hi class my name is Professor Paula and we are going to talk about end of life today learning objectives for today uh we will explain the path of physiology for the dying process compare the difference between hospice and posative Care discuss strategies to meet the cultural and spiritual needs of the dying client examine the illegal ethical considerations for the nurse regarding end of Life Care explain the differences in code status discuss evidence-based standards for end of life withdrawal of care and describe the role of the nurse and the end of Life Care death manifested by sensation of breath and pulse and two types of death brain biological death or clinical death brain of biological death occures when heart and lung function has stopped permanently but clinical deaths is when the heart and lungs have cease functioning but may be reversed through through cardiopulmonary resuscitation and stages of death early stage as loss of Mobility as well as a decrease in ability of or desire to eat or drink increase in sleeping and cognitive changes middle stage consist of contined decline in the client's mental status with only brief periods of wakefulness pulling of secretions and noisy respirations may be noted and are sometimes called a death rle late stage May cons of the client having dispnea with periods of apnea modling of the skin and fever clients proceed through the stages at different rates let's talk a little bit about pallative care the goal of this type of care is to improve the client's Quality of Life by controlling significant symptoms of the disease process while continuing to receive Curative medical care posative care also assist clients to understand their treatment choices the team may include providers nurses social worker dieticians chaplain and other and it's based on the needs of the client and the level of care required disar and pain are the two most common symptoms clients have that need paliative care controlling these symptoms and others are examples of how posative care improv the quality of life for these clients okay for example we have a patient who has colon cancer this colon cancer is grow and and Abstract the colon we have obstruction also this colon this cancer has mats maybe to the liver maybe to to the lungs we are trying to cure the cancer but at that moment we know even we will remove this um tumor we will not be able to remove all the mats already but if we will leave this tumor right now we the patient with obstruction will die of rapture of the colon and peritonitis that's why patient will have a paliative surgery this paliative surgery will probably remove the tumor and maybe Place colostomy as a positive care for this patient we will continue probably giving patient Kema we will try to treat um patient disease but at that moment we are treating symptoms to make this patient life more comfortable hospice hospice is utilized when the client cannot be cured or chooses not to be treated this type of care provides comfort care for the client and their families and it's usually started when the client is anticipated to have six or less months to leave but can be extended longer as needed um also we're going to talk about desite care a little bit respite care allows clients the options to be admitted to the facility to give their caregivers a break in care lasting from hours to weeks because we always think that patient will uh it's a better care if the patient is staying at home and their own home and their own own environment with their loved ones but a patient needs a lot of care and despite care pro uh giving option for the caregivers to actually go to vacation and take a break by sending the loved one to the facility for for a little bit instead of sending to the facility for um for the rest of the life Comfort Care interventions include managing shortness of breath administ medications for pain nausea anxiety or constipation limiting medical test in and ensuring spiritual and emotional counseling an indication for posative Sedation include terminal illness where death is nearly certain and treatments are ineffective to relieve the distressing syndrome or unlikely uh in a timely fashion the medications typically used to Rel client respiratory distress anxiety agitation are ipat B diant or anti psychotics cultural affiliations can affect how clients of you illness which includes the end of life nurses should complete a cultural assessment to assist in planning and of the Life Care by by embracing the client's culture the quality of life of the terminal client and family significantly increases nurses should respect and allow clients to observe cultural rituals to improve their well-being nurses should plan to include spiritual and emotional factors in a plan of care as well as therapeutic communication that is prompt and effective with clients and families this Factor will add to improved quality of life during end of Life Care nurses should respect and allow clients to observe cultural rituals to improve their well-being many facilities have chaplain religious figures available for Spiritual care to dying clients and their families and meet spiritual religion needs facilities frequently have religious leaders on staff for the more prominent religious of the area for clients with less common Faith nurses and the healthcare team must work with the client and family to allow assess to to uh religious leaders of their faith to decrease disparities in care this excess can lead to better clinical outcomes and an increase in satis satisfaction of end of Life Care nurses should assess the spiritual needs of the client using open-end questions to encourage the client to open up more about specific needs encourages client to express their feelings nurses should assess clients routinely for signs of spiritual distress one spiritual assessment uses the new morning hope and we're going to talk about it on the next slide okay that's the questions you're asking hope what gives you a sense of hope peace or strength organized do you have a religion you belong to is your religion important to you personal spirituality and practices what are your personal spiritual Bel beliefs what spiritual practices are most helpful for you effects on medical care and end of life issues has your illness interfered to be the ability to do things that give you life meaning and a sense of purpose what spiritual practices would we know about when we care for you end of Life Care has significant legal and ethical considerations that nurses should be aware of when providing care the g g the goal of uh end of the Life Care is to decrease client's suffering and respect the client's wishes Justice declares that all clients are to be treated equitably and fairly this requires um valuing the rights of individual clients as well as treating all clients in particular particular situation the same regardless of who the client is Health Care policies and laws utilize the ethical principle to ensure each person has access to health care Justice Fair distribution of available Health Resources this principle NE necessitates uh impartially during the delivery of these Health Services nurses are ethically obligated to advocate for inappropriate and fair treatment of endof Life clients non nonmaleficence is based on the concept do not harm nurses must understand that some interventions may cause pain or harm but non-maleficence uh refers to the just uh justification of why it is caused it can be justified if the benefit of the intervention intervention is greater than the pain of harm that may occur Ben uh beneficience involves nurses advocating for the best course of action for the end of life client at times the client may not have expressed end of life wishes through the advanced directives and the client's family may not know the client's wishes in the event the client is unable to make their requests uh known the client's provider will consult with the client's family or the client healthc care proxy if one has has been named and Fidelity requires the interprofessional team including providers and nurses to provide all information about the client's disease process when appropriate this includes detailed information to clients and the client decision makers about treatment options available during end of life care to include risk benefits and limitations next a couple slides we're going to talk about about legal considerations what is terminal sedation what is the physician assisted suicide Advanced directives living will durable power of attorney for Health Care terminal sedation is used for clients at the end of the life to to leave suffering when death is uh inevitable the purpose of terminal sedation is not to quaken or cause death but to Relief pain that is not responding to other interventions nursing interventions should never be performed with the intent to harm a client there are certain requirements that must be met for terminal sedation to be implemented provider assisted suicide client request a physician prescribe a medication for a terminal client to ingest for the purpose of causing the client's death used to relieve unaccept able or distressing symptoms and a poor quality of life provider assisted suicide is legal if the client does not have a uh is illegal if the client does not have a terminal illness that will likely result in a natural death within six months no provider assisted suicide is allowed for clients under the age 18 re requirements can include verbal requests twice by the client 15 to 20 days apart and submit at least one written request it is legal in 11 states in the United States involves a prescription from a license and a physician improved by the state and patient must be a resident of this state let's talk about Advanced director clients can be incapacitated as a result of disease or injury regardless of their age therefore these documents are not only for the age and should be completed before a medical emergency occures the two types of advanced directive documents include a living will and a durable power of attorney for Health Care Living will informs Health Care Providers What treatments the client desires if they are dying or not through to regain Consciousness and are unable to make their own decisions about available emergency treatment includes directions regarding CPR ventilator artificial hydration or nutrients durable power of attorney for Health Care designated the person as a health care proxy this person makes medical decisions for a client who is unable or incapacitated maybe in addition to a living will next couple slides we're going to talk about code statuses Advanced Directive State preferences for cardia pulmonary res resusitation but it's not the same as the order every patient who is uh admitted to the hospital supposed to have a code status order and it can be um do not resuscitate order or it can be full code order uh but every patient supposed to have it and it is important that the client would vag language preferences and procedures should be stated explicitly Advanced Directive should be included in the client's medical record and should be Revisited periodically some clients believe a DNR order means do not treat nurses have a key role reinforcing that code status does not stop all treatments or standards of care the cast status should be addressed with the client mind or if needed with a proxy prior to interventions or procedures particularly ones that required intubation if temporary changes to code stats are needed prior to procedure the DNR dni order should be changed for procedural period and then change back after procedure okay full code it's a full resusitation measures then DNR do not resuscitate it's no CPR no resusitation no intubation usually reserve for those with multiple chronic diseases um we already talk about the DNR order on in Mount Caramel you can see dnrcc or DNR CCA dnrcc it's a comfort care when patient besides uh almost going to the hospice care or paliative care and we don't do anything um D DNR CCA it is upon arrest it means we're doing everything if the patient's heart rate is going super high we're going to give medications to keep Cate under control if patient with flip to a fe with rvr we're going to put them on a cardiac drip if the patient for example blood pressure is is a super low we're going to put them on pressures we do everything until heart stops but if heart stops we're not going to resuscitate patient we're not going to do CPR it's a really tricky code because DNR CCA also can be with or without intubation it can be dni do not intubate or it can be with intubation it needs to be clarified in the order it means if the patient's Hearts stop we do not do CPR but if the patient decreasing in uh breathing if the patient was on a bip poop and and the patient is already 100% on the bip poop and maybe only ventilation will help this patient right now if patient is DNR CCA without intubation if the patient will stop breathing we will not intubate this patient but if the patient with intubation we will intubate this patient if heart is working and patient just cannot breathe we will intubate this patient but if heart will stop working we will not do cprs there are several standards key to withdrawal or withholding end of Life Care it is legally and ethically acceptable when consistent with the client's wishes to withhold or withdraw medical interventions withdrawing or withholding treatment may occur when the burdens of the treatments outweigh client's benefits if the intervention is not beneficial or when the intervention does not align with the client's goals medically administered nutrition and hydration is particularly ethically challenging for some nurses and clients use of it should be centered on informed decision making clients autonomy the plan of care and diagnosis in clients with Advanced disease um this nutrition hydration May sustain life but may also have a negative effect on the client's quality of life withdrawal of the hydration in nutrition might also align with the client's goals Health Care proxy clients who are incapable of making decisions and who do not have a designated proxy should have a person named as such according to local state and facility regulations a parent of or Guardian has the legal authority to make decisions about treatment for the child If the child is younger than 18 years old and they have the child's best interest in mind the child's treatment preferences asess and ref ascent and refusal of treatment when development suitable must be documented in taken into account in the decision-making process when the child's wishes defer from those of the adults the healthc care team must assist the family in reaching a suitable decision nurses are responsible for identifying client symptoms performing nursing interventions within the scope of practice such as administering medications in inter intervening with appropriate symptoms alleviation uh methods and working with the interdisciplinary team to increase the client's comfort and families understanding and adaptation of the dying process nurses are obligated to provide care that include relieving pain and other symptoms to promote comfort and support clients families and other individuals close to the client the nurse should uptain information about the client's diagnosis and medical history to more accurately determine the risk for distressing symptoms of the end of uh life this allows the nurse to better support the client during this time the the nurse should identify gaps in knowledge regarding end of life care and or withdrawal or withholding treatments clients who are nonverbal must be assessed for signs of distress such as restlessness grimacing or moaning the nures must also be alert to changing manifestations of impending death as death nears clients frequently have manifestations of Decline and physical and mental function impending death nurses must analyze the client's clinical presentation to anticipate client or family needs or changes in status nurses must understand the pathophysiology of dying utilize standards of care and anticipate progression towards death skin modeling purple and dark pink color or the black and posterior arms and and uh legs also fatig seek drowsiness confusion decrease interest in food and fluids urinary output decrease uh development of uh the cubitus ulcers decrease cerebral perfusion change toxic respirations okay and nursing interventions the type of treatment should be in line with the client's wishes and based on a comprehensive assessment nonpharmacological pain treatments uh can be include U can include for example music therapy massage and hidden cold therapy pharmacological treatment includes the administration of opiates nonopioids as well as anti-depressants and corticosteroids medical marijuana is also effective in treating pain in this client but is dependent on state lws when using pharmacological pain management pain medication should be given as ordered and routinely to prevent breakthrough pain as pain is easier to prevent and treat nurses must follow up after the administration of pain medication to evaluate its Effectiveness nurses should report to the provider if the PID medication is not effective enough to control the discomfort a common finding in the end of the clients is disp end of life clients is disp or shortness of breath complete throughout assessment of the dis including respiratory rate Rhythm depths breathing pattern and effort the respiratory distress observational scale can be used to assess dispnea nurses should keep the client clean and dry by providing prompt incontinent care and changing sheets as needed lotion can also be applied to the client's skin to decrease dryness the client should be turned every 2 hours to relieve pressure however if the client has pain with change in position decrease the frequency pressure relief mattresses can be used as needed if the client develops a debors wound care should be started the goal of wound care is is uh in the instance is to promote comfort and prevent worsening of the wound besides pain dispa and skin we also need to take care of uh some provide some G intestinal interventions such as offer favorite foods and drinks to help with anorexia small frequent meals are recommended never force a client to eat as anorexia is a natural part of the dying process constipation uh make sure a client is hydrated we giving Med medications for that increase fiber mobility and fatigue provide assistive devices such as commode shower chairs and performing bathing assess underlying cause for fatigue such as depression or dehydration this lecture is over if you have any question please email me anter mccn.edu