Critical Care Nursing

1. CARE OF THE PATIENT AT
END STAGE OF LIFE
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Prof. Dr. RS Mehta, BPKIHS

2. NURSING AND END OF LIFE CARE
• Nurses can have a significant and lasting
effect on the way in which patients live until
they die, and the enduring memories of that
death to the families.
• Indeed, the definition of nursing itself
highlights nursing commitment to the
diagnosis and treatment of human responses to
illness( ANA)
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Prof. Dr. RS Mehta, BPKIHS

3. TECHNOLOGYAND END OF LIFE CARE
• The application of technology to prolong life
has raised several ethical issues. In the later
part of 20th century, a “technologic imperative”
practice pattern among health care
professionals emerged, along with an
expectation from patients and families that
every available means to extend life must be
tried.
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Prof. Dr. RS Mehta, BPKIHS

4. SETTINGS FOR END OF LIFE CARE
Palliative care
Hospice care
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Prof. Dr. RS Mehta, BPKIHS

5. PALLIATIVE CARE
The word „palliative‟ means a medicine or
medical treatment that reduces pain without
curing its cause.
 WHO defines palliative care as the active,
total care of patients whose disease is not
responsive to treatment.
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Prof. Dr. RS Mehta, BPKIHS

6. WHO recently expanded the definition of
palliative care as an approach that improves
the quality of life of patients and their families
facing the problems associated with life-
threatening illness, through the prevention and
relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual.
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Prof. Dr. RS Mehta, BPKIHS

7. PALLIATIVE CARE TEAM
• Physicians
• Registered nurses
• Social workers
• Chaplains
• Physiotherapists
• Occupational therapist
• Massage therapist
• Nutritionist
• Pharmacist
• Volunteers
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Prof. Dr. RS Mehta, BPKIHS

8. HOSPICE CARE
• Hospice is a coordinated program of
interdisciplinary services provided by
professional caregivers and trained volunteers
to patients with serious, progressive illnesses
that are not responsive to care.
• The hospice philosophy recognizes death as the
final stage of life and seeks to enable patients to
continue a pain free life and to manage other
symptoms so that their last days may be spent with
dignity and quality, surrounded by their loved ones
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Prof. Dr. RS Mehta, BPKIHS

9. TEAM MEMBERS
 Doctors
 Nurses
 Home health aids
 Spiritual counsellors
 Social workers
 Volunteers
 Bereavement counsellors
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Prof. Dr. RS Mehta, BPKIHS

10. NURSING CARE OF TERMINALLY ILL
• Communication
• Spiritual care
• Hope
• Managing physiologic responses to terminal illness
• Palliative sedation at the end of life
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Prof. Dr. RS Mehta, BPKIHS

11. COMMUNICATION
 Dying process can be a time of emotional crisis.
Effective communication helps in better coping for the
clients and family.
NURSES ROLE
 Maintanig good IPR so that the patient and family feels
free to speak.
 Good listening skill.
 Encouraging participatory approach.
 Use less directive skills like: silence
 Promote opportunity for discussion and demonstrate
willingness to listen patient‟s concern.
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Prof. Dr. RS Mehta, BPKIHS

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Prof. Dr. RS Mehta, BPKIHS

13. SPIRITUAL CARE
Spirituality contains features of
religiosity and involves the „search for
meaning and purpose in life and
relatedness to transcendent dimension‟.
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Prof. Dr. RS Mehta, BPKIHS

14. MANAGING PHYSIOLOGIC RESPONSES
TO END OF LIFE
• Most encountered physical symptoms in clients at
the terminal phase of illnesses are:
 Pain
 Dyspnoea
 Cachexia- Anorexia syndrome
 Constipation
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Prof. Dr. RS Mehta, BPKIHS

15.  PAIN
 most feared consequence of cancer
 Can result from the disease and the modalities used to
treat it
 Inability to communicate pain should not be equated
with the absence of pain
 Pharmacological and non pharmacological measures
 Less ability to swallow medicine by oral route, so
opoids via rectal or sublingual routes
 For opoids, regimen to combat constipation must be
implemented , rectal suppository or enemas may be
necessary
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Prof. Dr. RS Mehta, BPKIHS

16.  DYSPNOEA
 Subjective experience described as difficult breathing
or an uncomfortable awareness of breathing that is
common in terminally ill patients.
 Client mentioned it in the form of labored breathing,
SOB, feeling of suffocation etc
 Assessment: increased respiratory rate, use of
accessory muscles, gasping or labored breathing,
restlessness and diaphoresis.
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Prof. Dr. RS Mehta, BPKIHS

17. • Management
 Administering medical treatment for underlying
pathology : bronchodilators, corticosteroids, low
doses of opoids
 oxygen therapy
 Monitoring patients response to treatment
 Assisting the patient and family to manage anxiety
 For patient receiving care at home instruction should
include anticipation and management of crisis
situations, medication administration
 Patient and family members should be continuously
reassured
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Prof. Dr. RS Mehta, BPKIHS

18.  CACHEXIA- ANOREXIA SYNDROME
 In Greek, chacexia means poor condition. Diagnostic
indicator is 5 pound weight loss in previous 2 months
or an estimated daily caloric intake of fewer than 70
calorie/kg body wt.
 It is caused due to chemical factors like cytokines,
interleukin, TNF release.
 Clinical manifestations: muscle loss, impaired
immunity, loss of body fat, glucose intolerance, fluid
retention, vitamin deficiency, fatigue and weakness
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Prof. Dr. RS Mehta, BPKIHS

19.  Pharmacological Management
 Progestational agent
( most promising, can induce weight gain after
several weeks of treatment in maximal dose e.g.
megestrol acetate 160 mg TID)
 Corticosteroids
 Nausea vomiting treatment
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Prof. Dr. RS Mehta, BPKIHS

20.  Non pharmacological management
 Stress management
 Assess impact of chemotherapy and radiotherapy
 Proper position
 proper oral care
 Assess and manage constipation
 Modify environment to eliminate unpleasant odours
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Prof. Dr. RS Mehta, BPKIHS

21. CONSTIPATION
 Management
 Plenty of fluids
 High fibre diet
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Prof. Dr. RS Mehta, BPKIHS

22. PALLIATIVE SEDATION AT END OF LIFE
• Control of symptoms offered to those patients who
are close to death, whose symptoms do not respond to
pharmacological and non-pharmacological
approaches and as a result are experiencing
unrelieved suffering.
• It is distinguished from euthanasia (physician-
assissted suicide) in that the palliative sedation is to
palliate the symptoms not to hasten the patient‟s
death.
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Prof. Dr. RS Mehta, BPKIHS

23. • It is a multidisciplinary team approach. Infusion of
benzodiazepines or barbiturates in doses adequate to
induce sleep and eliminate signs of discomfort.
• Once sedation is achieved, nurses will need to
continue comfort care, monitor physiological effects
of sedation, support to family, ensure communication
within the team and between the team and family
members
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Prof. Dr. RS Mehta, BPKIHS

24. Death: Criteria
• Skin: Cold Clammy
• No: P R BP
• No Reflexes: Superficial & DTR
• ECG: Flat 10 min
• EEG: Flat
• Calorie test: negative
• Declared by: physician
Consider: Post Mortem and Autopsy
Prof. Dr. RS Mehta, BPKIHS 24

25. Care of death and dying
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Prof. Dr. RS Mehta, BPKIHS

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Prof. Dr. RS Mehta, BPKIHS

27. Definition of dying
 Dying is the last stage
of life; a process that
from a medical point
of view begins when a
person has a disorder
that is untreatable
and inevitably ends in
DEATH, or the final
stages of a fatal
disease.
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Prof. Dr. RS Mehta, BPKIHS

28. Dying
• Dying also can be said as the process of
decline in body functions resulting in death
• Dying is a process, whereas death is an event.
The essential task of the dying person is to
work through psychological responses toward
the reality of approaching death to a final and
peaceful acceptance of that reality.
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Prof. Dr. RS Mehta, BPKIHS

29. Stages of dying/Response to dying
 Dr Kubler-Ross identified five stages of
grieving that dying patients and their families
may experience.
 They are denial, anger, bargaining , depression
and acceptance.
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Prof. Dr. RS Mehta, BPKIHS

30. Stages of death
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Prof. Dr. RS Mehta, BPKIHS

31. Dying person’s Bill of Rights
• Right to be treated as living human being
until the death
• Right to maintain the sense of hopefulness
however changing the focus may be.
• Right to be cared by those who can maintain
a sense of hopefulness
• Right to express feelings, emotions and
approaching death in own way.
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Prof. Dr. RS Mehta, BPKIHS

32. Dying person’s Bill of Rights
 Right to participate in decision concerning
owns care.
 Right to expect continuing nursing and
medical care , even thought cure goal must
be changed to comfort goal
Right not to die alone
 Right to be free from pain
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Prof. Dr. RS Mehta, BPKIHS

33. Dying person’s Bill of Rights
 Right to have
questions answered
honestly
 Right not to be
deceived
 Right to die in peace
and dignity
 Right to enlarge
religious and cultural
belief , regardless to
others
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Prof. Dr. RS Mehta, BPKIHS

34. Management of dying patient
• Cassen (1991) suggests seven essential
features in the management of the dying
patient:
Concern: Empathy, compassion, and
involvement are essential.
Competence: Skill and knowledge can be as
reassuring as warmth and concern.
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Prof. Dr. RS Mehta, BPKIHS

35. Management of dying patient
Communication: Allow
patients to speak their minds
and get to know them.
Children: If children want to
visit the dying, it is generally
advisable; they bring
consolation to dying patients.
Cohesion: Family cohesion
reassures both the patient
and family.
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Prof. Dr. RS Mehta, BPKIHS

36. Management of dying patient
Cheerfulness: A gentle,
appropriate sense of humor
can be palliative; a somber or
anxious demeanor should be
avoided.
Consistency: Continuing,
persistent attention is highly
valued by patients who often
fear that they are a burden
and will be abandoned;
consistent physician
involvement mitigates these
fears.
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Prof. Dr. RS Mehta, BPKIHS

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Prof. Dr. RS Mehta, BPKIHS