END-OF-LIFE CARE PART TWO JUNE 11, 2020 ANDREA HUERTAS, MBA, BSN, RN GOALS & OBJECTIVES
• JUNE 9TH • COMMUNICATING AT THE END OF LIFE • PAIN MANAGEMENT AT THE END OF LIFE • JUNE 11TH • SYMPTOM MANAGEMENT AT THE END-OF-LIFE • CARE OF THE PATIENT AND FAMILY WHEN DEATH IS NEARING PATIENT CARE: SYMPTOM MANAGEMENT & INTERVENTIONS Symptoms Interventions Agitation Administer benzodiazepines, provide music, massage, dim lighting, and a cool environment Dehydration Provide frequent oral care and ice chips as tolerated, consider initiation of hypodermoclysis or proctoclysis, if consistent with goals of care Dry mouth Provide frequent oral care and frequent application of lip balm. Offer ice chips and oral swabs as tolerated. Artificial saliva may be used Dyspnea Treat cause, if possible. Administer opioids as prescribed. Reposition patient for comfort. Use a fan to provide moving air and provide cool environment
Edema Elevate extremities as tolerated, use diuretics as indicated, consider decreasing or discontinuing artificial nutrition and/or hydration if symptoms of fluid overload arise
Fever Administer acetaminophen suppository as prescribed, use fan to circulate air, dress patient in light clothing, and apply cool washcloths to forehead
Incontinence Use disposable briefs and change promptly. Provide skin care after each incident of incontinence. Reposition patient frequently to prevent decubiti
Pain Administer oral medications until no longer tolerated. If patient is unable to swallow, provide pain medications subcutaneously or rectally. Use adjuvant medications as needed. Reposition patient for comfort, use distraction, massage, and/or heat/cold for comfort
Terminal secretions Reposition patient for comfort. Administer anticholinergic medications to dry excess secretions if necessary. Oral suctioning may be implemented but deep suctioning should be avoided
Decubitus ulcers Provide skin care with repositioning and when patient is incontinent. Provide appropriate wound care, and consider use of topical lidocaine to reduce pain
https://connect.springerpub.com/content/book/ NEUROLOGIC • APHASIA • DYSPHAGIA • ALTERED LEVEL • MYOCLONUS • PARESTHESIAS AND NEUROPATHIES MANIFEST • SEIZURES • DYSKINESIA • PARALYSIS • INCREASED ICP CARDIAC • BLEEDING AND HEMORRHAGE • DVT • PE • DIC • ANGINA • EDEMA • LYMPHEDEMA • SYNCOPE • SUPERIOR VENA CAVA SYNDROME (SVCS) RESPIRATORY • COUGH • DYSPNEA • PE • PNEUMOTHORAX • TERMINAL SECRETIONS GI • CONSTIPATION • DIARRHEA • BOWEL INCONTINENCE • ASCITES • HICCUPS • NAUSEA AND VOMITING • BOWEL OBSTRUCTION GU •SPASMS •INCONTINENCE •RETENTION MUSCULAR & SKIN •MOBILITY •XEROSTOMIA •PRURITUS •WOUNDS PSYCHOSOCIAL
• AT THE END OF LIFE, PATIENTS MAY EXPERIENCE FEAR, DENIAL, ANGER, DEPRESSION, GRIEF, AND/OR HOPELESSNESS. PATIENTS MAY ALSO STRUGGLE WITH THE MEANING OF THEIR LIFE OR OF THEIR SUFFERING. MANIFESTATIONS OF THESE EMOTIONS ARE CULTURALLY BASED AND SHOULD BE ADDRESSED BY THE INTERDISCIPLINARY TEAM IN A COMPASSIONATE AND CULTURALLY SENSITIVE MANNER. • NDA MAY OCCUR WITH THE PATIENT RELATING SPECIFIC INFORMATION ABOUT AN AFTERLIFE. THESE EXPERIENCES ARE OFTEN COMFORTING TO THE PATIENT AND SHOULD NOT BE NEGATED BY THE HEALTHCARE PROVIDER. • SLEEP DISTURBANCES ARE VERY COMMON AT THE END OF LIFE. THE NURSE SHOULD PROMOTE GOOD SLEEP HYGIENE AND MANAGE SYMPTOMS THAT INTERFERE WITH RESTFUL SLEEP. • SUICIDAL IDEATION MAY OCCUR IF PATIENTS BECOME FEARFUL OR DEEPLY DEPRESSED. THE NURSE SHOULD DETERMINE WHETHER THE PATIENT HAS A PLAN TO IMPLEMENT SELF-HARM AND THE MEANS TO DO SO. IF SO, INTERVENTIONS MUST BE TAKEN URGENTLY TO ENSURE THE PATIENT’S SAFETY. • INTIMACY MAY BE AFFECTED BY SERIOUS ILLNESS. THE NURSE SHOULD ENCOURAGE PATIENTS TO EXPRESS THEIR CONCERNS AND NORMALIZE THEIR EXPERIENCE. NUTRITIONAL •ANOREXIA •DEHYDRATION •FATIGUE •HYPERCALCEMIA OTHER •INFECTION •MYELOSUPPRESSION •CHANGE IN MENTAL STATUS PRACTICE QUESTIONS PATIENT AND FAMILY CARE, EDUCATION, AND ADVOCACY
• ESTABLISHING GOALS OF CARE • SMART GOALS • RESOURCE MANAGEMENT • ADVANCE DIRECTIVES • EXPERTISE IN DISCUSSING END-OF-LIFE CARE • GOALS OF CARE • IDT • HOSPICE BENEFIT BY INSURANCE: MCR MA PRIVATE • HOSPICE ELIGIBILITY • LEVELS OF CARE • CORE HOSPICE SERVICES INCLUDE PHYSICIAN SERVICES, NURSING SERVICES, MEDICAL SOCIAL WORK SERVICES, AND COUNSELING SERVICES. • NONCORE HOSPICE SERVICES INCLUDE PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY; VOLUNTEER SERVICES; HOMEMAKER SERVICES; HOSPICE AIDE SERVICES; MEDICATIONS; AND MEDICAL SUPPLIES. • PATIENTS ARE DISCHARGED FROM HOSPICE THROUGH DEATH, IMPROVEMENT IN CONDITION, OR BY REVOKING THE HOSPICE BENEFIT. PRACTICE QUESTIONS PATIENT & FAMILY CARE PSYCHOSOCIAL, SPIRITUAL, AND CULTURAL
• KNOWLEDGE AND UNDERSTANDING NEED TO BE EXPLORED WHEN ADDRESSING • PSYCHOSOCIAL • SPIRITUAL • CULTURAL SIMILARITIES AND DIFFERENCES PRACTICE QUESTIONS GRIEF AND LOSS
•GRIEF •LOSS •BEREAVEMENT PRACTICE QUESTIONS CAREGIVER SUPPORT
• ACKNOWLEDGE AND IDENTIFY STRESS • KNOWLEDGE IS POWER • WHO AND HOW WE TEACH THE FAMILY • BE A PATIENT ADVOCATE PRACTICE QUESTIONS CARE GIVER SUPPORT PRACTICE ISSUES
• INTERDISCIPLINARY TEAM • NURSE • PHYSICIAN • SOCIAL WORKER • CHAPLAIN • AIDE AND/OR HOMEMAKER • VOLUNTEER • THERAPIST • COUNSELING CARE COORDINATION SCOPE, STANDARDS AND GUIDELINES
• STRUCTURE AND PROCESSES OF CARE • PHYSICAL ASPECTS OF CARE • PSYCHOLOGICAL AND PSYCHIATRIC ASPECTS OF CARE • SOCIAL ASPECTS OF CARE: FOCUSES ON LEVERAGING FAMILY STRENGTHS AND SOCIAL SUPPORT MECHANISMS TO ALLEVIATE FAMILY STRESS. • SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE • CULTURAL ASPECTS OF CARE • CARE OF THE PATIENT AT THE END OF LIFE • ETHICAL AND LEGAL ASPECTS OF CARE PRACTICE QUESTONS ETHICS AT EOL • AUTONOMY: THE RIGHT TO MAKE DECISIONS FOR ONESELF. AUTONOMY IS THE PRINCIPLE THAT UNDERPINS THE PRACTICE OF INFORMED CONSENT • BENEFICENCE: THE PRINCIPLE OF DOING THE MOST GOOD; ACTING KINDLY AND CHARITABLY • CONFIDENTIALITY: THE EXPECTATION THAT THE PATIENT’S PRIVATE INFORMATION WILL NOT BE DISCLOSED TO ANYONE WITHOUT THE PATIENT'S CONSENT • JUSTICE: THE PROMOTION OF GOOD FOR ALL • NONMALEFICENCE: DOING NO HARM • PATERNALISM: RESTRICTING THE LIBERTY OR RIGHTS OF ANOTHER, SEEMINGLY FOR THE PERSON'S OWN GOOD • TRUTHFULNESS: PROVIDING INFORMATION WITH HONESTY AND INTEGRITY SELF-CARE & PROFESSIONAL DEVELOPMENT
• WHAT DO YOU DO TO TAKE CARE OF YOURSELF? • TEACH, MENTOR, ENGAGE QUESTIONS
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