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PALLIATIVE AND

END-OF-LIFE CARE

Cynthia Smith, RN, BA, MSN, AOCN

Oncology Clinical Nurse Specialist

CHI Franciscan Health Harrison Medical Center

2017 OCN Test Blueprint Content Areas Content Area Percentage of

2017 Test

# of Scored

Questions*

Health Promotion, Screening & Early

Detection

6% 9

Scientific Basis for Practice 9% 13

Treatment Modalities 16% 23

Symptom Management 22% 32

Psychosocial Dimensions of Care 8% 12

Oncologic Emergencies 12% 17

Survivorship 8% 12

Palliative & End of Life Care 11% 16

Professional Performance 8% 12

*To determine the number of scored items from each subject area, multiple the percentage by 145.

2017 OCCC Test Candidate Handbook (2017). Oncology Nursing Certification Corporation, page 8, http://www.oncc.org/files/2017TestCandidateHandbook.pdf .

Objectives – By end of this session, attendees

will be able to:

• Discuss differences / similarities between palliative care and

end of life care

• Identify common signs / symptoms of patients experiencing end

of life challenges: pain, dyspnea, chronic nausea/vomiting,

anorexia, fatigue, delirium, hiccups & terminal dehydration

• List 7 promises of palliative care

• Describe interventions relieve suffering, assist patients to attain

best quality of life and to optimize functional status

• Explore physical symptoms that indicate death is imminent

• Review strategies to deliver patient-centered comfort care

measures

• Educate family / care-givers on ways to take an active role in

palliative and end of life care.

/

Background

• By 2030 the number of people in Washington State > 65 will be close to 1.5 million (currently approximately 784,000)

• >80% will suffer from at least one chronic illness and 20% from more than one chronic illness with resultant pain, debilitation and suffering

Washington State Plan on Aging 2010-2014

CDC, 2012, Chronic Diseases and Health Promotion. Retrieved 5-10-17 at: http://www.cdc.gov/chronicdisease/overview/index.htm

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Background

• Advance chronic illness causes increased symptom

burden, pain, fatigue and breathlessness

• 70% of people with advanced chronic illness admitted to

hospital in last 6 mos. of life and estimated that 25%

receive inadequate symptom management

• Solano, J. P., Gomes, B., & Higginson, I. J. (2006). A Comparison of Symptom Prevalence in Far

Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease and Renal

Disease. Journal of Pain and Symptom Management, 31(1), 58-69.

• Morrison, R. S., & Meier, D. E. (2004). Palliative Care. New England Journal of Medicine,

350(25),2582-2590.

/

Serious Illness

• One that carries a high risk of death over the course of a

year but cure may be a possibility, ie awaiting liver

transplant

• Has a strong negative impact on one’s quality of life and

functioning in life roles, independent of impact on

mortality

• Highly burdensome to patient and family

Amy Kelley, MD MSHS JPM Vol 17, Number 9, 2014

/

What’s important to person with

serious illness?

• Maintaining independence

• Not being a burden

• Pain and symptom management

• Living longer

Institute of

Medicine, 2015

/

Sudden Death, Unexpected Cause

• <10%, MI, accident, etc.

Deat

h Time

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Steady Decline, Short “Terminal Phase”

Time

Death

Slow Decline, Periodic Crises, Sudden Death

Death

Time

/

The Cancer Control Continuum

Prevention Early

Detection

Diagnosis Treatment Survivorship End-of-

Life Care

-Tobacco Control

-Diet

-Physical activity

-Sun exposure

-Virus exposure

-Alcohol use

-Chemoprevention

-Cancer

screening

-Awareness of

cancer signs

and symptoms

-Oncology

consultations

-Tumor staging

-Patient

counseling and

decision making

-Chemotherapy

-Surgery

-Radiation therapy

-Adjuvant therapy

-Symptom

management

-Psychosocial care

-Long-term follow-

up/surveillance

-Late-effects

management

-Rehabilitation

-Coping

-Health promotion

-Palliation

-Spiritual

issues

-Hospice

Source: From Cancer Patient to Cancer Survivor: Lost in Transition; page 24, Box 2-2.

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Overview of Palliative Care

• To Palliate – to alleviate or to lessen the severity of, without curing (Webster’s)

• World Health Organization (WHO) defines palliative care:

- The active, total care of patients whose disease is not responsive to curative treatment.

- Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount.

- The goal of palliative care is to achieve the best possible quality of life for patients and their families.

- Many aspects palliative care are applicable earlier in course of illness, in conjunction with other anti-cancer treatments. /

Definition of Palliative Care

Palliative care is specialized medical care for people

with serious illnesses. It is focused on providing

patients with relief from the symptoms, pain, and stress

of a serious illness—whatever the diagnosis. The goal

is to improve quality of life for both the patient and the

family.

/

The relief of suffering and the cure of disease must be

seen as twin obligations of a medical profession that is

truly dedicated to the care of the sick.

Physicians’ failure to understand the nature of suffering

can result in medical intervention that (though technically

adequate) not only fails to relieve suffering but becomes a

source of suffering itself.

The Nature of Suffering and the Goals of Medicine - Eric J. Cassell

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“We’ve had a 50-year experiment with medicalizing

mortality, treating it as just another problem to be

solved…and it has failed”

Being Mortal Dr. Atul Gawande

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Palliative care is provided by a team of doctors, nurses,

and other specialists together with a patient’s other doctors

to provide an extra layer of support , appropriate at any age

and at any stage in a serious illness and can be given with

curative treatment.

Diane Meier, MD

CAPC 2012

/

Conceptual Shift for Palliative Care Goals

Medicare

Hospice

Benefit Life Prolonging

Care

Life

Prolonging

Care Palliative Care

Hospice

Care

Old Paradigm

New Paradigm

Diagnosis Death

/

Re-Branding

The Best Care Possible Ira Byock, MD

Good healthcare for person with serious

illness Bob Arnold, MD

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Hospice and Palliative Care

• Hospice and palliative care involve a team-oriented approach to expert medical care, symptom management, emotional and spiritual support (NHPCO, 2003).

• Hospice • Provides care for client and family when client is terminally ill

• Provides interdisciplinary support and care

• Palliative care • Approach that improves quality of life for client and family

when dealing with life-threatening disease (WHO, 2003)

• Focuses on symptom management, comfort, and support

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Palliative Care is Different from Hospice

Hospice

- Interdisciplinary care focused on improving

quality of life for those at the end-of-life

- Under Medicare, patients must:

• Have a prognosis of 6 months or less if the

disease follows its usual course AND

• Be willing to relinquish curative treatments and

Medicare Part A (hospital and acute care)

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Palliative Care and Hospice

• Both focus on symptom management & quality of life

• All hospice care IS palliative care

• All palliative care IS NOT hospice care

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Hospice Benefits

• Interdisciplinary team and home services

• Self determined life closure

• Respectful death

• Low hospital re-admission rate

• Bereavement care

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Hospice Referral

• Referral based on prognosis

• Life expectancy of less than 6 months if the condition takes a usual course

• Care until death occurs and for family for 13 months after death

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What Is Needed?

• Appropriate professional communication about palliative

care to our patients

• Referring clinicians

• Palliative care providers

• Generalist palliative care skills for all clinicians

• Focus on living with disease and promoting quality of life

• Appropriate professional referral to palliative care teams

Common Symptoms During Terminal Illness • Fatigue (90%)

• Anorexia (85%)

• Pain (75%)

• Dyspnea (79%)

• Nausea (68%)

• Constipation (65%)

• Delirium & Confusion (60%)

• Death rattle (56-92%)

• Xerostomia (10%)

“The art of palliative care encompasses creative

strategies to manage pain and deleterious symptoms

so that patients can experience a dignified death and

focus on more pertinent psychosocial and spiritual

issues…”

• Jeannine M. Bryant

Respect Patient Goal, Preferences and Choices

• Palliative care is approach to care that is patient-centered;

addresses patient needs in the context family, community

• Recognizes that family constellation is defined by patient -

encourages family plans, provide care to extent pt. desires

• Identify & honor preferences patient / family. Pay careful

attention: values, goals, priorities, cultural / spiritual issues

• Assists patient establish goals of care; foster understanding

of diagnosis / prognosis; clarify priorities; enhance informed

choices; gives opportunity to negotiate provider care plan

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Respect Patient Goal, Preferences and Choices

• Strives to meet patients' preferences about care settings,

living situations and services, recognizing the uniqueness

of these preferences & barriers to accomplishing them.

• Encourages advance care planning, including ADs,

through ongoing dialogue among providers, patient and

family.

• Recognizes potential for patient, family, providers & payor

conflict; develops processes to work toward resolution.

Comprehensive Caring

• Appreciates that dying, while a normal process, is a

critical period in the life of patient & family; therefore

requires an aggressive response to associated human

suffering while acknowledging the potential for personal

growth.

• Places a high priority on physical comfort and functional

capacity, including, but not limited to: expert

management of pain & other symptoms, diagnosis /

treatment of psychological distress; assist to remain

independent as possible or desired.

Seven Palliative Care Promises

Making Promises to Patients and Families

1. You will receive the best medical treatment

2. You will never be overwhelmed by symptoms

3. Your care will be delivered with continuity, coordination and

comprehensiveness.

4. You & your loved ones will be well-prepared and will not

surprised by what occurs.

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Making Promises to Patients and Families 5. Your care will be customized to reflect your preferences

6. We will provide you with resources, including: financial,

practical and emotional

7. We will do all that we can to see that you and your

family will have the opportunity to make the best of every

day. You will be treated as a person, not a disease – what

is important to you is important to the care team.

8. Your care team will respond to the physical, social,

psychological and spiritual needs of the patient / family.

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Supportive Care Topics Seen In Dying & Death • Hospice and palliative care

• Pain

• Elimination

• Dyspnea

• Anorexia / cachexia

• Nausea and vomiting

• Dehydration

• Depression and anxiety

• Delirium

• Social support

• Spiritual and cultural

• Bereavement

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Assessment

• Collaborate with physician.

• Evaluate client’s understanding of the disease trajectory and treatment options.

• Determine if client has advance directive or surrogate decision maker.

• Evaluate goals for care; emphasize symptom management.

• Assess symptoms.

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Interventions: Hospice & Palliative Care • Establish a therapeutic relationship

• Complete holistic assessment

• Consult palliative care team

• Provide symptom management

• Ensure client/family recognize possibility hospice care

• Inform client, family of appropriate agencies; complete referral

• Obtain informed consent from client for hospice care

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Pain • Cancer pain may be acute, chronic, or intermittent (American Pain Society, 1999).

• Barriers

- Family / patient

- Provider

- System

• Assessment

• Use pain assessment tools; non-verbal as indicated

- Checklist of Non-verbal Pain Indicators (CNPI)

- Pain Assessment in Advanced Dementia (PAINAD)

- Numeric Rating Scale; FACES; Modified FACES

• Obtain history of drugs used & extent of pain control

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Management of Pain

• Pharmacologic interventions (opioids, adjuvant

medications, and injections)

• Other invasive interventions (radiation, radiopharmaceuticals)

• Non-pharmacologic interventions i.e. physical, behavioral, and psychiatric). Multi-modal therapy is the new buzz word

• Be on the alert for opioid-induced neurotoxicity; may see hyper-algesia and/or allodynia. Opioid rotation / excess hydration may be required to manage myoclonic / dystonic reactions, seizures and uncontrolled pain.

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Interventions: Pain

• Instruct client and family on pain control regimen.

• Collaborate with physician regarding drug treatment.

• Consult physician regarding invasive interventions.

• Consider referral to pain team or clinic.

• Teach and evaluate psychologic interventions.

• Use complementary interventions.

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Dyspnea - Breathless Sensation Dyspnea: Breathless Sensation

• “Uncomfortable awareness of breathing or shortness of breath”

• Occurs days to weeks before death in up to 79% patients

• Similar to pain

• Complex issue, many causes

• “Subjective” – occurs when the patient says it does

• Symptoms often occur without changes in oxygen or carbon dioxide saturation values

Dyspnea Management: Breathless Sensation

• Goal - Change or reduce breathless sensation

• General Symptom Measures - Consider O2 therapy

- Position patient upright

- Use overhead / bedside table to support arms,

upper body

- Raise head of bed or add pillows

- Pace activities: allow rest periods, change

times (S/P sleep)

- Cool fan blowing breeze on patient

Dyspnea: General Non-Pharmacologic Supportive

Measures

• Breathing Techniques – pursed lip, diaphram

• Distraction - massage, music, movie, internet, progressive relaxation exercises

• Reassurance – very frightening experience like drowning

• Treat pain

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Dyspnea: Pharmacologic Management

• Bronchodilators • Albuterol by metered aerosol or 2.5-5 mg by nebulizer, Q 4-6

hours

• Aminophylline, theophylline

• Anxiolytics • Benzodiazepines may reduce dyspnea (anxiolytic and

sedative effect)

• Diazepam 2 mg po Q 8 hours (5-10 mg at HS)

• Lorazepam 0.5-2 mg PO / IV / SL

Dyspnea: Pharmacologic Management

Opioids

• Morphine Sulfate & other opioids are the most useful drugs in treatment of dyspnea

• Obtain order for morphine 5-10 mg PO / IV / SQ q 4 hr; titrate to effect

• Pt. already on morphine–increase dose by 25-50%

• Nebulized morphine or hydromorphone (Dilaudid)

Dyspnea: Pharmacologic Management

Obtain order for corticosteroids • May improve dyspnea associated with lung cancer

• Prednisolone 40-60 mg/d PO

• Dexamethasone 8-12 mg/d PO

Anticholinergics (for excessive secretions) • Scopolamine 0.4-0.8 mg IM Q 4 h; 0.8-2.4 mg/d SC infusion or injections

• Scopolamine patch (several hour delay onset of action)

- Benzodiazapines (Ativan, Valium, Versed)

- Consider diuretic if fluid overloaded in CHF or ARF

Chronic Nausea and Vomiting

Unrelated to Chemotherapy

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Chronic Nausea and Vomiting

Unrelated to Chemotherapy

• N/V affects up to 70% of patients with advanced cancer;

however, nausea is more common. Chronic nausea is

defined as lasting more than 1 week without identifiable

precipitating factors

• Causes include underlying cancer and its progressive

effects as well as medication use (e.g. opioids).

Assessment

• RNs and CNAs ask about duration, frequency of vomiting

episodes, and the ability of the patient to keep fluids

down: all affect the route of drug administration. Delayed

N/V due to chemotherapy is possible.

Chronic Nausea and Vomiting

Unrelated to Chemotherapy

Mechanisms

• Nausea and vomiting reflex found in the medulla; relays stimulus to the dorsal motor nucleus of the vagus to cause vomiting.

• Afferent input comes from the chemoreceptor trigger zone, vagus nerve, cortex, and vestibular pathways.

• Neurotransmitters found in areas critical to emetic reflex include: dopamine, serotonin, histamine, substance P, & acetylcholine; blocking these neurotransmitters is the basis of antiemetic therapy.

Chronic Nausea and Vomiting

Unrelated to Chemotherapy

• Large-volume emesis suggests gastric or bowel

obstruction, whereas polydipsia, polyuria, and

cognitive changes suggest metabolic causes.

• Constipation can also cause nausea.

• Papilledema suggests brain metastasis, whereas

orthostatic changes suggest autonomic insufficiency.

Management: Chronic Nausea / Vomiting

unrelated to Chemotherapy

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Management: Chronic Nausea / Vomiting

unrelated to Chemotherapy

Non-pharmacological.

• Surgery may be considered in cases of mechanical bowel

obstruction. However, surgery should be individualized, with

physicians weighing risks / benefits of the procedure.

• Use of acupuncture to treat N/V in advanced illness has not

been conclusively proven as best practice

• Lavender aromatherapy & use of ginger are being studied

• Cold compresses on neck (sides, back) may be helpful

• Some people wear copper bracelets to manage N/V

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Management: Nausea and Vomiting

• Palliative treatment most often consists of anti-emetics,

dietary manipulation, and behavioral interventions.

• Combining anti-emetics from different classes seems to

improve efficacy of the individual drugs.

• Bowel obstructions may be treated conservatively with anti-

emetics, stool softeners, and soft or liquid diets.

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Interventions: Nausea and Vomiting

• Treat causes of nausea and vomiting.

• Use anti-emetics.

• Educate client and family on medications.

• Suggest dietary changes.

• Limit sights, sounds, smells that affect vomiting.

• Provide fresh air.

• Provide distraction and relaxation.

• Report signs of bowel obstruction and treat.

Hiccups

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Hiccups: Causes • Diaphragmatic Irritation

• Malignant infiltration

• Inflammation/infection

• Hepatomegaly, ascites

• Gastric distention/obstruction/compression • Obstruction, gastric tumor

• Esophagitis

• Phrenic nerve irritation (mediastinal tumor)

• Intracranial disease (cerebellar or medullary tumor)

• Metabolic (uremia, hyponatremia, hypocalcemia)

• Meds (Benzodiazepines, Barbiturates, IV corticosteroids)

Hiccups: Nursing Interventions

• Vagal, pharyngeal stimulation • Swab, NG tube

• Massage external auditory meatus

• Sneezing

• Elevation of pCO2

• Reduce gastric distention • Aerated drink

• Peppermint water

• Metoclopramide

• NG tube

• Pharmacological • Chlorpromazine (10-25 mg PO Q 6 h)

• Baclofen

• Haldol

• Midazolam (if sedation not a concern)

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Anorexia / Cachexia

• Anorexia: decrease in appetite resulting in weight loss (Abrahm, 2000)

• Cachexia: metabolic syndrome associated with cancer that results in loss of fat, muscle, and bone minerals (Kemp, 2001)

• Assessment • Explore the meaning of not eating with the client and family.

• Identify factors that discourage eating.

• Obtain dietary history.

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Interventions: Anorexia / Cachexia

• Help family understand nutritional limitations (Kemp, 2001).

• Explain possible causes of anorexia/cachexia.

• Inform caregiver that the client is not able or is unwilling to eat.

• Suggest small meals, liquid supplements.

• Treat symptoms that may contribute (e.g., nausea).

• Consider appetite stimulant if appropriate (Abrahm, 2000).

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Delirium

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Delirium • Characterized by an alteration in the level of consciousness

that may occur abruptly and may fluctuate throughout the day (Sivesind & Baile, 2001)

• Possible causes (disease, medications, infection, and metabolic changes) (Block, 2001)

• Assessment - Assess for delirium, which may be manifested as agitation and

restlessness.

- Review medications that may contribute to delirium & agitation.

- Note degree of agitation and the effects on the family.

- Assess for safety.

Delirium: Identification and Treatment

• Delirium is a clinical emergency characterized by changes in consciousness, hallucinations, and changes in the sleep–wake cycle and language.

• Delirium is frequently seen in advanced cancer patients: drugs, infection, brain metastasis, and underlying dementia may all play a role.

• Experiencing delirium causes family distress, as delirious patients cannot communicate pain levels or other symptoms and may be unable to take part in health care decisions.

Delirium: Identification and Treatment

• Delirium differs from dementia: dementia does not have

acute alterations in consciousness.

• Delirium is classified according to level of agitation; for

example, an agitated patient has hyperactive delirium;

patient who is withdrawn / somnolent has hypoactive

delirium. Commonly see mix of both.

• Prevalence rates for delirium range from 30% to 50% for

hospitalized patients and is typical in the hours or days

before death. May be reversed 50% of time.

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Causes of Delirium

• Delirium results from underlying disorders that cause

imbalances in brain neurotransmitters.

• Neurotransmitters involved in delirium include

dopamine, glutamate, norepinephrine, acetylcholine, γ-

aminobutyric acid, & serotonin.

• Cytokines (interleukin-1, IL-2, tumor necrosis factor,

interferon) produced by immune system, tumor, or

cancer treatment may create central nervous system

effects, e.g. somnolence, agitation & cognitive decline

Delirium: Identification and Treatment

• A history of patient's baseline mental status prior to

symptom onset should be obtained from his or her

family, caregivers, or both parties.

• Fluctuating consciousness is hallmark of delirium.

Assessment tools can screen and/or rate delirium

• Commonly used tools include those for screening (e.g.

Mini Mental State Examination or Confusion Assessment

Method) or those tools used to rate severity (e.g.

Memorial Delirium Assessment Scale or the Disability

Rating Scale).

Delirium: Establish Cause

• Non-pharmacological.

- Identify reversible causes (50% of cases)

- Includes: infection, dehydration, drug and

metabolic abnormalities, fecal impaction, UTI

• Evaluate cancer patients for brain metastasis.

• Common drugs that may precipitate delirium episodes

include: opioids, anticholinergics, benzodiazepines,

steroids, and some chemotherapy agents.

Delirium: Management Approaches

Interventions

• Inquire about alcohol intake, as alcohol withdrawal can

precipitate delirium; responds to benzodiazepines,

clonidine.

• Non-pharmacological approaches to delirium are:

• Non-pharmacological approaches to delirium are:

- Keeping room lights on

- Have calendars and pictures at the bedside

- Frequent redirection

- Allow patients to participate in their care.

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Interventions: Delirium

• Treat reversible causes.

• Provide a calm environment and minimize disturbances.

• Teach family safety precautions.

• Support family with additional help.

• Provide respite in a facility for client and family.

• Use medications when appropriate.

• Minimize disturbances in the environment.

• Provide explanations and support to family.

Delirium Management: Common

Pharmacological Drugs (Table 1)

Drug Dosage Adverse Events Comment

Haloperidol 0.5 mg orally 2–3 times a

day

Acute extrapyramidal

events (eg, torticollis,

oculogyric crisis, tongue

and laryngeal spasm)

Mild to moderately

agitated elderly patients

1–2 mg intravenous /

subcutaneous every 30 min

to 1 h until agitation

resolved

Severe agitation in

patients aged < 60 y

Risperidone 1 mg orally each day or

every other day

QT interval and cardiac

arrhythmia

Potent dopamine

blocker

Olanzapine 2.5–11 mg daily QT interval and cardiac

arrhythmia Very anticholinergic

Quetiapine 25–75 mg orally every day QT interval and cardiac

arrhythmia

Lorazepam 0.5–1 mg

intravenous/subcutaneous

Do not use alone

Useful for severe

agitation in conjunction

with haloperidol

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Depression and Anxiety

• Factors related to psychologic distress (anxiety,

depression, and neurocognitive changes) (Sivesind

& Baile, 2001).

• Clients at the end of life may experience anxiety

(Pasacreta et al., 2001).

• Depression and anxiety are appropriate to the stress

of having a serious illness (Pasacreta et al., 2001).

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Assessment: Depression and Anxiety

• Recognize evidence of depression such as hopelessness,

helplessness, worthlessness, guilt, and sustained suicidal

ideation (Block, 2001).

• Assess for anxiety (Sivesind & Baile, 2001).

• Review medications for drugs that may contribute to anxiety

such as steroids.

• Assess for suicide plan.

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Interventions: Depression and Anxiety

• Use antidepressants or antianxiety medications.

• Consider need to refer to mental health care provider.

• Use holistic communication skills e.g., active listening (Klagsbrun, 2001).

• Seek immediate help if suicidal ideation.

• Identify support systems and referrals to community agencies.

• Discontinue medications or change doses of drugs that may contribute to anxiety or depression.

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Social Support

Seven dimensions

• Redefining roles within family, dealing with burden of caring

for the family member, struggling for paradox of living and

dying, contending with daily life, searching for meaning, living

day to day and attempting to enjoy the time left, and

preparing for death in concrete ways (e.g., legal, financial)

• Important to assess the family as a system (Goetschius, 2001).

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Assessment: Social Support

• Assess family functioning and structure.

- Assess strengths such as members with health care training or

weaknesses such as frail caregiver.

- Assess knowledge deficits in end-of-life care.

- Collaborate with social worker to complete a family assessment.

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Interventions: Social Support

• Strengthen family

- Encourage communication among family

- Respect the privacy of family

- Provide access to resources for family needs - Spend time with family (Goetschius, 2001)

• Teach caregiving skills to primary caregiver

- Teach and demonstrate technical skills

• Help client redefine long-term goals, set immediate goals

• Families desire a few basic interventions from the nurse.

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Spiritual and Cultural

• Spirituality involves finding meaning, finding hope,

defining relatedness, finding forgiveness.

• Spirituality and religion are complementary but not

identical concepts (Highfield, 2000).

• Culture identifies a group of people with similar

values, norms, lifestyles, rules, language, beliefs.

• Spirituality and culture overlap (Taylor, 2001).

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Assessment: Spiritual and Cultural

• Assess for spiritual distress and needs.

• Identify religious practices that have meaning for the

client.

• Assess for cultural values that may impact the

client’s terminal care.

• Assess for personal beliefs and practices that the

client regards as important.

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Interventions: Spiritual and Cultural

• Recognize spiritual and cultural values of client and family.

• Allow client to talk about spiritual concerns (actively listen, remain non-judgmental).

• Encourage family to remain present with client.

• Share information about fears, guilt, doubts.

• Activate client’s spiritual resources.

• Include cultural aspects in providing care to client and family.

Terminal Dehydration:

Nurse Role and Interventions

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Dehydration

• Dehydration in terminally ill clients may be

considered predictable (McAulay, 2001).

• “There is no consensus among experts on

whether it is physically, psychologically, socially,

or ethically appropriate to provide artificial

hydration or nutrition to a terminally ill patient”

(Kedziera, 2001).

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Assessment: Dehydration

• Assess client’s intake and output.

• Evaluate client’s and family’s wishes for intervention.

• Assess condition of client’s mouth.

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Interventions: Dehydration

• Recognize complex issue of whether to hydrate.

• Recognize family needs and respect wishes re: hydration.

• Initiate hydration if appropriate.

• Teach oral care every 2 hours (Kedziera, 2001).

• Provide small amounts of fluids or ice chips for comfort.

• Describe possible positive effects of dehydration.

• Discuss disadvantages of hydration.

Terminal Dehydration

• As patient approaches death, desire to consume food

decreases

• Dehydration predictable

• Emotional & ethical dilemma in palliative care

• Families/care providers find it difficult to hold

• May feel they are starving patient or causing suffering

• Experience sense of guilt, frustration, no control over death

• However, may lead to enhanced comfort

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Terminal Dehydration: Nursing Interventions

• Describe possible positive effects of dehydration

• Discuss disadvantages of hydration (invasive

procedure, increased cardio/pulmonary load, possible

need for catheter, may decrease comfort)

• Recognize family needs and respect wishes if they

choose hydration

• Oral care every 2 hours to moisten mouth and protect

mucous membranes

Signs / Symptoms Death is Imminent

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Assessment: Imminent Death

• Assess for signs of impending death (Berry & Gribbie,

2001; Matzo & Sherman, 2001).

• Assess caregiver knowledge related to recognition of

impending death.

• Assess for symptom control.

• Assess for unrelieved pain and suffering not

controlled with usual interventions.

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Interventions: Imminent Death

• Ensure all comfort measures are provided (e.g., medications, mouth and skin care).

• Use medications to relieve symptoms.

• Consider sedation if appropriate.

• Educate family on symptoms of impending death.

• Plan with the family for the death event.

• Ensure opportunity for family to say good-bye and give permission for dying person to go.

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Imminent Death • Continuous process since multi-organ failure occurs and physical

signs may occur gradually over weeks or months or rapidly over days

• Factors related to imminent death - Pain, dyspnea, restlessness, and agitation are the physical

symptoms requiring maximum care in the hours and days before

death occurs (Berry et al., 2002)

- Support the family during dying process (Berry & Gribbie, 2001).

- Dying is a continuous process once multi-organ failure occurs

(Arnold, 2001).

- Emotion, cognition, thinking behavior, and autonomic function all

slowly deteriorate; coma usually occurs before death (Berry &

Griffie, 2001).

Family Teaching: How To Tell Death is

Imminent? • Although we can never predict the exact time a person will die, we know when the time is getting close by a combination of signs and symptoms

• Not all of these signs will appear at the same time, some may never appear

• All of the signs described are ways the body prepares itself for the final stages of life.

Imminent Death: Recognize Physical Changes

Skin becomes cooler (hands, arms, feet, & legs) and color may

change to blue with purple splotches

• Normal indication that circulation is decreasing to extremities

and being reserved for vital organs

• Keep warm with blankets (no electric – burn risk)

Respiratory Congestion (“Death Rattle”)

• Gurgling (“as though marbles rolling around”)

• Caused by decreased fluid intake, ineffective cough

• Suctioning may increase secretions & discomfort

• Gently turn patient’s head to side

• Sound of congestion does not indicate pain

Imminent Death: Recognize Physical Changes

• Incontinence • May lose control of urine and/or bowels as the muscles in area begin to relax

• Discuss measures to keep patient clean & dry

• Decreased urine output

• Urine output normally decreases & becomes tea color (concentrated urine)

• Due to decreased fluid intake & decrease circulation through the kidneys

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Imminent Death: Recognize Physical Changes

Breathing pattern changes

• Apneic periods: spaces of 10-30 seconds where

there is no breathing at all

• Cheynes-Stokes respirations: irregular shallow

breaths with periods of up to 5-30 seconds and up

to full minute of no breathing

• Common, indicate decrease internal organ

circulation

• Elevating head and/or turning may increase comfort

Other Changes: Mentation, Affect & Cognition

• Increased sleeping

• Disorientation

• Restlessness

• Withdrawal

• Vision-like experiences

How Can Family Help with Care? How Family Can Help With Care

• Music

• Assist with turning every few hours, reposition head on pillows

• Massages, lotion rubs

• Washcloths placed inside patient’s hand

• Avoid bright lights, loud noises

• Frequent oral care: Moisten lips with lip salve, lip balm

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Plan with Family for Death Event

• Who does the family want to notify?

Intervention: Make a list with phone numbers

• See if patient / family wishes to notify chaplain or social worker

• Requirements regarding pronouncement at time of death

• Have funeral arrangements been made? Provide list of local mortuaries

98

Bereavement

• Bereavement is a human experience occurring with the

death of a loved one (Corless, 2001).

• Tasks of bereavement include accepting the reality of

the loss, experiencing the pain of grief, and adjusting

to the new environment.

• Many manifestations grief associated loss of loved one

• Possible factors e.g., re-awakening of an old loss,

multiple losses, social isolation (Potter, 2001)

99

Assessment: Bereavement

• Assess family for risk factors associated with

unresolved grief.

• Evaluate family members for manifestations of grief.

• Assess social support available to family.

100

Interventions: Bereavement

• Encourage family / friends to say good-bye to client.

1. One positive memory 2. Bilateral forgiveness 3. Declaration of love

• Provide time for family and others to relive traumatic

event of death.

• Add to stability of the family’s social world.

• Ensure bereavement follow-up.

• Provide information regarding grief response.

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The basic medical and nursing approach toward

patients in a hospice program is:

A. Acute Care

B. Curative Care

C. Palliative Care

D. Euthanasia Care

SAMPLE PRACTICE QUESTION

The basic medical and nursing approach toward

patients in a hospice program is:

A. Acute Care

B. Curative Care

C. Palliative Care

D. Euthanasia Care

SAMPLE PRACTICE QUESTION

Radiation is indicated for patients receiving

hospice care to:

A. Decrease brain metastases and prevent seizures

B. Prevent bowel obstruction

C. Decrease pain from bone metastases

D. Stop bleeding from a fungating breast mass

SAMPLE PRACTICE QUESTION

Radiation is indicated for patients receiving

hospice care to:

A. Decrease brain metastases and prevent seizures

B. Prevent bowel obstruction

C. Decrease pain from bone metastases

D. Stop bleeding from a fungating breast mass

SAMPLE PRACTICE QUESTION

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Sample Practice Question

When a patient end of life complains of dyspnea, the nurse

should most appropriately focus on which of the following?

A. Determine degree of dyspnea by assessing arterial

blood gases and pulmonary function tests

B. Monitor pulse oximetry to determine need for oxygen

C. Administer opioids to lessen the sensation of

breathlessness

D. Administer bronchodilators as needed.

Sample Practice Question

When a patient end of life complains of dyspnea, the nurse

should most appropriately focus on which of the following?

A. Determine degree of dyspnea by assessing arterial

blood gases and pulmonary function tests

B. Monitor pulse oximetry to determine need for oxygen

C. Administer opioids to lessen the sensation of

breathlessness

D. Administer bronchodilators as needed.

Sample Practice Question

Delirium is common in the final days of life. Which of the

following nursing interventions would be counterproductive in

the management of delirium?

A. Concentrate on orienting the individual to what is real and

what is not

B. Administer low-dose haloperidol to decrease anxiety

C. Discontinue benzodiazepines because they can worsen

delirium

D. Encourage the individual to speak about a loved one that

has died.

Sample Practice Question

Delirium is common in the final days of life. Which of the

following nursing interventions would be counterproductive in

the management of delirium?

A. Concentrate on orienting the individual to what is real

and what is not

B. Administer low-dose haloperidol to decrease anxiety

C. Discontinue benzodiazepines because they can worsen

delirium

D. Encourage the individual to speak about a loved one that

has died.

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Sample Practice Question

As your patient nears death, his daughter is distressed and believes he is suffering because he is unable to drink fluids. She insists you give him intravenous fluids. In an attempt to help her understand her father’s condition and provide optimal end-of-life care, which of the following is the MOST appropriate response?

A. She is right; dying of thirst is painful and you will call the doctor for intravenous hydration.

B. Assure her that he is not suffering or experiencing any discomfort from dehydration

C. Suggest they insert a small nasogastric tube to administer fluids to prevent dehydration

D. Suggest that she try to encourage her father to drink fluids in small amounts

Sample Practice Question

As your patient nears death, his daughter is distressed and believes he is suffering because he is unable to drink fluids. She insists you give him intravenous fluids. In an attempt to help her understand her father’s condition and provide optimal end-of-life care, which of the following is the MOST appropriate response?

A. She is right; dying of thirst is painful and you will call the doctor for intravenous hydration.

B. Assure her that he is not suffering or experiencing any discomfort from dehydration

C. Suggest they insert a small nasogastric tube to administer fluids to prevent dehydration

D. Suggest that she try to encourage her father to drink fluids in small amounts

Questions? References

• Abernathy, A.P., McDonald, C.F., Frith, P.A., Clark, K., Hendon, J.E., Marcell, J. et al.(2010a). Effect of

palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnea: a double-

blind, randomised controlled trial. Lancet, 376(9743), 784-793.

• American Academy of Hospice and Palliative Medicine (AAHPM) Board of Directors. (2013). Position

statement : Statement on artificial nutrition & hydration near the end of life. Retrieved September 25, 2014

from: http://aahpm.org/positions/anh

• American Geriatrics Society. (2012). Guiding principles for the care of older adults with multimorbidity: an

approach for clinicians. American Geriatrics Society Expert Panel on the Care of Older Adults with

Multimorbidity. Journal of the American Geriatric Society, 60(10), E1-E25.

• American Geriatrics Society. (2014). A guide to dementia diagnosis and treatment. Retrieved on

September 25, 2014 from http://dementia.americangeriatrics.org/

• American Geriatrics Society. (2014). Position statement on interdisciplinary team training in geriatrics: An

essential component of quality health care for older adults. Washington, DC Accessed: 9-2014

http://www.americangeriatrics.org/pha/partnership_for_health_in_aging/interdisciplinary_team_training_state

ment/

• American Geriatrics Society. (2014, April). Statement regarding the value of advance care planning.

http://www.americangeriatrics.org/files/documents/Adv_Resources/AGS.Statement.on.Advance.Care.Plannin

g.042014.pdf

• American Lung Association. (2014). Facts sheet chronic obstruction pulmonary disease. Accessed 10-2014

at: http://www.lung.org/lungdisease/copd/resources/factsfigures/COPD-Fact-Sheet.html

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Nursing Diagnoses: Death and Dying

• Impaired Comfort/Pain

• Constipation, diarrhea, or urinary elimination

• Deficient Knowledge related to pain, dyspnea

• Ineffective Role Management

• Impaired Skin Integrity

• Deficient Fluid Volume

• Impaired Gas Exchange

• Imbalanced Nutrition

• Anxiety, fear

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Nursing Diagnoses: Death & Dying (continued)

• Acute Confusion

• Spiritual Distress

• Impaired Oral Mucous Membrane

• Activity Intolerance

• Ineffective Client and Family Coping

• Deficient Knowledge RT care of client with terminal disease

• Caregiver role strain

• Anticipatory Grief

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Outcome Identification: Death and Dying

• Client will have symptoms controlled.

• Client will choose a hospice/palliative care program.

• Client will receive care appropriate for client & family goals.

• Client will meet goals for pain relief.

• Client has adequate knowledge related to pain regimen.

• Client will participate in ADLs.

• Client will have normal bowel and urinary elimination pattern.

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Outcome Identification: Death & Dying (continued)

• Client will have moist / intact oral mucous membranes.

• Client will report a reduction in level of anxiety.

• Client will be able to manage episodes of dyspnea.

• Client will eat what he or she wants.

• Client avoid inappropriate parenteral / enteral nutrition

• Client will control nausea and vomiting.

• Client will be adequately hydrated.

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Outcome Identification: Death & Dying (continued)

• Client will be comfortable at time of death.

• Client will verbalize a reduction in fear and anxiety.

• Client will be calm and suffer a minimum amount of agitation before death.

• Client receives adequate support & is prepared for death.

• Client will die with dignity.

• Family will complete the tasks of bereavement.

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Evaluation

• Oncology nurse systematically and regularly evaluates client’s

and family’s responses to interventions to determine progress

toward the achievement of expected outcomes.

• Relevant data are collected, and actual findings are compared

with expected findings.

• Nursing diagnoses, outcomes, and plans of care are reviewed

and revised as necessary.