1. Chapter 36 End-of-Life Care

2. Introduction
Death is an inevitable, unequivocal, and universal experience
Difficult for many individuals to face
Reluctance to accept mortality
Gerontological nurses often face death and must learn to deal with the entire dying process
Role of the nurse during this difficult time

3. Definitions of Death Final termination of life
Cessation of all vital functions
Act or fact of dying
United Nations Vital Statistics Division
Brain death: determined by EEG
Somatic death: determined by the absence of cardiac and pulmonary functions
Molecular death: determined by cessation of cellular function

4. Family Experience with the Dying Process
Past
Higher mortality rates
Death in the home viewed as natural process
Fewer hospitals and other institutions
Present
Limited experience with death
Change in the site and circumstance of death

5. Changes in Birth and Death Rates from 1950 to 2013
Insert Figure 36-1

6. Family Experience with the Dying Process (cont.)
Most people have minimal direct involvement with dying individuals
Death has become more impersonal and unusual event
Difficulty accepting one’s own mortality
Understanding one’s own mortality can be therapeutic to the nurse personally, as well as helpful in the care of dying individuals

7. Family Experience with the Dying Process (cont.)
Previous experiences with death
Religious, spiritual, and cultural beliefs
Philosophy of life
Age
Health status

8. Question Is the following statement true or false?
Nurses who understand their own mortality are more comfortable helping individuals through the dying process.

9. Answer
True
Rationale: Understanding one’s own mortality can be therapeutic to the nurse personally, as well as helpful in the care of dying patients.

10. Supporting the Dying Individual
Elisabeth Kubler-Ross’s (1969) conceptual framework
Five stages of coping mechanisms with dying
The nurse needs to understand which interventions are most appropriate during each stage
Not all dying persons progress through the stages in an orderly sequence or experience all of the stages

11. Supporting the Dying Individual (cont.)
Nurses were prepared to deal with care of a dead body—they now need to be more involved in the dying process
Humanistic approach to caring for dying patients and their families
Hospice care
Need for individualized nursing interventions
Nursing diagnoses

12. Stages of the Dying Process and Related Nursing Interventions
Denial: first stage
Initial awareness of impending death
Deny the reality of the situation
Serves several useful purposes
May occur at various times throughout an illness; fluctuation
Nursing care and interventions during this stage

13. Question
Which nursing intervention is appropriate for the dying person who is in the stage of denial?
Focus on the conflicting messages that dying people often demonstrate
Acceptance of the dying individual’s reaction
Suggest that the patient aggressively seeks a second opinion
Assist in the denial of the reality of impending death

14. Answer B. Acceptance of the dying individual’s reaction
Rationale: Perhaps the most important nursing action during the stage of denial is to accept the individual’s reactions and to provide an open door for honest dialogue.

15. Stages of the Dying Process and Related Nursing Interventions (cont.)
Anger: second stage
Feeling that nothing is right
Difficult for individuals around the dying person
Unfilled desires and unfinished business
Family may feel guilt, embarrassment, grief, or anger in response to the dying person’s anger
Nursing care and interventions

16. Stages of the Dying Process and Related Nursing Interventions (cont.)
Bargaining: third stage
Postponement of the inevitable
Promises in return for an extension of life
Most bargains are made with God and usually kept as secret
Nursing care and interventions at this stage

17. Stages of the Dying Process and Related Nursing Interventions (cont.)
Depression: fourth stage
Reality of the dying process is emphasized
Many losses can lead to depression
Usually a silent depression
Interest in prayer and desire for clergy
Nursing care and interventions during this stage

18. Stages of the Dying Process and Related Nursing Interventions (cont.)
Acceptance: fifth stage
Struggling ends and relief ensues
Possibility of this being a final rest to gain strength for the long journey
Come to terms with death and gain a sense of peace
Nursing care and interventions during this stage

19. Stages of the Dying Process and Related Nursing Interventions (cont.)
Hope
Commonly permeates all stages
Used as temporary form of denial
Rationalization for unpleasant therapies
Source of motivation
A realistic confrontation of impending death does not negate the presence of hope

20. Physical Care Challenges: Pain
Fear is common
Can be managed effectively
Patients perceive and express pain differently based on many factors
Indicators of pain
Regularly assess pain
Prevention is the goal
Pain management interventions

21. Question
Which intervention is most appropriate when caring for a dying patient who is experiencing pain?
Assess pain every 8 hours
Prevent pain from developing
Utilize morphine for any type of pain
Minimize the pain response of the confused

22. Answer B. Prevent pain from developing
Rationale: For the dying patient, the goal of pain management is to PREVENT pain from developing rather than to treat it once it occurs.

23. Physical Care Challenges: Respiratory Distress
Common problem in dying patients
Physical discomfort of dyspnea
Psychological distress
Causes
Nursing care and interventions

24. Physical Care Challenges: Constipation
Common
Causes
A source of additional discomfort to dying individuals
Prevention as a goal for care
Nursing care and interventions

25. Physical Care Challenges: Poor Nutritional Intake
Anorexia, nausea, and vomiting prevent adequate nutritional intake
Fatigue and weakness
Nursing care and interventions:
Stimulation of appetite
Nausea and vomiting
Other basic nursing measures

26. Spiritual Care Needs
Nurses need knowledge of different religious views related to death and dying
Assessment of religion and spirituality including individual practices
Religion and spirituality are not synonymous
Inclusion of clergy and members of the individual's own faith-based group
Role of the nurse

27. Signs of Imminent Death
Bodily functions slow down
Signs and symptoms
Nurses need to identify and recognize approach of death symptoms to keep family informed
Determine if clergy is desired by the patient and/or family
Care of the dying individual and family

28. Question Is the following statement true or false?
It is not appropriate for nurses to pray with dying patients and their families.

29. Answer
False
Rationale: If nursing staff feel comfortable with religious and spiritual practices of the patient, they can offer to pray with patients or read to them from religious texts. Nurses should ensure that prayers offered are consistent with the patient’s belief system.

30. Advance Directives
Legal document that allows patients to express their desires regarding terminal care and life-sustaining measures
Patient Self-Determination Act (PSDA)
Nurses need to determine if patients have advance directives, review the patients wishes, and place the document in the medical record

31. Supporting Family and Friends
Family and friends need to be considered
May have needs requiring therapeutic interventions
Interventions for family and friends going through the process
Offering appropriate support
May provide immense comfort

32. Supporting Through the Stages of the Dying Process
Family and friends may also pass through the stages of the dying process before they accept the impending death of a loved one
Responses common to the stages of dying demonstrated by family and friends
Nursing support and interventions depend on what stage the family member or friend is at the time of encounter

33. Helping Family and Friends After a Death
Be available to provide support
Variety of responses related to body viewing
Encourage open expression of grief/feelings
Guidance with funeral/burial arrangements
Identify an advocate for help with planning
Support through grieving/bereavement
“Postventive” work of Edwin Schneidman

34. Supporting Nursing Staff
Staff caring for the dying have their own feelings regarding the death/dying experience
Difficulty realizing one’s own mortality
Experience with death may be limited
Death may be viewed as a dissatisfying failure
Nurses may also experience the stages of the dying process

35. Supporting Nursing Staff (cont.)
Staff working with dying patients need support
Nurses need to explore their own reactions to death experiences
Acknowledgment of feelings
Resource people available to assist nurses through providing support