End of Life

1. End of Life Janna Wickham, MSN Marilee Elias, MSN, CNE Spring 2014

2. EOL ObjectivesSo Many Objectives, so little time… • Safe & Effective Care Environment • Legal & Ethical Obligations • Advanced Directives • Nurse as Client Advocate • Palliative & Hospice Care

3. Health Promotion & Maintenance • Planning for the Highest Possible Quality of Life for the Client (& Family) • How Cultural & Spiritual Beliefs affect the dying client • Teaching on the Death Process for the Client (& Family)

4. Physiologic Integrity • Physiologic manifestations of EOL • Nursing Management for the dying client • Common Physical & Emotional Signs of impending death • Prioritize Interventions for Symptoms • Post-mortem Responsibilities

5. Psychosocial Integrity • Strategies for Effective Communication with client (&family) • Special Needs of Family Caregivers • Special Needs of Nurses • Addressing Spiritual & Emotional conflicts of the dying client • Grief & Loss Theorists

6. “Everyone knows they are going to die, but nobody believes it. If we did, we would do things differently.” Mitch Albom (author, “Tuesdays with Morrie”)

7. How is Death Defined? • Historically • Heart-lung death • Whole brain death • Higher brain death • Uniform Determination of Death Act (1981) • Coma vs. Persistent Vegetative State (PVS) • Multiple Organ Dysfunction Syndrome (MODS) (LeMone p. 243)

8. What are your beliefs regarding Death and Dying? • What do YOU want for End of Life care? • Have YOU ever thought about these decisions?

9. Good Death vs. Bad Death • Good Death • Death that is free from avoidable distress and suffering, and is in agreement with the patient’s and family’s wishes. • Bad Death • Not having one’s wishes followed, pain and isolation.

10. Legal and Ethical Considerations at the End of Life • Patient Self-Care Determination Act • Advance Directives • Living Wills • DPOA • DNAR Order

11. Other Considerations • Assisted Suicide • Euthanasia • Active Euthanasia • Voluntary, Involuntary, Nonvoluntary • Passive Euthanasia • Autopsy • Organ Donation

12. Goals of End of Life Care • Control Symptoms • Identify Patient Needs • Promote Meaningful Interactions • Facilitate a Peaceful Death

13. What are your beliefs? “If you find yourself in a position where a patient’s desire to end life-sustaining interventions conflicts with your own belief system, request that his or her care be transferred to a colleague.” (NSO, 2009)

14. The Nurse as a Patient Advocate • Nurses spend the most time with the patient and their family • Preventing a “Bad Death” • Promoting a “Good Death” • We must possess knowledge of end of life care • We work in collaboration with the interdisciplinary healthcare team members

15. What are Patient and Family Needs? • Psychosocial Needs • Spiritual Needs • Cultural Needs • Family Support

16. What do the patient and family know? • Do they understand the diagnosis? • How much do they want to know? • Do they have unanswered questions? • Have then explain to you what they expect to occur with their loved one.

17. How will we communicate with people who are grieving? • Therapeutic Communication (again) • Listening • Eye contact and touch • Accepting people’s feelings • Providing reassurance • Being in touch with YOUR OWN feelings • Communicating with the dying person and encouraging family members to do the same

18. How do nurses help the family members? • Teach (of course) • Provide Information • Encourage Questions • Encourage seeking Spiritual Guidance • Encourage them to help care for the family member • Remind them to take care of themselves • Ask if they want to be present at time of death

19. Palliative Care vs. Hospice Care • Aren’t they the same thing? • Are they different types of care?

20. Palliative Care • What is Palliative Care? • Aggressively planned, holistic treatment of discomfort, symptoms and stress of serious life-threatening or incurable illnesses • Focuses on Symptom Management • Patient does not have to be actively dying • It is Comfort Care

21. When do we use Palliative Care? • When patients are suffering from symptoms R/T a serious illness • When pain is not under control • When patients need help understanding their illness • When patients need help coordinating their care

22. Palliative Care is NOT Hospice Care • Palliative care is available at any time during a serious illness • You can receive palliative care while you receive care to treat and cure your illness

23. It’s a Team Effort • Who can we find on the team? • Doctors, Nurse Practitioners • Nurses • Social Workers • Chaplains • Pharmacists • Nutritionists • Counselors • Others

24. Hospice Care • Founded in 1960s England • What is Hospice Care? • Where is it found?

25. “How people die remains on in the minds of those who live on.” Dame Cicely Saunders Founder, Hospice of England

26. Hospice Care • Palliative care may not be hospice care BUT Hospice care is ALWAYS palliative care

27. What are the Goals of Hospice Care? • Help the patient achieve their highest quality of life • Create an environment of Comfort • Support death with Dignity

28. Who receives Hospice Care? • Patients with terminal illnesses who are no longer receiving curative treatment • Traditionally patients who are expected to live 6 months or less

29. Who pays for hospice care? • Medicare is the leading payer for hospice care • Hospice care is available to patients REGARDLESS of their ability to pay • Hospice care is available to all

30. What is Loss? • The Absence of Something Desired or Previously Thought to be Available

31. Types of Losses • Actual Losses • Who can Identify the Loss? • Deaths • Loss of Aspects of Self (AKA Physical Losses) • Loss of Significant Relationships • External Losses • Natural Disasters • Environmental Losses

32. Perceived Losses AKA Internal or Psychological Losses • Who can Identify the Loss? • Feelings and Emotions • Environmental Losses • Aging

33. What is Grief? • Our Physical, Psychological and Spiritual Responses to Loss • Mourning • Bereavement

34. So Many Grief Theorists, So Little Time… • William Worden- 4 Tasks of Grieving • Teresa Rando- 3 Phases and the 6 R’s of Grieving • John Bowlby- 4 Phases of Grief • Elizabeth Kübler-Ross- 5 Stages of Dying and Grief • George Engel- 3 Stages of Grief

35. Elizabeth Kübler-RossStages of Dying and Grief • Seminal Research on Stages of Dying and Grief at the Dying Person’s Level: • Denial • Anger • Bargaining • Depression • Acceptance

36. Summing It Up What Similarities do you find among these Theorists? What Theorist do you relate to the Most? The Least?

37. End of Life Class 2

38. What Factors Affect Grief? • Significance of the Loss • Support Systems of the Bereaved • Unresolved Conflicts -In Both Sudden and Expected Deaths

39. Circumstances of the Death • Sudden vs. Expected • Suicide vs. Homicide • Guilt & Responsibility • If only I … • Previous Losses

40. Developmental Stages(Think Erikson) • Grief Affects Development & the Stage of Development Affects the Grieving Process • Childhood • Adolescence • Adulthood • Older Adults

41. Children & Death • Main Causes of Death R/T Age • Infants • Prematurity, Congenital Defects, Infections • Toddlers & Children • Accidents & Injuries • School-Age Children • Cancers & Unintentional Injuries • Adolescents • Homicide, Suicide & Cancers

42. The Dying Child’s Perceptions of Death • Toddlers • Something is Wrong • Preschool Age • Concrete and Magical Thinking • School Age • Often Realistic and Needs Honesty • Adolescent • Adult Understanding, but…

43. Diagnoses for the Dying Child • Pain • Alteration in Family Process • Anxiety • Alteration in Nutrition • Anticipatory Grieving • Social Isolation • Depression • Fear and more…

44. What Happens to the Dying Child’s Sibling(s)? • Sibling Feelings and Emotions • How are the Parents interacting with the Sibling(s)? • What can We Teach the Family about the Sibling(s) Needs? • What is Our Role and Our Nursing Interventions for the sibling(s)? • Support Sibling now and at the Death

45. Spiritual/Cultural Beliefs • Not One Size Fits All within Any Group • Caucasian • African American • Asian • Latino/Hispanic • Native Americans/American Indians • Judaism • There’s Never a Good Time… • The Timeliness of the Death…

46. Ethnocultural Considerations • Perform Cultural and Spiritual Assessments • Good Communication is Vital • Provide Culturally Competent Care of Patient and Family

47. Types of Grief • Uncomplicated vs. Complicated • Chronic • Pathological • Violence, Addictions, Poor Decision Making, Suicidal and/or Homicidal Ideation • Masked • It’s Not what I Say, it’s what I DO!

48. More Types of Grief • Delayed • Survival Mode • Disenfranchised • Not Socially Supported • Anticipatory • While Caring for …

49. Some Common Grief Reactions • Physical (AKA Somatic Grief Responses) • Emotional • Behavioral • Cognitive

50. Grief Education • Spouse, Significant Other, Family Members & Common Grief Reactions • The Special Needs of Children • When may Children need Professional Help? • What is their Knowledge Base? • What is their History of Loss? • Do they have Coping Skills & Support Systems?