1. End of Life Care Lisa B. Flatt, RN, MSN, CHPN

2. Objectives • Understand palliative care • Compare and contrast settings where palliative care and end of life care occur • Identify stages of grief, uncomplicated grief and mourning • Describe legal, historical, social and cultural aspects of palliative and end of life care

3. Definitions to know • Assisted suicide • Autonomy • Grief, Mourning & bereavement • Euthanasia • Terminal illness • Hospice • Medicare hospice benefit

4. Basic Concepts • Loss –something/person and be actual or potential no longer with you, valued • Sources of Loss – body image, death, loss of independence, brain ability, financial, memory

5. Grief Response • Bereavement (subjective) and Mourning (process follows bereavement, resolution of grief) • Normal grieving – essential for mental health following a loss, steps are involved, helps you move on • S/S of grieving – depression, sadness, isolation, wt loss, sleep disturbances, ETOH, SA, fatigue, N&V, HA, faint, palpitations • Variations of grief – anticipated or abbreviated • Dysfunctional grief – pathological, unresolved, extended s/s of grief, stuck in a phase

6. Kubler-Ross’s (1969) Stages of Grief • Denial – shock, didn’t happen, numb, disbelief • Anger – guilt, resentment, sadness • Bargaining – pining, searching, yearning • Depression – grieving • Acceptance - resolution

7. Engel’s (1964)Stages of Grief • Shock & disbelief • Developing awareness – directed anger, loss becomes real • Restitution – dealing with it all, looking more • Resolving the loss – memories, talk it out • Idealization – ‘the best at…..’ • Outcome – acceptance, moving on

8. Sander’s (1998) Five Phases of Bereavement • Shock – confused, unreal, disbelief • Awareness of loss – conflict, stress, seperation anxiety • Conservation/Withdrawal – despair, hopeless, isolation • Healing – identity, control • Renewal – acceptance, revitalization

9. Influencing factors and grieving • Age – younger/children, acceptance as we age, familiar, free from pain and poor quality of life • Significance of loss – how close, spouse, parents, pets, kids, relatives • Culture – major, beliefs • Spiritual belief – influences outcome of death and acceptance • Gender – woman disfigured with scar (idealization of beauty), stoic • Socioeconomic – affordability of care and funerals • Support system - acceptance, after-care • Cause of death/loss – traumatic injury, extended illness, unexpected death, suicide, drug OD

10. Death & Dying • More accepted with age • Develops over time • Children – temporary state • Adults – frightening • Quality of life and lack of it can determine a persons perspective on death

11. Concept of Death and Development

12. Definitions of Death • With life support & medical interventions, in 1968 World Medical Assembly redefined • Clinical – absence of apical pulse, respirations and BP • Lack of OR NO response to: • Eternal stimuli • Reflexes • Brain waves aeb flat encephalogram • Respirations or muscular movement

13. Dying Trajectories (Glaser & Strauss 1965) • Death and dying are unique • Series of graphs • Has limitations to ‘predictions’ • Progression may be difficult to predict • If someone knows outcome, this may affect trajectory (sense of control over dying process and illness)

14. Types of Trajectories • Expected trajectory – short duration, steadily progressing downward (terminal cancer) • Unexpected trajectory- episodes of acute deterioration, recovery, decline then unexpected death • Lingering/Prolonged – elderly escaping cancer and MOF then die later with dementia, Alzheimers, etc..

15. Physiologic Needs (pg 104) • Maintain airway • Pain free • Positioning/comfort • Pastoral/spiritual care • Mouth care • ADL’s, brushing hair

16. Impending Death • Muscle tone – decreased, relaxed face, swallowing, speaking • Circulation – slows down, mottling, cold • Respirations – rapid, shallow, noisy, dry, mouth breathing, slows and irregular • Sensory impairment • Vision- blurred • Decreased smell/taste (or hypersensivity)

17. Care Post-Mortem • When appropriate, after they are gone and family aware and in agreement • Clean, covered • Remove tubes and lines • Dignity • Teeth, eyes closed • Rigor mortis

18. Hospice • Cecily Saunders, MD founded concept • Support and care of person & family • Goal: peaceful and dignified death • Holistic and interdisciplinary • Qualified if MD certifies within the last 6 months of life

19. Where can hospice care occur? • Home • Facility • Hospital • ECF

20. Define Palliative Care • Relief from symptoms of disease • Relief from pain • Support to patient and family, coping mechanisms • Interdisciplinary team • Death not imminent • Allow pt and family to live as ‘normally’ as possible

21. The Nursing Process • Assessment/Analysis • Planning • Rationale • Factors influencing grief & dying • Implementation • Evaluation