Sally Nelson is a 68-year old client of Dr. Winters.

She was diagnosed about nine

months ago with Stage IV Pancreatic Cancer and was diagnosed with Acute
Renal Failure 10 days ago. She received three dialysis treatments but decided to
stop both dialysis and further chemotherapy when she learned her cancer was
spreading rapidly despite treatment. She decided to enter inpatient hospice as her
daughter has a full-time job and is unable to provide the care she needs at home.
Her daughter has been participating in her care as much as possible here in the
hospice unit. She is at home right now but wants to be called immediately if her
mother's condition changes. Mrs. Nelson is becoming increasingly weak. Her
symptoms have been well controlled with oral morphine (MS Contin) with Roxanol
for breakthrough pain. Her last dose of MS Contin was at 0400. She has had
Roxanol twice, at 0200 and 0600. She did not tolerate IV morphine (she
developed severe itching) after her exploratory laparotomy nine months ago but
has not had that side effect with oral morphine. She also has Ativan and Haldol
available for anxiety, dyspnea, and agitation. She has had one dose of Ativan at
0400 but has not needed the Haldol. She can have atropine for excessive
secretions. I haven't used it yet but she is starting to exhibit some "death rattle" so
you should probably start that to make her daughter less uncomfortable. Mrs.
Nelson also has acetaminophen and bisacodyl in suppository form. She can have
oxygen by nasal cannula or mask. The daughter feels the nasal prongs are
causing irritation and often removes the oxygen when she thinks her mother is
uncomfortable. Mrs. Nelson has been confined to bed for the last four days. She
has crackles throughout her lungs to auscultation. She has a Foley catheter at her
daughter's request, but her urine output in the last 24 hours was only 150 mL. I
think Mrs. Nelson has moved into the active dying phase. She responds to her
daughter's voice and has still been able to swallow her oral morphine. Her last
dose of MS Contin was at 0400. She has needed Roxanol twice for breakthrough
pain. Her daughter requests the pain medication when her mother begins to
moan. Mrs. Nelson is unable to rate her pain verbally at this point. Her vital signs
are on the flow sheet. The DNR order is on the chart and the advanced directive
has been signed. The family made funeral arrangements with the funeral home
last week. The family pastor has been providing spiritual support. He is Father
John Smith at the Episcopal Church. He has asked to be called if Mrs. Nelson's
condition deteriorates further and the family agrees with that request. Both phone
numbers are in the hanging file at the nurse's station. Do you have any questions?
I don't think Mrs. Nelson will still be here when I come back tonight.
 
For to have a meaningful discussion, let us dissect and analyze each significant
event and understand the main issue of the case presented above.
 
Patient's Medical History:
 
Sally Nelson is a 68-year old client of Dr. Winters. She was diagnosed about nine
months ago with Stage IV Pancreatic Cancer and was diagnosed with Acute
Renal Failure 10 days ago. She received three dialysis treatments but decided to
stop both dialysis and further chemotherapy when she learned her cancer was
spreading rapidly despite treatment. She decided to enter inpatient hospice as her
daughter has a full-time job and is unable to provide the care she needs at home. 
 
Patient's Previous Medications
 
PO tablets, Lorazepam (Ativan)  1 mg every 8 hours PRN anxiety or dyspnea
PO intensol Morphine sulfate (Roxanol) 20 mg/ml 5-10 mg SL PRN break through
pain 
PO liquid Bisacodyl 10 mg every other day
Suppository MS Contin 60 mg every 8 hours 
PO tablets Acetaminophen (Tylenol) 650 mg every 4 hours PRN fever/ mild pain 
Suppository Haloperidol (Halidol) 0.5 - 2 mg every hour PRN agitation 
PO liquid Atropine 1% ophthalmic solution 2-4 gtt SL prn excess secretions 
IV D5W ½ NS 50 ml/hr
 
Significant Points to Consider:
 
1. Patient had a Stage 4 Pancreatic Cancer
2. Patient was suffering
3. Patient was receiving Hospice Care
4. Patient exhibited "death rattle"
5. Patient went to Active Dying Phase
6. Patient has a DNR order
 
Before we address each question posted, it will be helpful if we reflect on the
identified important points or key aspects of the case. Moreso, it is a must first to
know and understand the condition of Mrs. Sally Nelson.
 
Stage 4 Pancreatic Cancer
 
In stage 4 pancreatic cancer, abnormal cells that grew into a tumor in the
pancreas have spread through the bloodstream to form tumors in distant parts of
the body, such as the bones or lungs. It is also called metastatic pancreatic
cancer. Stage 4 pancreatic cancer is not curable, but palliative care and
treatments can help improve quality of life and survival time. Stage 4
pancreatic cancers are aggressive and have few treatment options. Even with
treatment, survival beyond a year or two is low. Survival rates help healthcare
providers estimate how long a person with a diagnosis will survive, given how well
other people with that diagnosis have done.
 
Healthcare providers cannot cure stage 4 pancreatic cancer, but they can manage
it. The goal of stage 4 pancreatic cancer treatment is to increase life span and
decrease symptoms. This may involve surgery, chemotherapy, radiation, and/or
newer drug therapies, all of which are covered here. Palliative care - which is
focused on symptom and stress relief—can help increase the quality of life for as
long as possible. 
  
Therefore, the treatments aim to improve the person's quality of life, relieve their
symptoms, and prolong their life.
 
 
 
1 Are there any dignity-based changes you could recommend to the prescriber? 
What are they?

Let us first know what are the side effects of the medications prescribed to Mrs. Sally
Nelson:
 
1. Lorazepam (Ativan) -
 
Since Ativan works by depressing the nervous system, common side effects include
drowsiness, sedation, low blood pressure, dizziness, and unsteadiness. In severe cases,
Ativan can cause profound sedation, respiratory depression, coma, and, most severely,
death because it dampens the signal from your brain that tells your body to breathe. In
some populations, such as the children and the elderly, Ativan can cause a "paradoxical
effect." Instead of having a calming effect, it may cause agitation and confusion. Elderly
patients taking Ativan are also at a higher risk of falls.
 
2. Morphine sulfate (Roxanol)  -
 
Serious breathing problems may be more likely in older adults and people who are
debilitated or have a wasting syndrome or chronic breathing disorders. Common side
effects may include:
 

 drowsiness, dizziness, tiredness;

 constipation, stomach pain, nausea, vomiting;
 sweating; or
 feelings of extreme happiness or sadness

3. Bisacodyl - 
 
Chronic laxative use might potentially alter electrolytes, but data are limited. Older adults
with a history of electrolyte imbalances should use laxatives with caution. Other side
effects specific to stimulants include potential abdominal cramping, bloating, and nausea.
Some patients might not be able to control or predict the need to defecate; therefore,
caution should be used when prescribing stimulant laxatives to elderly patients who have
mobility issues and risk of falls.
 
4. Acetaminophen (Tylenol) -
 
For most seniors, the safest over-the-counter painkiller is acetaminophen (like Tylenol).
However, older adults must NOT take more than 3000 mg of acetaminophen in one day.
In high doses, acetaminophen can cause serious or fatal liver damage. In the case of Mrs.
Sally Nelson, she was taking Acetaminophen (Tylenol) approximately 3,900 mg a day.
 
5. Haloperidol (Haldol) -
 
High doses or long-term use of haloperidol can cause a serious movement disorder that
may not be reversible. The longer the use of haloperidol, the more likely the development
of this disorder, especially if you in a woman or an older adult. Common side effects may
include:
 

 drowsiness;
 headache;
 dizziness, spinning sensation;
 uncontrolled muscle movements;
 feeling restless or anxious;
 sleep problems (insomnia); or
 breast enlargement, irregular menstrual periods

6. Atropine -
 
Atropine acts as a competitive, reversible antagonist of muscarinic receptors - an
anticholinergic drug. Elderly patients can be particularly sensitive to the anticholinergic
action of drugs because of physiological and pathophysiological changes that often
accompany the aging process. The use of multiple drugs, a common finding in older
patients, may result in pharmacodynamic and pharmacokinetic drug interactions that
heighten anticholinergic effects. While the classic anticholinergic problems of decreased
secretions, slowed gastrointestinal motility, blurred vision, increased heart rate, heat
intolerance, sedation, and possibly mild confusion, may be uncomfortable for a younger
patient in relatively good health, these effects can be disastrous for older patients.
 
Discussion:
 
Now, by just looking at the potential side effects of these medications prescribed to Mrs.
Nelson, we can presume that it defeated one of the main goals of her treatment, which
was to provide her with a quality life. Let us remember, Mrs. Nelson was an elderly patient
with Stage 4 Pancreatic Cancer. The median survival rate for stage 4 pancreatic cancer is
between two and six months. Yes, older people are as likely to respond well to treatment
as younger ones, though life expectancy among older people with stage 4 pancreatic
cancer is shorter.
 
Human dignity is one of the most important medical features and ethical concerns in
health care. Since cancer patients are more vulnerable, compared to other patients, a
higher level of respect for dignity is required due to the nature and long-term involvement
with the disease. The health care provider must acknowledge the importance of respect
for Mrs. Nelson's values and dignity. She had already suffered enough from the disease-
related symptoms and could not cope with additional pressures. And the medications
prescribed to her can add more stress to her and may exacerbate her condition. 
 
It is not just the potential side effects of the medications that were prescribed to Mrs.
Nelson the concern, but also the burden it gave to Mrs. Sally Nelson. Treatment
recommendations for cancer patients require much involvement, but clinicians often have
little understanding of the burden that patients are experiencing. One of the components
of treatment burden is medication burden. Oral cancer medications have become a
standard of care for cancer treatment. It is now vital to understand the increased burden
and responsibility these medications impose on the patient. Due to the volume, variation,
complexity, difficulty of the treatment regimen, and cost, patients must assume increased
responsibility and address the challenges associated with this form of treatment.
Healthcare professionals have not considered what the patient's preexisting medication
workload is from existing comorbidities and what negative outcomes could result from
adding additional medications to their medication "burden."
 
Oral cancer medications might be viewed as good news for cancer patients as they would
require fewer visits to clinics to receive infusion therapy, fewer laboratory tests, and fewer
physician visits. However, the responsibility for medication acquisition, administration, side
effect monitoring, and management has now been transferred to patients and their
families.
 
Prescribing oral cancer medications for cancer patients like Mrs. Sally Nelson requires
careful assessment of the benefit and risks of the cancer treatment and the effect of the
increased workload on the patients' preexisting comorbid conditions. Health-care
professionals should acknowledge that oral cancer medications have been added to the
existing treatment burden. Given the serious illness of Mrs. Sally Nelson when oral cancer
medications are prescribed, patients' capacity to carry out the requirements (i.e., follow
the recommendation) of medication administration has to be considered.
 
Recommendation:
 
The health care provider must respect the human value of Mrs. Sally Nelson by
recognizing her autonomy. There is no doubt that the medications were prescribed with an
aim to alleviate any discomfort that the patient was experiencing. However, the pros and
cons must be weighed. It is important for the health care provider to provide medication
education to Mrs. Nelson and her daughter. This includes the type of medication, name,
and qualities, and most importantly the effects and side effects.  When prescribing a
medication, the health care provider must make sure the patient understands what the
drug is intended to treat.
 
Mrs. Nelson must take part in the decision-making of her care plan. The dignity of Mrs.
Nelson is also maintained when her autonomy is respected and receives quality care. We
must remember that safeguarding autonomy is another aspect of maintaining human
values and is the fundamental principle of patient-centered and ethical care contributing to
the preservation of a patient's dignity.
 
 
 
 
 

2 Are there any changes you recommend to the prescriber based upon the
. physical state of Sally? What are they (should be at least 1)? 

Before I proceed with my other specific recommendation, I would like to point out the
Acetaminophen (Tylenol) prescription to Mrs. Nelson. The health care provider prescribed
PO tablets Acetaminophen (Tylenol) 650 mg every 4 hours PRN fever/ mild pain to Mrs.
Nelson. This needs to be reviewed considering the physical state of Mrs. Nelson. If we are
going to calculate it, Mrs. Nelson was taking 650 mg of Tylenol every 4 hr in a day, and as
needed whenever she had a fever or was in pain. This constituted approximately 3,900
mg of Tylenol consumption in a day. And we mentioned earlier that older adults must NOT
take more than 3000 mg of acetaminophen in one day. In high doses, acetaminophen can
cause serious or fatal liver damage.
 
Since medication prescribed to Mrs. Sally Nelson was for alleviation of her discomforts,
which included pain, I would like to make a recommendation on her pain management.
Pain management can be challenging in light of the aggressive nature of this cancer. Pain
in pancreatic cancer may be visceral, somatic, or neuropathic in origin. Pain is produced
by tissue damage, inflammation, ductal obstruction, and infiltration. As we know, stage 4
pancreatic cancer is incurable, and we aim to provide Mrs. Nelson a quality life as best as
we can, and this includes the diminishment if not alleviation of her pain. There has been
considerable discussion on the positive effect of pain control on increasing patient
survival, yet only a few studies have addressed this issue. Newly diagnosed pancreatic
carcinoma patients who present with pain have been linked with a high likelihood of
recurrence and impaired survival whether they are amenable to resection or not.
 
Percutaneous Neurolytic Celiac Plexus Block
 
Percutaneous neurolytic celiac plexus block (PNCPB) is an excellent treatment option for
patients with intractable abdominal pain due to upper abdominal malignancies or chronic
pancreatitis. In these patients, chronic refractory pain significantly decreases the quality of
life and often requires high doses of narcotics, which can lead to serious adverse side
effects. PNCPB has been shown to have a long-lasting improvement in abdominal pain
and decreased narcotic usage in 70 to 90% of patients. In addition, with fewer than 2%
of patients experiencing major complications, PNCPB is a quick, safe procedure.
 
Management of pancreatic cancer-related pain can be quite challenging. It might best
ideally involve a multidisciplinary approach including pain and palliative medicine
specialists, surgeons, and oncologists. The goal of palliative care is to improve the quality
of life and ease the burden of pain. Optimization of pharmacotherapeutic options to control
pain is the initial step towards this goal. Should this fail or the adverse effects of
analgesics occur, other therapeutic options are best considered. NCPB has been shown
to relieve pain in a selected group of patients. However, t should be highlighted that NCPB
is not meant to be used as a replacement for pharmacotherapy, but rather as an
additional therapeutic tool in selected patients.
 
 
Sally's Initial State upon your first visit (Daughter Jane is present and
appears distressed and worn out): HR: 100  BP: 90/46 (set volume to 9) RR: 22
SpO2 92% Skin: pale, diaphoretic Auscultation sounds: with rales (set volume to
9) Vocal sounds: Response to name
 
Jane asks about pain management. She states she is worried that her mother will
overdose and the medication will kill her.   Also, she is asking why her mother is
grabbing at the bedding and seems to be getting all wound up (agitated).  You
note there is minimal dark tea-colored urine in the catheter bag at the end of the
bed.
 
How will you answer the daughter's question about her pain medication
concern?
 
How will you address the daughter's question about her mother's behavior?
 
How will you intervene?
 
What are you thinking about the low urine output?  Is this expected for this
client, or unexpected?
 
What actions do you take?
 

1 How will you answer the daughter's question about her pain medication
concern?
2 How will you address the daughter's question about her mother's behavior?

3 How will you intervene?

4 What are you thinking about the low urine output?  Is this expected for this
client, or unexpected?

5 What actions do you take?

 
As a healthcare provider, it is important to provide a medication education not just to Mrs.
Nelson, but also to her daughter Jane, since she is the significant other of the patient.
Effective education is a process that begins at treatment initiation and continues
throughout treatment. Family members, especially caregivers, frequently play important
roles in pain treatment and ought to be involved in educational efforts. Educational
approaches must be tailored to each patient's and significant other's needs. 
 
Approaches should consider in providing medication education to Jane:
 
Primary languages of Jane
Culture, gender, race/ethnicity, and age of Jane
Educational, general literacy, and health literacy levels of Jane
 
To enhance communication with Jane, I would use simple language and short sentences
and define technical terms. I would organize information so that the most important points
stand out and repeat this information.
 
While medical ethics place a high value on providing truthful information to patients,
disclosure practices are far from being the norm in many countries. Transmitting bad news
still remains a big problem that health care professionals face in their everyday clinical
practice. The patients' right to be fully informed of their medical condition, was based on
the individual s right of freedom to make decisions on his/her own behalf, without undue
manipulation by others. Being the significant other and daughter of the patient, I can
disclose the information of the patient to Jane. 
 
With regards to pain medication concerns, I will discuss with Jane the patient's condition
and the nature of the patient's chronic pain, the risks, and the benefits of treatment
options, common side effects of medication, their expected duration, and ways to manage
them, and the degree of pain relief the patient can realistically expect from treatment
among other things. 
 
Mrs. Nelson was exhibiting Terminal Restlessness, and this needs to be explained to
Jane. Terminal restlessness is a syndrome that may occur near the end of life. It is also
known as terminal agitation or terminal delirium. People who experience it show signs
of physical, emotional, and/or spiritual restlessness. These may include anxiety, agitation,
and cognitive decline in the days leading to death. Many of the behaviors are similar to
those seen in dementia, the decline of mental function often seen in older people. A dying
loved one may seem uncomfortable. They may constantly pull at their clothes, bedsheets
(like in the case of Mrs. Nelson - grabbing her bedding), and any intravenous (IV) lines.
 
It would be helpful if Jane understand the cause of terminal restlessness in relation to the
condition of her mother. I will explain to Jane the following most common cause of
terminal restlessness:
 

 Medications: Opioids for pain and drugs given to reduce anxiety often are used for
comfort at the end of life. They are known to increase the risk of delirium. If the
organs in a dying person's body have started to fail, the effects of drugs that lead to
delirium can be increased.
 Cancer treatments: Chemotherapy drugs and steroids are tough on the body. A
person who is dying is even more likely to experience the negative effects,
including restlessness.
 Poorly managed pain: Often, dying patients can't describe their pain. And even
with pain treatment, there is a careful balance that needs to be found. Overuse can
lead to toxicity, while under-use allows more pain and discomfort. This makes
terminal restlessness worse.
 Organ failure: As organs such as the liver and kidney begin to fail, changes in
body metabolism and chemistry may affect how the brain works. Heart and lung
failure, which are common in the days before death, lead to lower oxygen levels. All
of these effects will add to the terminal restlessness.
 Medical problems: Dehydration, anemia (decreased red blood cells), infections,
and fevers are all common when a loved one is dying. They weaken the body and
impair brain function, contributing to terminal restlessness.
 Bowel and urinary problems: Urinary retention (the inability to void urine) and
constipation are very common near the end of life. This is because the nerve and
muscle movements that control these functions are impaired. 4 Pain and severe
discomfort may result.
 An emotional response to dying: Often, terminally ill people are aware that they
are dying. As death nears, fear, anxiety, and emotional turmoil may arise. This may
include restlessness.

Concerning the low urine output and its tea color - low urine output is a symptom that
people who are sick and have lost too many liquids commonly experience.  Low urine
output, or no urine output, occurs in the setting of kidney failure and urinary obstruction.
As the kidneys fail or are compromised in their ability to function, the kidneys lose the
ability to regulate fluids and electrolytes and to remove waste products from the body. The
kidneys often gradually stop producing urine as death nears. As a result, urine will
become dark brown or dark red. Also, the amount of urine produced by the kidneys
decreases.
 
At this point in time, my role is to provide support to Jane by educating her on what she
might expect to happen during this time, addressing her questions and concerns honestly,
being an active listener, and providing emotional support and guidance.
 
 
 
 
 
 
 
 
 

The next time you visit (after the medication is administered) you note the
following changes: HR: 100 RR: 32 SpO2: 88% Auscultation sounds: with
course rales; alternate with SOB sounds (volume at 9) Unresponsive to name.
The daughter is worried-looking.  She states she is concerned about the shortness
of breath and the odd respirations she is hearing and seeing.  She asks, "What
can you do to make my mother more comfortable?"  Finally, she asks, "Will you
please contact my sister Jo and my mother's minister, John Christianson to let
them know mother seems to be getting worse?"
 

1 How will your response to the daughter's concerns:

2 What actions do you take?

 
In this situation, we must remember the phases of dying. Dying is a process. It involves
the cessation of physical, psychological, social, and spiritual life here on earth. What
happens beyond death is unknown to those reading this book. Typically, before a person
dies, there is a cascade of events that are collectively known as the dying process. The
dying process is the transition that a person goes through that ultimately ends in death.
Each person's dying process and death is individual to that person. Dying is an
individualized experience and each person dies in their own way and time (ELNEC,
2010). 
 
Before addressing Jane's question concerning her mother's respiration, I acknowledged
the fact that Jane knew that death is approaching her mother. She asked to contact her
sister Jo and her mother's minister. This was a sign that Jane was preparing for the
inevitable event as evidenced by her mother's odd respiration. Now as a health care
provider, perhaps it would Jane understand more if I explain the cause of her mother's
respiration characteristics.  When a person is just hours from death, we will notice
changes in their breathing:
 
  The rate changes from a normal rate and rhythm to a new pattern of several rapid
breaths followed by a period of no breathing (apnea). This is known as Cheyne-
Stokes breathing—named for the person who first described it.
 Coughing and noisy breathing are common as the body's fluids accumulate in the
throat. This breathing is often distressing to caregivers but it does not indicate pain
or suffering. The secretion that causes this sound can often be dried up with the
use of certain medicines, such as atropine or scopolamine. Sometimes a vaporizer
can ease breathing. You may also want to try repositioning your loved one to his or
her side, which can help diminish the sound of noisy breathing.

Again, at this point in time, my role is to provide support to Jane, by respecting her
request and helping her to contact her sister and her mother's minister, by educating her
on what she might expect to happen during this time, addressing her questions and
concerns honestly, being an active listener, and providing emotional support and
guidance.
 
 
A few hours later, you round on  Sally. You observe the following
changes: HR: 60 BP: 40 palpable RR: 8 with a period of apnea for 20 seconds
(Cheyne-Stokes pattern) (volume at 9) Auscultation sounds: breathing becomes
more shallow and at times she seems to stop breathing DEATH: HR: 40
decreasing to absent RR: 6 decreasing to absent
 
The daughter asks, "What is happening? Is it the end? Did my mother just die? I
think she just died. Can my children come in and see their grandmother before the
people from the mortuary come?"
 
1 How do you respond to Jane?

2 How do you answer her questions?

3 What actions do you take?

 
As we explained earlier, Mrs. Nelson was exhibiting Cheyne-Stokes' pattern of respiration.
At this stage, death reached Mrs. Nelson. As health care providers, we cannot with 100%
certainty ensure that each of our patient's dying processes will go smoothly without any
problems. Advanced illnesses and diseases that are terminal differ in the way they
progress from person to person. An intervention that works well for one person dying of
cancer might not work for another person. 
 
Witnessing a patient's death without the resuscitation process can be difficult for the nurse
or clinician, as we have been trained to do everything possible not to cause or contribute
to a patient's death. In end-of-life care, death is the expected outcome of the care we
provide, and as health care providers we want to ensure that the patient has as "good" a
death as possible and that they have died in the manner they wished.
 
As mentioned before, respirations can become quite erratic, very shallow with extended
periods of apnea in between breaths. The moment will come in which Mrs. Nelson's chest
will not rise again. This time period can seem like an eternity for the family and to us
health care providers. 
 
In handling this kind of situation, we must take extreme caution when determining whether
or not the last breath has been taken. Extended periods of apnea close to death can last
up to a minute or more. We must be certain that death has occurred before proceeding to
assess for signs of life. Typically the patient's mandible will drop and almost a sudden
pallor will appear. The pulse in the carotid artery may still be palpable, although very faint
and thready until the heart catches up with the absent respirations. This may take a
minute or two. We must be sure to listen for a heartbeat with a stethoscope for a full
minute. 
 
In hospice this is performed for two reasons: to ensure that the patient has died, and also
to provide the family with the extra peace of mind knowing that their loved one is really
gone. We must never fail to assess for signs of life, including heartbeat, respiration, and
pupil status by checking the patient's pupils with light for fixation and dilation. As a health
care provider, I should make sure that the patient is covered with a light sheet up to below
the shoulders. It is atypical for the deceased patient to be completely covered including
face and head, so I must refrain from doing so unless otherwise directed by the family.
 
Following the death of Mrs. Nelson, we must offer our condolences to Jane and her family
and extend assistance with contacting any other family members or individuals the family
requests. Depending on the location of the death, we should contact the medical examiner
to notify them of the death, as well as the physician and other clinicians who were
involved with the patient. We can also contact the funeral home for the family as
requested.  And we must maintain the highest dignity and respect for the deceased
patient during this post-mortem care.
 
 
Major symptoms related to the dying process are no urine output, death rattle,
withdrawing, shallow respiration, apneic spells, cool, pale mottled skin. The goal of
therapy is comfort and support of client and family as end of life approaches.
Effective hospice management includes referrals, therapeutic communication,
medication administration, and non-pharmacologic comfort interventions, the
pronouncement of death, and proper notification of MD, agencies, and others as
needed.
 
 
Debriefing / Guided Reflection Questions for this Simulation:
 
How would you feel if a patient or family member asked you to pray?
 
As health care providers, we may be asked by patients or the family to pray with
them or for them. Whether health care providers should pray with patients has
been a matter of longstanding controversy.  Yet decades of research show that
many of our patients want us to pray with them. Prayer may benefit both the
health care provider and the patient; both may find comfort in prayer. Prayer may
also help patients and their families adjust emotionally to their illness or life events
and support the patients' spiritual health.
 
When a patient or the family asks to pray, we recommend talking with the patient
and family members to determine their prayer preference before starting to pray. 
Some patients will want to pray silently.  Some patients will want the health care
provider to be present while they say a prayer out loud.  Others will want them to
lead them in prayer. Some will want to pray now, others may want the health care
provider to keep them in their prayers.
 
Regardless of the faith tradition or practices of the patient, family, or health care
provider; the moments taken to pray may provide comfort and renewal for all
present.  We must encourage to adapt these prayers and take the time to pray
today.
 
What could you say that would be comforting but not reflect any specific
religion? 
 
As health care providers, we have the honor of taking care of the most vulnerable
populations. This includes patients and loved ones who experience loss. It is
important to assess characteristic signs of grief and loss and address them
appropriately. It is important for the health care provider to start this process by
building rapport with the patient and any present loved ones. Encourage them to
speak, openly and honestly, about their emotional and physical feelings. Utilize
active listening skills and provide a nonjudgmental environment.
 
It is important for the health care provider to assist the patient and loved ones in
their coping with their grief to include anticipatory grief. Educate them on what is
expected to include the stages of grief and what are some normal feelings as well
as what are some resources to help adjust to this loss they are experiencing.
Evaluate how they are handling this experience and address any fears related to
grief and loss.
 
One of the most important goals of the health care provider is to validate the
experience and feelings of the bereaved family by encouraging them to tell their
stories and listen with care. At the very least, the health care provider should
acknowledge the loss with a simple but sincere comment, such as, "I am sorry."
The initial impulse may be to reduce one's sense of helplessness and to say or do
something that you think will reduce their pain.
 What did you notice about your patient, respiratory status, overall status
through your shift?
 
Based on what I had observed from my patient (including personal experience), as
a person is dying they will have less energy and become easily tired. They are
likely to become weaker and may spend more time asleep.
They may become detached from reality, or unaware of what is happening around
them. They may be less interested in eating and drinking. There are some
common indicators that death may be near, within days or weeks. Usually, the
following signs will be present:
 

 spending large amounts of the day in bed

 being unable to move from bed to chair without help
 difficulty swallowing solid food
 sleeping for many hours
 not talking very much
 occasional confusion with time, the past, and with people
 restlessness
 being unable to ask to go to the toilet
 changes in breathing

Did you have sufficient knowledge to interpret and respond to this

situation?

Yes, as a health care provider, I am expected to have the knowledge on

determining the characteristics of a dying patient and the skills to render the
appropriate management. The most common signs and symptoms before death
include increased pulse/respiratory rate, Cheyne-Stokes respirations, cool/mottled
skin, and decreased urine output. Again, as I explained earlier: We must take
extreme caution when determining whether or not the last breath has been taken.
Extended periods of apnea close to death can last up to a minute or more. Be
certain that death has occurred before proceeding to assess for signs of life.
Typically the patient's mandible will drop and almost a sudden pallor will appear.
The pulse in the carotid artery may still be palpable, although very faint and
thready until the heart catches up with the absent respirations. This may take a
minute or two. Be sure to listen for a heartbeat with a stethoscope for a full minute.
In hospice this is performed for two reasons: to ensure that the patient has died,
and also to provide the family with the extra peace of mind knowing that their
loved one is really gone. Never fail to assess for signs of life, including heartbeat,
respiration, and pupil status by checking the patient's pupils with light for fixation
and dilation.
 
Based on your observations, what was the highest priority for the patient?
And what other concerns did you have about this patient?
 
Watching someone you love die is hard enough, but thinking that person is also in
pain makes it worse. Not everyone who is dying experiences pain, but there are
things you can do to help someone who does. Experts believe that care for
someone who is dying should focus on relieving pain without worrying about
possible long-term problems of drug dependence or abuse. Pain is easier to
prevent than to relieve, and severe pain is hard to manage. We must try to make
sure that the level of pain does not get ahead of pain-relieving medicines.
 
My next priority would be the breathing problems. Shortness of breath or the
feeling that breathing is difficult is a common experience at the end of life. People
very near death might have noisy breathing, sometimes called a death rattle. This
is caused by fluids collecting in the throat or by the throat muscles relaxing. It
might help to try turning the person to rest on one side. There is also medicine that
can be prescribed that may help clear this up. Not all noisy breathing is a death
rattle. It may help to know that this noisy breathing is usually not upsetting to the
dying person, even if it is to family and friends.
 
Followed by the stabilization of respiratory patterns. Breathing will change as the
patient approaches the end of life, with breathing becoming slow and shallow or
rapid and shallow. Periods of apnea or increased work of breathing are common
but do not necessarily indicate dyspnea, and need not be treated unless it is
distressing to the patient. We must advise the family that breathing changes may
occur, but generally do not cause distress in the patient.
 
Also, the respiratory secretions. The patient often has impaired ability to swallow
at the end of life and cannot clear secretions. These secretions can accumulate
and lead to gurgling or rattling sounds. This most often occurs when the patient is
only minimally conscious or unconscious and does not cause the patient any
distress. We must position the patient on their side with the upper body elevated
to allow secretions to passively drain out of the mouth. Reduce or stop artificial
(IV) fluids or nutrition (IV or NG), since this will worsen this symptom. Suctioning is
not usually helpful and may be distressing to the patient. Consider suctioning only
if thick mucus or blood is present in the mouth and can easily be removed with a
soft catheter.
 
What were your priorities in responding to the patient?
 
My personal take is - comfort care is an essential part of medical care at the end
of life. It is care that helps or soothes a person who is dying. The goals are to
prevent or relieve suffering as much as possible and to improve the quality of life
while respecting the dying person's wishes. Generally speaking, people who are
dying need care in four areas - physical comfort, mental and emotional needs,
spiritual issues, and practical tasks. Their families need support as well. Care of
the dying patient generally refers to care in the last days or hours of life. My goals
of care during the last hours and days of life are to ensure comfort and dignity
 
How did you prioritize your care?
 
In providing care for this patient,  my utmost priority is to facilitate good death,
which means ensuring that patients' preferences are met and symptoms are
managed through the use of open communication.
 
The goal at this stage is comfort, not to reverse the underlying cause of the
symptom. One of the most important things we can do for patients who are dying
is to provide the best possible care for them and their families during the last
phase of life through death. This is particularly important during the "imminent"
phase. This is the phase that precedes the actual death and is also the time when
the patient typically loses consciousness. The care that I provide during this phase
will affect the family's memories of their loved one's final days and hours on earth.
It is vital that I performed thorough assessments, rapid response to changes in
status, rapid titration of medications, and timely discontinuation and introduction of
interventions aimed to promote comfort.
 
How did you feel about giving the pain medication at the doses ordered for
the client? Were there any medications that surprised you, or any
medications you thought might be prescribed that were not? How did you
address the daughter's concern that the pain medication might hasten her
mother's death?

In the case given, it was sad to know the medical regimen that was supposedly
providing comfort to the patient was affecting the patient the other way around. As
I explained earlier, the side effects of the prescribed medications can further
jeopardize the patient's condition. Again, to mention the Acetaminophen (Tylenol)
prescription to Mrs. Nelson. The health care provider prescribed PO tablets
Acetaminophen (Tylenol) 650 mg every 4 hours PRN fever/ mild pain to Mrs.
Nelson. This needs to be reviewed considering the physical state of Mrs. Nelson.
If we are going to calculate it, Mrs. Nelson was taking 650 mg of Tylenol every 4
hr in a day, and as needed whenever she had a fever or was in pain. This
constituted approximately 3,900 mg of Tylenol consumption in a day. And we
mentioned earlier that older adults must NOT take more than 3000 mg of
acetaminophen in one day. In high doses, acetaminophen can cause serious or
fatal liver damage.
 
In the course of her treatment,  the patient and her legal guardian/daughter has a
right to be informed of the result of the evaluation of the nature and extent of her
disease,  any other additional or further contemplated medical treatment on
surgical procedure or procedures, including any other additional medicines to be
administered and their generic counterpart including the possible complications.
 
In addressing the daughter's concern, as the family and significant other of the
patient, I disclosed to her the information of the prescription by providing pain
 medication information. The patient, as well as her daughter, are entitled to know
about her condition and every aspect of her treatment.
 
What is the most important thing you learned from this case?
 
Personally, If was the "real" nurse of the patient, I would exercise my professional
right and responsibility to review the physician's order. I am legally and ethically
bound to question an inappropriate order from a physician. In fact, many actions
described in physician's orders are simply nursing practices that are fundamental
to health maintenance: turn and position every two hours, oral hygiene, side rails
up.
 
Nurses have an ethical duty to be members of collaborative teams.
Communication, consultation, and interdisciplinary cooperation are the
benchmarks for quality outcomes. We are not a lesser profession to order around.
The language we use in everyday practice reflects how we perceive ourselves and
how our colleagues and the public perceive and speak about us. We are licensed
professionals, educators, leaders, lifesavers, and most of all, nurses.
 
Concerning providing care to the dying patient, again, one of the most important
things that a health care provider can do is to provide care for the family during
this time and remember that although you may not remember what care you
provided, the family will remember every second that took place during that time. If
there are things that they witnessed that were distressful, that could negatively
impact the perception of their loved one's death. If their concerns were addressed
and the patient was kept as comfortable as possible, that will positively impact the
perception of their loved one's death.
 
What are your thoughts about hospice care and hospice nursing?
 
HOSPICE CARE
 
Increasingly, people are choosing hospice care at the end of life. Hospice care
focuses on the care, comfort, and quality of life of a person with a serious illness
who is approaching the end of life. At some point, it may not be possible to cure a
serious illness, or a patient may choose not to undergo certain treatments.
Hospice is designed for this situation. The patient beginning hospice care
understands that his or her illness is not responding to medical attempts to
cure it or to slow the disease's progress.
 
Like palliative care, hospice provides comprehensive comfort care as well as
support for the family, but, in hospice, attempts to cure the person's illness are
stopped. Hospice is provided for a person with a terminal illness whose doctor
believes he or she has six months or less to live if the illness runs its natural
course. It is important for a patient to discuss hospice care options with their
doctor. Sometimes, people do not begin hospice care soon enough to take full
 advantage of the help it offers. Perhaps they wait too long to begin hospice and
they are too close to death. Or, some people are not eligible for hospice care soon
enough to receive its full benefit. Starting hospice early may be able to provide
months of meaningful care and quality time with loved ones.
 
Hospice is an approach to care, so it is not tied to a specific place. It can be
offered in two types of settings - at home or in a facility such as a nursing home,
hospital, or even in a separate hospice center. Hospice care brings together a
team of people with special skills - among them nurses, doctors, social workers,
spiritual advisors, and trained volunteers. Everyone works together with the
person who is dying, the caregiver, and/or the family to provide the medical,
emotional, and spiritual support needed.
 
When and Why Hospice Care?
 
Hospice care may be considered for anyone whom doctors believe to have a life
expectancy of fewer than six months. Usually, at this point, active treatment aimed
at recovery stops, and hospice care is initiated. Hospice care focuses on
producing the best possible quality of life in the patient's remaining time. The most
common of these diseases or conditions of hospice patients include ALS, cancer,
dementia, heart disease, HIV, kidney disease, liver disease, lung disease,
Parkinson's disease, stroke, and coma. 
 
Terminal Cancer as an example
 
Terminal cancer refers to cancer that cannot be cured or treated. It is sometimes
also called end-stage cancer. Any type of cancer can become terminal cancer.
Terminal cancer is different from advanced cancer. Like terminal cancer,
advanced cancer is not curable. But it does respond to treatment, which may slow
down its progression. Terminal cancer does not respond to treatment. As a result,
treating terminal cancer focuses on making someone as comfortable as possible.
Generally, terminal cancer shortens someone's life expectancy. But someone's
actual life expectancy depends on several factors, including:
 

 The type of cancer they have

 Their overall health
 Whether they have any other health conditions

As part of hospice care, palliative care looks at how the cancer experience is
affecting the whole person and helps to relieve symptoms, pain, and stress. It
gives patients options and allows them and their caregivers to take part in
planning their care. It is about assuring that all their care needs are addressed.
The specialized professionals who are part of the hospice care team can help look
for and manage mental, physical, emotional, social, and spiritual issues that may
come up.
 
Roles Nurses Play
 
Within the hospice care setting, the looming reality of a patient's death can be
extremely hard for both patients and family members to accept. This is the time
when many difficult decisions must be made regarding treatments that will benefit
the patient in their last weeks or months, often bringing quality of life concerns into
play. According to the American Nurses Association, nurses step in at this time to
provide guidance for patients and families confronting those tough decisions and
helping them adapt to painful realities.
 
Nurses are oftentimes a sole source of support at this delicate time. Families are
often confused, scared, and overwhelmed at this juncture. They are receiving the
facts from doctors about medications, treatments, and timelines, but often look to
nurses to lean on for emotional support once the doctor has left the room.
Therefore, nurses are there to help the patient and family as they struggle to
adjust to the reality they are facing. The nurse's primary responsibility is to the
patient and makes sure their wishes are honored. These wishes are not always in
accordance with the family's wishes. That is where the role of hospice nurse gets
tricky. They must maintain a focus on the patient's preferences and respect
their autonomy while at the same time supporting the family as they
navigate a process they have likely never been through before. Nurses must
be skilled in pain management to ensure their patients remain as comfortable as
possible. In addition to disease management, they must also attend to the
psychological, interpersonal, and spiritual needs of the patient as well.
 
Hospice nurses focus solely on end-of-life care, providing hands-on nursing care
around the clock - either in a facility or in the patient's home. Because each patient
and family both have a unique perspective concerning end-of-life needs, it
becomes the job of the hospice nurse to make cultural assessments and adjust
care accordingly. 
 
The duties of a hospice nurse that we do not see in brochures or lists of services
on websites are the other side of care, the softer side. The side that involves
sometimes simply doing nothing at all. When all other tasks are done - blood
pressure taken, sponge bath given, meds administered, nurses often sit by their
patients' side, hold their hand, rub their arms, look them in the eye, share stories
about growing up, and generally just be there for them. That is the side of hospice
nurses that makes them special. The dying process is often long and bewildering,
lonely and painful, oftentimes undignified, and fraught with the unknown. Hospice
nurses jump into the fray to provide that meaningful connection and ease the
transition from life to death.