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 nephew Disqualified if pt. has a PFA or “no contact” order If no one, Court of Chancery may appoint as guardian an adult who exhibits special care +concern, + who is familiar w/ patients values.
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)
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
TRADITIONAL ETHICS ETHICS OF CARE Autonomy • Interdependence Beneficence • Preventing Harm Non- • Providing Care Maleficence • Communication Justice • Maintaining Relationships Veracity
CARE AT THE END OF LIFE: One Chance to Do It Right Presented by: Sheila Grant, BSN, RN, CHPN
DISCLOSURES• I am employed by Heartland Hospice, IV, and Homecare as a Nurse-Liaison.
OBJECTIVES1—Describe the concept “Convergence of Symptoms”.2—Identify 7 common symptoms of the active phase ofdying.3—Identify strategies for controlling each of thosesymptoms.4—Describe ‘terminal agitation”, its possible causes,and options for treatment.5—Explain the principles of communicating bad news.
Most People Die Aftera prolonged illness Withgradual deterioration Withan active dying phase at the end of life
MOST CLINICIANS Have little or no formal training in managing the dying process.
Most FamiliesHave even less experience or knowledge of the dying process.
FAMILIES WILL REMEMBERA “good death”OR a “difficultdeath”.A difficult deathmay lead toanger,depression, orcomplicatedgrief
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
of Symptoms 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).
Concerns in the last hours of life Pain Shortness of Breath Secretions Feeding and hydration Changes in Consciousness Circulatory dysfunction Delirium
PAINYou may need to change the route and dose of pain medicine, due to increased pain, inability to swallow, or decreased metabolism.
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.
PAIN MEDICINE IS BEST GIVENATC, not PRN If allowed to wear off, pain becomes harder to treat, requiring higher doses.
P.O Narcotics Peak in 1 hour Half-life is 4 hours
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]
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.
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.
HOSPICE NURSES Are expert in managing opioids for pain relief Have access to Hospice Medical Director Can be a resource
*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.
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
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
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.
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.
CHANGES IN CONSCIOUSNESS Drowsiness Difficulty Awakening Unresponsive to stimuli
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
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
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 aromatx. Severe mental anguish…………. If recovery is impossible and death is near, consider terminal sedation
TWO ROADS TO DEATH The usual road--easy – Sleepy – Lethargic – Semi-comatose – Death
The DIFFICULT ROAD Restless Confused Hallucinations Delirium Myoclonic jerks, seizures Comatose Death
PROGNOSIS AT END-OF-LIFE Very difficult to be precise Better to give a general estimate (“days to weeks”) Always remind patients & families of the unpredictability of the dying process.
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.
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.
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
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.
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
Remember . . .We have only ONE CHANCE to get it right.
Your Expertise Can Provide a Smooth Passage for the Patient and Family
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