Palliative care: Approaches and goals

Counselling Services at KPU

• Counselling services can be accessed by visiting https://www.kpu.ca/counselling
• You can call KPU at 604-599-2828 for information about drop-in counselling
• The KPU office is in Room 1075, open Monday to Friday from 8:00 AM to 4:00 PM, except 12:00 PM to 1:00 PM daily
• An intake form needs to be filled out before seeing an Intake Counsellor
• The Crisis Centre of BC is available 24/7 at 604-872-3311 or 1-800-784-2433
• Online chat is operated by the Crisis Centre at crisiscentrechat.ca

Learning Objectives for End-of-Life Care

• Culture, religion, and age can influence attitudes toward death
• Grief can have a significant impact on individuals
• Stages, phases, or tasks encountered by clients, families, and caregivers when dealing with grief must be described
• It's important to understand how to meet the needs of a dying client
• The needs of the family of a dying client should be described
• Palliative care must be described
• Signs of approaching and actual are required in death identification
• It is important to understand how to assist in giving postmortem care

Questions to Ponder

• What has been your experience with death?
• What are your feelings and beliefs about death and dying?
• How have your experiences and culture shaped your beliefs?

Death and Dying

• Death can be either sudden or expected
• Personal feelings about death impact the care provided
• Dying processes must be understood
• Compassionate care should be given to the dying client, using DIPPS considerations

Life-Threatening Illnesses

• Life-threatening illnesses or injuries have no reasonable expectation of recovery
• Health care providers can't precisely predict the time of death
• Hope and the will to live significantly affect living and dying

Attitudes About Death

• Attitudes about death are influenced by experiences, culture, religion, personal beliefs, and age
• As people age and their circumstances change, their attitudes about death can shift

Attitudes About Death Continued

• Death attitudes are closely related to culture and religion
• Some people believe in an afterlife, while others don't
• Reincarnation is the belief in the rebirth of the spirit or soul in another form
• Strong religions provide comfort to the dying person and family
• Practices and attitudes vary across cultures and religions

Age and Experiences

• Adults fear pain, suffering, dying alone, loss of dignity, and separation from loved ones
• Adults worry about the care and support of those left behind
• Adults resent death, as it affects plans, hopes, dreams, and ambitions

Grief

• Grief is the emotional response to a loss or death
• Grief includes moving from deep sorrow towards healing and recovery
• Both the dying client and their loved ones experience a range of emotions

Critical Thinking About Grief

• Consider the physical and emotional symptoms associated with grief
• Understand the differences in how older adults grieve
• Know what type of help an older adult might need when grieving
• Review statements about grief to determine whether each represents fact or myth
• Contrast grief, mourning, and bereavement
• List 5 ways to advise loved ones to care for themselves (physical and emotional needs) as they grieve

Stages of Grieving: Kübler-Ross

• Dr. Elisabeth Kübler-Ross described the five stages of grieving
• Stage 1: Denial. Common response is "No, not me."
• Stage 2: Anger. The person thinks, "Why me?"
• Stage 3: Bargaining. The person says, "Yes, me, but ..."
• Stage 4: Depression. The person thinks, "Yes, me" and experiences sadness
• Stage 5: Acceptance. The person is calm and at peace
• Not all dying people pass through all five stages, and may move back and forth

Palliative Care

• The WHO defines palliative care, improving the lifes of patients and families facing a life-threatening illness.
• Palliative care prevents and relieves suffering through early identification, impeccable assessment, and treating pain alongside other physical, psychosocial, and spiritual issues

Palliative Care Continued

• Palliative and hospice care are terms that are often used interchangeably
• Palliative refers to the way care is given, while refers to the place the care is given
• Palliative care focuses on delivering compassion for dying individuals
• Providing comfort is a goal of hospice or palliative care
• Controlling pain and the symptoms of the patients illness is also a goal
• Ensuring death is natural is part of said care

Characteristics of Palliative Care

• Provides relief from pain and distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten nor postpone death
• Brings together the psychological and spiritual aspects of care with the physical aspects
• Offers support for patients to live actively until death
• Supports the family during the illness and bereavement
• Uses a team approach for patient and family needs, including bereavement counselling
• Enhances the quality of life and may positively influence the course of the illness

Palliative Care Core Values

• Hospice palliative care is entirely focused on facilitating an "appropriate death"
• "Appropriate death" includes the person being as comfortable as he/she wants
• "Appropriate death" includes taking the time to get to know the person and what dying means
• "Appropriate death" includes giving accurate information with compassion
• Supporting the families and patients, and in making judgements.

Providing Compassionate Care

• Focus on Dignity
• Focus on Independence
• Focus on Preferences
• Focus on Privacy
• Focus on Safety
• Remember DIPPS

Bill of Rights of the Dying Person

• To be treated as a living person until death
• To be cared for by people providing hope, and are compassionate and competent
• To participate to the best of their abilities in decisions about care
• To express feelings about approaching death in a unique way
• To be free of pain
• To have questions answered honestly
• To die in peace and dignity
• To have the sanctity of the human body respected after death

Dying Client Emotional, Social & Spiritual Needs

• Dying people have emotional, intellectual, social, and spiritual needs
• Be respectful, listen, and use touch
• Touch shows caring and concern when words cannot
• Some people want to see a spiritual leader
• Some want to participate in religious practices
• Provide privacy during prayer and spiritual moments
• Be courteous to the spiritual leader
• Handle religious objects with care and respect

Dying Client's Physical Needs

• Dying may take a few minutes, hours, days, or weeks
• Independence is encouraged when possible and as the client's basic needs are met
• Physical and psychological comfort is promoted
• Dying people are allowed to die in peace and with dignity

Dying Client's Physical Needs Continued

• Vision blurs and gradually fails
• Always assume that the client can hear
• Hearing is the last function to go
• Speech becomes harder
• Mouth and nostril care is important
• Circulation fails and body temperature rises as death nears
• The skin feels cool, pale, and mottled (blotchy) – provide good skin care
• Urinary and fecal incontinence may occur
• Constipation and urinary retention are common

More on Dying Client's Physical Needs

• Areas to aid with comfort and positioning
• Areas to aid with pain relief and vision problems
• Areas to aid with hearing and speech
• Areas to aid with mouth, nostril, and skin care
• Areas to aid with elimination and nutrition
• Provide a comfortable and pleasant room
• Remove unnecessary equipment
• Allow the client and family to arrange the room

Advance Directive or Living Will

• A living will is a document about measures for life support when death is likely
• A living will may instruct doctors not to start or that remove measures to prolong dying
• The power of attorney for personal care gives someone else the power to make health care decisions
• Proxies are named to make the decisions about personal care as well as medical care and treatment

"Do Not Resuscitate" Orders

• After consulting with the person and family, doctors write “Do Not Resuscitate" (DNR) or “No Code" orders
• This is for people who are terminally ill
• A DNR order means the person will not be resuscitated

Code Status and MOST Designations

• These are defined in settings with Meditech, which process is Order Entry
• Symptom control, resuscitation, intubation, ICU, site transfer, and treatment must be considered
• The Goal: Allow natural death with supportive care, symptom management.
• Transfer if comfort needs are not met.
• Treat readily reversible medical problems and sustain life within the capacity of the current location.
• Sustain life/ reverse problems
• DO NOT INCLUDE critical care interventions
• Reverse medical problems or sustain life.
• Transfer to acute care AND assessment for critical care interventions WITHOUT intubation
• Non-invasive ventilation may be offered.
• Reverse medical problems or sustain life, with transfer to acute care AND assessment for critical care.
• Resuscitation is not used.
• Cardiopulmonary resuscitation efforts, including chest compressions defibrillation /intubation
• Symptom management is always provided

Medical Assistance in Dying

• Medical Assistance in Dying (MAiD) is the process where a doctor or nurse practitioner helps a patient who chooses to end their life.
• MAiD is administered through drugs given either by mouth or intravenously
• Medical Assistance in Dying has been legal in Canada since 2016 under federal law

Eligibility for MAiD

• To be eligible for Medical Assistance in Dying, you must meet the following criteria:
• Be at least 18 years old
• Be eligible for publicly-funded health services in Canada
• Be able to give informed consent throughout the process
• Have a grievous and irremediable medical condition
• Be suffering intolerably from this condition
• Be in an advanced state of decline that cannot be reversed
• Be at the point with your condition where natural death is reasonably foreseeable
• Making a MAiD request as your own free will, with no influence from anyone

Medical Assistance in Dying Process in BC

• Talk to a nurse or doctor about end-of-life care options
• You must choose to go ahead with MAID and always have a chance to change the mind
• Palliative care is supportive and still available
• There are resources of support for patients and families: https://www.islandhealth.ca/sites/default/files/2019-05/maid-bereavement-guide-patients-families.pdf

MAiD Process Step by Step:

• Complete the Patient Request Record form
• This form you ask formally for Medical Assistance in Dying (MAiD)
• Undergo at least two assessments
• Assessments and criteria are given to be aware of health reasons

MAiD Process Continued Step by Step:

• "Complete a 10-day 'period of reflection'"
• In circumstances assessment shows that the individual qualifies for assisted death, the person will start a 10-day waiting/reflection period.
• Where desired to have Assisted Death, to be prepared for the assisted death, the patients plan where they assisted death will undergo.

Signs of Death

• Death may happen rapidly or slowly
• Movement, muscle tone/sensation are lost
• Circulation fails
• The respitory system fails
• Increased sleep and extreme fatigue
• Social withdraw
• Coolness/ bluish tint in fingers
• No blood pressure
• A doctor can make clear that the person is dead
• In some areas nurses can say the person is dead

Care of Body After Death

• Care of the body after death is postmortem care
• A nurse gives postmortem care with possible assistance
• Postmortem care begins after the person passes
• Postmortem care is given to give the body a healthy look
• One must give standard practices

Postmortem Care

• Provide privacy and respect when giving privacy
• Within 2-3 hours, the body has rigor mortis
• One needs to position the body to prepare for rigor mortis
• No sounds needed, is natural.

Explore palliative care's goals and holistic approach to well-being, including family support and cultural sensitivity. Discover how it differs from curative treatments and focuses on compassionate care for the terminally ill. Understand how age influences attitudes towards death.