Chapter 11: End-of-Life and Palliative Care

• • • • • • • • • • • • End-of-life care (EOL care) is the term currently used to describe issues related to dying and death care. EOL care focuses on the physical and psychosocial needs of the patients and their families at the end of life. Death is the irreversible cessation of circulatory and respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem. Bereavement is an individual’s emotional response to the loss of a significant person. Grief develops from bereavement and is a dynamic psychologic and physiologic response following the loss. Assessment of spiritual needs in EOL care is a key consideration. Family involvement is integral to providing culturally competent EOL care. Persons who are legally competent may choose organ donation. Advance care planning is focused on anticipated challenges that the patient and family will face because of illness, medical treatment, and other concerns. The nurse needs to be aware of legal issues and the wishes of the patient. Advance directives and organ donor information should be located in the medical record and identified on the patient’s record and/or the nursing care plan. Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Palliative care focuses on controlling pain and other symptoms, as well as reducing psychologic, social, and spiritual distress for the patient and the family. Palliative care is the framework for hospice care. Palliative care can start much earlier in a disease process, whereas hospice traditionally is limited to the projected last 6 months of life. Admission to a hospice program has two criteria: (1) the patient must desire the services; and (2) a physician must certify that the patient has 6 months or less to live. The objective of a bereavement program is to provide support and to assist survivors in the transition to a life without the deceased person. The physical assessment is abbreviated in EOL care and focuses on changes that accompany terminal illness and the specific disease process. Families need ongoing information on the disease, the dying process, and any care that will be provided. Respiratory distress and shortness of breath (dyspnea) are common near the end of life. The

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sensation of air hunger results in anxiety for the patient and family members. • • • • Most terminally ill and dying people do not want to be alone and fear loneliness. Priority interventions for grief must focus on providing an environment that allows the patient to express feelings. People who are dying deserve and require the same physical care as people who are expected to recover. To meet the holistic needs of the patient, the nurse collaborates with the social worker, chaplain, physical therapist, occupational therapists, certified nursing assistants, and physician. The patient near death may seem to be withdrawn from the physical environment, maintaining the ability to hear while not being able to respond. It is important not to delay or deny pain relief measures to a terminally ill patient. Skin integrity is difficult to maintain at the end of life due to immobility, urinary and bowel incontinence, dry skin, nutritional deficits, anemia, friction, and shearing forces. After the patient is pronounced dead, the nurse prepares or delegates preparation of the body for immediate viewing by the family with consideration for cultural customs and in accordance with state law and agency policies and procedures. The role of caregiver includes working and communicating with the patient, supporting the patient’s concerns, helping the patient resolve any unfinished business, working with other family members and friends, and dealing with the caregiver’s own needs and feelings. An understanding of the grieving process as it affects both the patient and the family caregivers is of great importance. Recognizing signs and behaviors among family members who may be at risk for abnormal grief reactions is an important nursing intervention. Caring for dying patients is intense and emotionally charged. It is important to consider interventions that help ease physical and emotional stress for the nurse. Terminal illness and dying are extremely personal events that affect the patient, the family, and health care providers.

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****Chapter 12: Addictive Behaviors
• • The illicit substances most commonly used in the United States include marijuana/hashish, cocaine, hallucinogens, and heroin. Compulsive behaviors, including eating disorders, gambling, computer gaming and interacting, and excessive exercise, are considered addictive behaviors.

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Addiction is a complex disorder that is a treatable, chronic, relapsing disease. It is considered a biobehavioral disorder. Addiction results from the prolonged effects of addictive drugs or behaviors on the brain. The brain reward system is a system that creates the sensation of pleasure. The neurotransmitter dopamine plays a role in addiction. Genetics, environment, and sociocultural factors contribute to addiction. Tobacco: o The most common addictive behavior is tobacco use. The complications associated with the use of tobacco (nicotine) are related to dose and method of ingestion. o Tobacco use is the leading cause of preventable illness and death in the United States. • Cocaine: o Is the most potent of the abused stimulants. Besides its effects on the brain reward system, cocaine produces adrenalin-like effects. o Persons who abuse cocaine have problems related to sleep, appetite, depression, respiratory infections, chest pain, and/or headaches.

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Amphetamines stimulate the central and peripheral nervous systems. They cause increased alertness, improved performance, relief of fatigue, and anorexia. Caffeine promotes alertness and alleviates fatigue. It is a weak CNS stimulant. Alcohol: o Is consumed by almost 50% of Americans over the age of 12. Alcohol abuse affects 10% of the population. o Alcoholism is a chronic and potentially fatal disease if not treated. o In alcoholics, abrupt withdrawal may have life-threatening effects. Persons who abuse alcohol often have a number of health problems. o Acute alcohol toxicity can occur with binge drinking or the use of alcohol with other CNS depressants. Sedative-hypnotic agents: o Commonly used ones include barbiturates, benzodiazepines, and barbiturate-like drugs. o Sedative-hypnotics act on the CNS to cause sedation at low doses and sleep at high doses. Tolerance develops rapidly. Signs and symptoms of opioid overdose include pinpoint pupils, clammy skin, depressed respiration, coma, and death (if not treated). Opioid overdose can precipitate a medical emergency. Cannabis (or marijuana) is the most widely used illicit drug in North America. Marijuana produces euphoria, sedation, and hallucinations.

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The nurse must be alert to signs and symptoms of the many health problems associated with addictive behaviors. It is important for the nurse to promote an open and nonjudgmental communication style with the patient. A drug overdose is an emergency situation, and management is based on the type of substance involved. In general, withdrawal signs and symptoms are opposite in nature from the direct effects of the drug. The patient who is dependent on substances is at risk for postoperative complications. Severe pain should be treated with opioids and at a much higher dosage than that used with drug-naïve persons. It is the nurse’s responsibility—in collaboration with a multidisciplinary team composed of physicians, social workers, and addiction specialists—to address the patient’s substance abuse problem and motivate the patient to change behaviors and seek treatment for the addiction.