This document discusses end of life care, death, grieving, and related topics. It begins with definitions of key terms like end of life care, death, and grief. It then covers historical perspectives on death. The goals of end of life care and palliative care are to relieve symptoms and enhance quality of life. Hospice care provides support for the dying and their families in a home-like setting. Nursing management at end of life involves comprehensive assessment, addressing psychosocial and physical needs, effective communication, and upholding patient dignity.
2. Manifestation of approaching and impending
death
Grief
Palliative care
Hospice care
Legal and ethical issues
Critical thinking
Nursing management
Care after death
REVIEW
3. Loss: an aspect of self no longer
available to a person
Death : cessation of life
Grief : pattern of physical and emotional
responses to bereavement
End of life : final phase of a patient’s
illness when death is imminent
TERMINOLOGIES
4. Death rattle : a sound that is
something heard coming from a
dying person’s throat or chest
Palliative care: it is a specialized
medical care for people with
serious illness
Hospice : a place that provides
care for people who are dying
5. Primitive societies: unnatural, accidental
occurrence
Preliterate societies: living either
honoured or feared the deceased
Early Greek history: spirits of the dead
continued to live after death
Western culture (6th through the early 12th
century): collective destiny of all human
beings
HISTORIC PERSPECTIVE
6. END OF LIFE CARE:
End of life care refers to health
care, not only of patients in the
final hours or days of their lives,
but more broadly care of all those
with a terminal illness or terminal
disease condition that has become
advanced, progressive and
incurable.
7. DEATH:
Death can be defined as the
cessation of all vital functions of
the body including the heartbeat,
brain activity (including the brain
stem) and breathing.
8. More than 2.5 million people die
in the United States each year.
25% of all deaths take place at
home, with about 50% occuring in
hospitals. Remaining 25% occur in
nursing homes.
INCIDENCE
9. GOALS FOR END OF LIFE CARE:
Control symptoms
Identify client needs
Promote meaningful
interactions between the client
and significant others
Facilitate a peaceful death
10. INDICATIONS OF DEATH:
Total lack of response to
external stimuli
No muscular movement,
especially breathing
No reflexes
Flat encephalogram (brain
waves)
11. DEVELOPMENT OF THE
CONCEPT OF DEATH:
Infancy to 5 years
5 to 9 years
9 to 12 years
12 to 18 years
18 to 45 years
45 to 65 years
65+ years
12. IMPORTANCE OF CARE OF A DYING
PATIENT:
1. Care of the whole person
2. Support meaningful living
3. Supports the family to cope with
loss and grief
4.Respect personal, cultural and
religious values
5. Value ethical principles
13. PHYSICAL MANIFESTATIONS OF
APPROACHING DEATH
SYSTEM MANIFESTATIONS
SENSORY Decreased sensation, decreased perception,
blurring of vision, sinking and glazing of
eyes, blink reflex absent, eyelids remain half
opened
INTEGUMENTARY Mottling on hands,feet,arms and
legs;cold,clammy skin;cyanosis on nose,nail
beds,knees;wax like skin when very near to
death
RESPIRATORY Increased respiratory rate; Cheyne-stokes
respiration;inability to cough or clear
secretions resulting in
granting,gurgling;irregular breathing
14. URINARY Decreased urinary output, urinary
incontinence, unable to urinate
GASTROINTESTINAL Accumulation of gas, distension and
nausea, loss of sphincter control
MUSCULOSKELETAL Inability to move, sagging of jaw,
difficulty speaking, difficulty in
swallowing, difficulty maintaining
body posture and allignment, loss of
gag reflex, jerking
CARDIOVASCULAR Increased heart rate , slower and
weakening pulse, irregular rhythm.
Decreased in blood pressure, delayed
absorption of drugs
Cont…
15. PSYCHOSOCIAL MANIFESTATIONS
OF APPROACHING DEATH
Altered decision making
Anxiety about
unfinished business
Withdrawal
Decreased socialization
Fear of loneliness
Fear of meaninglessness
of one’s life
Fear of pain
Helplessness
Life review
Peacefulness
Restlessness
Saying goodbyes
Unusual
communication
Vision like experiences
16. 1. Loss of muscle tone:
Relaxation of facial muscles
Difficulty speaking
Difficulty swallowing and gradual loss of gag
reflex
Decreased activity of the gastrointestinal
system
Urinary and rectal incontinence
Diminished body movement
IMPENDING CLINICAL DEATH
17. 2. Slowing of the circulation:
Diminished sensation
Mottling and cyanosis of the
extrimities
Cold skin
Slower and weaker pulse
Decreased blood pressure
18. 3. Changes in respiration:
Rapid, shallow, irregular or abnormal
slow respirations
Noisy breathing
Mouth breathing, dry oral mucous
membrane
4. Sensory impairment:
Blurred vision
Impaired senses of taste and smell
19. Grief is defined as the
emotional process of coping
with a loss
GRIEF
20. 1. Normal grief: complex
emotional,cognitive,social,physical,
behavioural and spiritual responses to loss
and death
2. Anticipatory grief: associated with the
normal grief response before the loss
actually occurs
3. Delayed or inhibited grief: absence of
evidence of grief when it ordinarily would
be expected
TYPES OF GRIEF
21. 4.Distorted (exaggerated) grief:
symptoms associated with normal
grieving are exaggerated
5.Chronic or prolonged grief: maintaining
personal possessions aimed at keeping a
lost loved one alive
6. Disenfranchised grief: when
relationship to the deceased person is not
socially sanctioned
22. 7. Ambiguous loss: when the lost person is
physically present but not psychologically
available,e.g- severe dementia
8. Complicated grief: prolonged or
significantly difficult time moving forward
after a loss
9. Masked grief: disruptive behaviour due
to loss and ineffective grief resolution
25. The Dual Process Model
of coping with loss,
adopted from Stroebe
(1998)
26. Loss oriented
Grief work
Intrusion of grief
Breaking
bonds/ties
Denial/avoidance
of restoration
change
Restoration oriented
Attending to life
changes
Doing new things
Distraction from
grief
Denial/avoidance of
grief
New roles/identities/
relationships
Everyday life
experience
27. PHYSIOLOGIC AND PSYCHOLOGIC
RESPONSES TO GRIEF
Physiologic
• Crying
• Sighing respiration
• Shortness of breath ,
palpitation
• Fatigue , weakness,
exhaustion
• Insomnia
• Loss of appetite
• Choking sensation
• Tightness in chest
• GI disturbances
Psychological
• Intense loneliness and
sadness
• Anxiety or panic
episodes
• Difficulty concentrating
and focusing
• Disorientation
• Anger
• Ambivalence and low
self esteem
28. NORMAL GRIEF REACTIONS VERSUS
SYMPTOMS OF CLINICAL
DEPRESSION
Self esteem intact
Accepts comfort and
support from others
Openly express anger
May experience
transient physical
symptoms
Self esteem is
disturbed
Does not respond to
social interaction and
support from others
Does not directly
express anger
Express chronic
physical complaints
29. Palliative care is any form of care or
treatment that focuses on reducing the
severity of disease symptoms , rather
than trying to delay or reverse the
progression of the disease itself or
provide a cure.
PALLIATIVE CARE
30.
31. GOALS OF PALLIATIVE CARE:
Provide relief from symptoms
Regard dying as a normal process
Affirm life and neither hasten nor
postpone death
Support holistic patient care and enhance
quality of life
Offer support to patients to live as
actively as possible until death
Offer support to the family
32. The palliative care team is an
interdisciplinary collaboration
involving physicians, social
workers, pharmacists, nurses,
chaplains and other health care
professionals.
37. Hospice is not a place but a
concept of care that provides
compassion, concern and support
for the dying.
HOSPICE CARE
38. GOALS OF HOSPICE CARE
To ensure that every moment
counts, in the last six months of
life.
To make the patient comfortable,
ease pain and other troublesome
symptoms and support the family
through a sad and difficult time.
42. HOSPICE CARE BENEFITS:
Offers a familiar environment.
Provides a comprehensive plan,
competent professionals.
Offers personalized care and
support.
Gives patient a sense of dignity.
Respect a patient’s wishes.
Lessens financial burdens.
Provide family counselling.
48. ADVANCE DIRECTIVE:
Documents that give
instructions about future medical
care and treatments and who
should make them in the event the
person is unable to communicate.
2. LEGAL DOCUMENTS USED
IN END OF LIFE CARE:
49. DIRECTIVE TO PHYSICIANS:
A written document specifying
the patients wish to be allowed
to die without heroic or
extraordinary
measures.
50. DO NOT RESUSCITATE (DNR):
A written physicians order
instructing health care providers
not to attempt CPR , often
requested by family ,
must be signed by a
physician to be valid.
51.
52. DURABLE POWER OF
ATTORNEY FOR HEALTH CARE:
A document used for listing the
person or persons to make
health care decisions when a
patient become unable to make
informed decisions for self.
53. LIVING WILL:
Documents that give
instructions about future
medical care and treatments or
the wish to allowed to die
without heroic or extraordinary
measures when the patient is
unable to communicate for self.
54. MEDICAL POWER OF ATTORNEY:
A document used for listing the
person or persons to make
health care decisions when a
patient become unable to make
informed decisions for self.
55. Physician assisted suicide
involves the prescription by a
physician of a lethal dose of
medication for the purpose of
ending someone’s life.
ASSISTED SUICIDE
64. Should I begin/continue/discontinue a
particular treatment?
Should I make plans to receive care in a
place other than my home?
Should I discuss my wishes for care and
treatment planning with my family?
Should I appoint someone to be my
substitute decision maker?
NURSES ROLE IN END-OF-LIFE
DECISION MAKING
65. O’ Conner (2008) suggested the
following as typical signs of decisional
conflict:
Being unsure about what to do
Concern about negative
outcomes
Distress or upset
Preoccupation with the decision
67. Provide information about options and
the benefits and harms associated with
each option
Assess in individual’s understanding of
information about options
Helps individuals build skills in
deliberation and communication
Assess support needs
Screen for implementation needs
NURSES CAN-
69. Right to be treated
Right to be in control
Right to maintain a sense of hopefulness
Right to be cared for by those who can
maintain a sense of hopefulness
Right to have a sense of purpose
Right to express feelings and emotions
A DYING PERSON’S BILL OF
RIGHTS
70. Right to participate in decision about care
Right to expect continuing medical and
nursing attention even through ‘cure’
goals must be changed to ‘comfort’goals
Right not to die alone
Right to be free from pain
Right to have a respected spirituality
Right to have questions answered
honestly
Right not to be decieved
71. Right to have help from and for family
Right to die in peace and dignity
Right to retain individuality and not be
judged for decisions
Right to discuss and enlarge religious
and/or spiritual experiences
Right to expect that the sanctity of
human body will be respected after death
Right to be cared for by caring, sensitive,
knowledgeable people
102. 1. Opioid analgesics: morphin, fentanyl
etc.
2. Non-opioid analgesics: paracetamol,
aspirin, ibuprofen etc.
3. Adjuvant analgesics : NSAID, tricyclic
antidepressant, anticonvulsants,
anticholinergic etc.
PHARMACEUTICALS
INTERVENTIONS
103. 4. Anti anxiety agents:
benzodiazepines etc
5. Bronchodialators
6. Corticosteroids
7. Oxygen therapy
8. Haloperidol for delirium
9. Laxatives
104. Euthanasia is the practice of intentionally
ending a life in order to relieve pain and
suffering.
EUTHANASIA
Voluntary
Non voluntary
Involuntary
105. 1. Relaxation and guided imagery
2. Massage and other touch-based
therapies
3. Aromatherapy
ADVANTAGES AND
DISADVANTAGES
COMPLEMENTARY MEDICINE IN
PALLIATIVE CARE
109. 1. Physician assisted suicide and
euthanasia: can you even imagine
teaching medical students how to end
their patients’ lives?
2. Assisted suicide and the killing of
people? May be, physician-assisted
suicide and the killing of patients? No:
the rejection of Shaw’s new perspective
on euthanasia.
JOURNAL ABSTRACT
110. 3. Parents perspective on the end of
life care of their child with cancer:
Indian perspective
4. Significance of end of life dreams
and visions experienced by the
terminally ill in rural and urban India.
5. The complexity of nurses attitudes
toward euthanasia : a review of the
literal.