4/10/2018. Preparing for Death. Describe a Recent Death You Have Observed. The Nurse, Dying and Death

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Preparing for Death Core Curriculum FINAL HOURS CARLA JOLLEY MN, ARNP, AOCN, ACHPN WHIDBEYHEALTH PALLIATIVE CARE JOLLEC@WHIDBEYHEALTH.

Interpersonal competence Being present Bearing witness Interdisciplinary care Describe a Recent Death You Have Observed What went well? Were the patient and family s wishes honored?

1 Preparing for Death Core Curriculum FINAL HOURS CARLA JOLLEY MN, ARNP, AOCN, ACHPN WHIDBEYHEALTH PALLIATIVE CARE Everyone dies Advance care planning Recognizing the transition to active dying Care for the dying Post death care The Nurse, Dying and Death Nurses provide support to staff, patients/families Interpersonal competence Being present Bearing witness Interdisciplinary care Describe a Recent Death You Have Observed What went well? Were the patient and family s wishes honored? Describe any cultural traditions that were honored. Was pain controlled, as well as other symptoms? Was interdisciplinary care evident? What could have been improved? What issue(s) could have been prevented? Are there policies/procedures that need to be developed to provide better direction? Living Until We Die End of life is not simply a problem to be solved; it is also a mystery to be experienced If we understand hope only as a future reality, we miss the relational dimension of hope We are not the experts in another s dying experience, we need to approach it with humility Each spiritual agenda is unique to the belief system of the person Dying is an Individualized, Personal Experience There is no typical death Patient preferences Nurses advocate for choices Setting of death Support Psychological and emotional considerations 1

2 Smooth transitions Transitioning to palliative care or comfort care in the ICU, acute care, or ER settings Transitioning from inpatient or ER to outpatient palliative or hospice care Transitioning to home or alternative settings What About Artificial Nutrition & Hydration at End of Life? Perceptions of starving to death Hydration does not decrease dry mouth Patients who fasted to end their lives experienced peaceful death Gabriel & Tschanz, 2015; HPNA, 2011a; Prince-Paul & Daly, 2010 Resuscitation No advance planning Unrealistic beliefs regarding survival Discontinuation of Dialysis When should dialysis be discontinued? When burdens outweigh benefits and/or, When dialysis is no longer prolonging life or only prolonging death Family presence during resuscitation Outcomes are usually poor Deactivating Implantable Cardiovertor Defibrillator When should it occur? Defining goals of care Allows for natural death Patients with terminal disease are more likely to develop hypoxia, sepsis, pain and electrolyte disturbances Organ/Tissue Donation Regulations Talking to the family about organ/tissue transplantation What can be donated? Death declared on the basis of cardio-pulmonary criteria versus neurological criteria in brain death Can cause ethical and moral angst for healthcare providers witnessing this Hastened Death Request Statement made by patient Progressive incurable illness Judgment not impaired Intervention to cause death more immediately than if illness took its natural course Assisted suicide/dying Clinician-assisted Stopping eating and drinking Other means 2

Psychosocial Changes Spiritual Considerations When Death is Imminent We only

introspective Cultural Considerations When Death is Imminent The Dying Older

woman diagnosed with stage IV ovarian cancer 16 months ago Admitted to the

adult sons Divorced Spiritual, but not affiliated with any religion Served in

3 Psychosocial Changes Spiritual Considerations When Death is Imminent We only die once Fear of dying Feelings of loss At end of life, patient may be more introspective Cultural Considerations When Death is Imminent The Dying Older Adult Death rites Rituals Mazanec & Panke, 2015 Case Study: Gail 62-year-old woman diagnosed with stage IV ovarian cancer 16 months ago Admitted to the hospital with a bowel obstruction, cachexia, and dehydration 1 week ago 3 adult sons Divorced Spiritual, but not affiliated with any religion Served in the Army for 20 years Home hospice Frequent Symptoms Associated with Imminent Death 3

Two Roads to Death Restless NORMAL Sleepy THE USUAL ROAD Confused Lethargic Tremulous Obtunded Semicomatose Comatose Hallucinations Seizures Myoclonic Jerks THE DIFFICULT ROAD Mumbling Delirium Most

unconsciousness Weakness and fatigue vs. surge of energy Drowsiness, sleeping vs.

4 Two Roads to Death Restless NORMAL Sleepy THE USUAL ROAD Confused Lethargic Tremulous Obtunded Semicomatose Comatose Hallucinations Seizures Myoclonic Jerks THE DIFFICULT ROAD Mumbling Delirium Most Common Symptoms in Final Days of Life DEAD NCI, 2014; Seow et al, 2011 Kehl & Kowalski, 2013 Physical Symptoms Vary Pain During the Final Hours of Life Confusion, disorientation, delirium vs. unconsciousness Weakness and fatigue vs. surge of energy Drowsiness, sleeping vs. restlessness/agitation Physical considerations: Fever Bowel changes Incontinence Decreased intake Changes in level of consciousness may make assessment and management of pain challenging. If self-report is not possible, behavioral cues, proxy report, analgesic trials What is causing the pain? Opioids Dosing of opioids given during last hours based on appropriate assessment and reassessment. Dose may be decreased or increased Consider other routes: Oral Rectal Subcutaneous National Comprehensive Cancer Network (NCCN): Guidelines for Treating Pain Weeks to Days Before Death Titrate to comfort Recognize and treat toxicities Analgesia vs. reduced LOC Use equianalgesic dose conversions Consult Consider sedation for refractory pain 4

5 Palliative Sedation at End of Life Consider: All possible etiologies and treatments Education of patient/family regarding goals and outcomes Interdisciplinary team approach Medications Myoclonus Assess potential etiologies Benzodiazepines can be helpful (i.e., diazepam) Switch opioids Can lead to seizures Terminal Secretions Respiratory congestion/terminal secretions Distressing and frightening to family, friends, healthcare providers Assessment Management Position changes, elevate head, education, consider use of anticholinergic drugs, reduce or withhold IV/enteral feedings Symptoms of Imminent Death Decreased urine output Cold and mottled extremities Vital sign and breathing changes Delirium / confusion Restlessness Nearing Death Awareness Common phenomena Keeping an open mind Supporting the family Case Study: Gail (cont) Gail is now unconscious Pain assessment Reassurance to family Death rattle Concerns about dehydration 5

Berry & Griffie, 2015 4/10/2018 Open, Honest Communication Convey caring, sensitivity, compassion Provide information in simple terms Patient awareness of dying Maintain presence The Death Vigil

6 Berry & Griffie, /10/2018 Open, Honest Communication Convey caring, sensitivity, compassion Provide information in simple terms Patient awareness of dying Maintain presence The Death Vigil Family presence Common fears Being alone with patient Painful death Time of death Giving last dose Bereavement Care Care and Respect of the Body Reflects importance and value of the patient Respect family rituals Allow family to provide physical care Comb hair Wash face/body Hold hand, kiss, hug Berry & Griffie, 2015 Death of a Parent.Remember the Children Be aware of the developmental stage of the child Communicate openly and honestly Children need opportunities to ask questions Questions should be answered in terms that they can comprehend Case Study: Gail (cont) Gail died the next day with her husband and 3 sons at her bedside Bereavement care 6

7 What can you do? Questions to ask you team? Become familiar with your palliative care and hospice resources Acknowledge earlier on when talking about support options that will be part of choices support in the future Talk about our overall goals for care to support quality of life Normalize transition points 7

Hospice and Palliative Medicine

Hospice and Palliative Medicine Certification Examination Blueprint Purpose of the exam The exam is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the