END OF LIFE CARE

Dr Indranil Ghosh
Role of the nurse in providing quality end-of-life care for cancer
patients and their families.
NURSES’ UNIQUE QUALIFICATIONS TO
PROVIDE END-OF-LIFE CARE
 Holistic view
 Comprehensive
 Effective
 Compassionate
 Cost effective
NURSES’ INVOLVEMENT IN END-OF-
LIFE CARE
 Spend the most time with patients and their family
members at the end-of- life than any other member of the
healthcare team
 Provide education, support, and guidance throughout the
dying process
NURSES’ INVOLVEMENT IN END-OF-
LIFE CARE
 Advocate for improved quality of life for the person with
serious illness
 Attend to physical, emotional, psychosocial, and
spiritual needs of the patient
NURSES WHO HELP THE PATIENT DIE
COMFORTABLY AND WITH DIGNITY
PROVIDE THE FOLLOWING BENEFITS OF
GOOD NURSING CARE:

 Attend to pain and symptom control

 Relieve psychosocial distress

 Coordinate care across settings with high-quality

communication between healthcare providers
 Prepare the patient and family for death
NURSES WHO HELP THE PATIENT DIE
COMFORTABLY AND WITH DIGNITY
PROVIDE THE FOLLOWING BENEFITS OF
GOOD NURSING CARE:

 Clarify and communicate goals of treatment and values

 Provide support and education during the decision-
making process, including the benefits and burdens of
treatment
NURSES WHO CARE FOR THE DYING
 Are well educated
 Have appropriate supports in the clinical setting
NURSES WHO CARE FOR THE DYING
 Must be confident in their clinical skills
 Are aware of the ethical, spiritual, and legal issues they
may confront while providing end-of-life care
NURSES NEED TO BE AWARE OF
PERSONAL FEELINGS ABOUT DEATH
 Improves ability to meet holistic needs of the patient and
family
 Clarifies one’s own beliefs and values
MEANING OF HOPE SHIFTS
 From striving for cure to achieving relief from pain and
suffering
 No “right” or “correct” way to die: It's everybody's right
to live independent and die with dignity
 Recognize changes in demographics, economics, and service
delivery that require improved nursing interventions at the end of
life.
CHANGING STATISTICS
 Primary cause of death
 10 leading causes of deaths in India
 Cardiovascular Diseases
 Diarrheal Diseases
 Neonatal Disorders
 Non-communicable Diseases
 Chronic Respiratory
 Diabetes
 Mental Disorders
 Unintentional Injuries
 Neoplasms
 Nutritional Deficiencies
CHANGING STATISTICS
 Demographic trends
 Today,more deaths occur at home
 The average life expectancy at birth: W 70/M 67 yrs

 Social trends
 Today, caregivers are more likely to be professionals rather
than family members
MOST AMERICANS PREFER TO DIE AT
HOME
 50% die in hospitals
 25% die in long-term-care facilities

 20% die at home or the home of a loved one

 5% die in other settings

SURVEY RESULTS OF HEALTHCARE
SYSTEM CARE OF DYING PEOPLE
 Excellent: 3%
 Very good: 8%

 Good: 31%

 Fair: 33%

 Poor: 25%
BARRIERS TO QUALITY END-OF-LIFE
CARE
 Failure of healthcare providers to acknowledge the limits
of medical technology
 Lack of communication among decision makers

 Disagreement regarding the goals of care

 Failure to implement a timely advance care plan

BARRIERS TO QUALITY END-OF-LIFE
CARE
 Lack of training about effective means of controlling
pain and symptoms
 Unwillingness to be honest about a poor prognosis
 Discomfort telling bad news
 Lack of understanding about the valuable contributions
to be made by referral and collaboration with
comprehensive hospice or palliative care services
Describe how pain and presence of adverse symptoms affect the
dying process.
NURSE’S ROLE IN PAIN TREATMENT
 Initial and ongoing assessment of levels of pain
 Administration of pain medication

 Evaluation of effectiveness of pain medication

HOW NURSES CAN ALLEVIATE THE
DISTRESS ASSOCIATED WITH
UNTREATED PAIN
 Ongoing assessment of levels of pain
 Administration of pain medication

 Evaluation of the effectiveness of the pain management

plan
NEGATIVE OUTCOMES OF PAIN
 Potential to hasten death
 Associated with needless suffering at the end of life

 People in pain do not eat or drink well

 Inability to engage in meaningful conversations with

others
 Isolation in order to save energy and cope with the pain
sensation
REASONS FOR UNDERTREATMENT OF
PAIN
 Patient’s inability to communicate due to
 Delirium
 Dementia
 Aphasia(speechless)
 Motor weakness
 Language barriers
CAUSES OF INADEQUATE CARE AT END
OF LIFE
 Disparity in access to treatment
 Insensitivity to cultural differences
 Attitudes about death
 Attitudes about end-of-life care
 Some prefer aggressive life-sustaining treatments
 Some prefer less aggressive treatment
CAUSES OF INADEQUATE CARE AT END
OF LIFE
 Mistrust of the healthcare system
 Pain is subjective and self-report is considered accurate
PAIN DURING THE DYING PROCESS
 Acute
 Sudden onset
 Usually associated with single cause or event
PAIN DURING THE DYING PROCESS
 Chronic
 Associated with long-term illness
 Always present
 Varies in intensity
 Tolerance to pain develops
 Associated factors
 Depression
 Poor self-care

 Decreased quality of life

PAIN DURING THE DYING PROCESS
 Neuropathic pain
 Nerves are damaged
 Burning, electrical, or tingling sensations
 Deep and severe

 Nociceptive pain
 Tissueinflammation or damaged tissues
 Cardiac ischemia
PAIN DURING THE DYING PROCESS
 Unrelieved pain during the dying process
 Hastens death
 Increases physiological stress
 Diminishes immuno-competency

 Decreases mobility

 Increases myocardial oxygen requirements

 Causes psychological distress to the patient and family

 Suffering
 Spiritual distress
Diverse settings for end-of-life care and the role of the nurse in
each setting.
PALLIATIVE CARE
 Philosophy of care
 Highly structured system for care delivery
EMPHASIS OF SUPPORTIVE CARE
DURING THE DYING AND
BEREAVEMENT PROCESS
 Quality of life
 Living a full life up until moment of death
PALLIATIVE CARE SETTINGS
 Hospitals
 Outpatient clinics

 Long-term-care facilities

 Home
PALLIATIVE CARE VS HOSPICE CARE
 Who definition
 Palliative care is an approach that improves the quality of life
of patients and their families facing the problem associated
with life-threatening illness, through the prevention and relief
of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems,
physical, psychosocial and spiritual.
 is applicable early in the course of illness, in conjunction with
other therapies that are intended to prolong life, such as
chemotherapy or radiation therapy
HOSPICE CARE
 Hospice care focuses on the quality of life rather than its
length. It provides humane and compassionate care for
people in the last phases of incurable disease so that they
may live as fully and comfortably as possible.

 Hospice care is used when patient can no longer be

helped by curative treatment and are expected to live
about 6 months or less
HOSPICE CARE
 Focuses on the whole person
 Mind
 Body
 Spirit

 Support and care

 Patients
 Family and caregivers
 Continues after death of a loved one
HOSPICE CARE
 Multidisciplinary team of professional caregivers
 Nurse
 Manages pain and controls symptoms
 Assesses patient and family abilities to cope

 Identifies available resources for patient care

 Recognizes patient wishes

 Assures that support systems are in place

HOSPICE CARE
 Multidisciplinary team of professional caregivers
 Physician
 Pharmacist
 Social workers
 Others
 Last phase (6 months) of incurable disease
 Live as fully and comfortably as possible
HOSPICE SETTINGS
 Freestanding
 Hospital

 Home health agencies with home care hospice

 Home

 Nursing home or other long-term-care settings

Pharmacological and alternative methods of treating pain.
ADMINISTER PAIN MEDICATION
ROUTINELY
 Prevent breakthrough pain and suffering
 Long-acting drugs provide consistent relief
 Chronic pain
 Short-acting or immediate release agents for prn use
 Acute pain
ANTICIPATE AND TREAT ADVERSE
EFFECTS OF PAIN MEDICATION
 Nausea
 Constipation
PAIN CONTROL AT THE END OF LIFE
 Non-opioids for mild to moderate pain
 Acetaminophen
 NSAIDs
PAIN CONTROL AT THE END OF LIFE
 Opioids
 Codeine
 Morphine is gold standard
 Hydromorphine
 Fentanyl
 Methadone
 Oxycodone
 Adjuvant analgesics
 Enhance effectiveness of other drug classes
 Muscle relaxants
 Corticosteroids

 Anticonvulsants

 Antidepressants

 Topical

 Useful for treatment with lower doses and less side effects
ROUTES OF ADMINISTRATION
 Oral
 Forpatient who can swallow
 Requires higher dosage
 Oral mucosa or sublingual
 Forpatients with difficulty swallowing
 May require more frequent administration
 Rectal
 For patients with difficulty swallowing or problems with
nausea and vomiting
 Patient needs to be able to reposition easily
ROUTES OF ADMINISTRATION
 Transdermal
 Delivers 72 hours of pain medication
 Topical
 For pain as a result of herpes, arthritis, or local invasive procedures
 Parenteral
 For patients who cannot swallow
 Epidural or intrathecal
 Use if unable to achieve pain control by other methods
MULTIPLE APPROACHES TO MANAGE
ADVERSE REACTIONS TO PAIN
MEDICATION
 Identify when pain is most severe
 Initiate constipation treatment at time opioids are started

 Keep patient warm

 Encourage music listening

 Visit with spiritual advisor

MULTIPLE APPROACHES TO MANAGE
ADVERSE REACTIONS TO PAIN
MEDICATION
 Provide comfort measures
 Back rub
 Position change
 Warm milk
ALTERNATIVE PAIN MANAGEMENT
APPROACHES
 Acupuncture
 Massage therapy

 Reiki therapy: a combination of all other alternative

therapeutic methods
 Chiropractors: is a health care discipline and profession
that emphasizes diagnosis, treatment and prevention of
mechanical disorders of the musculoskeletal system,
especially the spine
 Herbal medications
ADVERSE EFFECTS OF ANALGESIC
MEDICATIONS
 Constipation
 Respiratory depression

 Nausea and vomiting

 Myoclonus: is brief, involuntary twitching of a muscle or

a group of muscles
 Pruritis
Identify the signs of approaching death.
BODY CHANGES INDICATING
IMPENDING DEATH
 Circulation
 Mottling of lower extremities
 Mottling is sometimes used to describe uneven discolored
patches on the skin of humans as a result of
cutaneous ischemia (lowered blood flow to the surfaces of the
skin).
 Pulmonary
 “Death rattle”: s a medical term that describes the sound
produced by someone who is near death when saliva
accumulates in the throat
 Cheyne-Stokes respirations: is an abnormal pattern of
breathing characterized by progressively deeper and
sometimes faster breathing, followed by a gradual decrease
that results in a temporary stop in breathing called an apnea
BODY CHANGES INDICATING
IMPENDING DEATH
 Skin
 Clammy
 Dusky, gray coloration
 Eyes
 Discolored
 Deeper set
 Bruised appearance
DISCUSS THE DEATH PROCESS AND
REASSURE THOSE PRESENT
 Support family decisions to be present or to leave
 Reinforce that the dying process is as individualized as
process of living
Nursing interventions when caring for the dying.
END-OF LIFE CARE
 Care given to people who are near the end of life and
have stopped treatment to cure or control their disease.
CORE PRINCIPLES FOR END-OF-LIFE
CARE
 Respect the dignity of patients, families, and caregivers
 Display sensitivity and respect for patient and family
wishes
 Use appropriate interventions to accomplish patient
goals
 Alleviate pain and symptoms
 Assess, manage, and refer psychological, social, and
spiritual problems
CORE PRINCIPLES FOR END-OF-LIFE
CARE
 Offer continuity and collaboration with others
 Provide access to palliative care and hospice services

 Respect the rights of patients and families to refuse

treatments
 Promote and support evidence-based clinical practice
research
MUCOSAL AND CONJUNCTIVAL CARE
 Provide oral hygiene several times a day
 Ice chips to relieve the feeling of dry mouth can be used
as long as the swallowing reflex is present
 Soothing ointments or petroleum jelly may be used on
the lips
 Lack of dentures makes speech and swallowing difficult
MUCOSAL AND CONJUNCTIVAL CARE
 Disease processes contribute to halitosis and thrush
 Halitosis:is a term used to describe noticeably unpleasant
odors exhaled in breathing
 Artificial tears: are lubricant eye drops used to treat the
dryness and irritation associated with deficient tear
production
 Ophthalmic saline solutions

 Opened eyes become easily irritated

ANOREXIA AND DEHYDRATION
 Patients may choose to stop eating and drinking
 Anorexia may result in ketosis, leading to a peaceful
state of mind and decreased pain
 Initiation of parenteral or enteral nutrition neither
improves symptom control nor lengthens life
SKIN CARE
 Monitor skin changes
 Edema
 Bruising
 Dryness
 Venous pooling
 Avoid shearing forces
 Reposition frequently
 Gentle massage or lotion application may be provided by
the family
INCONTINENCE CARE
 Bowel and bladder incontinence frequently occurs at the
end of life
 Provide protective pads

 Apply barrier cream

 Encourage change of position

 Discourage the use of indwelling catheters

TERMINAL DELIRIUM
 Can be distressing to family or caregivers
 Presents as “confusion, restlessness, and/or agitation,
with or without day-night reversal”
 Visual, auditory, and olfactory hallucinations may occur
during this time
 Is often irreversible and may vary from patient to patient
TERMINAL DELIRIUM
 Management techniques include identifying underlying
cause, reducing stimuli and anxiety, and discontinuing
all nonessential medications
TYPE AND LEVEL OF CARE AT THE END
OF LIFE
 Comfort measure only
 Use of feeding tubes

 Euthanasia is illegal

 Euthanasia refers to the practice of ending a life in a

manner which relieves pain and suffering
Family support during the grief and bereavement period.
ALLEVIATE PATIENT AND FAMILY
FEARS AND ANXIETIES
 Prior to death
 Maintain hope for the patient and family
 After death
 Reliefstatements
 Rationalizations
 Educate about mourning and bereavement
EXPRESSIONS OF GRIEF
 First phase: “numb shock”: the feeling of distress and
disbelief that you have when something bad happens
accidentally; "his mother's death left him in a daze"; "he
was numb with shock"
 Second phase: emotional turmoil or depression

 Third phase: reorganization or resolution

CARING FOR THE CAREGIVER
 What have I done to meet my own needs today?
 Have I laughed today?

 Did I eat properly, rest enough, exercise, and play today?

 How have I felt today?

 Do I have something to look forward to?

THANK YOU