Transcript File

End of Life Care
Nursing Essentials
Standards
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HS-NE- 12: Basic Nursing Assistant Skills
The student will perform basic nursing skills
within the scope of practice for a nursing
assistant while maintaining
resident/patient/client rights. Beginning and
ending procedures will be performed with all
resident/patient/client care.
HS-NE-12-i:
Demonstrate the care of the
resident when death is imminent
and post-mortem care
Death and Dying
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We’ll answer all these questions and
more…
What are the stages of grieving?
What are the physical changes that occur
as death approaches?
What is the CNA’s role in caring for the
dying patient?
How does Hospice help with end of life
care issues?
How does a CNA perform postmortem
care?
Stages of Death
 Identified
by Dr. Kubler-Ross
 Medical personnel are now feeling
that patients should be told of their
approaching deaths, while still
leaving them with “some hope”
and letting them know that they
are not alone.
Stages of Death
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Denial
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Usually happens
first
“No, not me!”
“The doctor doesn’t
know what he’s
talking about!”
Provide support
without confirming
or denying their
statements
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Anger
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“Why me?”
Place blame on
others
Become hostile and
bitter
Respond to
patient’s demands
quickly
Be kind
Stages of Death
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Bargaining
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Patient’s bargain for
more time
Turn to religion or
spiritual beliefs
They strive to meet
goals while there is
still time
Be supportive and
good listeners
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Depression
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Regrets are
expressed
Become
withdrawn
Great sadness
and despair are
felt
Provide support,
allow patient’s to
cry
Stages of Death
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Acceptance
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Unfinished business
is completed
They try to help
their families deal
with their death
Provide support
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In order to be able
to provide care to
a dying patient,
you must first
understand your
feelings about
death and come to
term with these
feelings.
Hospice
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Provides palliative care
The philosophy behind hospice is to
allow the patient to die with dignity
and comfort
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Provide hospital equipment, pain
control, support, understanding,
counseling
Right to Die
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Allowing an individual who has a
terminal illness to refuse measures
which should prolong life is allowing
the individual the “right to die”
We are not assisting them in their
death, but allowing them their right
to make choices about their health
care
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Where advanced directives come in!!
Dying is unique to each person
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The days and hours leading to the
moment of death can be rich with
meaning and expressions of love.
Knowing the normal physical processes
can make this time more peaceful. When
a person is close to death, a natural
series of changes occurs. These changes
usually are not medical emergencies and
the goal at this point is to keep the dying
person as comfortable as possible
Sleeping
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A person nearing death may stop
talking or responding and begin
sleeping more and more as his body
changes how it uses energy.
Always assume that he can hear,
even if he seems unconscious and
no longer communicates.
Keep talking to him and touch him if
touching provides comfort.
Loss of Interest in Food and Fluids
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As the body begins to shut down and
loses its ability to process food and fluid,
the person may have little interest in
eating or drinking.
Urine production will decline and may be
the color of tea.
The question of whether to begin
providing fluids often arises. If food or
fluids are given artificially at this point,
the person may feel discomfort. However,
she may want small amounts of ice chips
or a Popsicle.
Proper care of the mouth is particularly
important at this time.
Coolness
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The patient's nose, ears, hands,
arms, feet and legs may feel
increasingly cool to the touch.
This is because blood circulation is
decreasing.
Keep him warm with extra covering,
but don't use an electric blanket.
He may not be able to sense or tell
you if the blanket overheats.
Changes in Skin Color
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The skin, especially on the hands
and feet, may look blue and
blotchy.
This is called mottling and is caused
by slow blood circulation.
The underside of his body may
become darker.
You may notice a bluish gray color
around the mouth or paleness in
the face.
Rattling Sounds in the Lungs and
Throat
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Rattling sounds, which can be quite loud,
can occur when a person is taking fewer
fluids and loses the ability to cough up
secretions.
This rattling does not signal additional
pain or discomfort.
Suctioning generally is not recommended,
since this increases secretions and
discomfort.
You can turn your loved one's head or
body gently to the side.
Keep the mouth moist and clean.
Bladder and Bowel Changes
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The ill person may lose the ability to
control urine and stool as the
muscles in that area begin to relax.
Check with your doctor about
whether a catheter is needed.
Disposable bed pads or adult
depends also may help.
Disorientation and Restlessness
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A person nearing death may seem confused
about the time or place.
She may not recognize familiar faces.
She may show restlessness, such as pulling at
bedding or clothing.
These behaviors occur as a result of less
oxygen to the brain, chemical changes in the
body and medications.
If disorientation occurs, identify yourself by
name and speak softly but clearly.
Explain the procedures your are doing, such as
"We're going to turn you now" or "I'm going to
help you take your medicine now."
Handholding, quiet music, or reading out loud
may be calming.
Surge of Energy
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Occasionally, when someone is close to
death, he has a temporary increase in
energy and alertness.
He may become talkative after a period of
disorientation or sleepiness.
He may ask for a favorite food after
having refused meals and he may ask for
visitors after a period of withdrawal.
Take advantage of this time; it can be
one of special closeness and a chance to
express your love and support.
Breathing Pattern Changes
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Breathing patterns often change as
the body continues to shut down.
You may notice period of rapid,
shallow breathing.
Or you may see shallow breathing
with a space of five to 60 seconds
between breaths.
This is called Cheyne-Stokes
breathing.
Withdrawal
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Your loved one may focus less and less energy on
the world around her.
She may appear to lose interest in surroundings,
favorite pastimes and visitors.
Her energy is limited and she may want only to
be with one or two people.
Respect this period of withdrawal.
Though it can be a sad time for family and
friends, this can be a peaceful time for your loved
one.
Your presence is the most important gift you can
offer during this period.
Vision-like Experiences
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Your loved one may speak to someone
you cannot see or tell you he sees
persons or places not visible to you.
These experiences are real to him and are
common in the transition from life to
death.
Do not argue or try to explain away the
experience.
Most often, these visions are comforting.
The Need for Permission to Let Go
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Difficult as it is, giving permission to let
go can be an important final gift.
A dying person may try to hold on, even
in the face of prolonged discomfort, to be
sure her loved ones will be all right.
Your permission can include saying goodbye, saying it's all right to let go and
reassuring your loved one you will be all
right.
You don't need to hide your tears; they
are a natural expression of your love.
The Need to Say Good-bye
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You might wish to call friends and family
members who want to share their
thoughts and expressions of love with
your dying loved one.
Good-byes can be as simple as "I love
you and I'll miss you."
Good-byes can include sharing some
beloved memories and saying "Thank
you," or making amends with "I'm sorry
for whatever difficulties..."
Share these important messages, even if
the dying person doesn't seem to
respond.
Remember, hearing is among the last
senses to fade.
The Need of Friends to Feel Useful
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Many times, friends may offer to
help.
These are sincere offers, so if you
need some practical help such as
picking up a prescription, picking up
a relative at the airport or delivering
dry cleaning, let friends and family
fell useful.
They will be grateful to you for
letting them help
Choosing the Setting
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Even during the dying process, a person
continues to protect and nurture those he
or she loves.
For many sick persons, death is a very
private act and they will wait for the few
brief minutes they can be alone to slip
away.
Others will wait until they are alone with
one or two special persons to let go.
Still others will leave amid a circle of
loving faces around their bedsides.
However death occurs, trust that it was
probably they way your loved one chose it
to be.
When Death Occurs
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Though you have been present during
the dying process, the actual moment
of death will be powerful.
Each person will experience it
differently.
The signs that death has occurred are
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No breathing for a prolonged period of
time
No heartbeat
Eyes fixed and slightly open, with
enlarged pupils
Jaw relaxed, with the mouth slightly open.
What to do next…
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Whether death occurs at home, a hospital or a
nursing home, family and friends may want to
sit with the body for a time. There is no need
to rush things, and sitting with the body,
praying or reminiscing, may be comforting.
If death occurs in a facility, the nurses will help
with procedures. If it occurs at home under
hospice care, the hospice nurse should be
called to come and assist. If death occurs at
home without hospice, the physician should be
notified. In some counties, the police may
come to the home. It is important that they
know the death was expected.
Although this is one of life's most painful
experiences, it also can be a rich time of
expressions of love and gratitude.