END-OF-LIFE CARE

by
Shahla Arshad
Lecturer
KMU-INS
 INTRODUCTION

Advances in technology

–Improved ability to care for the critically ill

–May be used appropriately when a patient has

a very poor prognosis
 DEATHS IN CRITICAL CARE

 Decisions made by surrogates

–Often not based on the medical prognosis
–Outcomes of decisions often not understood
–Highly stressful environment
 Nurse’s role to explain the choices to patients and
family
MEDICAL FUTILITY
Medical futility: Situation in which therapy or
interventions will not provide an expected
possibility of improvement in the patient’s
health condition.
END-OF-LIFE CARE
 Essential part of nursing practice, patient care.
 National Consensus Project for Quality Palliative
Care (2004)
 Physical aspects of care
 Psychological, psychiatric aspects of care
 Social aspects of care
 Spiritual, religious aspects of care
 Cultural aspects of care
 Ethical, legal aspects of care
 AWARENESS CONTEXTS
(GLASER & STRAUSS, 1965)
 Closed awareness:
The patient is unaware of his or her terminal
state, whereas others are aware.
 Suspected awareness:
The patient thinks what others know and
attempts to find out details about his or her
condition.
MUTUAL PRETENSE AWARENESS:
The patient, the family, and the health care
professionals are aware that the patient is
dying but all pretend otherwise.
OPEN AWARENESS:
The patient, the family, and the health care
professionals are aware that the patient is
dying and openly acknowledge that reality.
Palliative care:
Comprehensive care for patients whose
disease is not responsive to cure; care also
extends to patients’ families.
Palliative sedation:
Use of pharmacologic agents at the request of
the terminally ill patient to induce sedation
when symptoms have not responded to other
management measures.
PALLIATIVE CARE AND END-OF-LIFE SETTINGS

 Hospital setting

 Long-term care facility

HOSPICE CARE
Coordinated program of interdisciplinary care, services
provided primarily in home to terminally ill patients and
their families.
PRINCIPLES OF HOSPICE CARE
 Death must be accepted
 Patient’s total care best managed by interdisciplinary
team whose members communicate regularly
 Pain, other symptoms must be managed
 Patient, family should be viewed as single unit of care
 Home care of dying necessary
 Bereavement care must be provided to family members
 Four Levels of Hospice Care
1-Routine home care:
2-Inpatient interval care:
A 5-day inpatient stay, provided on an irregular basis
to relieve the family caregivers.
3-Continuous care:
Continuous nursing care provided in the home for
management of a medical crisis. Care reverts to the
routine home care level after the crisis is resolved .
4-General inpatient care:
Inpatient stay for symptom management that cannot
be provided in the home
Spiritual Care
 Spirituality includes religion
But is not synonyms with religion
 Maintaining hope
HOPE
 Listening attentively
 Encouraging sharing of feelings
 Providing accurate information
 Encouraging, supporting patient’s control over his or
her circumstances, choices, environment whenever
possible
 Assisting patients to explore ways for finding meaning
in their lives
 Encouraging realistic goals
 Facilitating effective communication within families
 Making referrals for psychosocial, spiritual counseling
DEATH AND DYING
by
Shahla Arshad
Lecturer
KMU-INS
 OBJECTIVES

At the end of session the learner will be able to:

 Define thanatology and death
 Explore Kobler Ross stages of coping with death
 Enlist common fears about death
 Enlist common body responses and changes
near death
 Describe Nursing care of terminally ill patient
 Define Bereavement
 THANATOLOGY

 Thanatology (study of death)

 The description of study

of the phenomena of death,
and of psychological mechanisms
for coping with death
 WHAT IS DEATH?

 Death is a universal experience, one that we

will all eventually face.
 Functional Death:
Is the absence of a heart beat and breathing.
 Brain Death:
Where brain activity is measured, has become
the medical measure of death (no possibility
of restoring brain function).
UNDERSTANDING THE PROCESS OF DYING

 Elisabeth Kubler-Ross identified five stages of

coping with death.
 KUBLER-ROSS’ 5 STAGES OF DEATH

Denial:
 Denial is resisting the whole idea of death
("No I'm not or she's not").
Anger:
 "Why me/her?" "Why not you?“
Bargaining:
 At this stage individuals are trying to negotiate
their way out of the death.
Depression:
 The individual at this stage is overwhelmed by
a deep sense of loss.
Acceptance:
 People are fully aware that death is impending
 In this stage individuals near death make peace
with death and may want to be left alone.
 Persons in this stage are often unemotional and
uncommunicative.
 FEARS ABOUT DEATH
PHYSICAL-
Dependence, loss of physical ability, injury, pain.
SOCIAL-
Separation from family, leaving behind unfinished
business.
EMOTIONAL-
Being unprepared for death and what happens
after death, Helplessness.
 INTERVENTIONS FOR FEARS

 Talk as needed

 Avoid superficial answers, i.e. “It’s God’s will

 Provide religious support as appropriate

 Stay with the patient as needed

 Work with families to strengthen and support

 BODY CHANGES INDICATING IMPENDING DEATH
Circulation
 Mottling of lower extremities
Pulmonary
 “Death rattle” a medical term that describes the sound
produced by some one who is near death when saliva
accumulates in the throat
Skin
 Clammy
 Dusky, gray coloration
Eyes
 Discolored
 Bruised appearance
 CHOOSING THE WAY ONE DIES -PEOPLE NOW HAVE
CHOICES

 DNR
 Living will
 Euthanasia
Euthanasia: Greek for “good death”; has evolved to mean the
intentional killing or the painless killing of a patient
suffering from an incurable and painful disease or in an
irreversible coma.
Assisted Suicide:
Assisted suicide is one form of euthanasia, the practice of
assisting terminally ill people to die more quickly.
 COMMON FEARS OF THE DYING PATIENT
 Fear of Loneliness

 Fear of Sorrow

 Fear of the unknown

 Loss of self concept and body integrity

 Fear of Loss of Self Control

 Fear of Suffering and Pain

 NURSING STRATEGIES

 Pain control

 Maintain independence

 Prevent isolation

 Spiritual comfort

 Support the family

 GRIEF AND BEREAVEMENT

After the death of a loved one, a painful period

of adjustment follows, involving bereavement
and grief
BEREAVEMENT
Is the acknowledgment of the objective fact that
one has experienced a death.
GRIEF
Is the emotional response to that loss
 REFERENCES:

• Smeltzer,S.C.C.,Bare,B.G.,Hinkle,J.L.andCheever,K.H
.eds.,2010.Brunner&Suddarth'stextbookofmedical-
surgicalnursing(Vol.1).Lippincott Williams & Wilkins
• Reference:Morton,P.G.,&Fontaine,D.K.
(2013).Essentialsofcriticalcarenursing:WoltersKluw
erHealth/Lippincott Williams & Wilkins.
• Sole,M.L.,Klein,D.G.,Moseley,M.J.,Brenner,Z.R.andP
owers,J.,2009.Introductiontocriticalcarenursing.5th
EditionSt.Louis,Mo.:Saunders,