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Chapter 41
End of Life Care
Definitions of Death
• United Nations Vital Statistics: death is the
permanent disappearance of every vital sign.
• Brain Death: the death of brain cells determined by a
flat electroencephalogram [EEG].
• Somatic Death: determined by the absence of cardiac
and pulmonary functions.
• Molecular Death: determined by the cessation of
cellular function.
Family Experiences with Death
• Past
– Most births and deaths occurred in the home and
were viewed as a natural process.
– Dying individuals could be surrounded by and cared
for by loved ones in the comfort of their homes.
• Present
– Lowered mortality rates and mobile nuclear families
have reduced family experience with death and end
of life care.
Family Experiences with Death (cont.)
– Most deaths occur in hospital and institutional
settings, not the home.
– The separation of individuals from their loved ones
during the dying process can be stressful.
Goals of Hospice Care
• Pain relief
• Symptom control
• Coordinated home care and institutional care
• Bereavement follow-up and counseling
Kubler-Ross Stages of Dying
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
Physical Care Needs of the Dying Patient
• Pain relief
• Respiratory distress
• Constipation
• Poor nutritional intake
Pain Management for the Dying Patient
• Assess pattern and severity of pain.
• Recommend patient takes analgesic on regular basis.
• Assess patient’s understanding of the analgesic.
• Consider the impact of psychological factors on physical
pain.
• Use nonpharmacologic pain relief measures.
Clues to the Presence of Pain
• Sleep disturbances
• Reduced activity
• Diaphoresis
• Pallor
• Poor appetite
• Grimacing
• Withdrawal
Alternative to Pain Medications
• Guided imagery
• Hypnosis
• Relaxation exercises
• Massage
• Acupressure
• Acupuncture
Alternative to Pain Medications (cont.)
• Therapeutic touch
• Diversion
• Application of heat or cold, even
Interventions for Respiratory Distress
• Elevating the head of the bed
• Administering oxygen
• Administering atropine or furosemide
• Using narcotics
Measures to Promote Nutritional Intake
• Assisting with oral hygiene
• Offering a clean and pleasant environment for dining
• Providing pleasant company during mealtime
• Assisting with feeding as necessary
Questions to Assess for Spiritual Needs
• What gives you the strength to face life’s challenges?
• Do you feel a connection with a higher being or spirit?
• What gives your life meaning?
Signs of Imminent Death
• Decline in blood pressure
• Rapid, weak pulse
• Dyspnea and periods of apnea
• Slower or no pupil response to light
• Profuse perspiration
• Cold extremities
Signs of Imminent Death (cont.)
• Bladder and bowel incontinence
• Pallor and mottling of skin
• Loss of hearing and vision
Stages of Family Acceptance of Death of
Loved One
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
Edwin Schneidman: Working with Family
of Deceased
• Total care of a dying person includes contact and rapport
with the survivors-to-be.
• It is best to begin work with survivors as soon as
possible after the tragedy.
• Remarkably little resistance is met from survivor-victims.
• The role of negative emotions toward the deceased
needs to be explored, but not at the beginning.
• The professional plays the important role of reality tester.
• Medical evaluation of the survivors is crucial.
Source
• Eliopoulos, C. (2005). Gerontological Nursing, (6th
ed.). Philadelphia: Lippincott, Williams & Wilkins (ISBN
0-7817-4428-8).