Palliative Care and End-of-Life Concerns

Counselling Services

• Counselling services are available at https://www.kpu.ca/counselling.
• KPU can be contacted at 604-599-2828 for information about drop-in sessions.
• Room 1075 is open Monday to Friday from 8:00 AM to 4:00 PM and is closed daily from 12:00 PM to 1:00 PM
• Intake forms can be filled out while waiting to see the Intake Counsellor
• The Crisis Centre of BC can be reached 24/7 at 604-872-3311 or 1-800-784-2433
• Online chat is available at crisiscentrechat.ca

Learning Objectives

• It is important to understand how culture, religion, and age can influence attitudes toward death
• Grief can have a major impact on people.
• Understanding the stages, phases, or tasks for clients, families, and caregivers when dealing with grief is essential
• It’s important to learn how to meet the needs of dying clients
• Knowing the needs of the family of a dying client is significant
• Be able to identify the signs of approaching death
• Be able to identify the signs of death
• Learn how to assist in giving postmortem care

Death & Dying

• Death may be either sudden or expected
• Personal feelings about death can influence the care provided
• Understanding the dying process is important in providing compassionate care
• Compassionate care is DIPPS: Dignity, Independence, Preferences, Privacy and Safety.

Life-Threatening Illnesses

• Recovery is not reasonably expected for certain illnesses or injuries
• Healthcare providers are unable to predict the time of death accurately
• An individual's hope and will to live greatly affects the experience of living and dying

Attitudes About Death

• Experiences, culture, religion, personal beliefs, and age influence attitudes toward death
• Attitudes about death can change as people age and as circumstances evolve
• Beliefs about death connect closely to culture and religion
• Some people believe in an afterlife, while others do not
• Reincarnation involves the soul being reborn into another body or life form
• In times of dying, people can often strengthen religious beliefs.
• Religion can provide comfort to dying individuals, as well as family members
• Differing practices and attitudes may exist among cultures and religions

Age & Experience

• Adults often fear pain and suffering, dying alone, loss of dignity, and separation from loved ones
• Adults often worry about the support of those left behind
• Death is often resented by adults because it affects plans, dreams, and ambitions

Grief

• Grief represents the emotional response to loss or death
• Grief involves the process of moving from deep sorrow toward healing and recovery
• Both the client who is dying and their loved ones may experience various emotions in the face of loss

Kübler-Ross Stages of Grieving

• Dr. Elisabeth Kübler-Ross describes five stages of grieving: belief, anger, bargaining, depression, and acceptance
• Denial often presents with a response of "No, not me."
• A person may think or say, "Why me"? during the anger stage
• The person may begin bargaining and say, "Yes, me, but ..."
• During the depression stage, the person may think, "Yes, me" and feel sadness
• Acceptance is the last phase where the person is calm
• The person is calm and at peace
• People who are dying do not always go through all five stages; some people may move back and forth

Palliative Care

• The WHO definition of palliative care involves improving the quality of life for patients and their families who are facing problems associated with life-threatening illnesses
• This is done through the prevention and relief of suffering with early identification and impeccable assessment and treatment of pain, and other physical, psychosocial and spiritual problems
• Hospice relates to a place one receives care
• Palliative refers to care that is being given

Main Goals of Hospice or Palliative Care

• Assist in controlling the pain and symptoms of illness
• Ensuring that death is a natural process
• Providing compassionate care

Characteristics of Palliative Care

• Palliative care provides relief from pain and other distressing symptoms
• It affirms life and regards dying as a normal process
• It intends to neither hasten nor postpone death.
• It brings together the psychological and spiritual aspects of patient care with the physical aspects
• It offers a support system, so patients live actively as possible until their death
• It offers a support system so the family copes during the patient's illness and on into their own bereavement
• It uses a team approach to address the needs of patients and their families, including bereavement counseling
• It will enhance the quality of life and may also positively influence the course of illness

Palliative Care Core Values

• Hospice palliative care emphasizes facilitating an “appropriate death”
• Appropriate care can be,
• Making sure the person is comfortable
• Taking the time to know the person's needs and what dying means to them
• Providing compassionate and accurate information
• Supporting the decisions of families and patients without judgment

How to Provide Compassionate Care for the Dying Client

• Compassionate care is DIPPS
• Dignity
• Independence
• Preferences
• Privacy
• Safety

Bill of Rights of the Dying Person

• To be treated as a living being until death
• To be cared for by compassionate and competent people who maintain a sense of hope
• To express feelings about approaching death in a unique way
• To participate to the best of one’s abilities in decisions regarding care
• To be free of pain
• To have all questions answered honestly
• To expect that the sanctity of the human body will be respected after death
• To die in peace and dignity

Dying Client: Emotional, Social & Spiritual Needs

• People who are dying have emotional, intellectual, social, and spiritual needs
• Listening, using touch, and acting respectfully is key
• A touch communicates concern if words cannot
• Some people may want to see a spiritual leader or take part in religious practices
• Privacy needs to be provided during prayer and spiritual moments
• Be courteous to the spiritual leader and handle religious objects with care and respect

Dying Client’s Physical Needs

• Dying may take a few minutes, hours, days, or weeks
• Independence should be encouraged as much as possible, as the client weakens, basic needs are met
• Effort needs to be made to promote psychological and physical comfort
• The client should be allowed to die in peace and with dignity

Physical Indicators that a Patient is Nearing Death

• Vision blurs and fails
• Assume the client can always hear, as hearing is the last function to go
• Speech becomes harder
• Circulation fails and body temperature rises as death approaches
• The skin may feel cool, pale, and mottled, requiring increased skin care
• Urinary and fecal incontinence can occur
• Constipation and urinary retention is common
• The following may need assistance:
• Comfort and positioning
• Pain relief drugs
• Vision and eye care
• Hearing, speech
• Mouth, nostril, and skin care
• Elimination and nutrition
• A comfortable and pleasant room needs to be provided
• Ensuring the client and family are able to set the arrangement
• Removing unnecessary equipment

Advance Directive or Living Will

• A living will documents life-sustaining measures when death is likely
• A living will can instruct doctors to either not start, or to remove measures that prolong dying
• A power of attorney for personal care can give another person the authority to make healthcare decisions

Do Not Resuscitate’ Orders

• With consultation between family and the person, doctors can write a “Do Not Resuscitate” (DNR) or “No Code” order for people who are terminally ill
• The person will not be resuscitated with this order

Medical Assistance in Dying (MAID)

• Medical Assistance in Dying (MAiD) is the process whereby a doctor or nurse practitioner supports a patients end-of-life wish, voluntarily and intentionally
• Medical Assistance in Dying can be administered orally or intravenously.
• This law sets out the processes and eligibility requirements under which MAiD is delivered to a patient
• Has been legal in Canada since June 2016

Eligibility for MAiD:

• To receive MAiD, the following must be met:
• Must be 18 years old
• Have a grievous and irremediable medical condition (disability, illness, or disease)
• Be able to consent throughout the process
• Be entitled to publicly-funded health services in Canada and:
• Must be suffering intolerably
• Be in an advanced state of irreversible decline
• Be at the point where natural death is reasonably foreseeable
• Must be made by the subject of their own free will, without any external pressure or influence

Medical Assistance in Dying Process in BC

• It’s important to talk to a doctor or nurse practitioner about end-of-life care options
• Those who are considering MAiD may seek support to navigate the process, or be referred to someone who can help assess your eligibility
• This process will also assist with awareness of the care options that are available to you and to have the materials that are required to make an informed decision.
• These available care options may include palliative care, comfort care, hospice care, or pain control
• If one goes ahead with Medical Assistance in Dying, one can change their mind at any time to stop this process
• Supports for patients and families https://www.islandhealth.ca/sites/default/files/2019-05/maid-bereavement-guide-patients-families.pdf

MAID - The Process Step-By-Step

• Signing this request is formally stating a wish for MAiD, and that one believes the eligibility criteria are met
• Two different doctors or nurse practitioners must perform separate MAiD assessments
• After an assessment shows MAiD eligibility, federal law mandates a 10-day reflection before the service can be completed
• Circumstances can allow for the waiting period to be shortened
• During the reflection period, one can choose the place where MAiD can be administered
• This could be at one’s home, residence at a care facility, or in a hospital

Signs of Death

• Signs that death is near may occur rapidly or slowly
• The loss of muscle tone, movement, and sensation
• Peristalsis slows, along with other digestive functions
• Circulation fails and there is a failure of the respiratory system
• Change in eating and/or social withdrawal
• There is increase in sleep and fatigue
• Bluish or skin around nail beds and coolness in fingers or toes The process of death includes,
• The pupils are fixed and dilated
• No respirations, pulse, or blood pressure
• Provinces hold varying regulatory procedures, a doctor must determine that death has occurred
• In certain provinces, nurses are allowed to pronounce one dead when death is expected
• The pupils are fixed and dilated

Care of the Body After Death

• Postmortem care involves caring for the body once death has occurred
• Nurses administer postmortem care, but assistance may be requested
• Postmortem should be provided with standard nursing practices.
• Postmortem care begins when the client is announced dead
• Postmortem care focuses on maintaining the body with good appearance

Postmortem Care

• The right to privacy, respect, dignity, and treated with respect apply after death
• Rigor mortis sets in approximately 2–3 hours after death from muscle stiffening and skeletal rigidity
• The body needs to be aligned once rigor mortis has set in
• Sounds emitted by the body due to air being expelled are normal and expected

Explore palliative care's focus on holistic support and patient needs beyond curing illness. Understand its influence on quality of life and addressing fears associated with death. Examine the Kübler-Ross model of grief and helpful interventions.