mod 5 final hours adult.ppt - kumc mod 5 final... · module 5 final hours (adult) advanced practice...
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MODULE 5FINAL HOURS (ADULT)
Advanced Practice Registered Nurse
APRN Curriculum
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All APRNs Are Exposed to Death and Dying
Children and adults who: Die suddenly (e.g. accidents, heart attacks, etc.). Are diagnosed with six months or less to live (i.e. cancer, etc). Die from chronic illness (i.e. diabetes,
cardiac/renal/respiratory disease, sickle cell, dementia, congenital defects, etc).
Stillborn infants, infants who die shortly after birth from congenital defects, SIDS, etc.
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Role of the APRN
Expert clinician, leader and facilitator of interdisciplinary teams, educator, researcher, consultant, collaborator, advocate, case manager and administrator.• often the one to coordinate a dignified, comfortable death that
honors patient/family choices, no matter where the setting of death occurs (home, nursing home, hospice, and in‐patient settings).
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Interpersonal Competence
Empathy: Putting oneself in another’s place
Unconditional positive regard: Nonjudgmental acceptance
Genuineness: Trustworthiness, openness
Attention to detail: Critical thinking
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Interpersonal Competence (cont)
APRN must be comfortable
“Being with”
“Bearing witness”
Not always being able to “fix” the problem
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Care of the Dying Must Be Interdisciplinary‐Focused
Open and honest communication with the patient/family provides education and support at the end of life.
APRNs must work closely with staff nurses, physicians and all team members to provide care at this poignant time.
The APRN must incorporate a cultural and spiritual assessment of patient and family in the dying process.
Helming, 2009
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Planning Site of Death
When patients are aware that they are dying, they:
Usually know where they want to die.
With whom they want to die.
How they want to die.
Family may also have wishes/concerns/ideas about where the death can occur.
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Planning Site of Death (cont)
APRNs need to advocate for patient/family choices.Planning includes: SiteOut of hospital do‐not‐resuscitate orders
Appropriate equipmentMedication management
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Home is Most Desired Place for the Patient’s Death
Consideration needs to include: Patient’s condition Patient’s probable declining signs Family support for 24/7 care, available services in the
patient’s region, and the ability to pay for such services Education and support for families Care oversight from hospice or home care
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Specific Concerns for Patient and Family
What will dying look like?
How long will it take?
Will I/we be alone?
Will it be painful?
Will there be social support?
Will there be loss of continuity of care?
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Leaving a Legacy
Finding meaning and comfort in a dignified death.
A personal history for family through: Recorded stories Written letters or journal Pictures as well as hopes and dreams for loved
ones
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Resuscitation Status
Unrealistic beliefs about survival after resuscitation, due to favorable survival portrayed on TV. Heyland et al., 2006
Code status discussions do not replace quality of life discussions.
Code status discussions
Choose words wisely when discussing code status:
– “Do you want us to restart you heart if it stops?”
– “Do you want us to try and save you?”
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Resuscitation Status (cont.)
Access earlier discussions of code status and have them available in medical records.
Code status can be confusing. Differentiate labels such as DNR, DNI
Code Status Options:– FULL
– DNAR‐FI
– DNAR‐LI
– DNAR‐CMO
Document any discussion related to code status or goals of care.
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Organ Donation
Federal law (Public Law 99‐5‐9; Section 9318) and Medicare regulations mandate that hospitals give surviving family members the chance to authorize donation of their family member’s organs and tissues
Organs and tissues that can be donated include: Corneas, the middle ear, skin, heart valves, bone, veins, cartilage, tendons, and ligaments can be stored in tissue banks and used to restore sight, cover burns, repair hearts, replace veins, and mend damaged connective tissue and cartilage in recipients
Bowman, 2015; IOM, 2006
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Organ Donation (cont.)
APRNs must understand the rules and regulations of his or her state
Organ donation and procedures are different depending on the US state and site of death
Some religions and cultures do not allow organ donation as it is against the sanctity of the body
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Withdrawal of Technology
Ventilator withdrawal/Bipap/Hi Flow oxygen
Automatic Implantable Cardioverter Defibrillators (AICDs)
Pacemakers
Left Ventricular Assist Devices (LVADs)
Ionotropic therapy (Dobutamine, Milrinone)
Pressors and epoprostenal (Flolan)
Dialysis
Artificial hydration and nutrition
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Withdrawal of Technology (cont)
The ideal time to have conversations regarding withdrawal of technology is PRIOR to initiating the technology!
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Withdrawal of Technology (cont
Planning/coordination for withdrawal of technology: Patient/family meeting to discuss/describe process Informed consent Appropriate orders (code status, medications, etc) Pre‐event team meeting to plan Interdisciplinary collaboration Post death support Debriefing the event
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Withdrawal of Artificial Nutrition & Hydration
Benefits:
Decreased GI fluid to reduce N/V & GI fluids
Decreased swellingDecreased secretionsMay help deliriumAppropriate for many cultures/religions
Burdens:
Dry mouth Appearance of abandoning patient
Feeding considered basic care
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Withdrawal of Artificial Nutrition & Hydration (cont)
Continuing artificial nutrition and hydration:May cause more secretions and edema. Enteral feedings may cause aspiration and pneumonia.
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Time of Death
Determine an estimation of prognosis to allow closure for patient and family, and planning for staff. Lynch, 2012 Prognosis is affected by the disease, patient’s will to live, desire and/or
choice to wait for special event and/or completion of life closure goals.
No one can predict the exact time of death.
Some patients seem to instinctively know when death will occur.
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Signs and Symptoms of Dying
Signs and symptoms of the dying process only serve as a guideline and may not occur in sequence.
Common symptoms at time of death occurred in at least 30% of 200 actively dying patients with the following frequency: Noise and moist breathing (56%) Pain (51%) Restlessness and agitation (42%) Urinary incontinence (32%)
Harlos, 2010; Lunney et al., 2003
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Signs and Symptoms of Dying (cont)
Signs Emotional withdrawal Near death awareness Increased time asleep
Symptoms Decreased oral intake Weakness Decreased urine output – part of process, no need to treat Mental status changes (i.e. delirium, restlessness, agitation, confusion, and lethargy, etc)
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Support for Family at Time of Death
Death pronouncement is not a palliative care emergency.Will they know death has occurred? Usually
Who to call when the patient dies? Will be setting specific
Sensitive and direct conveyance of confirmation of death and information by APRN.
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Care of the Body During and After Death
The goal is to provide a more personal closure experience for the family, leaving the family with memories of the deceased as a “loved one” rather than as a “patient”.
Removal of tubes, medical supplies and equipment.
– Many of these can be removed prior to death, when the decision has been made to transition to comfort measures only.
Assess, honor, and advocate for cultural and spiritual rituals, traditions, and practices.
Always ask!
– Amazing what can be facilitated if you ask!
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Palliative Sedation
What is palliative sedation? Monitored use of sedative medications with the intention to induce varying degrees of unconsciousness, but NOT death, in order to relieve otherwise intractable suffering.
Minimum sedation to achieve symptom relief.
May be urgent or planned intervention.
Most commonly used for delirium, dyspnea, pain, vomiting. Quill, 2012
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Palliative Sedation (cont)
Directed at relief of refractory and unendurable symptoms in dying patients in two scenarios.
Scenario 1: Circumstances which cannot be adequately relieved or controlled, despite aggressive use of usually effective therapies.
Scenario 2: Distressing symptoms are unlikely to respond to further invasive or non‐invasive therapies in a timely way without excessive or intolerable side effects/complications.
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Palliative Sedation: Considerations
Death that is expected to occur within hours to days based on:
Person’s current condition and function
Progression of diseases
Symptom burden
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Palliative Sedation: Assessment
Patient must: Be imminently dying. Have refractory pain or symptom that the palliative careteam has attempted to treat with other measures that have been unsuccessful.
Care around palliative sedation must be interdisciplinary.Consults should include psychiatry, pain/anesthesia, and ethics to assure all other appropriate treatments have been attempted.
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Palliative Sedation: Informed Consent
Process The standard for palliative sedation is obtaining an informed consent, as it is a procedure. – This assures that family members understand the seriousness of the procedure, focusing on comfort.
The patient will no longer be conscious and will be unable to interact.
The adverse effect is death ‐‐ patient will be DNR. Most services require a written signature for consent; yet some palliative care services prefer verbal consent. – This must be clearly documented ‐‐ what was explained/discussed with the family.
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Palliative Sedation: When is it needed?
Aggressively increasing the existing opioid regimen may be sufficient for many patients, for others it may not be. Increasing opioids is not considered palliative sedation.
If not sufficient, consider palliative sedation.
Myoclonus or other symptoms may obviate the ability to titrate opioids, requiring palliative sedation.
Fine, 2001
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Palliative Sedation and Opioids
Opioids such as morphine are not used as the primary medicine in palliative sedation since they are not effective sedative medications compared to benzodiazepines and other sedative medications.
If a patient was already on an opioid for pain relief, this is continued for pain relief while sedation is achieved.
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Palliative Sedation: Specific Medications
Benzodiazepines (i.e. lorazepam, or midazolam) May be used, either as an intravenous or a subcutaneous infusion. Infusion beginning at 0.5 mg/hr, with bolus injections as needed
(Hanks‐Bell et al., 2002). Midazolam can also be given rectally or orally (Truog et al., 2001).
Barbiturates (i.e. phenobarbital and pentobarbital) Often used when benzodiazepines are ineffective or unavailable In the hospice setting, these may be used more frequently as they
can be administrated via suppository.
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Specific Medications (cont)
Anesthetics (propofol [Diprivan®]) Used during invasive procedures. Can be given as an intravenous infusion with boluses as needed. While it has excellent sedative and hypnotic properties, propofol
has no analgesic properties (Liu & Gropper, 2003). Therefore, DO NOT DISCONTINUE OPIOIDS.
Ketamine, an NMDA antagonist Most commonly used as a dissociative anesthetic during operative
procedures. Can be given as an intravenous infusion. (Fine, 2001).
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Request for Hastened Death
Statement made by patient.
Patient with progressive incurable illness.
Judgment is not impaired.
Requesting intervention to cause death more immediately than if illness took its natural course: Assisted suicide Clinician assisted Stop eating and drinking
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Patients Most Likely to Request Hastened Death
Very independent, strong personality.
Need to avoid dependency.
Determined.
Inflexible.
Need to control timing and manner of death.
Bowers, 2006
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Legal Aspects of Assisted Death
Assisted suicide officially opposed by AMA, ANA, ONS, HPNA, as well as other professional organizations.
Legal in California, Oregon, Washington, Montana, Vermont, and New Mexico.
Legal precedents about assisted death from the Supreme Court Vacco vs. Quill Washington vs. Glucksberg
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State laws regarding assisted suicide in the United StatesLegal Legal under court rulingLaw under review by state supreme courtLegislation currently under review Illegal
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Bereavement Programs
A part of hospice and palliative care.Assessment of risk of complicated grief is important.Post death cards and information.Support groups or counseling.Memorial services or rituals.Bereavement support – Provided by a hospice or palliative care service. Referral to a bereavement program or service. Collaborative effort.
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Conclusion
The APRN has a vital role in the final hours of a patient’s life in coordinating compassionate care. Promoting comfort. Alleviating suffering. Collaborating with interdisciplinary team members.
It is important to understand the signs and symptoms of death.Attending to cultural, religious, and spiritual rituals and practices are essential.
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Conclusion (cont)
In some instances, withdrawal of technology or life‐sustaining measures will occur and this will be the cause of death.When symptoms are unmanageable, palliative sedation may be necessary. The APRN must work collaboratively with colleagues in this situationThe APRN must understand requests for hastened death and how to respond. Bereavement programs for family members.Self‐care must be an ongoing consideration for the APRN.
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References
Bowers, L. (2006) Ethical Issues Along the Cancer Continuum. In Carroll‐Johnson, R.M., Gorman, L.M., Busch, N.J. (Eds.) Psychosocial Nursing Care along the Cancer Continuum, 2nd ed. (pp 551‐564). Pittsburgh, PA: Oncology Nursing Society.
Bowman, M. (2015). The emergency department. In B. R. Ferrell, N. Coyle , & J. Paice(Eds.), Oxford textbook of palliative nursing, 4th edition (Chapter 50). New York, NY: Oxford University Press.
Fine, P. (2001). Total sedation in end‐of‐life care: Clinical considerations. Journal of Hospice and Palliative Nursing, 3(3), 81‐87.
Hanks‐Bell, M., Paice, J., & Krammer, L. (2002). The use of midazolam hydrochloride continuous infusions in palliative care. Clinical Journal of Oncology Nursing, 6(6), 367‐369.
Harlos, M. (2010). The terminal phase. In G. Hanks, N. I. Cherny, N.A. Christakis, M. Fallon, S. Kaasa & R.K. Portenoy (Eds.), Oxford textbook of palliative medicine, 4th edition (pp.1549‐1559). Oxford, UK: Oxford University Press.
Helming M. Integrating spirituality into nurse practitioner practice: the importance of finding the time. J Nurse Pract. 2009;5(8):598‐605.
Heyland, D.K., Frank, C., Groll, D., Pichora, D., Dodek, P., Rocker, G., & Gafni, A. (2006). Understanding cardiopulmonary resuscitation decision making: Perspectives of seriously ill hospitalized patients and family members. Chest, 130(2), 419‐428.
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References (cont)
Institute of Medicine (IOM). (2006). Organ donation: Opportunities for action. Washington DC: National Academy of Science. Brief report retrieved December 1, 2015; from: http://www.iom.edu/~/media/Files/Report%20Files/2006/Organ‐Donation‐Opportunities‐for‐Action/OrganDonationforweb.ashx
Liu, L., & Gropper, M. (2003). Postoperative analgesia and sedation in the adult intensive care unit. Drugs, 63(8), 756‐767.
Lunney, J.R., Lynn, J., Foley, D.J. Lipson, S., & Guralnik, J.M. (2003). Patterns of functional decline at the end of life. Journal of the American Medical Association, 289(18), 1387‐2392.
Lynch M. (2012). Care of the Actively Dying Patient. In C Dahlin and M Lynch (Eds.) Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse. Pittsburgh, PA: Hospice and Palliative Nurses Association. 565‐580.
Quill T. (2012). Physicians Should “Assist in Suicide” When It is Appropriate. Journal of Law, Medicine, & Ethics. 57‐65.
Truog, R.D., Cist, A.F., Brackett, S.E., Burns, J.P., Curley, M.A., Danis, M., et al. (2001). Recommendations for end‐of‐life care in the intensive care unit: The Ethics Committee of The Society of Critical Care Medicine. Critical Care Medicine, 29(12), 2332‐2348.