VN057 gerontology 8

1. VN057 gerontology 8 15,

2. Chapter 15 End-of-Life Care

5. The American Way of Dying • Not seen as a natural progression • Uncomfortable with death • fragmented, disorganized & inadequate guidance • forced to attempt to follow changing rules & regulations set up by multi bureaucracies • Gvt • insurance

6. Attitudes Toward Death and End-of-Life Planning

7. Attitudes • end-of-life care and death planning • Ideally, discussions before a health crisis • variety of options-end of life decisions difficult • too many choices • values, cultural & spiritual beliefs, & life experiences all affect choices • Most say that they do not fear death as much as they fear how they will die

9. Advance Directives • Specific end-of-life decisions • Written- official documents • Fewer issues-both providers & family • advance directive • living will • durable power of attorney for health care • Specify the type and amount of intervention desired by an individual

10. Advance Directives (cont.) • Copies to • PCP, hospital of choice, extended-care facility, power of attorney for health care, anyone else as appropriate • A competent person retains the right to change his or her mind about treatment at any time • Intubation or feeding • Full code to DNR • DNR to full or chem code • Comfort care to any of the above

11. Advance Directives (cont.) • Not official or required- • Medic-alert bracelet or necklace with code status • Copy on refrigerator if person lives @ home

12. Caregiver Attitudes Toward End-of-Life Care • providers see death as a professional failure rather than the inevitable end to the human experience • Caregivers need to be able to communicate effectively –deal with grief, loss & bereavement at the end of life • patient, • family • significant others

13. Death among older adults is typically caused by a(n): • acute illness. • accident. • chronic and debilitating conditions. • sudden, unexpected condition.

14. Values Clarification Related to Death and End-of-Life Care

16. Ethical Dilemmas • value systems of patient & caregiver are often very different • Caregivers benefit from spending time identifying their personal end of life values • Understanding the value systems of others help the nurse provide quality end-of-life care, even when his or her values are not the same

17. Values Clarification • Death, dying, and the end of life have different meanings for every person • Each individual must examine his or her own values

19. What Is a “Good Death”? • research to identify specific end-of-life outcomes most valued & desired by those nearing the end of life & by their families • Common theme: given their choice, most people wish to be treated with respect and dignity and to die quietly and peacefully, with loved ones nearby

20. Patients’ Wishes Related to End of Life • Most dying patients have similar desires

21. Where People Die • 90% indicated a wish to die at home • less than 25% actually occur there • 50% occur in hospitals • 25%in extended-care facilities • Hospice care • The focus is palliative • providing comfort • meeting the needs of patients & their families

22. Hospice care is usually available for the last __________ of life. • month. • 6 months. • 1 year. • 2 years.

23. Medicare covers hospice when death is expected to occur within 6 months • Not always exact timing-some lee way • Not always cancer • CHF • Dementia • COPD • etc

24. Hospice Care

25. Palliative Care • Focus-reduce or relieve symptoms without cure • neither hastens nor postpones death • Interventions designed to make the best of the time left & live as active and complete a life as possible until death comes • “Comfort Care”

26. Palliative Care (cont.) • Individuals choosing palliative care usually choose to decline procedures • Invasive diagnostic tests • cardiopulmonary resuscitation (CPR) • artificial ventilation • artificial feeding, • prolong the dying process

28. Collaborative Assessments and Interventions for End-of-Life Care • Commitment & collaboration of all caregivers • Disciplines must work together cooperatively & creatively • positive attitude to solve any problems • requires mutual respect & communication between all team members

29. Communication at the End of Life • responsibility for providing & maintaining effective communication • nurses and assistive caregivers, who spend the most time with dying patients • Nurses need to work to develop a climate that encourages open communication

30. Communication at the End of Life (cont.) • demonstrate verbally and nonverbally you are approachable • not detached or indifferent • demonstrate willingness to listen • suggestions, requests, or criticisms made by the dying person or, more likely, by family

31. Psychosocial Perspectives, Assessments, and Interventions

33. Cultural Perspectives • cultural beliefs influence people think, live & interact with other people-they also affect how a person approaches death • nurse’s responsibility to assess each person to find out their preferences & viewpoints • Develops trust & can plan culturally sensitive care

34. Communication About Death • The Western perspective emphasizes patient’s “right to know” diagnosis and prognosis • patient can make informed decisions • Asians & Native Americans often believe speaking about death or other bad things decreases hope and produces bad outcomes

35. Decision-Making Process • Amount and type of intervention that will be accepted • Individual/cultural • focus on helping people cope with death • focus on living and prolonging life

36. Decision-Making Process (cont.) • Significance of pain and suffering • Western perspective focuses on freedom from pain and suffering • Non-Western cultures often see pain as a test of faith or a preparation for the afterlife • something that is to be endured rather than avoided

37. Spiritual Considerations • Determine if there are specific religious beliefs or practices important to the patient or their family members • Assess whether they have a preferred spiritual counselor • Offer choices when available • Determine whether the person wishes any spiritual counselor to be notified

38. Spiritual Considerations (cont.) respect for the patient’s religious and spiritual views • Avoid imposing your own beliefs • Be present, be available, and listen • Avoid moving beyond your role and level of expertise unless you have specific ministerial or pastoral training in death and dying

39. Depression, Anxiety, and Fear • It is one thing to know that you will die eventually; it’s another to realize that you have lived most of your life and that death is likely to be a reality soon • Individuals must decide whether they will give up and let fear, anxiety, or depression overwhelm them or whether they will do something to remain in control of whatever time they have remaining

40. One of the most important things caregivers can do for a dying person is to: • not talk about when they will die. • allow them to be alone as much as possible. • talk to them about a “do not resuscitate” status. • spend more time with them.

42. Physiologic Changes, Assessments,and Interventions

43. Pain • Biggest concern of the dying person and their significant others • Can interfere with the ability to maintain control, cope, and complete end-of-life tasks • Increases the likelihood of fatigue, depression, and loss of appetite

44. Pain (cont.) • Interferes with the ability of the dying person to make thoughtful decisions & communicate effectively with loved ones at a critical time • Relief of pain begins with careful assessment • Perform assessment early & often • patient’s status can change dramatically in a relatively short period

45. Pain (cont.) • Pain is what the patient says it is, but many older patients who have lived with multiple discomforts often underreport pain • Don’t want to be a bother • Afraid of addiction to medication • Medical personnel • Family • patient • Self-reported logs or journals are helpful • patient and significant others more focused and attuned to subtle changes in the individual

46. Fatigue and Sleepiness • May be caused by underlying disease processes, stress, anxiety, or medications • can interfere with ability to carry out end-of-life tasks, including communicating with loved ones • Because of metabolic changes [& depression] patient may begin to sleep more and may be difficult to awaken as the end of life nears

47. Cardiovascular Changes • Diminished peripheral circulation • likely to worsen as death nears • resulting in dry, pale, or cyanotic extremities • Peripheral pulses are often weak • Blood pressure often decreased by 20 or more points from normal range and may be difficult to hear • Body temperature may elevate significantly as death nears

48. Respiratory Changes • Shortness of breath, difficulty breathing (dyspnea), and Cheyne-Stokes respirations during sleep are commonly observed in older adults as death nears • Mild respiratory difficulty usually can be relieved by changing positioning, elevating the upper body, opening windows or using a fan to increase ventilation, or administering oxygen by nasal cannula • Narcotics often given for air hunger

49. Gastrointestinal Changes • Loss of appetite (anorexia) and muscle wasting (cachexia) are commonly observed with advanced terminal conditions, particularly some forms of cancer • Dry mouth (xerostomia) and ulcerations of the mouth • Nausea and vomiting are not signs of impending death; rather, they are distressing symptoms of underlying problems

50. Gastrointestinal Changes (cont.) • Constipation is a common and distressing problem for the terminal patient • Diarrhea is a less common problem at the end of life, but one that can have a profound effect on the quality of life