Care Of The Dying

CARE OF THE DYING STANDARDS FOR HEALTHCARE IN PROVIDING END-OFLIFE CARE 1.Providing appropriate treatment for any primary and secondary symptom, according to the wishes of the patient and surrogate decision maker 2. Managing pain aggressively and effectively. 3. Sensitively addressing issues such as autopsy and organ donation 4. Respecting the patient’s values, religion, and philosophy.

 Support and education during the decision-making process, including the benefits and burdens of treatment PALLIATIVE CARE  GOAL: to prevent and relieve sufferings and to support the best possible quality of life for patients their families  both a philosophy of care and an organized highly structured system delivery of care  provided to older patients who have:

5. Involving the patient and the family in every aspect of care.

- acute, serious, life-threatening illness (stroke, trauma,MI,cancer)

6. Responding to the psychological, social, emotional, spiritual and cultural concerns of the patient and family.

- progressive chronic illness (end stage dementia,CHF, renal or liver failure)  may take place in the hospitals, in outpatient clinics, in long term care facilities or in home

CARE OF THE DYING: BENEFITS OF GOOD NURSING CARE SO PATIENT DIE WITH DIGNITY AND COMFORTABLY  Attention to pain and symptom control  Relief of psychological distress  Coordinated care across setting with high quality communication between health care providers

HOSPICE CARE  The support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible  Medicare hospice benefit was designed to support dying patients with less than 6months to live

 Preparation of the patient and family for death

 focuses on the whole person by caring for the body, mind and spirit

 Clarification and communication of goals of treatment and values

 hospice care nurse assesses the patients and family’s coping mechanisms, the available resources to care for

the patient, the patient’s wishes and the support system in place ALTERNATIVE CARE  traditional medicine may share spotlight with acupuncture, massage therapy, chiropractors and herbal medicines  National Institutes of Health initiated the National Center for Complementary and Alternative Medicine (NCCAM) – is dedicated to explore complementary and alternative medicine. COMMON FEARS AND CONCERN OF THE DYING  Death itself  Thought of a long and painful death  Facing death alone  Dying in the nursing home, hospital, or rest home  Loss of body control, such as bladder or bowel incontinence  Not being able to make decisions concerning care  Loss of consciousness

 The nurse will carry out a complete physical, psychological, social, and spiritual assessment and design a plan of care (in collaboration with the patient, family & interdisciplinary team) to meet the needs of the older patient. PAIN RELIEF AT THE END OF LIFE  providing the initial and ongoing assessment of levels of pain, administration of pain meds, and evaluation of the effectiveness of the pain mgt plan  PAIN the 5th vital sign – must be routinely carried out when other v/s such as the temp, pulse, RR, BP are assessed.  Pain hasten death and is associated with needless suffering at the end of life  the provision of culturally sensitive care is a necessary component of effective and comprehensive end-of-life care  pain is a subjective experience. Self report is the gold standard for measuring pain. If the patient can’t speak or cognitively impaired, nurse shld carefully observed for:

 Financial costs and becoming burden on others

 moaning, groaning at rest or with movement

 Dying before having a chance to put personal affairs in order

 failure to eat,drink

NURSE’S ROLE  Will assume the role of a clinician (expert clinician)

 grimacing or strained facial expression  guarding or not moving body parts  resisting care or noncooperation with therapeutic interventions

 rapid heartbeat, diaphoresis or change in V/S EFFECT OF PAIN DURING THE DYING PROCESS

Artificial tears or ophthalmic saline solutions to prevent drying of the eyes

 increasing physiological stress, potentially diminishing immunocompetency

 Anorexia and DHN- a benefit of DHN is decreased lung congestion, which prevents noisy or labored respirations

 decreasing mobility: worsening risk of pneumonia and thromboembolism

 Skin integrity should be monitored carefully to prevent complications.

 increasing the work of breathing and myocardial oxygen requirements  unrelieved pain at the end of life can cause psychological distress to the patient and family and associated with negative outcomes such as sufferings and spiritual distress PHARMACOLOGICAL APPROACH  Non-opioids - acetaminophen and NSAIDS. - Effective for mild to moderate pain.  Opioids –Codeine, MOSO4, methadone – block the receptor of the CNS  Adjuvant drugs – muscle relaxants, corticosteroids, anticonvulsant, antidepressants and topical meds – enhance the effectiveness of other classes of drugs NURSING CARE AT THE END OF LIFE  Personal hygiene (top priority) oral is crucial – oral swabs, soothing ointment or petroleum jelly  Eye care – provided to promote comfort.

Lotions, repositioning patient, avoid shearing forces, use of lift sheets  Bowel and bladder incontinence – protective pads to prevent decubitus ulcer - Avoid use of catheter because of UTI. - Constipation should be treated with stool softeners  Visual or auditory hallucinations – family members maybe upset  It is believed that the sense of hearing is intact in comatose patient. - Encourage family members to “let go” and give the terminal patient permission to die. - Appropriate affection should be encouraged and privacy provided.  read a poem, tell a joke, listen to past story sing a song, provide a hug. PREPARING FOR DEATH

 Watching the patient decline and the body itself starting to shutdown life process can bring helplessness and anxiety.  Nurse must help alleviate the fears and anxiety of the patient and family  Questions of an afterlife, unresolved emotional or social issues, acceptance of death and financial matters are common. Nurse must support themselves thru this difficult period and recognize and accept feelings  Older patients need reaasurance from their relatives that all is well and it is OK to let go POST MORTEM  When respirations cease, manually check breath sounds and heartsounds  check the eyes for pupillary light reflex  note the time of the occurrence of death and chart  notify the physician, family members and express condolences  notification comes a shock and needs to be handled gently and with empathy, allow relative sufficient time to spend with the deceased  actual post mortem care 

needs to be done promptly, quietly, efficiently and with dignity.

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If possible before death occurs the limbs should be straightened and the head placed on a pillow.

 If autopsy is to be done, the body should be left undisturbed  Do not secure or tie any body parts as this cause indentations, body tags.  Place a clean gown, insert dentures.  Prepare the necessary papers, charting  Call morgue, funeral home or other personnel for the removal of the body from the facility.