Care of Patients and their Family

Near the End of Life

Peggy Mossholder, RN, MSN, CHPN

The loss of a loved one is one of the most intensely painful experiences any human being
can suffer. - John Bowlby –

END OF LIFE CARE

Anyone, anywhere, anytime
Definition: issues related to death and dying as well as services provided to address
these issues.
End of life: the period of time during which an individual copes with declining health
from a terminal illness or from the frailties associated with advance age even if death
is not clearly imminent.
Focus: physical and psychosocial needs at the end of life for the patient and their family.
Goals:
Provide comfort and supportive care during the dying process
Improve the quality of the remaining life
Help ensure a dignified death

Death
The irreversible cessation of circulatory and respiratory function or the irreversible
cessation of all functions of the entire brain, including the brainstem.
Metabolism reduces, body slows down until functions end
Respirations cease first
Heart beat cessation next
Brain Death
Clinical diagnosis in which brain functions are irreversibly absent, heart may continue
to beat, usually with ventilator support.

Signs & Symptoms of Approaching Death

The dying process is variable depending on individual and family characteristics
There are predictable physical, physiologic, and emotional changes
During this important phase, the nurse serves as a consultant, collaborator, coach,
or guide to assist the patient to achieve symptom relief
Knowing what to expect is vital

Causes of Death
The three leading causes of death in adult Americans:

Signs & Symptoms of Imminent Death Physical, Physiological & Emotional

Anticipating the changes and symptoms and preparing the patient and family to expect
and deal with them decrease the uncertainty that often plagues this time of life

Signs of Death After Death Care: Various Cultural & Religious Groups
Cultural and religious beliefs and practices are important to nursing care at the end-of-life
 and immediately after death
The following tables offer a common rituals and customs for the following cultural and
religious groups:
American Indians, African Americans, Mexican Americans, Catholics,
Buddhists and Jews

Grief
Bereavement: an individual’s emotional response to the loss of a significant person.
Grief: a dynamic psychological and physiological response following the loss.
Manifestations:
Feelings
Behaviors
Thoughts
Physical manifestations
Goals for the grief process
Resolving emotions
Reflecting on the dying person
Expressing feelings of loss and sadness
Valuing what has been shared
Pathologic grief
Chronic grief
Intensity does not wane in first year
Conflicted grief
Bereaved person has not resolved ambivalent feelings toward the deceased
Absent grief
Bereaved person appears to be coping, carrying on as if nothing has happened
Maladaptive or dysfunctional grief
Prolonged, disruptive, or unresolved
Adaptive grief
Helpful or grief that assists the person in accepting the reality of death
Healthy response

Variables Affecting EOL Care

Attitudes
Beliefs
Cultural, religious, and family influences
Spiritual needs

Legal and Ethical Issues

Outcomes related to care based on patient’s wishes
Organ and tissue donations
Advance directives
Medical power of attorney or living wills
Resuscitation

Common Legal Documents

Advance directives
Written statements of medical care wishes
Directive to physicians
Patient’s desire to accept or deny treatment
Do not resuscitate (DNR)
Order instructing health care providers not to attempt CPR
Often requested by family
Must be signed by a physician to be valid
Durable power of attorney for health care
Lists the person(s) to make health care decisions should a patient become unable to
make informed decisions for self
Living will
Instructions in lay terms about
Future medical care and treatments
Death without heroic or extraordinary measures
Enacted when patient is unable to communicate

Medical power of attorney

Lists person(s) to make health care decisions should a patient become unable to make
informed decisions

Ethical Issues
Principle of beneficence
Adequate pain relief is important for all patients
In particular for patients who are terminally ill
Principle of nonmaleficence
Preventing or reducing harm to patient
Providing adequate pain control to alleviate suffering in the terminally ill
Secondary effect of hastening death is ethically justified
Euthanasia
Deliberate act of hastening death
Not morally acceptable
Adequate pain relief is a major concern of health care professionals and consumers

Hospice
Approximately 3300 hospice programs in the United States
Organized under a variety of models
Hospital-based, part of existing home health care agencies, free-standing, or
community-based
Emphasize palliative rather than curative care

What is Hospice Care?

Hospice focuses on caring, not curing.
Team-oriented approach to expert medical care, pain management, and emotional and
spiritual support tailored to the patient’s needs and wishes.
Who is appropriate for Hospice Care
Anyone seeking comfort care with approximately 6 months or less to live
Examples of illnesses cared for by Hospice Savannah:

The Benefits of Hospice

Team Approach to Care Giving
Patient Goals
Symptom Control and Comfort Measures
Pain Management
Palliative Care
Medications Covered
Medical Equipment and Disposable Products Supplied
Nursing Services
Bereavement Care—Social Work and Counseling Services
Hospice House—Inpatient Care Center

The Team Approach to Care Giving

Patient & Family
Patient’s own Physician
Hospice Savannah’s Medical Director
Registered Nurses
Social Workers
Certified Nursing Assistants
Chaplains
NH Staff
Bereavement Counselors
Dietician
Volunteers
Music Therapist
Harp Therapist
Art Therapist
Story Keeper
Pet Therapist
Massage Therapist

What is Palliative Care?

Palliative Care is interdisciplinary, comprehensive care and management of the physical,
emotional and spiritual needs of patients and families who have chronic, debilitating or
life threatening illness

The Goal of Palliative Care

Palliative care aims to relieve suffering and improve quality of life.

Palliative Care
The Palliative Care is a Consultative Service offered to the community through Hospice
 Savannah and offered at Memorial Medical University as a partnership.

Types of Patients Served

Patients with exacerbation of chronic illness who choose palliative life-extending
treatment
Patients receiving disease-directed treatment who may benefit from palliation of
symptoms arising from disease or treatment
Patients with serious, life-threatening illnesses for whom hospitalization may segue into
Hospice
Potential Benefits of Palliative Care Service
Provides options for reducing the amount of suffering patients may experience
Offers resources to help with difficult conversations
Delivers quality patient care
Can result in significant cost avoidance through reduced LOS and variable costs
Provides effective and affordable management of advanced illness in acute care settings
Makes more appropriate use of hospital resources
Contributes to patient, family and staff satisfaction
Helps meet JCAHO pain management standards

“What we leave behind is not what is engraved in stone monuments, but

what is woven into the lives of others.”
Pericles, 5th century Greek