Nursing Management: End-of-life Palliative care, Comfort Care, Hospice

End-of-Life: What is it? Final stage of life when death is imminent Unpredictable May last minutes, hours, or weeks End-of-life care refers of physical, psychosocial, and spiritual care provided to patients and their families Care addresses issues related to death and dying

Goals of End-of-Life Care Prevent or relieve suffering Provide comfort and support Maintain human dignity Respect patient’s wishes and desires Improve quality of life Provide emotional support (National Caregivers Library, 2015) (Death and Dying, n.d.)

Care Interrelationships Patient Hospice Care Palliative Care End of life Care Comfort Dignity Quality of Life Support

Palliative Care Focus on improving quality of life for patients & families. Provided during any stage of a life-limiting illness; acute, chronic, or terminal. Palliative Care

Palliative Care Programs Include: Relief of physical suffering Care of emotional needs Bereavement support Curative and life-prolonging treatments Interdisciplinary teams including physicians, nurses, social workers, pharmacists, and physical and occupational therapists

Hospice Care Reserved for terminally ill Life expectancy of six months or less Patients no longer seeking cure or life-prolonging treatments Comfort care at end of life Provides a palliative approach to care. (Hospice, n.d.)

Palliative Care Programs vs Hospice Hospice Care Focus on comfort care Curative or life-prolonging No time restrictions Do not have to be terminal Care teams oversee care Administered in hospitals, extended care facilities, and nursing homes Bereavement support Focus on comfort care Does not include curative or life- prolonging measures Life-limiting illness with prognosis of six months or less Reliance on family and visiting nurses and care is usually provided in the home Bereavement support

Pathophysiology of Dying As a person enters the final stage of the dying process, the body begins the final process of shutting down, which will end when all the physical systems cease to function. (Dying, n.d.)

Clinical Manifestations Sensory – decreased sensation & perception - loss of blink reflex – glazing appearance of eyes – hearing is the last sense to leave Cardiovascular – increased HR followed by decreased HR, BP, and irregular heart rhythm Respiratory – increased rate followed by decreased rate and depth - Cheyne-Stokes - audible congestion Renal – oliguria progressing to anuria – urine dark amber, brown, or reddish color - incontinence possible

Clinical Manifestations cont. Gastrointestinal – abdominal distension, gas, anorexia, & nausea Muscular Skeletal – decreased movement, tone, difficulty speaking & swallowing - loss of gag reflex Integumentary - mottling of extremities - cyanosis of nose, finger tips, nail beds & toes – cold and clammy – “waxy” appearance

Assessment: Subjective Varies depending on presenting symptoms, underlying illness, and nearness to death and may need to be obtained from someone other than the patient Review medical record and advance directives if available Cultural issues Personal desires, wishes, and choices regarding death and dying

Assessment: Objective Vital signs (if appropriate) General appearance Level of consciousness Affect Level of comfort

Physiological: ABCD Labored breathing Mottling of extremities Coolness and cyanosis of the tips of fingers, toes, and nose Edema in Extremities Decreased urinary output (Dying. n.d.)

Physiological Assessment Cont… Mental confusion Pain and discomfort Excessive fatigue and sleeping Increasing physical weakness Inability to perform self-care activities

Psychological Social withdrawal Isolation – loneliness Fear & Anxiety Grieving & Sorrow Spiritual unrest Saying “good byes” (Death and Dying, n.d.)

Nursing Diagnosis: Comfort Care Pain Analgesics (narcotics) Anxiolytics Impaired comfort Position of comfort Elevate head Social withdrawal Soft voice Gentle touch Social isolation Allow to sleep Acceptance

Interventions: Physical Pain and discomfort - position of comfort, cover with a light but warm blanket, anxiolytics, analgesics, eye lubricants Anorexia – follow patient cues, offer ice chips and sips of water, dab a moistened warm cloth around mouth, apply lip balm Labored breathing – elevate head – do not suction Fatigue and drowsiness – permit sleep, avoid quick movements and loud startling noises

Interventions: Psychosocial Respect sacred space Allow to be Gentle touch if culturally acceptable Allow to sleep Encourage family to be present if culturally acceptable Answer questions honestly Display empathy and compassion

Evaluation Pain control Comfort Psychosocial support Peace (Death and Dying, n.d.)