Chapter 41 End of Life Care

Definitions of Death United Nations Vital Statistics: death is the permanent disappearance of every vital sign. Brain Death: the death of brain cells determined by a flat electroencephalogram [EEG]. Somatic Death: determined by the absence of cardiac and pulmonary functions. Molecular Death: determined by the cessation of cellular function.

Family Experiences with Death Past –Most births and deaths occurred in the home and were viewed as a natural process. –Dying individuals could be surrounded by and cared for by loved ones in the comfort of their homes. Present –Lowered mortality rates and mobile nuclear families have reduced family experience with death and end of life care.

Family Experiences with Death (cont.) –Most deaths occur in hospital and institutional settings, not the home. –The separation of individuals from their loved ones during the dying process can be stressful.

Goals of Hospice Care Pain relief Symptom control Coordinated home care and institutional care Bereavement follow-up and counseling

Kubler-Ross Stages of Dying Denial Anger Bargaining Depression Acceptance

Physical Care Needs of the Dying Patient Pain relief Respiratory distress Constipation Poor nutritional intake

Pain Management for the Dying Patient Assess pattern and severity of pain. Recommend patient takes analgesic on regular basis. Assess patient’s understanding of the analgesic. Consider the impact of psychological factors on physical pain. Use nonpharmacologic pain relief measures.

Clues to the Presence of Pain Sleep disturbances Reduced activity Diaphoresis Pallor Poor appetite Grimacing Withdrawal

Alternative to Pain Medications Guided imagery Hypnosis Relaxation exercises Massage Acupressure Acupuncture

Alternative to Pain Medications (cont.) Therapeutic touch Diversion Application of heat or cold, even

Interventions for Respiratory Distress Elevating the head of the bed Administering oxygen Administering atropine or furosemide Using narcotics

Measures to Promote Nutritional Intake Assisting with oral hygiene Offering a clean and pleasant environment for dining Providing pleasant company during mealtime Assisting with feeding as necessary

Questions to Assess for Spiritual Needs What gives you the strength to face life’s challenges? Do you feel a connection with a higher being or spirit? What gives your life meaning?

Signs of Imminent Death Decline in blood pressure Rapid, weak pulse Dyspnea and periods of apnea Slower or no pupil response to light Profuse perspiration Cold extremities

Signs of Imminent Death (cont.) Bladder and bowel incontinence Pallor and mottling of skin Loss of hearing and vision

Stages of Family Acceptance of Death of Loved One Denial Anger Bargaining Depression Acceptance

Edwin Schneidman: Working with Family of Deceased Total care of a dying person includes contact and rapport with the survivors-to-be. It is best to begin work with survivors as soon as possible after the tragedy. Remarkably little resistance is met from survivor-victims. The role of negative emotions toward the deceased needs to be explored, but not at the beginning. The professional plays the important role of reality tester. Medical evaluation of the survivors is crucial.

Source Eliopoulos, C. (2005). Gerontological Nursing, (6 th ed.). Philadelphia: Lippincott, Williams & Wilkins (ISBN ).