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Chapter Ten End-of-Life Issues Chapter 10-1 Fourth Edition Linda D. Urden Kathleen M. Stacy Mary E. Lough Priorities in C RITICAL C ARE N URSING Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
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Slide 2 Objectives Describe the impact of advance directives and advance care planning on provision of end-of-life care in the ICU. Discuss the concepts of patient- and family-centered decision making. Explain the need for symptom assessment and management during end-of-life care in ICU. Discuss the role of collaborative practice on end-of-life care in the ICU.
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Recommendations to Improve End- of-Life Care Patients with fatal illnesses and their family should receive reliable, skillful, and supportive care. Health professionals should improve care for the dying. Policymakers and consumers should work with health professionals to improve quality and financing of care. (Continued)
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Advance Directives Also known as a living will or health care power of attorney Encouraged to ensure patients receive the care they desired Issues Underused Desires not discussed with primary physicians Applicability
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Recommendations to Improve End- of-Life Care (Continued) Health profession education should include end-of-life content. Palliative care should be developed, possibly as a medical specialty. Research on end of life should be funded. The public should communicate more about the experience of dying and options available.
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Advance Care Planning Communication of patient’s wishes between primary care providers and intensivists is critical. Patient desires: Aggressive care. No aggressive care.
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Ethical/Legal Issues Patient is respected as autonomous and able to make decisions. If patient is unable to make decisions, respect should be accorded to surrogates. Patient Self-Determination Act Basic ethical principles Beneficence Nonmaleficence
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Comfort Care Decision to withdraw life-sustaining treatments Withdrawing and withholding are morally and legally equivalent Families experience more stress in withdrawing Goal of withdrawal is to remove treatments that are not beneficial and may be uncomfortable
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Do Not Resuscitate (DNR) Should prevent initiation of CPR Does not equate to “Do Not Care” DNR should be written before withdrawal of life support
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Cardiopulmonary Resuscitation (CPR) Decisions related to CPR are frequently delayed CPR often offered as an option despite: Low possibility of survival following CPR Pain and suffering involved during and after CPR Potential for decline in functional status following CPR
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Prognostic Tools Acute Physiology and Chronic Health Evaluation (APACHE) Multiple Organ Dysfunction Scores (MODS)
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Communication Patient Limited by illness severity Family Need support for decisions
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Withdrawal or Withholding Treatment Discussions about potential for impending death are never held early enough. Proactive approach Disagreement and distress for caregivers Barriers to dying Steps toward comfort care
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Palliative Care Patients near the end of life require aggressive care for their symptom management. Pain management Symptom management
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Withdrawal of Mechanical Ventilation Time to initiate withdrawal should be established Patient moved to a separate room Notify noninvolved staff Avoid loud conversation and laughter (Continued)
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Withdrawal of Mechanical Ventilation (Continued) Pacemakers or implantable cardioverter- defibrillators should be turned off Neuromuscular blockade discontinued Removal of monitors—based on family responses (Continued)
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Withdrawal of Mechanical Ventilation (Continued) Opioids and sedatives Prevent dyspnea and anxiety Ventilator settings Reduced after patient comfort achieved Alarms should be turned off Terminal wean vs. extubation
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Organ Donation Social Security Act Section 1138 The Joint Commission standards Organ versus tissue donation Determination of brain death
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Family Care Family means whatever the patient states is family Communication needs Waiting for “good news” Family meetings Family presence during CPR Visiting hours (Continued)
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Family Care (Continued) Family presence during CPR Couple with staff support Visiting hours Following death
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Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Collaborative Care End-of-life care domains Patient- and family-centered decision making Communication Continuity of care Emotional and practical support Symptom management and comfort care Spiritual support Emotional and organizational support for ICU clinicians
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