chapter 17: ethical/legal principles and issues. ethics of care compassion equity fairness ...
TRANSCRIPT
Chapter 17: Chapter 17: Ethical/Legal Principles Ethical/Legal Principles
and Issuesand Issues
Ethics of CareEthics of Care
CompassionCompassion EquityEquity FairnessFairness DignityDignity ConfidentialityConfidentiality Mindfulness of a person’s autonomy Mindfulness of a person’s autonomy
within the realm of a person’s within the realm of a person’s abilities and mental capacityabilities and mental capacity
Ethical ConceptsEthical Concepts Principles that facilitate decision making and Principles that facilitate decision making and
guide our professional behaviorguide our professional behavior Evolve from our beliefs and valuesEvolve from our beliefs and values Ethical decision making is driven by moral Ethical decision making is driven by moral
reasoning – our determination of what is right and reasoning – our determination of what is right and wrongwrong
Define our character and are expressed in our Define our character and are expressed in our conduct and actionsconduct and actions
Code of Ethics: ANA Code for NursesCode of Ethics: ANA Code for Nurses– A set of moral principles accepted by all members of the A set of moral principles accepted by all members of the
professionprofession– Provides tools for identifying ethical responsibilities and Provides tools for identifying ethical responsibilities and
to guide decision makingto guide decision making
Conflict and DilemmaConflict and Dilemma
Moral distress: occurs when someone Moral distress: occurs when someone wants to do the right thing but is wants to do the right thing but is limited by the constraints of the limited by the constraints of the organization or societyorganization or society
Moral uncertainty: defines the Moral uncertainty: defines the confusion surrounding situations in confusion surrounding situations in which a person is uncertain what the which a person is uncertain what the moral problem is or which moral moral problem is or which moral principles or values applyprinciples or values apply
Conflict and Dilemma (cont’d)Conflict and Dilemma (cont’d)
Moral dilemma: arises when two or Moral dilemma: arises when two or more moral principles apply that more moral principles apply that support mutually inconsistent actionssupport mutually inconsistent actions
True dilemma: occurs when it True dilemma: occurs when it appears there are no acceptable appears there are no acceptable choices choices
Ethical/Moral PrinciplesEthical/Moral Principles AdvocacyAdvocacy
– Championing of the needs and interests of Championing of the needs and interests of others others
AutonomyAutonomy– Person’s right to make independent Person’s right to make independent
choices/decisionschoices/decisions– Respect for personal lifestyle, values, beliefs, Respect for personal lifestyle, values, beliefs,
and choicesand choices– Educate, provide support and resources but Educate, provide support and resources but
cannot force compliance with recommended cannot force compliance with recommended treatmenttreatment
Informed consentInformed consent Advance directivesAdvance directives
– Avoid paternalismAvoid paternalism
Beneficence/NonmaleficenceBeneficence/Nonmaleficence
To do good and do no harmTo do good and do no harm To prevent or remove harmTo prevent or remove harm Failure to rescueFailure to rescue
– Effectiveness in rescuing a patient from Effectiveness in rescuing a patient from a complication vs. preventing a a complication vs. preventing a complicationcomplication
DefinitionsDefinitions
Confidentiality Confidentiality – The right to privacyThe right to privacy– HIPPA (need to know)HIPPA (need to know)
FidelityFidelity– Keeping promises or being true to Keeping promises or being true to
anotheranother– Being faithful to commitments and Being faithful to commitments and
responsibilitiesresponsibilities Fiduciary ResponsibilityFiduciary Responsibility
– Good stewardshipGood stewardship
Definitions (cont’d)Definitions (cont’d)
JusticeJustice– Fairness of an act or situationFairness of an act or situation– Treat equals equally and treat those Treat equals equally and treat those
who are unequal according to their who are unequal according to their needsneeds
– QOLQOL– Sanctity of life (right to live)Sanctity of life (right to live)
ANA Code of Ethics for NursesANA Code of Ethics for Nurses ““Nurses may not act with the intent Nurses may not act with the intent
to end life but may support and act to end life but may support and act on well-thought-out decisions on well-thought-out decisions regarding resuscitation status, regarding resuscitation status, withholding and withdrawing of life-withholding and withdrawing of life-sustaining care including nutrition sustaining care including nutrition and hydration, and aggressively and hydration, and aggressively managing pain and other symptoms managing pain and other symptoms at the end of life even if such care at the end of life even if such care hastens death.” (Mauk, page 592)hastens death.” (Mauk, page 592)
More DefinitionsMore Definitions
ReciprocityReciprocity– Ability to be true to one’s self while Ability to be true to one’s self while
respecting and supporting the values respecting and supporting the values and views of anotherand views of another
VeracityVeracity– Accuracy, truthAccuracy, truth– Not misleading or deceivingNot misleading or deceiving
Patient RightsPatient Rights
Advance Directives and Living WillsAdvance Directives and Living Wills Durable Power of AttorneyDurable Power of Attorney CompetenceCompetence
– May be transientMay be transient– Legal competence is determined by the courtsLegal competence is determined by the courts
Assisted SuicideAssisted Suicide– ANA does not support it in any formANA does not support it in any form– ANA suggests that nurses focus on providing ANA suggests that nurses focus on providing
competent, comprehensive, and competent, comprehensive, and compassionate EOL carecompassionate EOL care
Ethics in PracticeEthics in Practice Mistakes happenMistakes happen
– Admit the errorAdmit the error– Take steps to correct the situationTake steps to correct the situation– ApologizeApologize– Make amends if possibleMake amends if possible– Evaluate how to prevent in the futureEvaluate how to prevent in the future
MalpracticeMalpractice– deviation from standard of care than results in deviation from standard of care than results in
injury or damageinjury or damage Conflict of InterestConflict of Interest
– Competing loyalties and opportunitiesCompeting loyalties and opportunities
Chapter 21: Alternative Chapter 21: Alternative Health ModalitiesHealth Modalities
What is Complementary and What is Complementary and Alternative Medicine?Alternative Medicine?
NCCAM: “A group of diverse medical and NCCAM: “A group of diverse medical and health care systems, practices, and health care systems, practices, and products that are not presently considered products that are not presently considered part of conventional medicine”part of conventional medicine”
5 domains or classifications5 domains or classifications– Whole medical systemsWhole medical systems– Mind-body medicineMind-body medicine– Biologically based practicesBiologically based practices– Manipulative and body-based practicesManipulative and body-based practices– Energy medicineEnergy medicine
Whole Medical SystemsWhole Medical Systems HomeopathyHomeopathy
– Goal: Stimulate the body’s own healing Goal: Stimulate the body’s own healing responses to prevent or treat illnessesresponses to prevent or treat illnesses
– Dilution processDilution process Naturopathic medicineNaturopathic medicine
– Body is supported and barriers to cure are Body is supported and barriers to cure are removedremoved
– Diet and nutritionDiet and nutrition– HydrotherapyHydrotherapy– Spine and soft tissue manipulationSpine and soft tissue manipulation– Acupuncture and acupressureAcupuncture and acupressure– Herbs, Exercise, Counseling, Light TherapyHerbs, Exercise, Counseling, Light Therapy
Whole Medical Systems (cont’d)Whole Medical Systems (cont’d) AyurvedaAyurveda
– Comprehensive system that encompasses the Comprehensive system that encompasses the body, mind, and consciousness connectionbody, mind, and consciousness connection
– Seeks to restore a person’s harmony or Seeks to restore a person’s harmony or balancebalance
– Includes diet, exercise, meditation, herbs, Includes diet, exercise, meditation, herbs, massage, exposure to sunlight, controlled massage, exposure to sunlight, controlled breathing, and detoxificationbreathing, and detoxification
– 5 elements and 3 types of energy5 elements and 3 types of energy Traditional Chinese medicineTraditional Chinese medicine
– Includes acupuncture, herbal medicine, Includes acupuncture, herbal medicine, massage, and meditationmassage, and meditation
– Two apposing forces: Yin and yangTwo apposing forces: Yin and yang
AcupunctureAcupuncture Promotes the flow of qi through pathways in the Promotes the flow of qi through pathways in the
body called meridiansbody called meridians According to WHO, there is support for the use in According to WHO, there is support for the use in
the following:the following:– Post-op painPost-op pain– Chemotherapy induced n/vChemotherapy induced n/v– Pregnancy induced nauseaPregnancy induced nausea– Dental painDental pain
It is believed that it releases endogenous opioids It is believed that it releases endogenous opioids similar to TENSsimilar to TENS
Promising in the treatment of Promising in the treatment of – Headache, CVA rehab, OA, LBP, carpel tunnel, and Headache, CVA rehab, OA, LBP, carpel tunnel, and
asthmaasthma
Mind-Body InterventionsMind-Body Interventions Acknowledge that emotional, mental, Acknowledge that emotional, mental,
social, spiritual, and behavioral factors can social, spiritual, and behavioral factors can directly affect healthdirectly affect health
Includes:Includes:– PrayerPrayer– Deep breathingDeep breathing– MeditationMeditation– YogaYoga– BiofeedbackBiofeedback– Tai chiTai chi– Guided imagery Guided imagery – Pet Therapy and Music TherapyPet Therapy and Music Therapy
Biologically Based TherapiesBiologically Based Therapies
BotanicalsBotanicals Animal-derived extractsAnimal-derived extracts Vitamins/MineralsVitamins/Minerals Fatty acidsFatty acids ProteinsProteins Prebiotics and probioticsPrebiotics and probiotics Whole diets: vegetarian, macrobiotic, Whole diets: vegetarian, macrobiotic,
Atkins, Zone (see page 674 of text)Atkins, Zone (see page 674 of text) Myth: “If a little is good, more must be Myth: “If a little is good, more must be
better.”better.”
Manipulation and Body-Based Manipulation and Body-Based PracticesPractices
Believe that parts of the body are Believe that parts of the body are interdependent and the body has the interdependent and the body has the ability to heal itselfability to heal itself
Includes:Includes:– Chiropractic and osteopathic medicineChiropractic and osteopathic medicine– Massage therapyMassage therapy– ReflexologyReflexology– RolfingRolfing
Energy MedicineEnergy Medicine
Veritable energy fieldsVeritable energy fields– Mechanical vibrationMechanical vibration– Electromagnetic forcesElectromagnetic forces
Putative energy fieldsPutative energy fields– ReikiReiki– qi gongqi gong– Healing (or therapeutic) touchHealing (or therapeutic) touch– Prayer for the health of others (intercessory Prayer for the health of others (intercessory
prayer)prayer) Most controversial because they can’t be Most controversial because they can’t be
measuredmeasured
Reasons for CAM UseReasons for CAM Use
Pain reliefPain relief Increased quality of lifeIncreased quality of life Maintain health and fitnessMaintain health and fitness Sense of well beingSense of well being Dissatisfaction with traditional Western Dissatisfaction with traditional Western
medicinemedicine Supplement to traditional medicineSupplement to traditional medicine Kinder and gentler medicineKinder and gentler medicine Difficulty with accessing health systemDifficulty with accessing health system
Nursing Interventions Nursing Interventions
Ask about use of CAMAsk about use of CAM Ask specifically about use of vitamins Ask specifically about use of vitamins
and herbsand herbs Some herbs/vitamins may interfere Some herbs/vitamins may interfere
with prescribed medicationswith prescribed medications Integrated care may be best for the Integrated care may be best for the
older adultolder adult
Chapter 24: End-of-Life Chapter 24: End-of-Life CareCare
EOL InitiativesEOL Initiatives
EPEC: Education in Palliative and EOL EPEC: Education in Palliative and EOL CareCare
ELNEC: EOL Nursing Education ELNEC: EOL Nursing Education ConsortiumConsortium
CAPC: Center to Advance Palliative CAPC: Center to Advance Palliative CareCare
Historical AttitudesHistorical Attitudes
““In the Orient, dying is a In the Orient, dying is a requirement. In Europe, dying is requirement. In Europe, dying is inevitable. In America, dying appears inevitable. In America, dying appears to be an option.”to be an option.”
Results in expensive medical careResults in expensive medical care– Medicare pays out 5-6 times more for Medicare pays out 5-6 times more for
care within the last 12 months of life care within the last 12 months of life than any other timethan any other time
Background informationBackground information Every person has the right to a peaceful Every person has the right to a peaceful
death and some control at the end of death and some control at the end of life.life.
80% of Americans say their wish is to 80% of Americans say their wish is to die at home but less than 25% get to do die at home but less than 25% get to do so.so.
Nurses have the opportunity to Nurses have the opportunity to influence the processinfluence the process– Nurses spend more time with patients and Nurses spend more time with patients and
familiesfamilies– Can provide support, education, and Can provide support, education, and
guidanceguidance
CommunicationCommunication Talk about the elephant in the roomTalk about the elephant in the room EPEC 6 stepsEPEC 6 steps
– Get started: plan what to sayGet started: plan what to say– Find out what the patient knowsFind out what the patient knows– Find out how much the patient wants to Find out how much the patient wants to
knowknow– Share informationShare information– Respond to feelingsRespond to feelings– Plan/follow upPlan/follow up
Advance DirectivesAdvance Directives
Durable Medical Power of AttorneyDurable Medical Power of Attorney Living WillLiving Will
– 5 Wishes (legal in 40 states)5 Wishes (legal in 40 states) CPR DirectiveCPR Directive
– Colorado specificColorado specific– MD orderMD order– Allow natural death (AND)Allow natural death (AND)
Curative CareCurative Care
There are patients, families, and There are patients, families, and cultures who choose the life-cultures who choose the life-prolonging focus of care of a hospital prolonging focus of care of a hospital deathdeath
Usually an ICU settingUsually an ICU setting Promotes doing everything possiblePromotes doing everything possible Don’t make judgmentsDon’t make judgments
Hospice Hospice Dying is a normal part of the life cycleDying is a normal part of the life cycle Promotes the idea of “living until you die”Promotes the idea of “living until you die” Provides comfort and dignity at EOLProvides comfort and dignity at EOL Care is provided in multiple settings and Care is provided in multiple settings and
supports the patient/family through the supports the patient/family through the dying process as well as providing later dying process as well as providing later bereavement support to surviving familybereavement support to surviving family
Eligibility is based on life expectancy of 6 Eligibility is based on life expectancy of 6 months or lessmonths or less
Palliative CarePalliative Care ““Seeks to prevent, relieve, reduce, or Seeks to prevent, relieve, reduce, or
soothe the symptoms of disease or disorder soothe the symptoms of disease or disorder without effecting a cure” (Field & Cassel, without effecting a cure” (Field & Cassel, 1997).1997).
Whole-person care for those with life-Whole-person care for those with life-limiting illnesses who are not yet eligible for limiting illnesses who are not yet eligible for hospicehospice
Care, not cure, orientedCare, not cure, oriented Goal is highest quality of life possible for Goal is highest quality of life possible for
patients and their families in their given patients and their families in their given situationsituation
Control pain and other symptomsControl pain and other symptoms
Symptom Management: Symptom Management: RespiratoryRespiratory
DyspneaDyspnea– Morphine po or scMorphine po or sc– Relaxation techniquesRelaxation techniques– Use fans and/or cool, humidified airUse fans and/or cool, humidified air– Elevate the head of the bedElevate the head of the bed– OxygenOxygen
Anxiety r/t fear of suffocatingAnxiety r/t fear of suffocating – LorazepamLorazepam
Excessive secretions results from fluid Excessive secretions results from fluid overloadoverload– ScopolamineScopolamine– AtropineAtropine
Symptom Management: Symptom Management: Gastrointestinal/NutritionalGastrointestinal/Nutritional
ConstipationConstipation– Combination softner/stimulantCombination softner/stimulant– RelistorRelistor (methylnaltrexone bromide): an injectable (methylnaltrexone bromide): an injectable
medication, approved for patients with later-stage medication, approved for patients with later-stage advanced illness who use a continual regimen advanced illness who use a continual regimen of opioids of opioids
Nausea/vomitingNausea/vomiting– DexamethasoneDexamethasone– MeclizineMeclizine– ScopolamineScopolamine– Compazine pr or poCompazine pr or po– MetoclopramideMetoclopramide– Zofran, KytrilZofran, Kytril
Symptom Management: Symptom Management: Gastrointestinal/NutritionalGastrointestinal/Nutritional
Decreased appetiteDecreased appetite– Eating for pleasure is the goal - provide favorite Eating for pleasure is the goal - provide favorite
foodsfoods– No dietary restrictions - high calorie, small No dietary restrictions - high calorie, small
frequent mealsfrequent meals– PEG tubes and TPN have limited rolePEG tubes and TPN have limited role– Less nourishment requiredLess nourishment required
HydrationHydration– May be detrimental to comfortMay be detrimental to comfort– Contributes to fluid overloadContributes to fluid overload– Popsicles, ice chipsPopsicles, ice chips– Meticulous mouth careMeticulous mouth care
Symptom Management: Symptom Management: Anxiety/DeliriumAnxiety/Delirium
Realize that these often occur together - in Realize that these often occur together - in the elderly especiallythe elderly especially
DeliriumDelirium– Occurs in last hours to days of lifeOccurs in last hours to days of life– Causes: pain, dyspnea, constipation, urinary Causes: pain, dyspnea, constipation, urinary
retentionretention– Reduce stimuliReduce stimuli– Family/loved one at bedsideFamily/loved one at bedside– Re-orient if possibleRe-orient if possible– Provide emotional supportProvide emotional support– Music therapyMusic therapy– Anti-anxiety meds may be helpfulAnti-anxiety meds may be helpful
Symptom Management: Symptom Management: Anxiety/Delirium/DepressionAnxiety/Delirium/Depression
AnxietyAnxiety– Relieve physical symptoms, i.e. pain, SOBRelieve physical symptoms, i.e. pain, SOB– Family/loved one at bedsideFamily/loved one at bedside– Anti-anxiety medicationAnti-anxiety medication
Maximize symptom managementMaximize symptom management Assist persons to draw on sources of Assist persons to draw on sources of
strengthstrength Encourage verbalization/Acknowledge fearsEncourage verbalization/Acknowledge fears Educate (help sort real fears from Educate (help sort real fears from
imagined)imagined) ListenListen
Symptom Management: PainSymptom Management: Pain
Unrelieved pain can contribute to Unrelieved pain can contribute to unnecessary sufferingunnecessary suffering
Pain may actually hasten death by Pain may actually hasten death by increasing physiological stressincreasing physiological stress
Under-appreciated, under-reported, Under-appreciated, under-reported, and under-treatedand under-treated
Misconceptions About Pain Misconceptions About Pain in the Elderlyin the Elderly
Pain is a natural outcome of growing old.Pain is a natural outcome of growing old. Pain perception or sensitivity decreases with age.Pain perception or sensitivity decreases with age. If an elderly person does not report pain, he or If an elderly person does not report pain, he or
she doesn’t have pain.she doesn’t have pain. If an elderly patient appears to be asleep or If an elderly patient appears to be asleep or
otherwise distracted, he or she doesn’t have pain.otherwise distracted, he or she doesn’t have pain. Potential side effects of opioids make them too Potential side effects of opioids make them too
dangerous to use to relieve pain in the elderly.dangerous to use to relieve pain in the elderly. Alzheimer patients and others with cognitive Alzheimer patients and others with cognitive
impairments do not have pain, and their reports impairments do not have pain, and their reports of pain are most likely invalid.of pain are most likely invalid.
PainPain Pain is subjectivePain is subjective Pain is whatever the experiencing person Pain is whatever the experiencing person
says it is, existing whenever he says it says it is, existing whenever he says it does.” (McCaffery, 1968)does.” (McCaffery, 1968)
There are many different descriptions of There are many different descriptions of pain: sharp, dull, nagging, burning, pain: sharp, dull, nagging, burning, tingling, electrical, shooting, aching, tingling, electrical, shooting, aching, throbbing, squeezing, cramping.throbbing, squeezing, cramping.
Fear of addiction should not be a factor in Fear of addiction should not be a factor in pain control.pain control.
Types of PainTypes of Pain NociceptiveNociceptive
– SomaticSomatic Tissue, bone, joint, connective tissue injuryTissue, bone, joint, connective tissue injury Can localizeCan localize NSAIDS, steroids, opioids, may require comboNSAIDS, steroids, opioids, may require combo Ex: fracture, bone mets, muscle strainEx: fracture, bone mets, muscle strain
– VisceralVisceral Internal organsInternal organs Unable to localizeUnable to localize OpioidsOpioids Ex: shoulder pain, lung or liver metsEx: shoulder pain, lung or liver mets
NeuropathicNeuropathic– Injury to peripheral or central nervesInjury to peripheral or central nerves– Anticonvulsants or tricyclic antidepressantsAnticonvulsants or tricyclic antidepressants– Ex: shingles, diabetic neuropathyEx: shingles, diabetic neuropathy
Pain ManagementPain Management
Good assessment of pain is the first Good assessment of pain is the first step in treatmentstep in treatment
Suffering can increase painSuffering can increase pain Excellent and safe medications are Excellent and safe medications are
available so that persons should not available so that persons should not have to die in uncontrolled pain. have to die in uncontrolled pain. Other therapeutic modalities can also Other therapeutic modalities can also help relieve pain and sufferinghelp relieve pain and suffering
Pain ManagementPain Management Step 1:Step 1: Mild pain (1–3 on 0–10 scale) Mild pain (1–3 on 0–10 scale)
– Acetaminophen and NSAIDs Acetaminophen and NSAIDs – Acetaminophen should be dosed at 4,000 Acetaminophen should be dosed at 4,000
mg/day or less. An adjuvant may also be usedmg/day or less. An adjuvant may also be used Step 2:Step 2: Moderate pain (4–6 on a 0–10 scale) Moderate pain (4–6 on a 0–10 scale)
– Low-dose, short-acting opioids, in combination Low-dose, short-acting opioids, in combination with acetaminophen and NSAIDswith acetaminophen and NSAIDs
– Combination medications have a ceiling dose Combination medications have a ceiling dose – Adjuvants may also be usedAdjuvants may also be used
Step 3:Step 3: Severe pain (7–10 on a 0–10 scale) Severe pain (7–10 on a 0–10 scale)– Opioids; not used in combination with Tylenol Opioids; not used in combination with Tylenol
or NSAIDs so there is no ceiling for dosingor NSAIDs so there is no ceiling for dosing– Allows for the use of higher doses of these Allows for the use of higher doses of these
opioids opioids – Nonopioids and adjuvants may also be usedNonopioids and adjuvants may also be used
Grief, Loss, BereavementGrief, Loss, Bereavement The dying process involves loss.The dying process involves loss. Most losses trigger mourning and grief Most losses trigger mourning and grief
reactions.reactions. Grief is an emotional response to a loss. It Grief is an emotional response to a loss. It
is an individual process, not an event.is an individual process, not an event. Mourning is the outward expression of a Mourning is the outward expression of a
loss. How one mourns is often influenced loss. How one mourns is often influenced by culture and religion.by culture and religion.
Bereavement includes grief and mourning. Bereavement includes grief and mourning. This includes inner feelings and outward This includes inner feelings and outward behavior. behavior.
CommunicationCommunication 80% of communication is nonverbal80% of communication is nonverbal We should communicate respect, We should communicate respect,
acceptance, a value of human life, an acceptance, a value of human life, an understanding of suffering, a compassion understanding of suffering, a compassion for the dying as well as the livingfor the dying as well as the living
We should advocate for the patient’s best We should advocate for the patient’s best interestinterest
Patients and families want to know that we Patients and families want to know that we will not abandon them, but will listen, tell will not abandon them, but will listen, tell the truth, and be there for themthe truth, and be there for them
HopeHope
A patient can hear a terminal diagnosis A patient can hear a terminal diagnosis and still have hopes for the type of life and still have hopes for the type of life remainingremaining
Hope for appropriate help and supportHope for appropriate help and support A good death is possibleA good death is possible
– Instilling good memoriesInstilling good memories– Uniting familyUniting family– Avoiding suffering and painAvoiding suffering and pain– Becoming spiritually readyBecoming spiritually ready– Saying good-byeSaying good-bye
DeathDeath
Death is a universal processDeath is a universal process 10% sudden10% sudden 90% from chronic illness90% from chronic illness Advocacy, communication, education Advocacy, communication, education
and support are keyand support are key Be ready and prepared to assist Be ready and prepared to assist
families with the death vigilfamilies with the death vigil
The Dying ProcessThe Dying Process
No one can predict the exact time of No one can predict the exact time of death. It is determined by a number death. It is determined by a number of variables.of variables.
The dying process is a natural The dying process is a natural slowing down of all biological and slowing down of all biological and mental functions.mental functions.
The Dying ProcessThe Dying Process
Some patients seem to know when Some patients seem to know when death will occur. Listen to what they death will occur. Listen to what they tell you and believe them.tell you and believe them.
When hydration and nutrition are When hydration and nutrition are removed, death often does not occur removed, death often does not occur “quickly”, as family members might “quickly”, as family members might expect. Help them be prepared.expect. Help them be prepared.
Physical Signs and Symptoms of Physical Signs and Symptoms of End of LifeEnd of Life
Confusion, disorientation, deliriumConfusion, disorientation, delirium Weakness and fatigue with surges of Weakness and fatigue with surges of
energy at timesenergy at times Change in sleeping patternsChange in sleeping patterns Decreased oral intakeDecreased oral intake Decreased swallow reflexDecreased swallow reflex Restlessness, agitation, picking at Restlessness, agitation, picking at
thingsthings Change in bowel and bladder patternsChange in bowel and bladder patterns
Signs and Symptoms of Signs and Symptoms of Impending Death Impending Death
Decreased urine outputDecreased urine output Cold and mottled extremities Cold and mottled extremities
(earlobes may mottle first)(earlobes may mottle first) Vital sign changesVital sign changes Respiratory congestion Respiratory congestion Breathing pattern changesBreathing pattern changes
Signs and Symptoms of DeathSigns and Symptoms of Death Non-responsiveNon-responsive No heart beat and respirationsNo heart beat and respirations Incontinence of stool and urine possibleIncontinence of stool and urine possible Pupils fixed and dilatedPupils fixed and dilated Skin is pale, waxen, and cool to the Skin is pale, waxen, and cool to the
touchtouch Eyes may remain openEyes may remain open Jaw may fall openJaw may fall open
Nursing InterventionsNursing Interventions
Be there. Remember that you may Be there. Remember that you may be there as much for the family as be there as much for the family as for the patient.for the patient.
ListenListen TouchTouch PrayPray Make accommodations for any Make accommodations for any
cultural issues/beliefscultural issues/beliefs
Nursing InterventionsNursing Interventions
Give the family something to do. For Give the family something to do. For example, keeping the cool wash example, keeping the cool wash cloth on the forehead. Some family cloth on the forehead. Some family members will need a “job”.members will need a “job”.
Give the family time to rest. Give the family time to rest. Remember that the death vigil may Remember that the death vigil may be long.be long.
Promote family involvement. Promote family involvement.
Nursing InterventionsNursing Interventions Educate the family as to what to expect. Educate the family as to what to expect.
Remember that they may not only feel Remember that they may not only feel grief, but also guilt, uncertainty, grief, but also guilt, uncertainty, frustration and other emotions.frustration and other emotions.
Encourage family members to talk to Encourage family members to talk to the dying person.the dying person.
Provide a peaceful environment.Provide a peaceful environment. Allow the person to die the way they Allow the person to die the way they
wish.wish.
QuestionsQuestions
How do I feel about palliative How do I feel about palliative (comfort-based) care?(comfort-based) care?
How would I feel if I knew that I was How would I feel if I knew that I was going to die?going to die?