Info Mod2 Info to Know

Question 1

Death that is free from avoidable distress and suffering for patients and families, in agreement with patients’ and families’ wishes, and consistent with clinical practice standards.

Answer 1

Peaceful death

Question 2

• care that begins after treatment of the disease is stopped and when it is clear that the person is not going to survive the illness.

is the model for quality, compassionate care for people facing a life-limiting illness or injury.

Patients have a prognosis of six (6) months or less to live. Care is provided when curative treatment such as chemotherapy has been stopped. Care is provided in 60- and 90-day periods with an opportunity to continue if eligibility criteria are met.

Ongoing care is provided by RNs, social workers, chaplains, and volunteers.

Answer 2

Hospice

Question 3

Patients can be in any stage of serious illness.

Comfort is given to the patient at diagnosis and at the same time as treatment.

a philosophy of care for people with life-threatening disease that helps patients and families identify their outcomes for care, assists them with informed decision making, and facilitates quality symptom management.
A consultation is provided that is concurrent with curative therapies or therapies that prolong life. Care is not limited by specific time periods. Care is in the form of a consult visit by a primary health care provider who makes recommendations; follow-up visits may be provided.

Answer 3

Palliative care

Question 4

What is the pathophysiology of dying

Answer 4

Death is defined as the cessation of integrated tissue and organ function, manifested by lack of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction. It generally occurs as a result of an illness or trauma that overwhelms the compensatory mechanisms of the body, eventually leading to cardiopulmonary failure/arrest.

Question 5

Direct causes of death include:

Answer 5

• Heart failure secondary to cardiac dysrhythmias, myocardial infarction, or cardiogenic shock
• Respiratory failure secondary to pulmonary embolism, heart failure, pneumonia, lung disease, or respiratory arrest caused by increased intracranial pressure
• Shock secondary to infection, blood loss, or organ dysfunction, which leads to lack of blood flow (i.e., PERFUSION) to vital organs

Question 6

​​What are the physical signs/symptoms you might observe leading to death?

Answer 6

Weakness; sleeping more; anorexia; and changes in cardiovascular function, breathing patterns, and genitourinary function.

Level of consciousness often declines to lethargy, disorientation, increased sleep, unresponsiveness, or coma.

Cardiovascular dysfunction leads to decreases in peripheral circulation and poor tissue PERFUSION manifested as cold, mottled, and cyanotic extremities. Blood pressure decreases and often is only palpable. The dying person’s heart rate may increase, become irregular, and gradually decrease before stopping.

Changes in breathing pattern and restlessness, are common, with breaths becoming very shallow and rapid. Periods of apnea and Cheyne-Stokes respirations (apnea alternating with periods of rapid breathing) are also common. Death occurs when respirations and heartbeat stop.

As the patient’s level of consciousness decreases, he or she may lose the ability to eat/drink, speak, and become incontinent with urine and bowel movements.
Congestion and gurgling due to increased secretions.

Question 7

Common Emotional Signs of Approaching Death Withdrawal:

Answer 7

The person is preparing to “let go” from surroundings and relationships. Vision-Like Experiences
The person may talk to people you cannot see or hear and see objects and places not visible to you. These are not hallucinations or drug reactions.

Question 8

Physical Manifestations Indicating That Death Has Occurred

Answer 8

• Breathing stops.
• Heart stops beating.
• Pupils become fixed and dilated.
• Body color becomes pale and waxen.
• Body temperature drops.
• Muscles and sphincters relax.
• Urine and stool may be released.
• Eyes may remain open, and there is no blinking.
• The jaw may fall open.
• Observers may hear trickling of fluids internally.

Question 9

Advanced directives

​​What are the different types of advanced directives?

Answer 9

Advanced directives

DPOA

Living will

DNR

POLST

Question 10

• A written document prepared by a competent person to specify what, if any, extraordinary actions he or she would want when no longer able to make decisions about personal health care
  durable power of attorney for health care

Answer 10

advance directive (AD)

Question 11

-A legal document in which a person appoints someone else to make health care decisions in the event he or she becomes incapable of making decisions.

Answer 11

durable power of attorney for health care (DPOAHC)

Question 12

A legal document that instructs physicians and family members about what life-sustaining treatment is wanted (or not wanted) if the patient becomes unable to make decisions.

Answer 12

Living will

Question 13

signed by a physician or other authorized primary health care provider, which instructs that CPR not be attempted in the event of cardiac or respiratory arrest. DNRs/DNARs are intended for people with life-limiting conditions, for whom resuscitation is not prudent.

Answer 13

Do-not-resuscitate (DNR) or do-not-attempt-to-resuscitate (DNAR) order,

Question 14

, which document additional instructions in case of cardiac or pulmonary arrest. Like portable DNRs/DNARs, POLST follow the patient across health care settings.

Answer 14

POLST (physician orders for life-sustaining treatment)

Question 15

​What dilemmas might you face when enforcing of advanced directives?

Answer 15

By law all primary health care providers in the United States must initiate CPR for a person who is not breathing or is pulseless unless that person has a DNR order.

The problem with performing CPR is that it can be a violent and likely painful intervention that prevents a peaceful death. CPR may also be unsuccessful or result in the patient being more compromised than they were before the event, perhaps for life.

Many patients and families do not understand the limitations of CPR and do not realize that it was never intended to be performed on patients with end-stage disease. Some families may want to keep patient at a full code status regardless of underlying health issues.

Question 16

What is grief versus mourning?

Answer 16

Grief-is the emotional feeling related to the perception of the loss. Patients who are dying suffer not only from the anticipated death but also from the loss of the ability to engage with others and in the world.

Mourning- is the outward social expression of the loss. Interventions to help patients and families grieve and mourn are based on cultural beliefs, values, and practices. Some patients and their families express their grief openly and loudly, whereas others are quiet and reserved.

Question 17

cultural beliefs regarding end of life

• The dying person is encouraged to recite the confessional or the affirmation of faith, called the Shema.

a person who is extremely ill and dying should not be left alone.

• The body, which was the vessel and vehicle to the soul, deserves reverence and respect.
• The body should not be left unattended until the funeral, which should take place as soon as possible (preferably within 24 hours).
• Autopsies are not allowed, except under special circumstances.
• The body should not be embalmed, displayed, or cremated.

Answer 17

Judaism-

Question 18

• tradition encourages people to receive Sacrament of the Sick, administered by a priest at any point during an illness. This sacrament may be administered more than once. Not receiving this sacrament will NOT prohibit them from entering heaven after death.
• People may be baptized in an emergency situation (e.g., person is dying) by a layperson. Otherwise they are baptized by a priest.
• They believe in an afterlife of heaven or hell once the soul has left the body after death.

Answer 18

Christianity

Question 19

• Based on belief in one God Allah and his prophet Muhammad.
Qur’an is the scripture, composed of Muhammad’s revelations of the Word of God (Allah).

• Death is seen as the beginning of a new and better life.
• God has prescribed an appointed time of death for everyone.
• Qur’an encourages humans to seek treatment and not to refuse treatment. Belief is that only Allah cures but that Allah cures through the work of humans.
• On death the eyelids are to be closed, and the body should be covered. Before moving and handling the body, contact someone from the person’s mosque to perform rituals of bathing and wrapping body in cloth.

Answer 19

Islam-

Question 20

What is the proper way to pronounce a death?

Answer 20

Pronouncement of Death
• Note time of death that the family or staff reported the cessation of respirations.
• Identify the patient by identification (ID) tag if in facility. Note the general appearance of the body.
• Ascertain that the patient does not rouse to verbal or tactile stimuli. Avoid overtly painful stimuli, especially if family members are present.
• Auscultate for the absence of heart sounds; palpate for the absence of carotid pulse.
• Look and listen for the absence of spontaneous respirations.
• Document the time of pronouncement and all notifications in the medical record (i.e., to attending physician). Document if the medical examiner needs to be notified (may be required for unexpected or suspicious death). Document if an autopsy is planned per the attending primary health care provider and family.
• If your state and agency policy allow an RN to pronounce death, document as indicated on the death certificate.

Question 21

6. What nursing interventions can be done to manage symptoms of distress in a dying patient?

Answer 21

Give low doses of opioids initially, with slow increases, monitoring for changes in mental status or excessive sedation.

Offer oxygen to any patient with dyspnea near death, regardless of his or her oxygen saturation, because COMFORT is the desired outcome.

Patients receiving opioids for pain or dyspnea and other drugs such as antiemetics or antianxiety agents may experience mild sedation as a side effect to therapy.
Depending on the patient and how soon death is expected, sedation may decrease with time.
What is important to understand is that drug therapy for symptoms of distress at the end of life are guided by protocols, using medications believed to be safe, with the intent of alleviating suffering.
There is no evidence that administering medications for symptoms of distress using established protocols hastens death.

A small percentage of patients have refractory symptoms of distress that do not respond to treatment near the end of life.
These patients may be candidates for proportionate palliative sedation—a care management approach involving the administration of drugs such as benzodiazepines (e.g., midazolam [Versed]), neuroleptics, barbiturates, or anesthetic agents (e.g., propofol [Diprivan]) for the purpose of decreasing suffering by lowering patient consciousness. The intent of proportionate palliative sedation to promote comfort and not hasten death distinguishes it from euthanasia.

Question 22

What interventions can be geared towards the family of a dying patient?

Answer 22

Teach family caregivers to watch closely for objective signs of impaired COMFORT (e.g., restlessness, grimacing, moaning) and identify when these symptoms occur in relation to positioning, movement, medication, or other external stimuli. Teach them how to perform interventions that can help relieve discomfort and stress.

Question 23

Patient and Family Education: Preparing for Self-Management:

Answer 23

Coolness of Extremities Circulation to the extremities is decreased; the skin may become mottled or discolored.
• Cover the person with a blanket.
• Do not use an electric blanket, hot water bottle, electric heating pad, or hair dryer to warm the person.

Increased Sleeping
Metabolism is decreased.
• Spend time sitting quietly with the person.
• Do not force the person to stay awake.
• Talk to the person as you normally would, even if he or she does not respond.

Fluid and Food Decrease Metabolic needs have decreased.
• Do not force the person to eat or drink.
• Offer small sips of liquids or ice chips at frequent intervals if the person is alert and able to swallow.
• Use moist swabs to keep the mouth and lips moist and comfortable.
• Coat the lips with lip balm.

Incontinence
The perineal muscles relax. • Keep the perineal area clean and dry. Use disposable underpads (Chux) and disposable undergarments. • Offer a Foley catheter for comfort.

Congestion and Gurgling
The person is unable to cough up secretions effectively. • Position the patient on his or her side. Use toothette to gently clean mouth of secretions. • Administer medications to decrease the production of secretions.

Breathing Pattern Change
Slowed circulation to the brain may cause the breathing pattern to become irregular, with brief periods of no breathing or shallow breathing. • Elevate the person’s head. • Position the person on his or her side.

Disorientation
Decreased metabolism and slowed circulation to the brain. • Identify yourself whenever you communicate with the person. • Reorient the patient as needed. • Speak softly, clearly, and truthfully.

Restlessness
Decreased metabolism and slowed circulation to the brain. • Play soothing music and use aromatherapy. • Do not restrain the person. • Massage the person’s forehead. • Reduce the number of people in the room. • Talk quietly. • Keep the room dimly lit. • Keep the noise level to a minimum. • Consider sedation if other methods do not work.

Question 24

Name at least three complementary therapies and their benefits

Answer 24

Common complementary and integrative therapies used for symptom management at the end of life include aromatherapy, music therapy, and energy therapies such as Therapeutic Touch.

Question 25

This may decrease pain in people with cancer and is one of the most popular complementary interventions used for patients at the end of life. This technique involves manipulating the patient’s muscles and soft tissue, which improves circulation and promotes relaxation. Patients who are severely weak, are arthritic, or have advanced age may not tolerate extensive massage but may benefit from a short treatment to sites of their choice. In working with patients with cancer, use light pressure and avoid deep or intense pressure. It should not be performed over the site of tissue damage (e.g., open wounds, tissue undergoing radiation therapy), in patients with bleeding disorders, and in those who are uncomfortable with touch (Westman & Blaisdell, 2016).

Answer 25

Massage

Question 26

complementary therapy used by people near the end of life that has been shown to decrease pain by promoting relaxation. Select music based on patient preferences and values.

Answer 26

Music therapy

Question 27

involves moving one’s hands through the patient’s energy field to relieve pain.

Answer 27

Therapeutic Touch

Question 28

is another type of energy therapy being evaluated for its role in pain and symptom management.

Use of It requires a practitioner who is trained in the method.

Answer 28

Reiki therapy

Question 29

can be used in conjunction with other treatments to relieve pain near the end of life. It is thought to decrease pain by promoting relaxation and reducing anxiety. Lavender, capsicum, bergamot, chamomile, rose, ginger, rosemary, lemongrass, sage, and camphor have been used in end-of-life care

Answer 29

Aromatherapy

Question 30

What are dysphagia precautions

Answer 30

Once the patient has difficulty swallowing, oral intake should be limited to soft foods and sips of liquids, offered but not forced.

Teach families about the risk for aspiration and reassure them that anorexia is normal at this stage. Families often have difficulty accepting that their loved ones are not being fed and may request that IV fluids be started. With great sensitivity, reinforce that having no appetite or desire for food or fluids is expected. Inform families that giving fluids can actually increase discomfort in a person with multisystem slowdown. Impaired COMFORT from fluid replacement could lead to respiratory secretions (and distress), increased GI secretions, nausea, vomiting, edema, and ascites. Most experts believe that dehydration in the last hours of life (i.e., terminal dehydration) does not cause distress and may stimulate endorphin release that promotes the patient’s sense of well-being. To avoid a dry mouth and lips, moisten them with soft applicators and apply an emollient to lips.

In collaboration with a pharmacist experienced in palliation, identify alternative routes and/or alternative drugs to promote COMFORT and maintain control of symptoms. Choose the least invasive route such as oral, buccal mucosa (inside cheek), transdermal (via the skin), or rectal. Some oral drugs can be given rectally. Depending on patient needs, the subcutaneous or IV route may be used if access is available. The intramuscular (IM) route is almost never used at the end of life because it is considered painful and drug distribution varies among patients.

Question 31

The client is terminally ill and has 20 second periods of apnea followed by periods of deep rapid breathing. The nurse documents this finding as which of the following?

Answer 31

D. Cheyne-Stokes respirations**

Question 32

A client says that he ingests only herbal preparations and not medications prescribed from a physician. Which response by the nurse is most appropriate?

Answer 32

What herbal preparations do you take?**

Question 33

A hospice nurse visits a client who is being cared for by her daughter. The client is no longer able to answer questions. The daughter is concerned that her mother may still be in pain. What assessment data may indicate that the client is in pain?

Answer 33

A. Moaning while being turned**