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Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 23: Palliative and End-of-Life Care

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Page 1: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 23: Palliative and End-of-Life Care

Page 2: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Is the following statement True or False?

Studies have documented that the American health care system has the best care in the world of seriously ill clients and their families.

Page 3: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

False

Rationale: Studies have documented that the American health care system has substantial shortcomings in the care of seriously ill clients and their families.

Page 4: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hospice Care

• Services that are reasonable and necessary for the comfort and management of a terminal illness; these may include the following:

– Physician services

– Nursing care

– Physical therapy, occupational therapy, and speech-language pathology services

– Medical social services

– Hospice aide services

Page 5: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hospice Care (cont.)

– Homemaker services

– Medical supplies, including drugs and biologicals and medical appliances

– Counseling, including dietary counseling, counseling about care of the terminally ill client, and bereavement counseling

– Short-term inpatient care for respite care, pain control, and symptom management

Page 6: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Care for Dying with Dignity• Attention to pain and symptom control

• Relief of psychosocial distress

• Coordinated care in various settings, with high-quality communication between health care providers

• Preparation of the client and family for death

• Support of self-care, self-management, and independence

• Clarification and communication of goals of treatment and values

• Support and education during the decision-making process, including the benefits and burdens of treatment

Page 7: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Is the following statement True or False?

It must be remembered that a dying patient will go through denial, anger, bargaining and acceptance stages of dying.

Page 8: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

False

Rationale: A dying person may not exhibit all of these stages, or may move quickly through a stage, only to return to it at a later time.

Page 9: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Death in America

• Stages in the dying process

• Specialized care at the end of life

Page 10: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Care When Death Is Imminent

• Most Americans, regardless of age, would prefer to die in their own homes rather than in institutions.

• Help families and patients make decisions about level of care

Page 11: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Comfort Measures Only

• A plan of care that specifies nursing interventions designed not to treat disease but to

– Improve pain

– Function or quality of life

Page 12: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Advance Directives

• Legal documents that allow people to convey their wishes for end-of-life care include the following:

– Living wills

– Durable power of attorney

– Health care proxies

Page 13: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Artificial Nutrition and Hydration

• Benefits and risks

• Administration of artificial nutrition and hydration is a medical treatment, and thus a client can accept or reject it.

Page 14: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cardiopulmonary Resuscitation

• Deciding to put a do-not-resuscitate (DNR) order in place usually involves the client, his or her family, the nurse, physician, and others on the health care team.

• When the nurse approaches the seriously ill client and the family for clarification of the client’s "code" status, best to discuss the issue as fully and objectively as possible.

Page 15: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Euthanasia and Physician-Assisted Suicide

• Active euthanasia is the practice of ending the life of a terminally ill client at the request of the client for the purpose of limiting suffering.

• A medication given for pain relief may have the unintended consequence of shortening the client’s life; however, because the intent of the medication is relief of pain and not the hastening of death, this is not considered euthanasia.

Page 16: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cultural and Religious Issues

• Sensitivity and empathy are essential when caring for a dying person from a different culture.

• Each person is a unique individual with cultural preferences that influence the specialized needs of the client, the family, and their caregivers.

Page 17: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Palliative Care

• Interdisciplinary team-based care that is focused on the relief of suffering for clients with serious illness.

• Best possible quality of life not only for clients but for their families

• Acute, serious, life-threatening illness

• Progressive chronic illness

Page 18: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Focus of Palliative Care

• Controlling symptoms

• Coordinating care

• Reducing unnecessary tests and futile interventions

• Ongoing conversations with the client and family

Page 19: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hospice Care

• Support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible.

Page 20: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common Fears and Concerns of the Dying• Death itself

• Thoughts of a long or painful death

• Facing death alone

• Dying in a nursing home, hospital, or rest home

• Loss of body control

• Not being able to make decisions concerning care

• Loss of consciousness

• Financial costs and becoming a burden on others

• Dying before having a chance to put personal affairs in order

Page 21: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pain Management• Pain assessment

– Moaning or groaning at rest or with movement

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

– Grimacing or strained facial expression

– Guarding or not moving parts of the body

– Resisting care or noncooperation with therapeutic interventions

– Rapid heartbeat, diaphoresis, or change in vital signs

Page 22: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Pain in Dying Clients

• Noiceptive

– Somatic

– Visceral

• Neuropathic

Page 23: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Is the following statement True or False?

Short-acting or immediate-release agents are excellent prn medications and their only use should be for control of breakthrough pain.

Page 24: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

True

Rationale: Short-acting or immediate-release agents are excellent prn medications and their only use should be for control of breakthrough pain. Breakthrough pain is defined as “intermittent episodes of moderate to severe pain that occur in spite of control of baseline continuous pain.”

Page 25: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pain Relief During the Dying Process

• Nonpharmacologic

• Pharmacologic

– Adjuvant drugs

– Opioids

Page 26: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Drugs Used to Control Pain

• Nonopioid analgesics

• Opioids

• Adjuvant analgesics

Page 27: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Routes of Administration

• Oral

• Oral muscosa

• Rectal

• Transdermal

• Topical

• Parenteral

• Intraspinal

Page 28: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Preventing and Managing Adverse Effects

• Constipation

• Sedation

• Respiratory depression

• Nausea and vomiting

• Myoclonus

• Pruritus

Page 29: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Management of Distressing Symptoms at the End of Life

• Secretions

• Anorexia and dehydration

• Skin integrity

• Incontinence

• Terminal delirium

Page 30: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Care of Clients Who Are Close to Death

• Preparing for death

• Dying process includes the following:

– Buildup of saliva and oropharyngeal

– Changes in respiratory patterns

– Skin may appear dusky or gray and feel cold or clammy

– Eyes may appear discolored, deeper set, or bruised

Page 31: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Care After Death

• Postmortem care

• Grief—emotion felt after the loss

• Mourning—recovery from the loss

Page 32: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Phases of Grief

• Numb shock

• Emotional turmoil or depression

• Reorganization or resolution

Page 33: Chapter 23 ppt

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Caring for the Caregiver

• What have you done to meet your own needs today?

• Have you laughed today?

• Did you eat properly, rest enough, exercise, and play today?

• What have you felt today?

• Do you have something to look forward to?