End of life Flashcards

Question

Justice

Answer 1

Ensure equitable withholding or discontinuation of treatments for all clients, if desired, regardless of race, culture, ethnicity, or socioeconomic status.

Answer 2

Do no harm. Protect client from care that can cause suffering.

Answer 3

Using best practices to manage manifestations and illnesses.

Answer 4

Requires honesty for their end-of-life prognosis and potential consequences of the client’s disease.

Answer 5

The client must have a terminal illness. The client must have severe, intolerable manifestations that are not responding to treatment efforts. The client’s death is imminent. The client has a Do Not Resuscitate order.

Answer 6

(previously referred to as physician-assisted suicide)client requests a provider to prescribe a medication for the client to ingest to cause the client’s death, relieving them of unacceptable or distressing manifestations and a poor quality of life

Answer 7

Clients can ensure their end-of-life decisions are known through advanced directives. Should be included in MAR

Answer 8

living will and durable power of attorney

Answer 9

A document that informs health care providers what treatments the client desires if they are dying or not thought to regain consciousness.

Answer 10

A durable power of attorney for health care is a legal document used to designate a person as a health care proxy who is then legally able to make medical decisions for the client when the client is unable to or incapacitated.

Answer 11

A durable power of attorney for health care is a legal document used to designate a person as a health care proxy who is then legally able to make medical decisions for the client when the client is unable to or incapacitated.

Answer 12

With cessation of the client’s heart and respirations, the client will not receive CPR.

Answer 13

The medical orders are written after a detailed discussion regarding the client’s medical condition and potential treatment option

Answer 14

The medical orders are written after a detailed discussion regarding the client’s medical condition and potential treatment option

Answer 15

Withdrawing or withholding nutrition or hydration.

Answer 16

General changes, food and fluid changes, urinary function, skin changes,

Answer 17

Breakdown of an area of skin caused by consistent pressure for a prolonged time, which results in decreased blood flow to the area that leads to tissue damage and death.

Answer 18

decreased LOC, drowsiness, confusion, delirium, mottle extremities, cyanosis, hypotension, tachycardia, respiration changes

Answer 19

Breakdown of an area of skin caused by consistent pressure for a prolonged time, which results in decreased blood flow to the area that leads to tissue damage and death.

Answer 20

Respiratory secretions will pool in the pharynx and upper respiratory tract.

Answer 21

Contain glucocorticoid and mineral corticoids that have immunosuppressive, anti-inflammatory, regular electrolytes and water balance, and have vasoconstrictive effects.

Answer 22

Indigestion

Answer 23

Neuroendocrine tumor of adrenal gland

Answer 24

can be used to assess dyspnea in clients who have trouble verbalizing their manifestations and clients who are unable to communicate

Answer 25

Heart rate Respiratory rate Restlessness Paradoxical breathing Accessory muscle use Grunting exhalation Accessory muscle use Nasal flaring Look of fear

Answer 26

gather supplies identify client supine position close eyes and mouth Remove all lines and tubes wash and dry body Brush hair Remove dressings id tag on toe bag client place belongings in bag with id

Answer 27

30min-3hrs

Answer 28

mindfulness, healthy eating, exercise, hobbies, yoga

Answer 29

which includes four pieces: setting the stage, creating a blame-free environment by creating expectations, acknowledging emotions, and providing knowledge and resources.

Answer 30

Page 1 Pathophysiology of the Dying Process Death is manifested as the cessation of both breathing and the heartbeat. The process of natural death typically follows a characteristic pattern of physical indications and stages. The early stage of death involves a loss of mobility, as well as a decrease in the ability or the desire to eat or drink. These clients will have cognitive changes, such as delirium or increased sleeping. The middle stage consists of a continued decline in the client’s mental status with only brief periods of wakefulness. Clients may have noisy respirations due to the pooling of mucus and saliva in the back of the throat and upper airways when the client is too weak to cough. This is often called the “death rattle”. In the late stage, the client may have a fever with periods of apnea. They also may have mottling of the skin beginning in the extremities due to loss of peripheral circulation. Clients will proceed through these stages at different rates, from 24 hr to over 14 days. apnea Breathing that stops for any cause. Each client and family will have varying needs and coping strategies as the stages of death are experienced. Nurses must respect the client’s dignity and final wishes despite the caregivers’ beliefs and values. Most clients desire a “good death,” which is typically described as occurring in a place of their choosing, surrounded by family and friends. “Good deaths” are typically considered to be pain and distress-free. A clinical death occurs when the heart and lungs have ceased functioning, but the brain is still viable. Function may possibly be restored through effective, timely cardiopulmonary resuscitation (CPR). Irreversible brain damage starts after just 4 min without oxygen, and death can occur as early as 4 to 6 min later. clinical death cardiopulmonary resuscitation (CPR) Life-saving procedure when a client’s breathing or heart has stopped and involves rescue breathing to provide oxygen to a person’s lungs and chest compressions to keep the client’s blood circulating. A biologic death is also known as brain death. With biologic death, there is a lack of activity on an electroencephalogram or no blood flow to the brain. For the provider to establish a diagnosis of irreversible biologic death, the client must have apnea, a lack of brainstem reflexes, and be in a coma from a known cause. Biologic death can result from an intracranial or extracranial cause. The most common intracranial injuries include subarachnoid hemorrhage or traumatic brain injury (TBI). Cardiopulmonary arrest and inadequate CPR are the most common extracranial causes. Additional causes of biologic death include a head injury from blunt trauma or gunshot wounds, hanging, drowning, drug overdose, stroke, or aneurysm. biologic death Lack of activity on an electroencephalogram or no blood flow to the brain. The pathophysiology of biologic death includes a decrease in oxygenation of the brain, which causes an increase in edema in the brain. This increase in fluid increases intracranial pressure and leads to a further decrease in cerebral perfusion and subsequent herniation. However, even as brain function is lost, lung and cardiac function can be prolonged through mechanical means. Clients must be declared brain dead to be eligible to be vital organ donors. edema perfusion herniation Complete cessation of blood flow to the brain that causes death of brain tissue. Sort the following options into biologic death or clinical death. Drag the options on the left to the corresponding category on the right (or select the option on the left and then the corresponding category on the right). Biologic death Clinical death Palliative Care Palliative care is specially designed care for clients who have a serious disease and their families. Clients receiving palliative care may receive medical care to improve the client’s quality of life by controlling significant manifestations of the disease while choosing not to receive curative or traditional treatments. Clients may also receive palliative care for manifestation management while continuing to receive curative medical care. Palliative care also assists clients in understanding their treatment choices. curative The ability to cure disease. Examples include surgery, medication, and chemotherapy. An interprofessional team is necessary to provide emotional, physical, social, medical, and spiritual support. The team may include nurses, social workers, dietitians, chaplains, and providers and is individualized based on the needs of the client and the level of care required. Palliative care provides a support team to assist clients in living as active of a life as possible until death. Dyspnea and pain are the two most common manifestations clients have that need palliative care. Controlling these manifestations and others is an example of how palliative care improves the quality of life for these clients. Palliative care is more effective when it is started in the beginning stages of the illness and may reduce unnecessary hospitalizations. dyspnea Difficulty breathing. Hospice Care Hospice care specializes in the care, quality of life, and comfort of a client who has a serious illness and is advancing toward the end of life. Hospice is used when the client cannot be cured or chooses not to be treated. This type of care provides comfort care for the client and their family and is usually started when the client is anticipated to have fewer than 6 months to live, but it can be extended longer as needed. comfort care Includes interventions to relieve a client’s end of life suffering while respecting their wishes. Hospice can be provided at home or in a facility, such as a hospital, hospice center, or nursing home. Hospice uses an interprofessional team to provide medical, emotional, physical, spiritual, and social support. A client who wishes to die at home is primarily cared for by family and friends with support from hospice. Respite care is also available. The nurse works collaboratively with the client and their family as well as members of the interprofessional team to ensure the wishes of the client are integrated into the care and provides education as needed as seen in the following video. respite care Respite care allows clients the option to be admitted to a facility to give their caregivers a break in care lasting from hours to weeks. Palliative and Hospice Care The nurse explains to the client some differences between palliative care and hospice care to assist the client with decisions about end-of-life care. Sort the characteristics by whether they describe palliative care, hospice care, or both. Drag the options on the left to the corresponding category on the right (or select the option on the left and then the corresponding category on the right). Palliative care Hospice care Both palliative and hospice care The nurse continues to provide education to the client about taking around-the-clock opioid pain medication in hospice care. Which statement by the client indicates an understanding of the rationales for around-the-clock dosing? a “Strong medication will be the only thing that works to manage the pain.” b “I’ll die faster than if I just take the pain medicine as I need it.” c “It sounds like it can help control my pain and shortness of breath.” d "I guess we’ll have to make sure my family knows CPR.” Hospice care in the home environment A nurse is caring for a client who has colon cancer and is receiving hospice care. Which of the following should the nurse understand are associated with hospice care? Select all that apply. a The client usually has less than six months to live. b The client is receiving chemotherapy. c The client is scheduled to have surgery to remove part of their colon. d The family can use respite care to have a break from providing the client’s care. e The client receives comfort care only. Comfort Care Comfort care involves any interventions to soothe and relieve suffering while respecting the client’s final wishes. Comfort care interventions include managing shortness of breath; administering medications for pain, nausea, anxiety, or constipation; limiting medical testing; and ensuring spiritual and emotional support. Palliative Sedation Palliative sedation is used when there are distressing manifestations in clients who are terminally ill or actively dying. This practice is indicated to provide relief from pain, agitation, and anxiety in clients to prevent unnecessary suffering. Indications for palliative sedation include terminal illness in which death is nearly certain, and treatments are ineffective to relieve the distressing manifestations or unlikely in a timely fashion. This type of sedation is not used to cause the death of the client or shorten their lifespan. The medications typically used to relieve the client’s respiratory distress, anxiety, and agitation are opiates, benzodiazepines, or antipsychotics. The dose and frequency of the medications administered should be titrated to the desired clinical outcome. This type of sedation can increase the risk of respiratory depression, aspiration, and possibly increased agitation from delirium. The client, family, and providers must be informed of the potential adverse effects of palliative sedation. titrated Changes to medication doses to get the best clinical outcome. Clients and their families should participate in a plan of care conference and documentation of the client’s consent for palliative sedation must be obtained. If the client is unable to communicate their wishes, the client’s advanced directive should be followed. If there are no advanced directives, consent should be received from the legal proxy. Cultural and Spiritual Needs of the Dying Client Cultural affiliations can affect how clients view illnesses and the end of life. Complete a cultural assessment to assist in planning end-of-life care. By embracing the client’s culture, the quality of life of the terminal client and their family significantly increases. Allowing clients to observe cultural rituals improves their well-being. Plan to include spiritual and emotional support in the client’s plan of care if they want it, and use prompt and effective therapeutic communication during interactions with the client and their family. These factors will add to improvements in quality of life during end-of-life care. Many facilities have chaplains or other religious personnel available from the prominent religions of the area to provide spiritual care to dying clients and their families. For clients with less common faiths or beliefs, work with the client and family and health care team to allow the client and family access to religious leaders of their faith to decrease disparities in care. This access can lead to better clinical outcomes and an increase in satisfaction with end-of-life care. Assess the spiritual needs of the client. Asking open-ended questions prompts the client to discuss specific needs and encourages clients to express their feelings. Spiritual distress can cause a state of suffering due to unresolved questions and needs. An inability to find purpose and meaning in life often affects their mental and physical health. Assess clients routinely for manifestations of spiritual distress. Clients in spiritual distress may develop manifestations such as feeling depressed, scared, or worried, and they may have a fear of being alone. Some clients may refuse care and become more isolated and withdrawn. Causes of spiritual distress in clients during end of life include a loss of identity and independence. These clients often worry about becoming a burden to family and often feel a loss of control over their life, future, and mental and physical health. Fear of the dying process and what happens following death are often voiced. Discuss spiritual concerns and needs with the client. When a nurse takes the time to get to know the client, a trusting relationship can develop. Clients are more likely to discuss spiritual concerns with someone they know and trust. Listening to the client without judgment or dismissal of their concerns is essential. Allowing the client time to explore their needs assists them to talk about their spiritual concerns. Nurses should avoid imposing their own beliefs on their clients. Provide all clients, regardless of their beliefs (religious or nonreligious), with individualized client-centered care. Nonreligious clients have historically reported feeling disregarded in health care settings. Approach the client with acceptance and genuine caring to assist the client with communication of their needs. These clients also desire a nurturing relationship that provides for the whole person. It is imperative that the nurse approaches the client using cultural humility and inclusive language and avoids imposing their personal values or religion on the client, as that can cause the client to feel misunderstood, judged, or pressured. cultural humility Having self-awareness and curiosity about others to assist health care personnel to build relationships and provide high quality health care encounters. There are a few different assessments nurses can use to determine the spiritual needs of the client. One spiritual assessment uses the mnemonic HOPE. Use this assessment tool to initiate a conversation about the client’s spiritual needs. Based on the answers the client provides, arrange for services that would benefit the client, such as visits from a religious leader, uninterrupted quiet time for reflection, or other accommodations. HOPE H: Hope “What gives you a sense of hope, peace, comfort, or strength?” O: Organized religion “Do you have a religion you belong to? Is your religion important to you?” P: Personal spirituality and practices “What are your personal spiritual beliefs? What spiritual practices are most helpful for you?” E: Effects on medical care and end-of-life issues “Has your illness interfered with your ability to do things that give your life meaning and a sense of purpose? What spiritual practices should we know about when we care for you?” A nurse is caring for a client who has a terminal illness. The client and their family are struggling with the idea of death and wish to participate in the rituals of their religion while in the hospital. Which of the following questions should the nurse use to assess the need for spiritual practices? a “What spiritual practices are important to you while we care for you in this facility?” b “How does performing this ritual help you during this illness?” c “Do you believe this practice will cure your illness?” d “How long have you practiced this type of ritual?” Legal and Ethical Considerations with End-of-Life Care There are many legal and ethical considerations that nurses will encounter during end-of-life care. The goal of end-of-life care is to decrease client suffering and respect the client’s wishes. As health care providers, it is imperative to protect the client’s rights and to ensure client dignity during the decision-making process and throughout their care. Nurses are in a unique position to assist clients with advance directive planning to ensure these decisions are in line with the client’s goals, beliefs, and wishes. advanced directive Legal document used when clients are incapacitated and unable to voice their wishes. The health care goals of care for end-of-life clients are to provide comfort, optimize the quality of remaining life, and alleviate suffering. Decisions during this time are difficult. There are several ethical principles applicable to end-of-life care: justice, nonmaleficence, beneficence, fidelity, and autonomy. justice nonmaleficence beneficence fidelity Requires honesty for their end-of-life prognosis and potential consequences of the client’s disease. The ethical principle of justice declares that all clients are to be treated equitably and fairly. This requires valuing the rights of individual clients, as well as treating all clients in particular situations the same, regardless of who the client is. Health care policies and laws use this ethical principle to ensure each person has access to health care. Justice also encompasses fair distribution of available health resources. This principle necessitates impartiality during the delivery of these health services. Examples of these resources include medications, equipment, and tests. Clients with a need must have the same access and rights to services as other clients with the same need. If medical resources are limited, they must be distributed in a fair and equitable way. Nurses are ethically obligated to advocate for appropriate and fair treatment of clients who are at the end of their lives. The principle of nonmaleficence is based on the concept of “do no harm.” Some interventions may cause pain or harm, but nonmaleficence refers to the justification of why it is caused. It can be justified if the benefit of the intervention is greater than the pain or harm that may occur. For example, a client who receives chemotherapy or radiation may have harm to various parts of their body. However, the benefit of curing the cancer is greater than the harm that was caused by the treatment. Beneficence involves nurses advocating for the best course of action for the end-of-life client. At times, the client may not have expressed end-of-life wishes through advanced directives and the client’s family may not know the client’s wishes. In the event the client is unable to make their requests known, the client’s provider will consult with the client’s family or the client’s health care proxy if one has been named. The principle of fidelity requires the interprofessional team, including providers and nurses, to provide all information about a client’s disease process when appropriate. That includes detailed information to clients and the client’s decision makers about treatment options available during end-of-life care, including risks, benefits, and limitations. Autonomy during end-of-life care respects the client’s right to self-determination. The client has the right to make their own care decisions, and those decisions must be respected. One limitation of autonomy is that the client cannot make a decision that will cause them harm. An example of this is if the client wants an antibiotic to treat a viral infection. These types of situations are avoided through the education of clients so they can make informed decisions. The provider cannot provide care requested by the client that will in fact harm the client. A nurse is reinforcing teaching with a newly licensed nurse about principles that help guide nurses make ethical decisions. Match the example in the right column with the ethical principle in the left column. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). Fidelity Beneficence Nonmaleficence Justice Autonomy Terminal Sedation Terminal sedation is used for clients at the end of life to end suffering when death is unavoidable. The purpose of terminal sedation is not to quicken or cause death but to relieve pain that is not responding to other interventions. Never perform nursing interventions with the intent to harm a client. There are certain requirements that must be met for terminal sedation to be implemented. terminal sedation The purpose of terminal sedation is to relieve pain not responding to other interventions. Requirements for Terminal Sedation The client must have a terminal illness. The client must have severe, intolerable manifestations that are not responding to treatment efforts. The client’s death is imminent. The client has a Do Not Resuscitate order. Medical Aid in Dying Medical aid in dying (MAiD) (previously referred to as physician-assisted suicide) is a controversial topic in the United States. In MAiD, a terminal client requests a provider to prescribe a medication for the client to ingest to cause the client’s death, relieving them of unacceptable or distressing manifestations and a poor quality of life. The core beliefs in this practice include respect for autonomy and the relief of suffering. In the United States, multiple states have legalized MAiD. However, in most states, it is punishable by law. Statements opposing MAiD claim this practice contradicts the do no harm and healing role of the provider and argue that alternative approaches to controlling distressing manifestations exist for extreme cases. Most states that have passed MAiD laws have similar requirements. Currently, no state allows MAiD in clients under 18 years old. The client must live in the state in which they are requesting MAiD and have a terminal illness that is expected to result in a natural death within six months. Additional common requirements include the client must make a request to their provider for MAiD verbally on more than one occasion and submit at least one written request that is witnessed by non-relatives. Clients must also be capable of making decisions and able to communicate those decisions and must be able to self-administer the medication prescribed. If the nurse becomes uncomfortable with withdrawing or withholding treatments, it is recommended they discuss the situation with the charge nurse and locate a replacement so they can remove themselves from the situation. If a disagreement arises between the interprofessional team, the client, and the family, an ethics committee should be consulted to ensure all involved individuals are represented. Clients must also be capable of making decisions and be able to communicate those decisions. Decision-making capacity involves the ability of the client to understand risks, benefits, and alternatives to a suggested treatment. This also includes non-treatment. Decision-making capacity is considered the basis of the informed consent process. Advanced Directives Clients can ensure their end-of-life decisions are known through advanced directives. Clients can be incapacitated because of disease or injury regardless of their age. Therefore, these documents are not only for older adults and should be completed before a medical emergency occurs. Preferences should be stated explicitly. Advanced directives should be included in the client’s medical record and should be revisited periodically. The two types of advanced directive documents include a living will and a durable power of attorney for health care. living will durable power of attorney A durable power of attorney for health care is a legal document used to designate a person as a health care proxy who is then legally able to make medical decisions for the client when the client is unable to or incapacitated. Living Will A living will is a document that informs health care providers what treatments the client desires if they are dying or if regaining consciousness is unlikely. This document also allows the client to make their wishes known when they are unable to make their own decisions about available emergency treatment. In the living will, the client typically documents if they would allow or deny the use of a ventilator, CPR, dialysis, artificial hydration and nutrition, or comfort care measures. The client also specifies under which conditions each choice applies. Laws about living wills vary in each state regarding what can be included in a living will. However, they typically follow a general template. Durable Power of Attorney for Health Care A durable power of attorney for health care is a legal document used to designate a person as a health care proxy. This person is then legally able to make medical decisions for the client when the client is unable to or incapacitated. The proxy is aware of the client’s wishes regarding treatment. The durable power of attorney may be named in addition to a living will. The use of a proxy allows planning for use in emergency situations. Case Study A nurse is caring for a client who has a living will on file in the medical record that states they do not want a feeding tube. The client also has a durable power of attorney for health care naming their sibling as proxy. The client’s proxy asked the provider to insert a feeding tube to prolong the client’s life. The proxy refuses to acknowledge the client’s advanced directives requesting not to have a feeding tube inserted. What should the health care team do when this ethical dilemma happens? (Enter your response and submit to compare to the correct answer.) Type your answer here. Explanation of Code Status Discuss a client’s CPR preferences, also known as code status, during end-of-life care. The interprofessional team has a responsibility to have discussions with their clients regarding code status and advanced directives. Advance directives are legal documents, not medical orders. Advance directives state preferences for CPR but are not the same as code status orders such as Do-Not-Intubate (DNI) or Do-Not-Resuscitate (DNR) orders. Do-Not-Intubate (DNI) Do-Not-Resuscitate (DNR) With cessation of the client’s heart and respirations, the client will not receive CPR. Some clients mistakenly believe a DNR order means “do not treat.” Nurses have a key role in reinforcing that code status does not stop all treatments or standards of care. The goal of these discussions is to educate the client and their family about the meaning of the code status and that the client’s quality of life will still be important. Offer assurances that their loved one will be kept comfortable and any pain they have will be addressed promptly. When the client’s code status has been finalized, an order is added to the medical record. The type of document to indicate DNR or DNI will vary across facilities and states but may include Medical Orders for Life Sustaining Treatment (MOLST), Medical Orders for Scope of Treatment (MOST), Physician Orders for Life Sustaining Treatment (POLST), or Physician Orders for Scope of Treatment (POST). Each state uses a different name for these documents, but all have the same principles. These are voluntary, portable, out-of-the-hospital medical orders for seriously ill clients and are completed by the client’s provider. The medical orders are written after a detailed discussion regarding the client’s medical condition and potential treatment options. The client will sign the form along with the physician. The client carries the form when traveling to inform other providers what the client’s wishes are in a medical emergency when the client is unable to communicate. This allows other providers to respect the treatments chosen by the client. Ensure that the POLST form is scanned into the client’s electronic medical record. This document is a medical order that is legally valid. Physician Orders for Life-Sustaining Treatment Code status should be addressed with the client or, if needed, the proxy prior to interventions or procedures, particularly ones that require intubation. If temporary changes to code status are needed prior to a procedure, the DNR or DNI order should be changed prior to the procedure and then changed back after completion. Types of Code Status Nurses must understand the different code statuses they may encounter. The types of code statuses are full code, DNR, and DNI. full code A full code indicates that if a client’s heart stops beating and/or their respirations stop, the health care team will use full resuscitation measures to restore a heart rhythm and respirations. A full code indicates that if a client’s heart stops beating or their respirations stop, the health care team will use full resuscitation measures to restore a heart rhythm and respiration. That includes intubation, chest compressions, and defibrillation. A full code is assumed unless the client communicates otherwise or documentation is provided of other client preferences when the client cannot communicate. Another type of code status is DNR. This type of code status means that if the client’s heart or lung function fails, they do not want CPR. This includes chest compressions and defibrillation. Other lifesaving treatments may be attempted. The client would be allowed to die naturally. DNR status is typically chosen by clients who have multiple chronic diseases. A DNI, sometimes called a chemical code, indicates the client does not want to be intubated or placed on the ventilator in the event they stop breathing. A DNI order does allow basic CPR, medications, defibrillation, external pacemaker, and chest compressions. A nurse is caring for a client who has a DNI order in their chart. Which of the following actions can be taken if cardiac arrest occurs? Select all that apply. a Chest compressions b Insertion of a breathing tube c Defibrillation d Administration of medications e Use of an external pacemaker End-of-Life Withdrawal or Withholding of Treatments There is no ethical or legal difference between stopping a therapy that is not benefiting a client and never starting it. Nurses are often able to guide clients and families through the difficult decision making that occurs in end-of-life situations, as well as assist clients to understand and cope with the reality of their situation. Quality of life is often the focus when making decisions about end-of-life care. Be an advocate for client preferences and assist the client and their family in making their wishes known. Provide education about treatments, including accurate and understandable information about the benefits, risks, and alternatives of withdrawing or withholding. There are several standards that are key to withdrawal or withholding of end-of-life care. It is legally and ethically acceptable, when consistent with the client’s wishes, to withhold or withdraw medical interventions. Withdrawing or withholding treatment may occur when the burdens of the treatments outweigh the client's benefits if the intervention is not beneficial, or when the intervention does not align with the client’s goals. Another important standard to remember is the client has the right to begin a medical treatment that can benefit them and has the right to withdraw or withhold any treatment. The client has the right to appoint a medical proxy in the event the client is not capable of making decisions. Health care personnel must honor the client’s advance directives, as well as the appointed proxy’s decisions. Withdrawing or withholding interventions does not mean limiting or stopping care. Continue to provide nursing care when withdrawing or withholding medical interventions. Effectively communicate to the client and family that this decision will not cause the loss of care, such as treatment for pain and other distressing manifestations. Clients who are incapable of making decisions and who do not have a designated proxy should have a person named as such according to local, state, and facility regulations. In the case of minors under the age of 18, a parent or legal guardian has the legal authority to make decisions about treatment for their child if the parent or guardian has the child’s best interest in mind. The child’s treatment preferences and assent or refusal of treatment (when developmentally suitable) must be documented and considered in the decision-making process. When the child and adult have differing wishes, the health care team must assist the family in reaching a suitable decision. Assisting Families Through Withdrawal or Withholding Treatments Family-centered care is essential during the process of withdrawal or withholding treatments and focuses on collaboration, mutual respect, and support. Providing care within a family context serves as a helpful foundation for assisting clients and families through complicated end-of-life processes. Assisting the family through this process includes several steps: helping the family understand, giving family time, setting the stage, and assessing for family readiness. An important nursing role in caring for clients and families during the withdrawal of life-saving therapies is providing essential client information. How the nurse communicates the information is just as important as what information is communicated, and it must be tailored to the families so that they can make informed decisions. Letting the family guide the discussions with their questions conveys assurance and confidence in the interprofessional team. Crucial parts of the process include relationship building, communication, and honesty. Nurses must also act as client and family advocates throughout this journey. The treatment plan must honor the client’s wishes if they are known. The family must understand the initial goal is life, but when this is no longer feasible, the decision to withdraw lifesaving therapies is based on it being the right decision for their loved one. Some interprofessional teams ensure the families are present during rounds with the providers so the family members can see the client is being cared for and provide their input. That conveys to the family that the team is trying their best to do the right thing for the client. A trial of intensive care is typically done to understand if client findings are reversible or not, and a full diagnostic evaluation is performed. This step helps earn the family’s trust and confidence. If withdrawal or withholding of care is then recommended, the family is more likely to understand it was a thoughtful, well-informed one. Giving the family time to understand what is happening with their loved one helps the family understand and accept the reality of the situation. Assist the family in understanding the entire process of withdrawal of care to facilitate an informed decision. Nurses and providers must work closely together by having frequent discussions about the client’s prognosis and plan of care. It is important that the team stays informed about what the family has been told so everyone is reinforcing the same information. Also, nurses should share what the family has communicated with the interprofessional team, as this is a key piece of the decision-making process. Destructive communication can occur when the nurse and the provider have counter purposes, and constructive communication occurs when they work together. Nurses frequently initiate conversations with the family about what care and treatments are available to make the client more comfortable, what treatments the client would want, the client's advanced directives, if available, and about the client's changes in condition. These conversations often set the stage for discussions between the providers and family about possible withdrawal of care. Nurses are often present and assist with these discussions. Assessing for family readiness for withdrawal or withholding of care is the next step. Family members often give cues that they are ready to make important end-of-life decisions and begin end-of-life conversations. These often occur during conversations with the nurse at the bedside. One example is the family member stating their loved one would not want all the treatments they are receiving. Nurses are invaluable in recognizing family readiness and often serve as the mediator between the family and the interprofessional team. Nurses must support families through the process of withdrawal of care and through the dying process itself. Nurses must provide ethical, compassionate care and assist families in understanding what to expect, such as changes in the client’s breathing pattern and sounds, changes in the level of consciousness, potential involuntary movements, and the variability in the dying process between clients. Nurses must prepare the environment by reducing noise, lowering the level of lighting, and removing unnecessary equipment from the room. Being available and present during the dying process is also comforting to the family. Medically administered nutrition and hydration (MANH) is particularly ethically challenging for some nurses and clients. The use of MANH should be centered on informed decision making, client autonomy, the plan of care, and diagnosis. In clients who have advanced disease, MANH may sustain life but may also have a negative effect on the client’s quality of life. Withdrawal of MANH must also align with the client’s goals. Consider the client’s ethnicity, culture, preferences, beliefs, religion, and values. Understand the client’s religious and cultural views on withdrawing or withholding nutrition or hydration. The nurse should also recognize and understand their own values and beliefs about withdrawal or withholding MANH for clients. Nurses who are distressed about withdrawing or withholding treatments should discuss the issue with their charge nurse and change assignments when possible. withdrawal of MANH Withdrawing or withholding nutrition or hydration. The decision to terminate medical interventions can also be led by recommendations from an ethics committee, particularly when the health care team identifies that ethical dilemmas are present. Interprofessional team members must use therapeutic communication and consider any identified issues of concern throughout end-of-life care and ensure the client continues to remain the center of decision making. If it is not possible to honor the client’s wishes for any reason, the health care team must document the reason why they cannot do so. A nurse is caring for a client who has withdrawn medically administered nutrition and hydration (MANH). Which of the following actions should the nurse take? Select all that apply. a Let the family guide discussions based on their questions. b Allow the family to be present during provider rounds. c Discuss expected findings during the dying process with families. d Increase lighting in the client’s room. e Remove tube feeding and IV pole from room. Nursing Process Nurses are responsible for identifying client’s manifestations, performing nursing interventions within their scope of practice (such as administering medications), intervening with appropriate manifestation alleviation methods, and working with the interprofessional team to increase the client’s comfort and family’s understanding and adaptation of the dying process. Nurses are obligated to provide care that includes assessment, relieving pain and other manifestations, promoting comfort, and supporting clients, families, and other individuals close to the client. Recognize Cue (Assessment) To better support the client during this time, obtain information about the client’s diagnosis and medical history to determine the risks for distressing manifestations at the end of life. Identify gaps in knowledge regarding end-of-life care or withdrawal or withholding treatments. Clients who are nonverbal must be assessed for manifestations of distress, such as restlessness, grimacing, or moaning. Be alert to changing manifestations of impending death. As death nears, clients frequently experience a decline in physical and mental functioning. Manifestations of Impending Death General Changes Clients who are near death are often profoundly weak and report fatigue. They may be drowsy and have an increase in sleeping. Disorientation is another common finding. Clients may speak to individuals who have died previously or see things others cannot see. Food and Fluids The client often begins to show a decrease in interest in food or fluids. Weight loss and dehydration may be noted. Clients often have difficulty swallowing, indicated by choking or coughing when attempting to eat or drink. Urinary Function Urinary output will decrease, and the client may develop urinary incontinence. The urine will often be dark and concentrated from decreased fluid intake. Skin Changes The skin may develop mottling, which appears as a webbed pattern that is usually purple or dark pink color on the client’s back and posterior arms and legs. In darker skin, mottling may appear brown. Pressure injuries may develop from prolonged pressure from lying in the bed, decreased perfusion, and a decrease in nutritional intake. Assess for any skin changes, from redness to actual skin breakdown. pressure injuries Breakdown of an area of skin caused by consistent pressure for a prolonged time, which results in decreased blood flow to the area that leads to tissue damage and death. Mottling Cardiac and Circulation Changes Clients will have a decrease in cerebral perfusion, which is manifested as a decreased level of consciousness, drowsiness, confusion, or terminal delirium. Clients will also have a decrease in perfusion to other parts of the body. The skin may begin to mottle from the lack of perfusion or blood flow to the skin. Cyanosis and mottling in the upper extremities indicate impending death. A decrease in cardiac output and intravascular volume also occurs, indicated by hypotension, tachycardia, and peripheral cooling of the body. cyanosis hypotension tachycardia Respiratory Changes Respiratory secretions will pool in the pharynx and upper respiratory tract. This will cause noisy respirations often called the “death rattle.” The client will usually have a weak or absent cough reflex. Changes in breathing patterns and dyspnea are common. Cheyne-Stokes respirations are typically noted. The respirations will be shallow and rapid, progressing to periods of apnea. Cheyne-Stokes respirations Type of breathing pattern with cyclical hyperventilation and apnea. Role of the RN and PN in Assessment Registered Nurse (RN): Performs assessments of clients Practical Nurse (PN): Assists with data collection and reports changes to the supervising RN or provider A nurse is caring for a client who is actively dying. Which of the following manifestations should the nurse expect? Select all that apply. a Increased respiratory rate b Mottling of skin c Decreased urinary output d Quiet respirations e Confusion Analyze Cue (Analysis) Analyze the client’s clinical presentation to anticipate client or family needs or changes in status. Nurses must understand the pathophysiology of dying, use standards of care, and anticipate progression toward death. Prioritize Hypotheses (Analysis) Following analysis of client assessment findings, establish client priorities based on accepted priority frameworks. Monitor for changes in the client that may indicate distressing manifestations in need of prompt treatment. Prioritize nursing interventions to alleviate the most distressing manifestations first. Generate Solutions (Planning) Planning nursing interventions for end-of-life care should focus on meeting the client’s needs in multiple areas, such as physiological, psychosocial, spiritual, and cultural. Planning care should involve the entire interprofessional team to ensure the client and family are fully supported. Part of the planning process should involve identifying if the client wishes to die at home or in a facility. If the client wishes to die at home, the interprofessional team should work with the client and family to facilitate this process, if possible. A meeting between the client, family, and hospice will help the decision-making process. The Role of the RN and PN in Planning RN: Develops the client’s plan of care and delegates tasks to other RNs, the PN, and assistive personnel (AP) according to their skill level and scope of practice PN: Assists the RN with planning care for the client and may delegate tasks to other PNs and assistive personnel Take Actions (Implementation) Management of Distressing Manifestations Pain Control Pain is one of the most common concerns for clients who are at the end of life. Not all clients who are dying have pain. However, clients who do experience pain should be assessed and treated effectively and promptly without worry about long-term dependence. Pain significantly decreases the quality of life for the client and should be adequately managed. Pain is treatable through both non-pharmacological and pharmacological means. The type of treatment should be in line with the client’s wishes and based on a comprehensive assessment. Nonpharmacologic pain treatments can include music therapy, massage, and heat and cold therapy. Pharmacological treatment includes the administration of pain medications (morphine, ibuprofen), antidepressants, and corticosteroids (methylprednisolone). Medical marijuana is also effective in treating pain in these clients but is dependent on state laws. music therapy heat and cold therapy corticosteroids Contain glucocorticoid and mineral corticoids that have immunosuppressive, anti-inflammatory, regular electrolytes and water balance, and have vasoconstrictive effects. When using pharmacological pain management, pain medications should be given as ordered to prevent breakthrough pain, as pain is easier to prevent than it is to treat. Follow up after the administration of pain medication to evaluate its effectiveness. Report to the provider if the pain medication is not effective enough to control the client’s discomfort. Morphine (Duramorph) is an opioid analgesic frequently used for treating severe pain during end of life. Common adverse effects of this medication include hypotension, confusion, bradycardia, constipation, respiratory depression, nausea and vomiting, hallucinations, and urinary retention. Clients should rise slowly as orthostatic hypotension is a risk with this medication. Ibuprofen (Advil) is a nonsteroidal anti-inflammatory medication used for mild to moderate pain. Adverse effects include headache, constipation, dyspepsia, nausea, vomiting, and prolonged bleeding time. Advise clients to take ibuprofen with a full eight-ounce glass of water as tolerated and sit in an upright position for 30 min following administration. This medication can cause dizziness or drowsiness. dyspepsia Indigestion. Methylprednisolone (Depo-Medrol) is a corticosteroid and can be used to reduce pain through a decrease in inflammation and edema. Adverse effects include pheochromocytomas, depression, euphoria, hypertension, decreased wound healing, hirsutism, adrenal suppression, hyperglycemia, leukocytosis, thromboembolism, osteoporosis, and cushingoid appearance. pheochromocytomas hirsutism cushingoid Term for someone who has a Cushing’s syndrome appearance. Manifestations include round face, fat at the base of the neck, thin arms and legs, and hump between shoulders. Opioid Safety Monitor clients who have received opioids for respiratory depression. Monitor oxygen saturation, respiratory rate, and effort frequently. Administer Narcan for respiratory distress. A nurse is evaluating the adverse effects of medications that a client is receiving in palliative care. Match the adverse effect in the left column with the pharmacological treatment in the right column. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). Morphine Ibuprofen Methylprednisolone Dyspnea Interventions A common finding in end-of-life clients is dyspnea, or shortness of breath. Complete a thorough respiratory assessment of the client, including the respiratory rate, rhythm, depth, breathing pattern, and effort. The client is the primary source of information regarding their dyspnea. When clients are unable to voice information about their dyspnea, an alternative assessment tool is used. The Respiratory Distress Observational Scale (RDOS) can be used to assess dyspnea in clients who have trouble verbalizing their manifestations and clients who are unable to communicate. This assessment gives the interprofessional team more comprehensive data to assist in the treatment of dyspnea. Respiratory Distress Observational Scale Respiratory Distress Observational Scale Assesses the client’s: Heart rate Respiratory rate Restlessness Paradoxical breathing Accessory muscle use Grunting exhalation Accessory muscle use Nasal flaring Look of fear Pharmacological treatment of dyspnea includes opioids and bronchodilators. Oxygen therapy at two to three liters via nasal cannula should be initiated. Nonpharmacological interventions include raising the head of the bed or using a fan to circulate air in the room. bronchodilators Class of medications that cause the smooth muscle of the airways to relax to increase airflow. Dryness Interventions Dryness is a common finding with the client, particularly in the lips or eyes, which can cause discomfort. To alleviate, apply a lip balm to the lips. Use eye drops to keep the eyes lubricated. If the client’s mouth is dry, give them ice chips if the client is alert. The mouth can also be dampened with a cloth or swab as needed. Skin Interventions Keep the client clean and dry by providing prompt incontinence care and changing linens as needed. Lotion can also be applied to the client’s skin to decrease dryness. Turn the client every 2 hr to relieve pressure and reduce the risk of pressure ulcers. However, if the client has pain with changes in position, decrease the frequency of repositioning. Pressure relief mattresses can be used as needed. If the client develops a pressure ulcer, wound care should be started. The goal of wound care in this instance is to promote comfort and prevent worsening of the wound. Gastrointestinal Interventions A client at the end of life often experiences anorexia and constipation. These manifestations can result from the disease process, side effects of treatments, or a combination of both. If the client develops anorexia, offer small amounts of a favorite food, if desired and tolerated. Serving small, frequent meals is also recommended. Never force a client who is terminally ill to eat, as anorexia is a natural part of the dying process. anorexia Decreased appetite. Constipation is another common end-of-life finding. Perform a thorough gastrointestinal assessment to determine the cause. Constipation can be a side effect of the pain medication the client is receiving. Providing medications, hydration, increased fiber in the diet, and more mobility can help relieve constipation in these clients. Fatigue Fatigue is another common finding in dying clients. It can be caused by depression, anemia, dehydration, or infection. The manifestation of fatigue in these cases can be treated by eliminating the cause. Offer interventions to help alleviate fatigue, such as offering a bedside commode, providing a shower chair, or performing sponge baths. Steps for Discontinuation of MANH Discontinuation Education Educate the client and their family regarding expectations after withdrawal of nutrition and hydration, as well as the prognosis. The client can expect to live without fluids or nutrition for days or weeks, and removal of MANH will result in a peaceful death. Review steps of progression through the dying process and interventions to relieve any discomfort with the client and their family. Provide psychosocial support during the decision-making process. The best choice for the client is the one that supports the client’s and family’s preferences and goals according to their view of quality of life. Discontinuation Preparation Review the procedure with the client and their family. Encourage the family to be present at the point of discontinuation if this is in line with their beliefs, religion, spirituality, and culture. Support any rituals of importance to the client and family. Discontinuation Steps Assure the client and family that the client will not have any discomfort or notice any changes immediately after discontinuation of nutrition and hydration. Time should be allowed for rituals and prayers if requested. Then disconnect or remove tubes or catheters and discontinue any fluids. Offer small amounts of ice chips, fluids, soft foods, frozen treats, or mouth sponges with flavored liquids. Frequent oral care using finger brushes, toothbrushes, or oral care swabs will be provided, as will the application of lip balm and use of artificial saliva every 2 to 3 hr. Assess for lesions in the oral cavity. Viscous lidocaine, if ordered, can be used for painful lesions. To decrease excessive saliva, hyoscine drops will be used as ordered. Oral suctioning should not be used as it can cause discomfort or increase secretions. Monitor the client’s skin for any redness, edema, painful areas, or drainage, and administer skin protective creams. If a catheter remains in place, change dressings daily and cleanse with mild soap and water. Provide comfort care and education to promote informed decisions. Care that values the client’s beliefs, preferences, culture, and religion is essential. Support decision making that is in alignment with the client’s wishes and ensure accurate information is provided. Refer the client and family to spiritual leaders if they have expressed interest in that. The Role of the RN and PN in Implementation RN: Provides nursing care to clients, develops and provides teaching plans, and provides IV therapy to all types of devices, including central lines and blood products PN: Provides care to clients who are stable, assists the RN with client care, reinforces teaching to clients, and assists with IV therapy Evaluate Outcomes (Evaluation) Evaluate the client for successful management of distressing manifestations. The aim of this evaluation is to assess the achievement of a peaceful end of life and the promotion of meaningful interactions with family and friends. The Role of the RN and PN in Evaluation RN: Evaluates the plan of care and revise it based on client outcomes and initiate referrals for clients PN: Evaluates client responses to care, suggest revisions in the plan of care based on client findings, and recommends referrals for continuation of care Pronouncement of Death The pronouncement of death is a solemn occasion and should be respectful to the client and family present. If the death occurred in a facility, the client should be identified by their wristband. The general appearance of the client should be observed. The provider should confirm the following: lack of response to stimuli, absence of spontaneous respiration, absence of heart sounds, and the absence of a pupil response. The provider should note the time the examination is completed and record this as the time of death. The family should be asked if they would like an autopsy. The Role of the RN in Death Pronouncement In some states, nurses are granted the authority to pronounce a client as dead. Refer to your state nurse practice act and your agency policy. Postmortem Care Care associated with death is considered a professional nursing responsibility. Provide respectful care to the deceased client as well as bereavement support for the family. During this process, remain respectful of the cultural and spiritual beliefs or any other practices of the client. Nurses must understand the instances when a death requires coroner notification or an autopsy and follow their applicable agency/local regulatory policies regarding that. Steps of Postmortem Care Following a client death, perform the following steps. Gather supplies and a postmortem care kit if available. Identify the client. Place the client in a supine position with the legs extended and the arms extended along the side of the body. Insert a pad under the client’s buttocks for possible incontinence. Elevate the head of the bed by 15 to 20 degrees or use a small pillow under the head. Close the client’s eyes as needed using gentle downward pressure. Follow facility policy regarding dentures and glasses. Close the client’s mouth using a chin strap or a rolled towel under the chin. Remove all lines and tubes and cover sites with gauze. Wash and dry the body. Brush the client’s hair. Remove and replace any dressings that have been soiled, leaving sutures and staples intact if applicable. Apply an identification tag to the client’s right great toe or ankle. Place the client in a body bag or cover with a shroud. Label the bag if any infectious diseases are associated with the client. Place all belongings in a bag and place an identification label on the bag. Physiologic Changes After Death Immediate changes to the body after death include the absence of respirations, heart rate, responsiveness, voluntary movement, muscle relaxation, and nervous system functions. Algor mortis, rigor mortis, and livor mortis are usually noted 30 min to 3 hr following death. Algor mortis is manifested by pale skin, a loss of turgor, and body cooling. Rigor mortis occurs when muscle rigidity is noted. Livor mortis causes discoloration in the dependent or lower areas of the body. turgor A nurse is performing postmortem care for a client who died. Drag the steps of postmortem care below into the correct sequence. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). 1 2 3 4 5 Self-Care of the Nurse Caring for the Dying Nurses experience death frequently as part of their careers. Nurses often develop significant therapeutic relationships with their clients and learn about their dreams, hopes, family, histories, hobbies, and more. Nurses experience grief related to the loss of clients. Repeated loss of clients is cumulative and often overwhelming to nurses. Nurses who care for clients who are seriously ill have an increased risk of decreased well-being, compassion fatigue, moral distress, and burnout. Compassion fatigue can be caused by an empathy imbalance that leads to a decrease in job performance, a failure to see to personal health, and the inability to share in the suffering. Palliative nurses are also at high risk for burnout, which is known to accompany compassion fatigue. Moral distress can occur due to the internal struggle between the nurse’s innate need to heal their clients and to also help clients have a peaceful death. compassion fatigue moral distress Physical or emotional suffering from an internal or external restriction that prevents the individual from following a course of action they believe is right. burnout Self-Care Interventions Self-care begins with the identification and prevention of any of these conditions and includes self-reflection and self-awareness. When coping with cumulative loss, identify ways to build resilience. Self-care must be prioritized to find ways to grieve and process client losses. Nurses must not rely only on organizations for support. Self-care assists nurses with grieving and processing client losses and includes prioritizing relationships with loved ones, family, and the community. Other helpful interventions include living a healthy lifestyle with regular exercise, engaging in hobbies, and taking vacations. Involvement in personal spiritual practices, practicing mindfulness, therapy, and maintaining a work-life balance are also helpful. When health care providers focus on their personal wellness, there is a positive correlation between resilience, compassion satisfaction, and job engagement. Resilience There are multiple experiences in nurses’ careers that can lead to burnout, compassion fatigue, or moral distress. If clients choose to forgo treatments, the nurse may disagree with that decision. When the client cannot be healed or chooses withdrawal or withholding of treatments, the established nurse-client relationship can cause the nurse additional distress due to the anticipated loss. Each loss is cumulative for nurses, which causes a heavy burden. Nurses must use self-awareness and self-reflection to identify when there is an issue that needs to be dealt with, such as burnout, compassion fatigue, or moral distress, and develop helpful interventions, such as exercise, meditation, reflective writing, counseling, and proper maintenance of a healthy work-life balance. Nurses must ensure there are appropriate boundaries in nurse and client relationships. Debriefing After a Client Death After the death of a client, the health care team may have strong feelings such as sadness, guilt, and self-doubt. Health care providers report feeling more supported and more able to emotionally cope if they participate in a debrief following the death of a client. One tool the Mount Sinai Hospital uses for debriefs is the mnemonic SEEK, which includes four pieces: setting the stage, creating a blame-free environment by creating expectations, acknowledging emotions, and providing knowledge and resources. SEEK S: Stage refers to the creation of a safe space with a set uninterrupted amount of time. E: Expectations remind the leader to thank everyone for their help during the client death and to ensure interruptions are minimized. E: Emotions and events refer to recognizing guilt and the facilitation of questions. K: Knowledge is the provision of resources and a reminder to set a check in time for all involved team members. A nurse is teaching a group of nursing students about debriefing after a client death. Which of the following elements should they include in their teaching? Select all that apply. a Situational awareness b Creating a blame free environment c Providing knowledge and resources d Acknowledging emotions e Evidenced-based practice Dying with Dignity 00:00 13:28 A nurse shares experiences of supporting clients in their last weeks and days, and how students can prepare for it. Podcast Transcript The Nurse’s Role in Organ Donation The organ donation process starts by recognizing clients who are potential donors. To qualify as an organ donor, the client must have experienced brain death. To confirm brain death, the client must have an irreversible cessation of all brain functioning resulting in apnea, a coma that has a known cause, and the absence of brainstem reflexes. Types of Organs and Tissues Eligible for Donation Organs Kidneys, liver, lungs, heart, pancreas, intestines Corneas Tissues Middle ear, heart valves, bone, veins, ligaments, tendons, cartilage, skin Hands and face Bone marrow, cord blood, blood stem cells Blood and platelets Live organ donation One kidney, one lung, part of the liver, part of the pancreas, part of the intestine

Answer 31

ventilator associated pneumonia

Answer 32

30-45 degrees. If the client can not bend at the waist, reverse Trendelenburg position

Answer 33

skin, long bones, middle ear bones, and corneas.

Answer 34

heart, lungs, pancreas, liver, and kidneys

End of life Flashcards

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