This presentation helpful for all critical care Nurses

2. End of life care
Presented by
Nahida Akhter
(SSN) ICU,
BIRDEM
General Hospital

3. ----Robert louis
stevenson
“It is not death I fear to
face, it is dying ’’

4. Introduction:

5. Definition of End of Life Care
“The End of life or terminal phase is defined as the
period when day to day deterioration, particularly of
strength, appetite and awareness, are occurring”.
- Oxford Handbook of Palliative Care, Page No. -
735

6. Definition Cont…….
• This refers to the last year of life
• Physicians often use what is referred to as the ‘
surperise question.’
• That is it likely that the person will die in the next
year.
• Acknowledgement of this leads to planning for the
care that may be required .

7. Purposes of End of Life Care
To provide best possible of quality care.
To give mental support to the patient and their
families .
To reduce pain and supportive care.

8. Quality of End-of-Life Care
Five components:
. Adequate pain and symptom management
• Avoiding inapproprite prolongation of dying
• Achieving a sense of control
• Relieving burden
• Strengthening relationships with loved ones

9. Principle of End of Life Care
Recognition of the requirements, complications.
Meet any emergency
Prepare the unit by all necessary equipment's for
smooth running.
Provide quality care and necessary and appropriate
action to prevent complications.

10. Principel Cont…
 Collaborative practice between physician and
nurse for giving End of Life Care

11. Indication:
• Cancer
• Cardiac disease
• Renal Failure
• Pulmonary Disease
• Stroke
• Coma

12. Indication Cont...
. Alzheimer‘s Disease
• Dementia
• Liver Disease
• HIV Disease

13. Signs of EOL
General Condition
Patient’s condition is getting worse day by day or
hour by hour
Profound Weakness, Bed-bound, Needs
assistance with all care

14. Sign Cont…
Decreasing interaction:
Less interested in getting out of bed or receiving
guests
Less interested in things happening around
him/her

15. Sign Cont.…
Sleeping most of the time, Confused or Comatose
May be Disoriented in Time and Place
Scarcely able to Co-operate with Careers.

16. Sign Cont...
Decreasing level of consciousness:
Drowsy or Reduced Cognition
Difficulty Concentrating

17. Sign Cont…
Minimal intake:
Minimal Oral Intake progressing to no oral intake–
no Hunger or Thirst
Difficulty in swallowing medicine
Decreasing urine output:
Reduced Bowel & urine, may be incontinence

18. Sign Cont…
Hemodynamic decline:
Tachycardia, weak/thready pulse,
Cool extremities beginning from distal extremities
Change in Color – Skin becomes Grey or purple

19. Sign Cont…
Respiratory change:
Tachypnea, accessory muscle utilization and
shallow breathing
Breathing becomes irregular, sometimes noisy –
Death Rattle

20. Sign Cont…
In the final minutes or hours, the breathing pattern
often becomes irregular, with clusters of breathing
such as the Chine-Stokes pattern or atonal of
breath separated by apneic periods of several
seconds to 1-3 min
Breathing will ultimately stop, followed several
minutes later by cessation of the heart beat

21. Symptoms at EOL :
• Current literature emphasize that too many people still die
in pain.
• Equally or even more distress are–
*Fatigue ( asthenia)
* Anorexia / cachexia
*Drowsiness or insomnia
* Confusion
* Anxiety
* Dyspnea
* Nausea and vomiting
* Constipation and diarrhoea

22. Management of End of Life care
Psychological support:
The psychological need of a dying person can be summarized as
follows:
Relief from loneliness, fear and depression.
Maintenance of security, self confidence and dignity.
Maintenance of hope.
Meeting the spiritual needs according to his religious
customs.
The dying person may be shifted to privet room, or
privacy is maintained by putting the screen, so that other
patients may not be disturbed by the unpleasant sight,
the crises and other disturbances.

23. SYMPTOMATIC MANAGEMENT
Problem associated with breathing:
The dying person who is restless, apprehensive
and short of breath may be given-
Oxygen inhalation to remove his discomfort.
 Elevation of the patient’s head and shoulders may
make breathing easier.
Keep the room well ventilated and keep crowed
away.
Periodic suctioning is necessary.

24. Asthenia :
• Most distressing symptom in dying patient
• Easy tiring ,generalized weakness or mental
tiredness
• Co- ordinate activities with times of most energy
• Arrange to help from family, home care, nursing
home.

25. Problem associated with Eating &
Drinking
 Anorexia, nausea, and vomiting are commonly seen
in dying patient person. They are unable to take any
form of food and if they taken, they are unable to
retain the food.

26. Problem associated eating drinking
Cont.…
 The patient is unable to swallow even the sips of
water poured in the mouth. Most of them may
require I.V fluids.
 If they can tolerate the oral fluids, sips of water is
given with teaspoon. That will help the patient to
keep the mouth moist.

27. Problem associated with elimination:
Constipation, retention of urine and incontinence
of urine and stool are some of problem faced by
the patient.
Catheterization has to be done
Through skin and Perineal care is to be given, to
keep the patient clean and to prevent skin
breakdown

28. Problem associated with immobility:
Frequent skin care should be given with particular
attention to the pressure point.
Patient should be comfortably placed and their
position frequently changed in the bed.

29. Problem associated with sense organ:
• Since the patient loses sight, before given any care
to the patient, the nurse should touch the patient
and say what she is going to do.
• Since the hearing is retained longer, speak only
what is appropriate.
• Avoid whispering any think in patient room

30. Sense of organ Cont…
• Avoid whispering any think in patient room.
• Speak distinctly so that patient may understand
what is done for him.

31. Problem associated with rest and sleep:
Since the patient loses sight, before given any care
to the patient, the nurse should touch the patient
and say what she is going to do.
Since the hearing is retained longer, speak only
what is appropriate.

32. Rest and sleep Cont…
Avoid whispering any think in patient
room.
Speak distinctly so that patient may
understand what is done for him.

33. Problem associated with cleanliness
and grooming:
• Cleanliness and appearance are important until the
end.
• Cleanliness of the skin, hair, mouth, and cloth has
to be maintained.

34. Comprehensive care at the end of life:

35. What does end of life care involve?
• Good control of symptoms
• Psychological support
• Social support
• Spiritual support

36. Address fears of dying and death :
* People are afraid of
dying and death for
many different reasons
it the process of dying
with its associated pain
and loss of dignity; not
knowing what will
happen after death;
and dying before
fulfilling dreams goals

37. Therapeutic communication :
Nurse must----
• have an understanding of processess
and stage of grieving .
• be physically and mentally present
listen attentively and ask open-
ended question.
• acknowledge the client’s feelings by
using touch and listening through
out the discussion.
• Show desire to start a therapeutic
relationship
• Convey a willingness to be available
if client initially choosen not to be
open
• Inform the client and family member
that anger towards individual are
normal
• Learn to recognize the needs of
patients.

38. Our Feelings to End of life care:

39. Our feeling Cont…

40. Component of peacefully dying:
The key to peacefully dying is achieving the component of
peaceful living during the time you have left ( Preston ,2000
)
• Instilling good memories
• Uniting with family medical staff
• Avoiding suffering, with relief of pain and other symptoms
• Maintaining alertness, control , privacy dignity and support
• Becoming spiritually ready
• Saying good bye
• Dying quality

41. Meeting the needs of dying individuals:
• Assisting needs
• Explaining the client’s condition and treatment
• Maintaining good communication
• Promoting self care self esteem
• Allowing family members to assist in care
• Meeting client’s needs—
* Physical needs
* psychological needs
* spiritual needs

42. STAGES OF DYING
DENIAL
ISOLATION
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE

43. Cont…

44. Conclusion:
When death cannot be prevented it becomes
imperative that the doctor and nurse do all whatever
is necessary to make dating less difficult for the
patient. The dying patient has a variety of needs
ranging from the need for open communication to
physiological and spiritual needs. They should
maintain self care as long as possible. Families of the
dying patient may like to assist in providing care. The
nurse should provide emotional support for the
grieving family.