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NSG 430 Palliative Care[ 24]

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Adult Health Nursing II (NSG-430)

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Grand Canyon University

Academic year: 2023/2024

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NSG 430 Palliative Care Topic 1

Palliative Care o Care or treatment focusing on reducing the severity of symptoms  Begins during curative or restorative health care  Extends into end-of-life care  Bereavement care follows death  care at the same time.  Palliative care extends into the period of end-of-life care.  Bereavement care follows the patient’s death. o Need for this care is increasing  Demographic changes  Longer life expectancies  Improved health care technology  Increased health care utilization  Older adults living with multiple chronic illnesses  The older population is growing, in part to the aging Baby Boomer generation. o Indication for Palliative:  diagnosis of a life-limiting illness o Involves:  Interprofessional collaboration  Ongoing communication  Care in multiple settings o Patients just diagnosed with illnesses such as cancer, heart failure, COPD, dementia, or ESRD can benefit from implementation of palliative care. o The interprofessional palliative care team includes physicians, nurses, social workers, pharmacists, chaplains, and others. o Communication is important for optimal care. o Patients may receive palliative care services in the home, long-term and acute care and mental health facilities, rehabilitation centers, and prisons. o Many institutions have established interprofessional palliative and hospice care teams.
Palliative Care vs Hospice Care o Palliative care: curative and palliative treatment simultaneously  Palliative care often includes hospice care before or at the end of life.  Palliative care is different in that it allows a person to simultaneously receive curative and palliative treatments whereas hospice care is initiated only after the decision is made by the patient or a proxy not to pursue a cure. o Hospice care:  curative care is forgone  Requires physician certification that life expectancy is 6 months or less
Death o Occurs when all vital organs and body systems cease to function o Irreversible cessation of cardiovascular, respiratory, and brain function
Brain Death o Irreversible loss of all brain functions including the brainstem o Cerebral cortex stops functioning or is destroyed o Exact definition of death can be controversial  Technological developments in life support have led to questions about when death actually occurs:  When the whole brain (cortex and brainstem) ceases activity  Or when function of the cortex alone stops.  The American Academy of Neurology developed the diagnostic criteria that must be validated by a physician:  Coma or unresponsiveness  Absence of brainstem reflexes  Apnea  Currently legal and medical standards require that all brain function must cease for brain death to be pronounced and life support to be disconnected.  In some states and under specific circumstances, registered nurses are legally permitted to pronounce death.  Diagnosis of brain death is of particular importance when organ donation is an option.
End of Life

o Final phase of a patient’s illness, when death is imminent  Diagnosis of a terminal illness to actual death varies depending on diagnosis and extent of disease o IOM defines end of life as the period of time during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age even if death is not clearly imminent. o Uncertainty about how close at hand the end is adds to the challenge of answering patient and family questions including “how much time is left?” o Goals  Provide comfort and supportive care during dying process  Improve quality of remaining life  Help ensure a dignified death  Provide emotional support to family o End-of-life care (EOL care) is the term used for issues and services related to death and dying. EOL care focuses on physical and psychosocial needs for the patient and family.  Nurses spend more time with patients near the end of life than do any other health care professionals.

Physical Manifestations at End of Life o Metabolism is decreased  As death approaches, metabolism is reduced and the body gradually slows down until all functions end. o When respirations cease, the heart stops beating within a few minutes. o Respiratory changes are common at the end of life.  Respirations may be rapid or slow, shallow, and irregular.  Breath sounds may become wet and noisy, both audibly and on auscultation. Noisy, wet-sounding respirations, termed the death rattle or terminal secretions, are caused by mouth breathing and accumulation of mucus in the airways.  Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. o Body function slows down until all function ends o Respiration generally ceases first  Heart stops beating within a few minutes o Respiratory System  Irregular breathing that gradually slows  Cheyne-Stokes respiration  Inability to cough or clear secretions  Grunting, gurgling, or noisy congested breathing (“death rattle”)
Physical Manifestations at EOL Sensory System o Hearing, Touch  Hearing is usually last sense to disappear  Decreased sensation  Decreased perception of pain and touch  The sense of touch is decreased first in the lower extremities because of circulatory alterations.  o Taste, Smell, and Sight  Blurring of vision  Blink reflex absent  Patient appears to stare  Eyelids remain half-open  Decreased sense of taste and smell
Physical Manifestations at EOL o Integumentary System  Mottling on hands, feet, arms, and legs  Mottling looks faintly like purple and white leopard skin.  Cold, clammy skin  The skin cools first on lower, then upper extremities and finally the torso unless a fever is present.  Cyanosis of nose, nail beds, knees  “Waxlike” skin when very near death o Urinary System  Gradual decrease in urinary output  Incontinent of urine  Unable to urinate o Gastrointestinal System  Slowing of digestive tract  Accumulation of gas

 Feelings are often repressed or internalized.  Beliefs include “toughing it out” and “being strong.” o Some groups (African Americans and Hispanic/Latinos) easily express feelings and emotions.  Kinships are very strong in Hispanic cultures.  Both immediate and extended family provide support.  Expression of feelings is encouraged and accepted.  Rituals associated with dying are part of all cultures. o In certain cultures the family may want to keep constant vigil in the room of a dying patient or in the waiting area. For example, some Jewish Americans believe that the spirit should not be alone when it leaves the body at the time of death. Therefore someone who is terminally ill should never be left alone. The Jewish culture believes all body tissues must be buried with the individual.  Once a death has occurred, some cultures, such as the Puerto Rican American culture, may want to kiss and touch the body to say goodbye. o In the Islamic cultures the traditional rites of washing, shrouding, funeral prayers, and burial are done as soon as possible.  Families with non–English-speaking members are at risk for receiving less information about their family member’s critical illness and prognosis.  Cultural variations also exist in symptom expression (e., pain expression) and use of health care services.  Providing culturally competent care requires assessment of nonverbal cues such as grimaces, body position, and decreased or guarded movements.

Legal and Ethical Issues o Patients and families struggle with many decisions during the terminal illness and dying experience o Decisional capacity refers to the ability to consent or refuse care  Organ and tissue donations  Advance directives  Resuscitation  Mechanical ventilation  Tube feeding placement  Decisional capacity refers to the ability to consent or refuse care. It means that the individual has an understanding and appreciation of the information that is shared and has the capacity to engage in the reasoning process.
Organ and Tissue Donation o Any body part or the entire body may be donated  Decided by a person before death  With family permission after death  Follow specific legal guidelines for organ or tissue donation.  Some tissues must be used within hours after death so require immediate physician notification. o Provide information so that care outcomes are based on wishes and values. o Organ donation  Can be made by legally competent persons  Can be made by immediate family following death  Can be specified on donor cards or, in some states, on drivers’ licenses  Handled by various agencies that differ by state and community (organ bank, organ-sharing network, organ-sharing alliance)  Follow specific legal guidelines for organ or tissue donation.  Some tissues must be used within hours after death so require immediate physician notification.
Resuscitation o A common health care practice  Patients and families have the right to decide whether CPR will be used  Physician’s orders should specify  Full Code  Chemical Code  No Code - DNR or AND o CPR is given for respiratory or cardiac arrest unless otherwise ordered by a physician.  However, whether and to what extent CPR is used is no longer the sole decision of the physician. o The ANA supports patient’s right to self-determination, and a primary role of nurses is supporting patient and family decisions.  Full code refers to use of complete and total heroic measures including CPR, drugs, and mechanical ventilation.  Chemical code involves use of drugs without CPR.  DNR indicates comfort measures only without interference of technology.

 Some states have out-of-hospital DNR for patients being cared for out of acute care facilities.  Term being used to replace DNR is AND – Allow Natural Death: o More accurately conveys what actually happens. o Also referred to as “comfort measures only” status. o Comfort measures include pain control and symptom management. o Natural progression to death is not delayed or interrupted. o Care is not withheld. Care is supportive, providing comfort and dignity, while allowing nature to take its course.

Role of the Nurse o Relieve suffering  The use of opioids for symptom management at the end of life is often misunderstood and feared by patients, families, and HCPs. For this reason, many patients will refuse to take the medications, which leads to physical and emotional suffering due to uncontrolled pain and symptoms.  Your moral obligation to relieve suffering, which includes giving medications that have the potential of producing harm, such as with opioids. o Clarify misunderstanding about the use of pain medications  Addiction is not a concern when providing comfort for the terminally ill patient o The principle of double effect  morally permissible to give a medication that has the potential for harm if it is given with the intent of relieving pain and suffering and not intended to hasten death o The principle of double effect refers to a principle that regards it morally permissible to give a medication that has the potential for harm if it is given with the intent of relieving pain and suffering and not intended to hasten death. o As a nurse, your role is to teach the patient and family regarding addiction, tolerance, and dependence to medications. The person with terminal illness should not be concerned with addiction when the goal of treatment is comfort.
End of Life Nursing Management o Nurses spend more time with patients near the end of life than any other health care professionals o Respect, dignity, and comfort are important for patient and family o Nurses need to recognize their own needs when dealing with grief and dying  What guides our care?  Code of Ethics for Nurses--relieve suffering  principle of beneficence--means that care is provided to benefit  standard of care-- used to define the nursing acts that are required for safe and competent nursing practice o If patient is alert  Brief review of body systems to detect signs and symptoms  Assess for discomfort, pain, nausea, or dyspnea  Follow specific legal guidelines for organ or tissue donation.  Some tissues must be used within hours after death so require immediate physician notification.  Assess coping abilities of patient and family o Promptly address discomfort. o Use evidence-based tools for symptom assessment including numeric scales or visual analog scales for pain rating. o Evaluate and manage co-morbid health care problems. o Gather information about abilities, intake, rest, and general response to the terminal illness and its prognosis. o Determine family’s ability to manage and cope with the needed care and consequences of the illness.
Nursing Management Assessment o Stability determines frequency of assessment o At least every 8 hours in the inpatient setting o More frequently as changes occur o Document o Monitor for system failure as death approaches o Attention to subtle physical changes requires vigilance o Neuro, Circulation (CV), Respiratory. I&O, Integumentary o What type of changes/symptoms are seen?  Physical assessments are abbreviated and focused on changes that accompany terminal illness.  Assessment may occur weekly for patients cared for in their homes by hospice programs.  In the final hours of life, physical assessment may be limited to essential data.  Key elements of social assessment include:  family relationships  communication patterns  differences in expectations

o Surviving family members may be angry with dying loved one who is leaving them. o You may sometimes be the target of anger and must understand what is happening and not react on a personal level. o Encourage expression of feelings, at the same time realizing how difficult it is to come to terms with loss. o you may remember reading about the five stages of death and dying, these are chronologically: denial, anger, bargaining, depression and acceptance. The model was first introduced by Swiss-American psychiatrist Elisabeth Kübler-Ross in her 1969 book On Death and Dying, and was inspired by her work with terminally ill patients.

Psychosocial Care Hopelessness, Powerlessness, and Fear o Encourage realistic hope within the limits of the situation  Feelings of hopelessness and powerlessness are common during the EOL period.  Allow patient and family to deal with what is within their control and help them to recognize what is beyond their control. o Decision making about care can foster a sense of control and autonomy o Four specific fears  Pain  Shortness of breath  Loneliness and abandonment  Meaninglessness o Management  Relaxation and coping strategies
Psychosocial Care Fear of Pain o Physiologically  No indication that death is always painful o Psychologically  Pain may occur based on anxieties or separations related to dying o Many people assume that pain always accompanies death. o Terminally ill patients who do experience physical pain should have pain-relieving drugs available. o Assure the patient and family that drugs will be given promptly when needed and that side effects of drugs can and will be managed. o Re-assessment of pain after medications are given is an important nursing action. o Patients can participate in their own pain relief by discussing pain relief measures and their effects. o Most patients want their pain relieved without the side effects of grogginess or sleepiness. Pain relief measures do not need to deprive the patient of the ability to interact with others.
Psychosocial Care Fear of Dyspnea o Sensation of air hunger results in anxiety for patient and family o Therapies depend on the cause and may include  Opioids  Bronchodilators  Oxygen o Respiratory distress and dyspnea are common near the EOL. o Anxiety-reducing agents (e., anxiolytics) may help produce relaxation.
Psychosocial Care Fear of Loneliness and Abandonment o Do not want to be alone o Fear abandonment o Presence of people provides comfort, support, and a sense of security o Life review  Intentions during life  Actions  Regrets about what might have been o Most terminally ill and dying people fear loneliness and do not want to be alone. o Many dying patients are afraid that loved ones who are unable to cope with the patient’s imminent death will abandon them. o Holding hands, touching, and listening are important nursing interventions.
Psychosocial Care Communication o Communication is essential o Use empathy and active listening  Allow patients and families time to express their feelings and thoughts  Accept silence o Prepare family for unusual patient communication o Empathy is identification with and understanding of another’s situation, feelings, and/or motives. o Active listening is paying attention to what is said, observing nonverbal cues, and not interrupting.

o Silence may be related to overwhelming feelings experienced at the end of life. It can allow time to gather thoughts. Listening conveys acceptance and comfort. Consider ethnic, cultural, and religious backgrounds. o Patients and families may have difficulties expressing themselves emotionally. o Make time to listen and interact in a sensitive way to enhance the relationship among you, patient, and family. o A family conference can create a more conducive environment for communication. o Prepare family members for changes in emotional and cognitive function that occur at end of life. o Unusual communication may take place. Patients may:  speak to or about family or others who have predeceased them  give instructions to those who will survive them  speak of projects yet to be completed. o Listening carefully:  helps identify specific communication patterns  decreases risk for inappropriate labeling of behaviors.

Physical Care o Symptom management and comfort o Physiologic and safety needs o Dying patients deserve and require the same care as people who are expected to recover o Table 9-  Pain, delirium, anxiety, dysphagia, fatigue, dehydration, dyspnea, myoclonus, skin breakdown, bowel changes, urinary incontinence, N/V, candida  What care would you provide for each system? o Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. o Skin integrity is difficult to maintain at the end of life because of immobility, urinary and bowel incontinence, dry skin, nutritional deficits, anemia, friction, and shearing forces. o If possible, it is important to discuss with the patient and family the goals of care before treatment begins. An advanced directive should be completed so that the patient and family wishes are followed.
Postmortem Care o After death is pronounced, the nurse prepares or delegates preparation of the body for immediate viewing by the family  Close patient’s eyes  Replace dentures  Wash and position body o Consideration must be given for: o Cultural customs o State law o Agency policy and procedure. o May be important to allow family to prepare or assist in preparing body in some cultures and some types of death o Remove tubes and dressings if appropriate. o Straighten the body, leaving the pillow to support the head and prevent pooling of blood and discoloration of the face.
Postmortem Care Needs of Family Caregivers o Allow family privacy and as much time as they need with deceased person o Maintain respect for patient and family o Role of family caregivers includes  Working and communicating with the patient, other family members, and friends  Supporting patient concerns  Helping patient resolve any unfinished business o In the case of an unexpected or unanticipated death, preparation of the patient’s body for viewing or release to a funeral home depends on state law and agency policies and procedures. o Never refer to the deceased person as “the body.” o Care of and discussion related to the person should continue to be respectful even after death. o Family caregivers:  are important in meeting patient’s physical and psychosocial needs.  often face high levels of stress and emotional, physical, and economic consequences from caring for a dying member.  responsibilities do not end when the person is admitted to an inpatient facility.
Needs of Family Caregivers Importance of Support o Encourage  Usual activities  Some control over their lives

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NSG 430 Palliative Care[ 24]

Course: Adult Health Nursing II (NSG-430)

114 Documents

Students shared 114 documents in this course

University: Grand Canyon University

Was this document helpful?

NSG 430 Palliative Care

Topic 1

-Palliative Care

oCare or treatment focusing on reducing the severity of symptoms

Begins during curative or restorative health care

Extends into end-of-life care

Bereavement care follows death

care at the same time.

Palliative care extends into the period of end-of-life care.

Bereavement care follows the patient’s death.

oNeed for this care is increasing

Demographic changes

Longer life expectancies

Improved health care technology

Increased health care utilization

Older adults living with multiple chronic illnesses

The older population is growing, in part to the aging Baby Boomer generation.

oIndication for Palliative:

diagnosis of a life-limiting illness

oInvolves:

Interprofessional collaboration

Ongoing communication

Care in multiple settings

oPatients just diagnosed with illnesses such as cancer, heart failure, COPD, dementia, or ESRD can benefit from

implementation of palliative care.

oThe interprofessional palliative care team includes physicians, nurses, social workers, pharmacists, chaplains, and

others.

oCommunication is important for optimal care.

oPatients may receive palliative care services in the home, long-term and acute care and mental health facilities,

rehabilitation centers, and prisons.

oMany institutions have established interprofessional palliative and hospice care teams.

-Palliative Care vs Hospice Care

oPalliative care: curative and palliative treatment simultaneously

Palliative care often includes hospice care before or at the end of life.

Palliative care is different in that it allows a person to simultaneously receive curative and palliative

treatments whereas hospice care is initiated only after the decision is made by the patient or a proxy not to

pursue a cure.

oHospice care:

curative care is forgone

Requires physician certification that life expectancy is 6 months or less

-Death

oOccurs when all vital organs and body systems cease to function

oIrreversible cessation of cardiovascular, respiratory, and brain function

-Brain Death

oIrreversible loss of all brain functions including the brainstem

oCerebral cortex stops functioning or is destroyed

oExact definition of death can be controversial

Technological developments in life support have led to questions about when death actually occurs:

When the whole brain (cortex and brainstem) ceases activity

Or when function of the cortex alone stops.

The American Academy of Neurology developed the diagnostic criteria that must be validated by a

physician:

Coma or unresponsiveness

Absence of brainstem reflexes

Apnea

Currently legal and medical standards require that all brain function must cease for brain death to

be pronounced and life support to be disconnected.

In some states and under specific circumstances, registered nurses are legally permitted to

pronounce death.

Diagnosis of brain death is of particular importance when organ donation is an option.

-End of Life

NSG 430 Palliative Care[ 24]

Adult Health Nursing II (NSG-430)

Grand Canyon University

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NSG 430 Palliative Care[ 24]

Course: Adult Health Nursing II (NSG-430)

University: Grand Canyon University

Recommended for you

Students also viewed

Related documents