End of Life CareEnd of Life Care

Lisa B. Flatt, RN, MSN, CHPNLisa B. Flatt, RN, MSN, CHPN

ObjectivesObjectives

Understand palliative careUnderstand palliative care Compare and contrast settings where Compare and contrast settings where

palliative care and end of life care occur palliative care and end of life care occur Identify stages of grief, Identify stages of grief,

uncomplicated grief and mourninguncomplicated grief and mourning Describe legal, historical, social and Describe legal, historical, social and

cultural aspects of palliative and end cultural aspects of palliative and end of life careof life care

Definitions to knowDefinitions to know

Assisted suicideAssisted suicide AutonomyAutonomy Grief, Mourning & bereavementGrief, Mourning & bereavement EuthanasiaEuthanasia Terminal illnessTerminal illness HospiceHospice Medicare hospice benefitMedicare hospice benefit

Basic ConceptsBasic Concepts

Loss –something/person and be Loss –something/person and be actual or potential no longer with actual or potential no longer with you, valuedyou, valued

Sources of Loss – body image, Sources of Loss – body image, death, loss of independence, death, loss of independence, brain ability, financial, memorybrain ability, financial, memory

Grief ResponseGrief Response

Bereavement (subjective) and Mourning (process Bereavement (subjective) and Mourning (process follows bereavement, resolution of grief)follows bereavement, resolution of grief)

Normal grieving – essential for mental health Normal grieving – essential for mental health following a loss, steps are involved, helps you move following a loss, steps are involved, helps you move onon

S/S of grieving – depression, sadness, isolation, wt S/S of grieving – depression, sadness, isolation, wt loss, sleep disturbances, ETOH, SA, fatigue, N&V, loss, sleep disturbances, ETOH, SA, fatigue, N&V, HA, faint, palpitationsHA, faint, palpitations

Variations of grief – anticipated or abbreviatedVariations of grief – anticipated or abbreviated Dysfunctional grief – pathological, unresolved, Dysfunctional grief – pathological, unresolved,

extended s/s of grief, stuck in a phaseextended s/s of grief, stuck in a phase

Kubler-Ross’s (1969) Stages Kubler-Ross’s (1969) Stages of Griefof Grief

Denial – shock, didn’t happen, Denial – shock, didn’t happen, numb, disbeliefnumb, disbelief

Anger – guilt, resentment, Anger – guilt, resentment, sadnesssadness

Bargaining – pining, searching, Bargaining – pining, searching, yearningyearning

Depression – grievingDepression – grieving Acceptance - resolution Acceptance - resolution

Engel’s (1964)Stages of GriefEngel’s (1964)Stages of Grief

Shock & disbeliefShock & disbelief Developing awareness – directed Developing awareness – directed

anger, loss becomes realanger, loss becomes real Restitution – dealing with it all, Restitution – dealing with it all,

looking more looking more Resolving the loss – memories, talk Resolving the loss – memories, talk

it outit out Idealization – ‘the best at…..’Idealization – ‘the best at…..’ Outcome – acceptance, moving onOutcome – acceptance, moving on

Sander’s (1998) Five Phases Sander’s (1998) Five Phases of Bereavementof Bereavement Shock – confused, unreal, Shock – confused, unreal,

disbeliefdisbelief Awareness of loss – conflict, Awareness of loss – conflict,

stress, seperation anxietystress, seperation anxiety Conservation/Withdrawal – Conservation/Withdrawal –

despair, hopeless, isolationdespair, hopeless, isolation Healing – identity, controlHealing – identity, control Renewal – acceptance, Renewal – acceptance,

revitalizationrevitalization

Influencing factors and Influencing factors and grievinggrieving Age – younger/children, acceptance as we age, Age – younger/children, acceptance as we age,

familiar, free from pain and poor quality of lifefamiliar, free from pain and poor quality of life Significance of loss – how close, spouse, parents, Significance of loss – how close, spouse, parents,

pets, kids, relativespets, kids, relatives Culture – major, beliefsCulture – major, beliefs Spiritual belief – influences outcome of death and Spiritual belief – influences outcome of death and

acceptanceacceptance Gender – woman disfigured with scar (idealization Gender – woman disfigured with scar (idealization

of beauty), stoicof beauty), stoic Socioeconomic – affordability of care and funeralsSocioeconomic – affordability of care and funerals Support system - acceptance, after-careSupport system - acceptance, after-care Cause of death/loss – traumatic injury, extended Cause of death/loss – traumatic injury, extended

illness, unexpected death, suicide, drug ODillness, unexpected death, suicide, drug OD

Death & DyingDeath & Dying

More accepted with ageMore accepted with age Develops over time Develops over time Children – temporary stateChildren – temporary state Adults – frighteningAdults – frightening Quality of life and lack of it can Quality of life and lack of it can

determine a persons determine a persons perspective on deathperspective on death

Concept of Death and Concept of Death and DevelopmentDevelopmentAgeAge Attitudes and BeliefsAttitudes and Beliefs

0 to 5 0 to 5 Reversible; Sleep; Temporary ‘trip’’; immobility & Reversible; Sleep; Temporary ‘trip’’; immobility & inactivity are part of death; separation forms basis for inactivity are part of death; separation forms basis for undstg laterundstg later

5 - 95 - 9 Death is final; own death avoidable; aggression & Death is final; own death avoidable; aggression & violence; wishes/unrelated actions may be responsibleviolence; wishes/unrelated actions may be responsible

9 - 129 - 12 Inevitable end of life; understanding mortality = interest Inevitable end of life; understanding mortality = interest in fear of death or interest in afterlifein fear of death or interest in afterlife

12 – 1812 – 18 Fear lingering death; doesn’t think much about; views in Fear lingering death; doesn’t think much about; views in religious/philosophic ways; emotionally difficult to religious/philosophic ways; emotionally difficult to accept; fantasize it can be defied (acting out in reckless accept; fantasize it can be defied (acting out in reckless behaviors)behaviors)

18 – 4518 – 45 Attitude is influences: religious and culture belief systemAttitude is influences: religious and culture belief system

45 – 6545 – 65 Accepting of own mortality; peaks of death anxiety; Accepting of own mortality; peaks of death anxiety; emotional well being = decrease of death anxiety; death emotional well being = decrease of death anxiety; death of parents and peers occurs of parents and peers occurs

65 +65 + Fear of prolonged illness, death of family and peers; Fear of prolonged illness, death of family and peers; multiple meanings = reunion, free from painmultiple meanings = reunion, free from pain

Definitions of DeathDefinitions of Death

With life support & medical With life support & medical interventions, in 1968 World interventions, in 1968 World Medical Assembly redefinedMedical Assembly redefined Clinical – absence of apical pulse, Clinical – absence of apical pulse,

respirations and BPrespirations and BP Lack of OR NO response to:Lack of OR NO response to:

Eternal stimuliEternal stimuli ReflexesReflexes Brain waves aeb flat encephalogramBrain waves aeb flat encephalogram Respirations or muscular movementRespirations or muscular movement

Dying Trajectories (Glaser & Dying Trajectories (Glaser & Strauss 1965)Strauss 1965) Death and dying are uniqueDeath and dying are unique Series of graphsSeries of graphs Has limitations to ‘predictions’Has limitations to ‘predictions’ Progression may be difficult to Progression may be difficult to

predictpredict If someone knows outcome, this If someone knows outcome, this

may affect trajectory (sense of may affect trajectory (sense of control over dying process and control over dying process and illness)illness)

Types of TrajectoriesTypes of Trajectories

Expected trajectory – short duration, Expected trajectory – short duration, steadily progressing downward steadily progressing downward (terminal cancer)(terminal cancer)

Unexpected trajectory- episodes of Unexpected trajectory- episodes of acute deterioration, recovery, decline acute deterioration, recovery, decline then unexpected deaththen unexpected death

Lingering/Prolonged – elderly Lingering/Prolonged – elderly escaping cancer and MOF then die escaping cancer and MOF then die later with dementia, Alzheimers, etc..later with dementia, Alzheimers, etc..

Physiologic Needs (pg 104)Physiologic Needs (pg 104)

Maintain airwayMaintain airway Pain freePain free Positioning/comfortPositioning/comfort Pastoral/spiritual carePastoral/spiritual care Mouth careMouth care ADL’s, brushing hairADL’s, brushing hair

Impending DeathImpending Death

Muscle tone – decreased, relaxed Muscle tone – decreased, relaxed face, swallowing, speakingface, swallowing, speaking

Circulation – slows down, mottling, Circulation – slows down, mottling, coldcold

Respirations – rapid, shallow, noisy, Respirations – rapid, shallow, noisy, dry, mouth breathing, slows and dry, mouth breathing, slows and irregularirregular

Sensory impairmentSensory impairment Vision- blurredVision- blurred Decreased smell/taste (or Decreased smell/taste (or

hypersensivity)hypersensivity)

Care Post-MortemCare Post-Mortem

When appropriate, after they are When appropriate, after they are gone and family aware and in gone and family aware and in agreementagreement

Clean, coveredClean, covered Remove tubes and linesRemove tubes and lines DignityDignity Teeth, eyes closedTeeth, eyes closed Rigor mortisRigor mortis

HospiceHospice

Cecily Saunders, MD founded Cecily Saunders, MD founded conceptconcept

Support and care of person & Support and care of person & familyfamily

Goal: peaceful and dignified Goal: peaceful and dignified deathdeath

Holistic and interdisciplinaryHolistic and interdisciplinary Qualified if MD certifies within Qualified if MD certifies within

the last 6 months of lifethe last 6 months of life

Where can hospice care Where can hospice care occur?occur?

HomeHome Facility Facility HospitalHospital ECFECF

Define Palliative CareDefine Palliative Care

Relief from symptoms of diseaseRelief from symptoms of disease Relief from painRelief from pain Support to patient and family, coping Support to patient and family, coping

mechanismsmechanisms Interdisciplinary teamInterdisciplinary team Death not imminentDeath not imminent Allow pt and family to live as Allow pt and family to live as

‘normally’ as possible‘normally’ as possible

The Nursing ProcessThe Nursing Process

Assessment/AnalysisAssessment/Analysis PlanningPlanning

RationaleRationale Factors influencing grief & dyingFactors influencing grief & dying

ImplementationImplementation EvaluationEvaluation