End of Life Care for Older Adults

By the end of this lecture the student will be able to:

Define end of life care.

Identify Target population for better “End of Life Care”

Identify the ten leading causes of death.

Differentiate between Palliative Care and Hospice Care.

List services provided by Hospice programs.

Identify Nursing Skills needed to provide Palliative Care.

Enumerates factors that influence attitude of people towards death.

Understand decision making at the End of Life.

List Barriers to Good End of Life Care.

Apply Nursing Interventions for patients in End-Of-Life.

Identify Signs of Imminent Death.

Apply Postmortem Care.

Introduction:

End of life care is support for people who are approaching death. It helps

them to live as well as possible until they die, and to die with dignity. It also

includes support for their family or carers.

End of life care includes palliative care. If you have an incurable illness,

palliative care will help to make you as comfortable as possible by relieving

pain and other distressing symptoms, while providing psychological, social

and spiritual support for you and your family or carers. This is called a

holistic approach to care, as it deals with the ‘whole’ person rather than just

one aspect of their care.

Thanatology: (i.e., the study of death and dying)

Death: The United Nations Vital Statistics Division defines death as

the cessation of vital functions without capability of resuscitation.

Dying: is regarded as a less specific, individualized process in which

an organism’s life comes to an end (i.e., the final portion of the life

cycle).

When does the dying process begin?

People are considered to be dying when they are ill with a

progressive condition that is expected to end in death and for which

there is no treatment that can substantially alter the outcome

The length of the dying process varies and depends on the

individual’s holistic situation. Its duration may be a matter of minutes,

hours, weeks, or months.

The end of life is the period for patients when “there is little

likelihood of cure for their disease(s); further aggressive therapy is

judged to be futile; and comfort is the primary goal”

This period can last from hours to months, and it encompasses

the time during which a person is actively dying.

Palliation is defined as “the relief of suffering when cure is

impossible”

Palliative care defined as the comprehensive management of the

physical, psychological, social, spiritual, and existential needs of

patients, particularly those with incurable, progressive illness.

The goal of palliative care:

Focuses on comfort rather than cure, on the treatment of symptoms

rather than disease, on quality of life left rather than quantity of life

lived

Target population for better “End of Life Care”

1. Very sick (disabled, dependent, debilitated)

2. Generally getting worse

3. Will die without a period of being well again

4. Most likely will die from progression of current illness (es)

Primary cause of death

10 leading causes of death account for 80% of all deaths in the

United States

1. Heart disease

2. Malignant neoplasms (cancer)

3. Cerebrovascular disease (stroke)

4. Chronic obstructive pulmonary disease

5. Pneumonia and Influenza

6. Diabetes mellitus

7. Alzheimer’s disease

8. Renal disease

9. Accidents

10. Septicemia

Palliative Care vs. Hospice Care:

• The core of Palliative care and Hospice care is the same: to

provide comfort and pain/symptom management and optimize quality

of life.

• Hospice patients receive Palliative care, but not every Palliative care

patient will enter Hospice.

• The goals of Palliative care and Hospice care are different, and

depend on what the patient wants to accomplish.

Palliative Care:

• Palliative care improves the quality of life for patients with serious

illnesses by relieving symptoms, pain and stress.

• Palliative care can happen at any point during a patient's illness.

• can even be provided at the same time a person is receiving curative

care for something else, such as receiving treatment for a bladder

infection while terminally ill with heart disease

Who is eligible for Palliative Care?

• Patients with life-limiting diseases who may still be seeking curative

treatment

• Sufferers of chronic conditions which require aggressive pain

management and symptom management

• May not have a terminal prognosis

Palliative Care Settings

• Hospitals

• Outpatient clinics

• Long-term-care facilities

• Home

Hospice Care:

• Hospice is a care program that provides assistance to those individuals

who have an incurable disease and have chosen not to carry out any

further aggressive treatment.

• Hospice considers the patient and family/caregivers as one unit of care

– provides support for all.

• The majority of hospice care is provided at home.

• Hospice care is a cost-effective alternative to the high costs associated

with hospitals and traditional institutional care.

Who is eligible for Hospice Care?

• An individual who has a life expectancy of six months or less if the

terminal illness runs its normal course, as determined by a physician,

and…

• …is no longer seeking aggressive treatment

Hospice Settings

Freestanding

Hospital

Home health agencies with home care hospice

Home

Nursing home or other long-term-care settings

Hospice programs offer the following services:

● Physician and nursing care

● Home health aide

● Therapies such as music, art, and other supportive services

● Social work and counseling services

● Spiritual care

● Volunteer support

● Bereavement counseling, including support programs for1 year after death

● Medical equipment and supplies

● Drugs related to the disease

● Inpatient care for symptom management, caregiver respite, or both

Nursing Skills for Palliative Care:

The American Nurses Association’s Standards and Scope of Hospice and

Palliative Nursing Practice (2002) enumerates the special skills, knowledge,

and abilities needed by a nurse who provides end-of-life care:

1. Thorough knowledge of anatomy and physiology and considerable

familiarity with pathophysiological causes of numerous diseases

2. Well-grounded skill in physical assessment and in various nursing

procedures, such as catheterization and colostomy and traction care

3. Above-average knowledge of pharmacology, especially of analgesics,

narcotics, antiemetics, tranquilizers, anti-biotics, hormone therapy,

steroids, cardiotonic agents, and cancer chemotherapy

4. Skill in using psychological principles in individual and group

situations

5. Great sensitivity in human relationships

6. Personal characteristics such as stamina, emotional stability,

flexibility, cooperativeness, and a life philosophy or faith

7. Knowledge of measures to comfort the dying in the last hours

Factors that influence attitude of people towards death:

Everyone has their own attitude toward death based on personal experiences,

age, and culture. As nurse aides, we need to respect these attitudes and care

for them the best we can.

1. Age

People of different ages have different attitudes towards death

children see death as temporary

Adults develop fears and sufferings of being alone

elderly generally have fewer fears

2. Individuals reactions to death

they may accept or completely deny death

open and receptive

they may talk about their uncertainties

may be fearful or angry

may be anxious

hostile

or thoughtful and meditative

3. Religion

Residents may have different attitudes toward death depending on

their religion, they may believe in:

Life after death

Reunion with loved ones

Punishment for sins

No afterlife

Decision Making at the End of Life:

The adult has the ultimate authority to accept or reject medical care,

including the decision to leave off life-sustaining treatment, decisions

about dialysis, antibiotics, tube feedings, cardiopulmonary resuscitation

(CPR), and so on. Through the legislation related to the Patient Self-

Determination Act (PSDA).

1. Advance Directives

A legal document (as a living will) signed by a living competent person in

order to provide guidance for medical and health-care decisions (as the

termination of life support and organ donation) in the event that the person

becomes incompetent to make such decisions

Or

Are written instructions which communicate your wishes about the care

and treatment you want to receive if you reach the point where you can no

longer speak for yourself.

Forms of advance directive:

A. The durable power of attorney for health care.

(Also called the "medical power of attorney")

The patient chooses someone e.g. a relative or friend to make medical

decisions for him/ her when he/she is not able. Then this person is called an

agent, proxy, or surrogate.

B. Living will.

Called "instructions," "directive to physicians," or "declaration," states your

desires regarding life-sustaining or life-prolonging medical treatment. They

do not appoint a surrogate to make decisions for you.

2. Euthanasia called also mercy killing

The act or practice of killing hopelessly sick or injured individuals in a

relatively painless way for reasons of mercy. By not providing necessary

and ordinary care or food and water, or giving fatal dose of a medication

(usually secobarbital or phenobarbital)

Euthanasia is categorized in different ways, which include

A. Voluntary euthanasia: When the person who is killed has requested to be

killed.

Is legal in some countries, U.S. states, and Canadian Provinces

B. Non-voluntary euthanasia: When the person who is killed made no

request and gave no consent.

Is illegal in all countries. Involuntary euthanasia is usually considered

murder.

Barriers to Good End of Life Care:

1. Policies that prohibit families from freely visiting dying patients

2. Absence of pain and symptom management services

3. Absence of policies that promote adequate assessment and reporting

4. There are still patients, families, and professionals who feel there is

"nothing more to do" for a patient who has a life-threatening prognosis

5. Failure of healthcare providers to acknowledge the limits of medical

technology

6. Lack of communication among decision makers

7. Failure to implement a timely advance care plan

8. Unwillingness to be honest about a poor prognosis or telling bad news

9. Lack of understanding about the valuable contributions to be made by

referral and collaboration with comprehensive hospice or palliative care

services

Nursing Interventions in End-Of-Life Care

As healthcare providers, we become skilled in nursing and medical science,

but the care of the dying person encompasses much more. Certain aspects of

this care are taking on more importance for patients, families, and healthcare

providers. These include pain and other symptom management;

psychological, spiritual, and grief/bereavement support. To help the patient

die in comfort, with their dignity intact and their wishes and values

respected.

Promoting Communication.

Offering Spiritual Support.

Managing Symptoms.

1. Promoting Communication.

By using communication strategies and interpersonal skills, these

interventions include presence, compassion, touch, recognition of an

individual’s autonomy, and honesty.

Presence: described as a “gift of self” in which the nurse is available

and open to the situation, valuing what the patient says, accepting the

patient’s meaning for things.

Compassion: The nurse strives to be totally and compassionately with

the patient and family, allowing the most positive experience.

Touch: A powerful therapeutic intervention, a means of

communicating genuine care and compassion.

Recognition of autonomy: The nurse realizes and respects the

individual’s right to make all end-of-life decisions.

Honesty: The nurse communicate/explain what can be expected

honesty and builds trust with the older adult facing death and his or

her family.

Ability to communicate with the patient and family clearly and

supportively.

Provide emotional support that facilitates the experience of self-

transcendence and a sense of win over death.

2. Help provide psychosocial and spiritual support

Be prepared to discuss spiritual matters if patient would like to.

Learn to listen with empathy.

Understand reactions to the losses in their life (the different stages of

grief).

Be prepared to “absorb” some reactions, for example anger projected

onto the health worker.

Connect with spiritual counselor or pastoral care according to the

patient’s religion and wishes.

Do not impose your own views. If you share religious beliefs, praying

together may be appropriate.

Protect your patient from over religious excitement.

For some patients, it is better to talk about meaning of their life, rather

than directly about spirituality or religion.

As human beings, we know how to care for each other. Reassure the

family caregivers that they already have much of the capacity needed.

Give information and skills.

Managing Symptoms:

Fatigue (asthenia)

• Assess for associated conditions, including infection, fever, pain,

depression, insomnia, anxiety, dehydration, hypoxia, medication

effects.

• Inform older adult and family of the normality of fatigue at end of life.

• Pace activities and care according to tolerance.

• Exercise if tolerated.

• Promote optimal sleep, with regular times of rest, sleep, and waking.

• Corticosteroids, although generally contraindicated in older adults,

may decrease fatigue in patients with cancer.

• Treat associated conditions (e.g., with antibiotics, antidepressants).

Constipation

• Identify risks (e.g., chronic laxative users, medications).

• Perform abdominal assessment, including palpation for distention,

tenderness, or masses and auscultation of bowel sounds and pitch.

• Assess patients taking pain medications daily.

• Monitor the character of the bowel movements.

• Check the rectum if the older adult has not had a bowel movement in

more than 3 days or is leaking liquid stool (which can occur with an

impaction).

• Anticipate and prevent constipation with emphasis on fiber, fluid

intake, and activity, but recognize that patients may have difficulty

tolerating the optimal interventions.

• Promote regular routine. Strongest propulsive contractions occur after

breakfast; provide patient privacy at this time.

• Individualize laxative regimen based on the cause(s) of constipation,

history, and preferences.

• Use bulk-forming and stool-softening agents for patients with normal

peristalsis.

• A laxative regimen (with stimulant laxative) may be ordered for

patients taking a pain medication known to cause constipation.

• Stimulant laxatives are the most appropriate for opioid-induced

constipation.

Dyspnea

• Respiratory: Assess vital signs, including oxygen saturation, breathing

pat-tern, and use of accessory muscles.

• Auscultate breath sounds.

• Assess cough (type, if present).

• Check for tachypnea and cyanosis.

• General: Assess for restlessness, anxiety, and activity tolerance.

• Pace activities and rest.

• Provide oxygen; usually at 2–4 L per cannula (avoid using face mask

because of discomfort and sensation of smothering).

• Provide calm reassurance.

• Use a fan to circulate air and help reduce the feeling of breathlessness.

• Position for optimal respiratory function (e.g., leaning forward over a

table with a pillow on top is helpful for COPD; on the side with head

slightly elevated for unresponsive patient).

• Teach patient to use pursed-lip breathing, and encourage relaxation

techniques to reduce muscle tightness and associated sensation of

breathlessness.

• Treat symptoms with morphine or hydromorphone, which relieves the

breathless sensation in almost all cases.

• Use antianxiety agents or antidepressants if appropriate (and if

perception of breathlessness is exaggerated because of anxiety or

depression).

• Corticosteroids can be used for their anti-inflammatory effects in

certain conditions (e.g., COPD, radiation pneumonitis).

Nausea and vomiting

• Assess for potential cause (e.g., constipation, bowel obstruction).

• Palpate abdomen and check for distention.

• Assess vomitus for fecal odor.

• Assess heartburn and nausea, which may occur after meals in

squashed stomach syndrome.

• Assess pain (e.g., pain on swallowing may indicate oral thrush; pain

on standing may be caused by mesenteric traction).

• Hiccups occur with uremia.

• Offer frequent, small meals; serve foods cold or at room temperature.

• Apply damp, cool cloth to face when nauseated.

• Provide oral care after vomiting.

• Medications need to be specific to the cause:

● Use metoclopramide drug in Squashed stomach syndrome, gastritis,

and functional bowel obstruction: (contraindicated in full bowel

obstruction)

●Use haloperidol drug in chemical causes, such as morphine,

hypercalcemia, or renal failure:

● Use diphenhydramine in dysfunction of vomiting center (e.g.,

associated with mechanical bowel obstruction, increased intracranial

pressure, motion sickness): meclizine or

Dehydration

• Assess for clinical signs of hydration (e.g., skin turgor over the upper

chest or forehead).

• Assess buccal membranes for moistness.

• Assess vital signs: pulse, orthostatic blood pressure.

• Encourage fluids as tolerated; offer ice chips and popsicles if

swallowing.

• Provide frequent oral care; use swabs or moistened toothettes.

• Give intravenous fluids or administer clysis per advance directives.

• Discuss continued diuretic use with physician.

Anorexia and cachexia

• Assess for weight loss.

• Assess for levels of weakness and fatigue.

• Conduct physical examination for decreased fat, muscle wasting,

decreased strength.

• Assess mental status, including depression.

• Remove unpleasant odors.

• Provide frequent oral care.

• Treat pain optimally.

• Provide frequent, small meals.

• Provide companionship.

• Serve meals in a place that is separate from the bed area.

• Involve patient with meal planning.

• Collaborate with dietician for nutritional analysis and meal planning.

• Encourage culturally appropriate foods.

• Consider using an alcoholic beverage before meals.

• Medications that are used to stimulate appetite, promote weight gain,

and provide a sense of well-being: megestrol acetate, corticosteroids,

and mirtazapine.

• Metoclopramide is used to improve gastric motility and appetite.

Pain management:

• Assess present pain, including intensity, onset, location, duration,

characteristics, aggravating and relieving factors, and treatment (OLD

CART).

• Assess pain history, including prior injuries, illnesses, and surgeries;

pain experiences; and pain interference with daily activities.

• Assess patient's attitudes and beliefs about use of analgesics, adjuvant

drugs, and non-pharmacological treatments.

• Use a standardized tool to assess self-reported pain.

• Verbal Descriptor Scale, or (B) Numerical Rating Scale, or (C) Visual

Analog Scale

• Assess pain regularly and frequently to facilitate appropriate

treatment.

• Observe for nonverbal and behavioral signs of pain.

• Older adults with cognitive impairment experience pain but are often

unable to verbalize it. Such as:

Moaning or groaning at rest or with movement

Failure to eat, drink, or respond to presence of others

Grimacing or strained facial expressions

Guarding or not moving body parts

Resisting care or noncooperation with therapeutic interventions

Rapid heartbeat, diaphoresis, change in vital signs

• Work with the patient and his family to set realistic goals and

expectations because achieving these goals will promote a sense of

accomplishment.

• Give the patient an opportunity to express anger, frustration, sadness,

and concerns about living with pain. And show empathy.

• Educate patients, families, and other clinicians to use analgesic

medications prophylactically prior to and after painful procedures.

• Administer analgesics 30 minutes prior to activities.

• Educate patients and families about pain medications and their side

effects; adverse effects; and issues of addiction, dependence, and

tolerance.

• Use opioids for treating moderate-to-severe pain and nonopioid for

mild-to-moderate pain.

• Acetaminophen drug. Guidelines recommend not exceeding 4 g per

day (maximum 3 g/day in frail elders).

• Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with

caution in older adults. Monitor for gastrointestinal (GI) bleeding and

consider giving with a proton pump inhibitor to reduce gastric

irritation. Also monitor for bleeding, nephrotoxicity, and delirium.

• Monitor medication effects closely to avoid overmedication or under

medication and to detect adverse effects. Assess hepatic and renal

functioning.

• Educate patients, families, and other clinicians to use

nonpharmacological strategies to manage pain, such as relaxation,

massage, and heat/cold, deep-breathing, and diversionary activities.

• Provide opportunities for the patient to rest to increases pain tolerance

and provides energy for participation in other activities.

• Combination approaches that include both pharmacological and

nonpharmacological pain treatments are often the most effective.

• Pain characteristics in Cognitively-Impaired Older Persons

Signs of Imminent Death:

When death is near, bodily functions will slow and certain signs and

symptoms will occur, including:

Decline in blood pressure

Rapid, weak pulse

Dyspnea and periods of apnea

Slower or no pupil response to light

Profuse perspiration

Cold extremities

Bladder and bowel incontinence

Pallor and mottling of skin

Loss of hearing and vision

Postmortem Care:

1. Needs to be done promptly, quietly, efficiently, and with dignity

2. Straighten limbs before death, if possible

3. Place head on pillow

4. Remove tubes

5. Replace soiled dressings

6. Pad anal area

7. Gently wash body to remove discharge, if appropriate

8. Place body on back with head and shoulders elevated

9. Grasp eyelashes and gently pull lids down

10. Insert dentures

11. Place clean gown on body and cover with clean sheet

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Palliative Care, 12, 51–58.

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