ul><li>Depression </li></ul>The inevitability of the news eventually (and not before time) sinks in and the person reluctantly accepts that it is going to happen Interventions: a. Be available and don’t attempt to cheer patient b. Find out about any religious support
    5. 5. <ul><li>Acceptance </li></ul>Restful time, but not necessarily happy . Often begin putting their life in order, sorting out wills and helping others to accept the inevitability. Interventions : a. Plan care to allow person with whom patient is comfortable to care for him/her b. Important that you don’t withdraw. <ul><li>Hope </li></ul>“ Where there is life, there is hope” May permeate all stages
    6. 6. SIGNS & SYMPTOMS of APPROACHING DEATH <ul><li>May have increased hallucinations </li></ul><ul><li>Decreased appetite </li></ul><ul><li>Decreased urine output </li></ul><ul><li>May have temperature spikes </li></ul><ul><li>Incontinent of stool & urine 24 to 72 hours prior to death </li></ul><ul><li>Pain may be more intense </li></ul>-- if feel pain should be controlled, check for an impaction ( 5 to 10% of pain at death due to impaction) <ul><li>Restlessness is common 12 to 24 hours prior to death </li></ul>
    7. 7. <ul><li>Changes in respiratory status </li></ul>-- Periods of Cheyne-Stokes 36 to 72 hours prior (may be constant final 6 to 12 hours) -- Oxygen is not usually helpful <ul><li>Increase in chest fluids </li></ul>-- Audible rattle or gurgle (Death Rattle) -- Atropine SQ may be ordered (Why?) <ul><li>Grunting & moaning on expiration </li></ul><ul><li>Skin changes </li></ul>-- Extremities begin to cool -- Cyanosis & mottling -- Color shallow -- Face sunken
    8. 8. Emotional <ul><li>Listen, be sensitive, and respond </li></ul><ul><li>Be aware of your own feelings </li></ul><ul><li>Assess family needs </li></ul><ul><li>Caring for the dying patient involves taking risks </li></ul>-- ask family, especially wife or husband, how they would like to help with their loved ones care. -- be prepared for a wide variety of behaviors from family members. <ul><li>Carry out requests if possible </li></ul><ul><li>Foster communication between you, the patient, and the family </li></ul>
    9. 9. The nurse <ul><li>Understand that you may experience grief </li></ul><ul><li>Help your colleagues if you see them going through this </li></ul><ul><li>Providing care for the dying patient and supporting the family can be very rewarding. </li></ul>After Death <ul><li>Check your hospital policy and procedures </li></ul><ul><li>RN’s can pronounce a patient dead </li></ul><ul><li>Care of the body generally involves: </li></ul>a. supine position b. clean body c. tidy room and turn down lights d. pads to perineal area
    10. 10. AUTOPSY Deaths which come under the jurisdiction of the Medical Examiner's Office include but are not limited to the following circumstances: 1. Persons who die suddenly when in apparent good health and without medical attendance within thirty-six hours preceding death or die within 24 hours of admission to a healthcare facility. 2. Circumstances which indicate death was caused in part or entirely by unnatural or unlawful means. 3. Suspicious circumstances. 4. Unknown or obscure causes. 5. Deaths caused by any violence whatsoever, whether the primary cause or any contributory factor in the death. 6. Contagious disease. 7. Unclaimed bodies.
    11. 11. <ul><ul><li>This Act required all institutions that participate with Medicare to provide written information to patients concerning their rights to accept or refuse treatment, including information about written advanced directives </li></ul></ul><ul><li>Durable Power of Attorney – allows individuals to select someone to make healthcare decisions if they are unable to. </li></ul><ul><li>The Omnibus Reconciliation Act became effective in 1991. </li></ul><ul><li>Also called the Patient Self- determination Act </li></ul>
    12. 13. 3. General Statement of Authority Granted. My Health Care Agent is specifically authorized to give informed consent for health care treatment when I am not capable of doing so. This includes but is not limited to consent to initiate, continue, discontinue, or forgo medical care and treatment including artificially supplied nutrition and hydration, following and interpreting my instructions for the provision, withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or other form of “living will” I may have executed or elsewhere, and to receive and consent to the release of medical information. When the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act in my best interest in making health care decisions. The above authorization to make health care decisions does not include the following absent a court order: (1) Therapy or other procedure given for the purpose of inducing convulsion; (2) Surgery solely for the purpose of psychosurgery; (3) Commitment to or placement in a treatment facility for the mentally ill, except pursuant to the provisions of Chapter 71.05 RCW; (4) Sterilization. I hereby revoke any prior grants of durable power of attorney for health care. 4. Special Provisions ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ DATED this _______________________ day of _______________________ , ______________ . GRANTOR __________________________________________ STATE OF WASHINGTON ) (COUNTY OF ________________________ ) I certify that I know or have satisfactory evidence that the GRANTOR, ___________________________________________________________ signed this instrument and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in the instrument. DATED this _______________________ day of _______________________ , ______________ . _____________________________________________________________________ NOTARY PUBLIC in and for the State of Washington, residing at_____________________________________________________________ My commission expires __________________________________________________ (Year) (Year)
    13. 14. HEALTH CARE DIRECTIVE Directive made this _______________________________ day of _________ , ______________ . I, _____________________________________________ being of sound mind, willfully, and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that: (A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my attending physician, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand “terminal condition” means an incurable and irreversible condition caused by injury, disease or illness that would, within reasonable medical judgment, cause death within a reasonable period of time in accordance with accepted medical standards. (B) If I should be in an irreversible coma or persistent vegetative state, or other permanent unconscious condition as certified by two physicians, and from which those physicians believe that I have no reasonable probability of recovery, I direct that life-sustaining treatment be withheld or withdrawn. (C) If I am diagnosed to be in a terminal or permanent unconscious condition, [ Choose one ] I want _________ do not want _________ artificially administered nutrition and hydration to be withdrawn or withheld the same as other forms of life-sustaining treatment. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in certain circumstances. I request all health care providers who care for me to honor this directive. (D) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family, physicians and other health care providers as the final expression of my fundamental right to refuse medical or surgical treatment, and also honored by any person appointed to make these decisions for me, whether by durable power of attorney or otherwise. I accept the consequences of such refusal. (E) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy. (F) I understand the full import of this directive and I am emotionally and mentally competent to make this directive. I also understand that I may amend or revoke this directive at any time. (G) I make the following additional directions regarding my care: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Signed: _______________________________________ The declarer has been personally known to me and I believe him or her to be of sound mind. In addition, I am not the attending physician, an employee of the attending physician or health care facility in which the declarer is a patient, or any person who has a claim against any portion of the estate of the declarer upon the declarer’s decease at the time of the execution of the directive. Witness: __________________________________ Witness: __________________________________
    14. 15. Physician Orders for Life Sustaining Treatment (POLST) The POLST form is a “portable” physician order form that describes the patient’s code directions. -- It is intended to go with the patient from one healthcare setting to another. -- It summarizes the wishes of an individual regarding life-sustaining treatment that was identified in an advanced directive and includes the following: a. Patient wishes for resuscitation b. Medical interventions c. Antibiotics d. Artificial feedings -- The advantage of this form is that it translates the patient’s wishes into actual physician’s orders .
    16. 17. PHILOSOPHY <ul><li>Right to make health care decisions </li></ul><ul><li>Includes decisions about life sustaining treatment </li></ul><ul><li>Includes description for life sustaining treatment to Health care providers </li></ul><ul><ul><ul><li>provide comfort care </li></ul></ul></ul><ul><ul><ul><li>honor life sustaining treatment. </li></ul></ul></ul>
    17. 18. FORM? <ul><li>Bright lime green form </li></ul><ul><ul><li>short summary treatment preferences </li></ul></ul><ul><ul><li>physician’s order </li></ul></ul><ul><li>“ portable“ </li></ul><ul><ul><li>describes patient’s code directions </li></ul></ul><ul><ul><ul><li>resuscitation, medical interventions, antibiotics, artificially administered fluids, nutrition. </li></ul></ul></ul><ul><ul><li>transfer one care setting with single uniform document. </li></ul></ul>
    18. 19. FORM? <ul><li>Voluntary </li></ul><ul><li>Promote discussions </li></ul><ul><ul><ul><li>plan end of life care wishes </li></ul></ul></ul><ul><ul><ul><li>assist physicians, nurses, health care facilities, emergency personnel honor wishes for life-sustaining treatment. </li></ul></ul></ul><ul><li>EMS treatment direction & action </li></ul>
    19. 20. FORM? <ul><li>Replaces current EMS-No CPR Code directions to EMS Directive </li></ul><ul><li>Translates an Advanced Directive into physician orders. </li></ul><ul><li>NOTE: POLST is NOT an Advance Directive and DOES NOT replace the patient’s advance directive. </li></ul>
    20. 21. QUALIFICATION? <ul><li>Any adult 18 or older </li></ul><ul><li>With serious health conditions </li></ul>
    21. 22. FORM LOCATION? <ul><li>Health Care Setting Recommendations </li></ul><ul><li>Keep with patient </li></ul><ul><ul><li>In hospital </li></ul></ul><ul><ul><ul><li>Medical Chart </li></ul></ul></ul><ul><ul><li>In long-term care facility . </li></ul></ul><ul><ul><ul><li>Medical Chart </li></ul></ul></ul>
    22. 23. PHYSICIAN ORDER FORM REVIEW <ul><li>LAST NAME (Patient/Resident) </li></ul><ul><li>FIRST NAME & Initial </li></ul><ul><li>DATE of BIRTH </li></ul>
    23. 24. Part A Resuscitation* <ul><li>No pulse & not breathing </li></ul><ul><ul><li> Resuscitate </li></ul></ul><ul><ul><li> Do not resuscitate </li></ul></ul><ul><ul><li>Patient wants CPR </li></ul></ul><ul><ul><ul><li>Resuscitate box </li></ul></ul></ul><ul><ul><li>Does not want CPR </li></ul></ul><ul><ul><ul><li>Do Not Resuscitate box </li></ul></ul></ul><ul><ul><ul><li>(Resuscitation not attempted.) </li></ul></ul></ul><ul><ul><li>Comfort measures provided </li></ul></ul>
    24. 25. Part B Medical Interventions* <ul><li>Patient HAS pulse &/or breathing. </li></ul><ul><li> Comfort measures only </li></ul><ul><li> Limited Interventions – Comfort measures, consider oxygen, suction, manual airway obstruction </li></ul><ul><li> Advanced Interventions – All above, consider oral/nasal airway, BVM/demand valve, monitor cardiac rhythm, medications, IV fluids </li></ul><ul><li> Full treatment/Resuscitation – All above plus CPR, intubation and defibrillation </li></ul><ul><li> Other instructions ____________________ </li></ul>
    25. 26. Part C Antibiotics <ul><ul><li>(notify physician of new infection) </li></ul></ul><ul><li> No antibiotics except comfort </li></ul><ul><li> No invasive (IM/IV) antibiotics </li></ul><ul><li> Full treatment </li></ul><ul><li> Other instructions ____________ </li></ul>
    26. 27. Part D Artificially Administered Fluids and Nutrition <ul><ul><li>Other fluids & nutrition offered (medically feasible) </li></ul></ul><ul><li> No feeding tube/IV fluids . </li></ul><ul><li> No long term feeding tube/IV fluids </li></ul><ul><li> Full treatment </li></ul><ul><li> Other instructions ______________ </li></ul>
    27. 28. Part E Discussed With <ul><li> Patient </li></ul><ul><li> Agent Durable Power of Attorney </li></ul><ul><li> Court Appointed Guardian </li></ul><ul><li> Spouse </li></ul><ul><li> Other ________________________ </li></ul>
    28. 29. Part E Order Basis <ul><li> Patient Request </li></ul><ul><li> Patient Best Interest </li></ul><ul><li> Patient's Known Preference </li></ul><ul><li> Medical Futility </li></ul><ul><ul><li>Check all that apply </li></ul></ul>
    29. 30. SIGNATURE BLOCK (Mandatory) <ul><li>Physician Name (print) </li></ul><ul><ul><li>Signature </li></ul></ul><ul><ul><li>Phone Number </li></ul></ul><ul><ul><li>Date </li></ul></ul><ul><li>Patient (or legal Surrogate) </li></ul><ul><ul><li>Signature </li></ul></ul><ul><ul><li>Date </li></ul></ul><ul><ul><li>End first page </li></ul></ul>
    30. 31. Part F Guide <ul><li>Patient Treatment Preferences </li></ul><ul><li> Advance Directive (Attach copy) </li></ul><ul><li> Court Appointed Guardian (Attach copy) </li></ul><ul><ul><li>Name: __________________ </li></ul></ul><ul><li> Agent for Durable Power of Attorney (Attach copy) </li></ul><ul><ul><li>Name: __________________ </li></ul></ul>
    31. 32. Part F Guide <ul><li>Patient Treatment Preferences </li></ul><ul><li> Advance Directive (Attach copy) </li></ul><ul><li> Court Appointed Guardian (Attach copy) </li></ul><ul><ul><li>Name: __________________ </li></ul></ul><ul><li> Agent for Durable Power of Attorney (Attach copy) </li></ul><ul><ul><li>Name: __________________ </li></ul></ul>
    32. 33. HEALTH STATUS CHANGE <ul><li>Close to death </li></ul><ul><li>Extraordinary suffering </li></ul><ul><li>Improved condition </li></ul><ul><li>Permanent unconsciousness </li></ul><ul><li>Advanced progressive illness </li></ul><ul><li>Signature Block of PREPARER </li></ul><ul><ul><li>Name (Print) </li></ul></ul><ul><ul><li>Date </li></ul></ul>
    33. 34. PERIODIC FORM CHANGE REVIEW <ul><li>Patient Transfer </li></ul><ul><li>Substantial health status change </li></ul><ul><li>Treatment Change </li></ul><ul><ul><li>REVIEW (Part F) </li></ul></ul><ul><ul><li>RECORD (Part G) </li></ul></ul><ul><ul><li>Draw Line & &quot;VOID“ (Initial or sign) </li></ul></ul><ul><ul><ul><li>(Physician Orders) </li></ul></ul></ul><ul><li>Options </li></ul><ul><li>(May complete new form) </li></ul><ul><li>(No new form full treatment & resuscitation) </li></ul>
    34. 35. Part G Review POLST <ul><ul><li>Review Date: </li></ul></ul><ul><ul><li>Reviewer’s name: </li></ul></ul><ul><ul><li>Location of review: </li></ul></ul><ul><ul><li>Review Outcome: </li></ul></ul><ul><ul><li> No Change </li></ul></ul><ul><ul><li> Form voided </li></ul></ul><ul><ul><li> New form completed </li></ul></ul><ul><li>SIGNATURE BLOCK </li></ul><ul><ul><li>Patient </li></ul></ul><ul><ul><li>Legal Surrogate </li></ul></ul><ul><ul><li>Date </li></ul></ul><ul><li>(SIGNATURES MANDATORY) </li></ul><ul><ul><li>End last page </li></ul></ul>
    35. 36. WASHINGTON STATE PLAN <ul><li>Replacing State EMS-No CPR </li></ul><ul><ul><ul><li>phased out of counties receiving POLST orientation </li></ul></ul></ul><ul><li>EMS will honor </li></ul><ul><ul><li>EMS-No CPR or </li></ul></ul><ul><ul><li>POLST </li></ul></ul>
    36. 37. Assisted Suicide ASSISTED SUICIDE : Helping a person to end his or her life by request in order to end suffering. (Rarely prosecuted and only lawful in Switzerland where the reasons must be altruistic.) PHYSICIAN-ASSISTED SUICIDE : Medical doctor helping patient to die by prescribing a lethal overdose. Patient can chose whether to drink it. (Lawful only in Oregon, Switzerland, Netherlands and Belgium.) EUTHANASIA : A broad, generic term meaning 'help with a good death.' VOLUNTARY EUTHANASIA : Death by lethal injection by doctor when requested by patient. (Only lawful in Belgium and the Netherlands for the terminally or hopelessly ill.) NON-VOLUNTARY EUTHANASIA : Using powerful drugs, doctor ends life of suffering, dying patient who is comatose. Illegal, but happens all the time, discreetly, in the interest of compassion. Definitions :
    37. 38. MERCY KILLING : Taking the life of another person in the belief that this is a compassionate act because the ill person is unable to do so. Unlawful. TERMINAL SEDATION : Upon patient request, doctor puts patient into deep sleep with medications, during which time the patient dies either of the underlying illness or starvation/dehydration. Widely practiced and generally accepted as ethical and lawful. -- Oregon Death with Dignity Act passed in 1997 is the first and only legislative initiative that has passed. --It allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose. --In order to participate, the patient must: 1) 18 years of age or older, 2) a resident of Oregon, 3) capable of making and communicating health care decisions for him/herself
    38. 39. 4) diagnosed with a terminal illness that will lead to death within six (6) months. --It is up to the attending physician to determine whether these criteria have been met. -- Since the law was passed in 1997, 292 patients have died under the terms of the law.
    39. 40. Types of CPR Decisions : <ul><li>Complete </li></ul>-- CPR; medications; mechanical ventilation -- Also called a “Full Code” <ul><li>Chemical Code </li></ul>-- Use of medication without use of CPR or mechanical ventilation <ul><li>No Code or DNR </li></ul>-- Person dies without any medical interference