DEATH AND DYINGDEATH AND DYING

Definitions:

-- The concepts of death and dying were rarely studied before the 1960’s

-- Death is an inevitable, unequivocal, universal experience.

-- Physiologically it is a cessation of all vital functions

-- Emotionally it is looked at as one of life’s mysteries

Attitudes about death & dying

-- Present generation (you) may be unaware of feelings

-- Prolonging life

-- Common fears

-- Behaviors of healthcare professionals

Coping Mechanisms

(Elizabeth Kubler-Ross)

Denial

After the initial shock has worn off, the next stage is usually one ofclassic denial, where they pretend that the news has not been given. They effectively close their eyes to any evidence and pretend that nothing has happened.

“No, not me”

Interventions: a. Do not interfere unless it becomes

destructive b. Do not support denial; conversations

should include reality c. Continue to teach and encourage self-

care and activities

Anger

This stage often occurs in an explosion of emotion, where the bottled-up feelings of the previous stages are expulsed in a huge outpouring of grief. Whoever is in the way is likely to be blamed .

“Why me”

Interventions: a. Give them space, allowing them

to rail and bellow. The more the storm blows, the sooner it will blow itself out.

b. Try not to respond in “kind” c. When anger becomes destructive, it

must be address directly. Remind person of appropriate and

inappropriate behavior

Bargaining

“Yes me, but”The patient attempts to negotiate a postponement, usually with God and is generally kept a secret

Interventions: a. Spend time with patient b. Discuss importance of valued objects and people

DepressionThe inevitability of the news eventually (and not before time) sinks in and the person reluctantly accepts that it is going to happen

Interventions: a. Be available and don’t attempt to

cheer patient b. Find out about any religious support

Acceptance

Restful time, but not necessarily happy. Often begin putting their life in order, sorting out wills and helping others to accept the inevitability.

Interventions: a. Plan care to allow person with whom patient is comfortable to care

for him/her b. Important that you don’t withdraw.

Hope“Where there is life, there is hope”

May permeate all stages

SIGNS & SYMPTOMS of SIGNS & SYMPTOMS of APPROACHING DEATHAPPROACHING DEATH

May have increased hallucinations

Decreased appetite

Decreased urine output

May have temperature spikes

Incontinent of stool & urine 24 to 72 hours prior to death

Pain may be more intense

-- if feel pain should be controlled, check for an impaction ( 5 to 10% of pain at death due to impaction)

Restlessness is common 12 to 24 hours prior to death

Changes in respiratory status

-- Periods of Cheyne-Stokes 36 to 72 hours prior (may be constant final 6 to 12 hours)

-- Oxygen is not usually helpful

Increase in chest fluids

-- Audible rattle or gurgle (Death Rattle)

-- Atropine SQ may be ordered (Why?)

Grunting & moaning on expiration

Skin changes

-- Extremities begin to cool

-- Cyanosis & mottling

-- Color shallow

-- Face sunken

Emotional

Listen, be sensitive, and respond

Carry out requests if possible

Be aware of your own feelings

Assess family needs

Caring for the dying patient involves taking risks

Foster communication between you, the

patient, and the family

-- ask family, especially wife or husband, how they would like to help with their loved ones care.

-- be prepared for a wide variety of behaviors from family members.

The nurse

Understand that you may experience grief

Help your colleagues if you see them going through this

Providing care for the dying patient and supporting the family can be very rewarding.

After Death

Check your hospital policy and procedures

RN’s can pronounce a patient dead

Care of the body generally involves:a. supine position b. clean body c. tidy room and turn down lights d. pads to perineal area

AUTOPSYDeaths which come under the jurisdiction of

the Medical Examiner's Office include but are not limited to the following circumstances:

1. Persons who die suddenly when in apparent good health and without medical attendance within thirty-six hours preceding death or die within 24 hours of admission to a healthcare facility.

2. Circumstances which indicate death was caused in part or entirely by unnatural or unlawful means.

3. Suspicious circumstances.

4. Unknown or obscure causes.

5. Deaths caused by any violence whatsoever, whether the primary cause or any contributory factor in the death.

6. Contagious disease.

7. Unclaimed bodies.

The Omnibus Reconciliation Act became effective in 1991.

Also called the Patient Self-determination Act

This Act required all institutions that participate with Medicare to provide written information to patients concerning their rights to accept or refuse treatment, including information about written advanced directives

Durable Power of Attorney – allows individuals to select someone to make healthcare decisions if they are unable to.

3. General Statement of Authority Granted.

My Health Care Agent is specifically authorized to give informed consent for health care treatment when I am not capable

of doing so. This includes but is not limited to consent to initiate, continue, discontinue, or forgo medical care and

treatment including artificially supplied nutrition and hydration, following and interpreting my instructions for the

provision, withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or

other form of “living will” I may have executed or elsewhere, and to receive and consent to the release of medical information.

When the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act

in my best interest in making health care decisions.

The above authorization to make health care decisions does not include the following absent a court order:

(1) Therapy or other procedure given for the purpose of inducing convulsion;

(2) Surgery solely for the purpose of psychosurgery;

(3) Commitment to or placement in a treatment facility for the mentally ill, except pursuant to the provisions of

Chapter 71.05 RCW;

(4) Sterilization.

I hereby revoke any prior grants of durable power of attorney for health care.

4. Special Provisions

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

DATED this _______________________ day of _______________________ , ______________ .

GRANTOR __________________________________________

STATE OF WASHINGTON )

(COUNTY OF ________________________ )

I certify that I know or have satisfactory evidence that the GRANTOR, ___________________________________________________________

signed this instrument and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in the instrument.

DATED this _______________________ day of _______________________ , ______________ .

_____________________________________________________________________

NOTARY PUBLIC in and for the State of Washington,

residing at_____________________________________________________________

My commission expires __________________________________________________

(Year)

(Year)

HEALTH CARE DIRECTIVE

Directive made this _______________________________ day of _________ , ______________ .

I, _____________________________________________ being of sound mind, willfully, and voluntarily make known my desire that my dying

shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that:

(A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my attending

physician, and where the application of life-sustaining treatment would serve only to artificially prolong the

process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.

I understand “terminal condition” means an incurable and irreversible condition caused by injury, disease or illness

that would, within reasonable medical judgment, cause death within a reasonable period of time in accordance with

accepted medical standards.

(B) If I should be in an irreversible coma or persistent vegetative state, or other permanent unconscious condition as

certified by two physicians, and from which those physicians believe that I have no reasonable probability of recovery,

I direct that life-sustaining treatment be withheld or withdrawn.

(C) If I am diagnosed to be in a terminal or permanent unconscious condition, [Choose one]

I want _________ do not want _________

artificially administered nutrition and hydration to be withdrawn or withheld the same as other forms of life-sustaining

treatment. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in

certain circumstances. I request all health care providers who care for me to honor this directive.

(D) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention

that this directive shall be honored by my family, physicians and other health care providers as the final expression of

my fundamental right to refuse medical or surgical treatment, and also honored by any person appointed to make

these decisions for me, whether by durable power of attorney or otherwise. I accept the consequences of such refusal.

(E) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or

effect during the course of my pregnancy.

(F) I understand the full import of this directive and I am emotionally and mentally competent to make this directive. I

also understand that I may amend or revoke this directive at any time.

(G) I make the following additional directions regarding my care:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Signed: _______________________________________

The declarer has been personally known to me and I believe him or her to be of sound mind. In addition, I am

not the attending physician, an employee of the attending physician or health care facility in which the declarer is

a patient, or any person who has a claim against any portion of the estate of the declarer upon the declarer’s

decease at the time of the execution of the directive.

Witness: __________________________________

Witness: __________________________________

Physician Orders for Life Sustaining Treatment (POLST)

The POLST form is a “portable” physician order form that describes the patient’s code directions.

-- It is intended to go with the patient from one healthcare setting to another.

-- It summarizes the wishes of an individual regarding life-sustaining treatment that was identified in an advanced directive

and includes the following: a. Patient wishes for resuscitation b. Medical interventions c. Antibiotics d. Artificial feedings

-- The advantage of this form is that it translates the patient’s wishes into actual physician’s orders.

HEALTH CARE POLST SPECIFIC

for

LONG TERM CARE

HOSPITALS

NURSING HOMES

HOSPICE

PHILOSOPHY

• Right to make health care decisions

• Includes decisions about life sustaining treatment

• Includes description for life sustaining treatment to Health care providers

• provide comfort care • honor life sustaining treatment.

FORM?

• Bright lime green form – short summary treatment

preferences – physician’s order

• “portable“– describes patient’s code

directions• resuscitation, medical

interventions, antibiotics, artificially administered fluids, nutrition.

– transfer one care setting with single uniform document.

FORM?

• Voluntary

• Promote discussions• plan end of life care wishes• assist physicians, nurses, health

care facilities, emergency personnel honor wishes for life-sustaining treatment.

• EMS treatment direction & action

FORM?

• Replaces current EMS-No CPR Code directions to EMS Directive

• Translates an Advanced Directive into physician orders.

• NOTE: POLST is NOT an Advance Directive and DOES NOT replace the patient’s advance directive.

QUALIFICATION?

• Any adult 18 or older

• With serious health conditions

FORM LOCATION?

• Health Care Setting Recommendations

• Keep with patient– In hospital

• Medical Chart

– In long-term care facility.• Medical Chart

PHYSICIAN ORDER FORM

REVIEW

• LAST NAME (Patient/Resident)

• FIRST NAME & Initial

• DATE of BIRTH

Part A Resuscitation*

• No pulse & not breathing– Resuscitate– Do not resuscitate

– Patient wants CPR• Resuscitate box

– Does not want CPR• Do Not Resuscitate box• (Resuscitation not attempted.)

– Comfort measures provided

Part B Medical

Interventions*• Patient HAS pulse &/or

breathing.• � Comfort measures only• � Limited Interventions – Comfort

measures, consider oxygen, suction, manual airway obstruction

• � Advanced Interventions – All above, consider oral/nasal airway, BVM/demand valve, monitor cardiac rhythm, medications, IV fluids

• � Full treatment/Resuscitation – All above plus CPR, intubation and defibrillation

• � Other instructions ____________________

Part C Antibiotics

– (notify physician of new infection)

• No antibiotics except comfort

• No invasive (IM/IV) antibiotics

• Full treatment• Other instructions

____________

Part D Artificially Administered Fluids and

Nutrition

– Other fluids & nutrition offered (medically feasible)

• No feeding tube/IV fluids.• No long term feeding

tube/IV fluids• Full treatment• Other instructions

______________

Part E Discussed With

• Patient • Agent Durable Power of

Attorney• Court Appointed Guardian • Spouse• Other

________________________

Part E Order Basis

• Patient Request

• Patient Best Interest

• Patient's Known Preference

• Medical Futility

Check all that apply

SIGNATURE BLOCK(Mandatory)

• Physician Name (print)– Signature– Phone Number– Date

• Patient (or legal Surrogate)– Signature– Date

End first page

Part FGuide

Patient Treatment Preferences

• Advance Directive (Attach copy)

• Court Appointed Guardian (Attach copy)– Name: __________________

• Agent for Durable Power of Attorney (Attach copy)– Name: __________________

Part FGuide

Patient Treatment Preferences• Advance Directive (Attach

copy)• Court Appointed Guardian

(Attach copy)– Name: __________________

• Agent for Durable Power of Attorney (Attach copy)– Name: __________________

HEALTH STATUS CHANGE

• Close to death• Extraordinary suffering• Improved condition• Permanent unconsciousness• Advanced progressive illness

• Signature Block of PREPARER– Name (Print)– Date

PERIODIC FORM CHANGE REVIEW

• Patient Transfer• Substantial health status

change• Treatment Change

1. REVIEW (Part F)2. RECORD (Part G)3. Draw Line & "VOID“ (Initial or

sign)– (Physician Orders)

Options(May complete new form)(No new form full treatment &

resuscitation)

Part G Review POLST

Review Date:

Reviewer’s name:

Location of review:

Review Outcome:

No Change

Form voided

New form completed

• SIGNATURE BLOCK– Patient

– Legal Surrogate

– Date

• (SIGNATURES MANDATORY)

– End last page

WASHINGTON STATE PLAN

• Replacing State EMS-No CPR• phased out of counties receiving

POLST orientation

• EMS will honor – EMS-No CPR or– POLST

Assisted Suicide

ASSISTED SUICIDE: Helping a person to end his or her life by request in order to end suffering. (Rarely prosecuted and only lawful in Switzerland where the reasons must be altruistic.)

PHYSICIAN-ASSISTED SUICIDE: Medical doctor helping patient to die by prescribing a lethal overdose. Patient can chose whether to drink it. (Lawful only in Oregon, Switzerland, Netherlands and Belgium.)

EUTHANASIA: A broad, generic term meaning 'help with a good death.'

VOLUNTARY EUTHANASIA: Death by lethal injection by doctor when requested by patient. (Only lawful in Belgium and the Netherlands for the terminally or hopelessly ill.)

NON-VOLUNTARY EUTHANASIA: Using powerful drugs, doctor ends life of suffering, dying patient who is comatose. Illegal, but happens all the time, discreetly, in the interest of compassion.

Definitions:

MERCY KILLING: Taking the life of another person in the belief that this is a compassionate act because the ill person is unable to do so. Unlawful.

TERMINAL SEDATION: Upon patient request, doctor puts patient into deep sleep with medications, during which time the patient dies either of the underlying illness or starvation/dehydration. Widely practiced and generally accepted as ethical and lawful.

--Oregon Death with Dignity Act passed in 1997 is the first and only legislative initiative that has passed.

--It allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose.

--In order to participate, the patient must:

1) 18 years of age or older,

2) a resident of Oregon,

3) capable of making and communicating

health care decisions for him/herself

4) diagnosed with a terminal illness that will lead to death within six (6) months. --It is up to the attending physician to

determine whether these criteria have been met.

--Since the law was passed in 1997, 292 patients have died under the terms of the law.

Types of CPR DecisionsTypes of CPR Decisions:

Complete

-- CPR; medications; mechanical ventilation

-- Also called a “Full Code”

Chemical Code

-- Use of medication without use of CPR or mechanical ventilation

No Code or DNR

-- Person dies without any medical interference