end of life.docx

End of Life Care Hospice care is defined as the provision of medical and psychosocial care to support clients who have a terminal illness so as to allow them to live the last days of their life as best as they can, and for as long as they can. In general, hospice care is provided when treatment will...

End of Life Care Hospice care is defined as the provision of medical and psychosocial care to support clients who have a terminal illness so as to allow them to live the last days of their life as best as they can, and for as long as they can. In general, hospice care is provided when treatment will no longer cure or control the illness; the focus then becomes providing for comfort, dignity, and personal growth as the client faces death. Originally hospice care was offered to clients diagnosed with terminal cancer only, but over the years it has grown to include clients with life-limiting illnesses. When clients enroll in hospice care, they are asked to select someone to be their primary caregiver. The primary caregiver is usually a family member or a close friend. Hospice care is generally provided in the client’s home or a family member’s home. However, such care may also be delivered in other settings, such as a hospital, an extended-care facility, or an inpatient hospice center. Admission into hospice care depends on the client meeting specific criteria in addition to having the DR. making a diagnosis of a life expectancy of 6 months. The Centers for Medicare and Medicaid Services has developed specific criteria that must be met for a client to be eligible for hospice services, including: (1) a hospice provider and the primary care provider must officially state the client is terminally ill (2) the client must agree to palliative care as opposed to curing their illness (3) the client is required to sign a statement that they are choosing hospice care in place of other benefits to treat their illness. Palliative care, which is discussed in more depth later in this lesson, focuses on the relief and prevention of suffering and improving the quality of life for clients and their families/caregivers. If the client lives beyond the 6-months life expectancy term, an approved hospice provider will need to recertify that the client is terminally ill. The client can stop hospice services at any time, such as if their condition improves or their illness goes into remission. Other considerations that the client and family should discuss when considering enrolling in hospice care include the client’s readiness to discontinue treatments that are aimed at prolonging life and the client’s rate of deterioration despite medical treatment received. Modern hospice care is provided by an interdisciplinary team, consisting of providers, nurses, assistive personnel, social workers, spiritual leaders, and other health care professional services necessary to meet client needs. The interdisciplinary team approach allows for the holistic care of the whole person, considering the client’s mental, social, physical, and spiritual considerations within the dying experience. The team focuses on the significance of the quality of life rather than delaying the dying process. Hospice care also offers services in which volunteers provide respite care support for family/caregivers, including help with running errands, housekeeping, transportation, childcare assistance, and visitation. Other services offered include complementary medicine such as aromatherapy and Therapeutic Touch. When caring for hospice clients, expertise in managing pain and other manifestations is required to serve the purpose of hospice care. An acute awareness of intrapersonal and interpersonal undercurrents during this time is necessary as well. Hospice care provides supportive services for a period of up to 13 months following the death of the client for those individuals identified as family and in the primary caregiver role. As noted earlier, hospice care is holistic, treating the whole person, including caregivers and family members. Since hospice care is typically delivered in the client’s home, the client’s family or friends typically serve as caregivers and therefore, play a vital role with the health care team. In assisting the family in meeting the challenges of caring for their loved one, the hospice nurse plays an essential role in the education and support of family caregivers. Hospice nurses can assist the family caregivers in meeting the client’s daily care needs including the administration of medications and help with activities of daily living. These nurses support the family’s and other caregivers’ needs by assisting them to understand what they can anticipate as the client’s condition deteriorates, and how to meet the changing needs of their loved one. It is not unusual for the hospice nurse to become someone with whom caregivers can confide regarding their fears, anxiety, and doubts in caring for the client. The hospice nurse can provide the family and caregiver with an understanding of what they can do to keep the client comfortable as the client’s condition worsens. Awareness of caregivers’ possible feelings of doubt and fear will assist the nurse is providing care. As the team member who has the most direct contact with the client, the nurse also shares information with other team members, enabling them to adapt the plan of care as needed. Respite care provides a brief break for primary caregivers, which can last for hours, days, or weeks. Caregivers can request that their terminally ill loved one be admitted to a professional care facility for a maximum of 5 days. Respite care provides the caregivers with an opportunity to rest while knowing that their loved one is being cared for by hospice-trained professionals. As the nurse builds a relationship with the client’s caregivers, the nurse evaluates their ability to adjust to their role in caring for the client. In addition, the nurse, in collaboration with other team members, such as the chaplain and social worker, changes the care plan to meet the specific needs of the caregivers. Palliative care is defined as holistic care provided for clients throughout the lifespan who are experiencing a severe medical illness, and particularly for clients approaching end of life. Palliative care initially concentrated on lessening the client’s distress at the end of life. Today, however, best practice dictates that palliative care be implemented earlier in the course of life-threatening health events. In the past, palliative care was generally provided for those clients with a cancer diagnosis, but now it is offered to clients who are suffering from any life-threatening health event or chronic illness. The goal is to improve the quality of life for the client as well as for the family and caregivers. Examples of diseases for which palliative care may be appropriate include advanced stages of cancer, refractory cardiac disease (heart failure), renal or respiratory failure, and neurodegenerative conditions such as Alzheimer’s disease and Parkinson’s disease. Palliative care has been shown to improve a client’s quality of life, reduce time in the hospital, and improve client satisfaction. Palliative care differs from hospice care in that palliative care can be provided while the client is still receiving curative treatments. Moreover, unlike hospice care, palliative care is not subject to time constraints. Palliative care services may be suitable and provided long before a client has been identified with a terminal illness. Any client with a life-limiting disease, regardless of projected life expectancy or prognosis, is eligible to receive this care. A key aspect of palliative care is the use of a holistic approach—that is, caring for the client as a whole person, and treating both physical and psychosocial needs. It uses an interprofessional team approach with providers, nurses, and other associated health care personnel to meet the client’s needs. Physiological changes in clients at the end of life follow a predictable pattern of manifestations as the end of life nears. The terminal phase of a client’s life is characteristically referred to as “actively dying” or “imminent death”. Nurses need to be knowledgeable about the process of dying so that they are aware of the care required at the end of life and can share with the family what is most likely to happen as the client is actively dying. As the client approaches the end of life, physiological changes in the respiratory system commonly include dyspnea, defined as shortness of breath; retention of secretions in the respiratory tract, also known as “death rattle” and Cheyne-Stokes respirations, an irregular respiratory rate fluctuating between several quick breaths and periods of apnea. Nurses need to educate families that many of these physiological changes are predictable as the client is dying. Although some of the changes may be expected, the manifestations experienced may still vary for the individual client. Dyspnea may be related to advanced-stage cancer, ascites, chronic obstructive respiratory disease, a physical decline in respiratory functioning, and pneumonia. Opioids, such as morphine, are the first choice in treating dyspnea. These medications increase peripheral vasodilation (widening of the blood vessels, which permits increased blood flow), reduce the client’s sense of breathing difficulty, and decrease anxiety. Oxygen therapy is used to relieve dyspnea and provides psychological comfort to the client’s family. If death is imminent, comfort measures such as positioning, using a fan to facilitate the movement of air, reducing exertion, and relaxation techniques should be the focus. Anxiolytics such as benzodiazepines may be used to help relieve anxiety associated with difficulty in breathing. Death rattle is caused by the accumulation of secretions in the lungs and throat, causing congestion and a “rattling” sound as the secretions become trapped, and the client is unable to clear these secretions. The sound of “rattling” can upset family members and caregivers, although it is not an indication of client discomfort. Death rattle is an indication of approaching death, often within hours or days. Turning the client’s head to the side or rolling the client to the side can assist with drainage of the secretions from the throat and lungs. Medications such as oral atropine drops or scopolamine patches may also be used to dry up the secretions. A moist washcloth and oral suctioning can be used to eliminate secretions from the mouth. Deep suctioning is ineffective in removing the accumulated secretions that are pooled in the lungs. Cheyne-Stokes respirations are visible changes in the client’s pattern of breathing. This manner of breathing typically occurs within three days of impending death. The client’s rate of respiration becomes irregular, fluctuating between several quick breaths, followed by periods of apnea. The nurse can provide relief by positioning a fan to blow lightly in the direction of the client. The family should be educated that this type of breathing pattern is typical and expected. Nurses must promote the management of pain through means that are considered safe, sufficient, and successful in providing relief when a client is actively dying. Pain is experienced by nearly 60% of older adult hospice clients with cancer. As both hospice care and palliative care aim to improve the end-of-life experience, pain management is critical in ensuring that clients receive adequate relief from their pain and do not suffer unnecessarily. Guidelines suggest a combination of approaches will be most effective for these clients, including the administration of scheduled medications, as-needed (PRN) medications, and nonpharmacologic interventions. Clients may experience pain at the end of life resulting from nerve injury, an organ being stretched and compressed, and bone pain. It is not unusual for a nurse to hesitate about providing pain medication to such clients due to a fear of reducing the respiratory rate or hastening the client’s death. According to an American Nurses Association position statement, the nurse has an ethical responsibility to alleviate pain and suffering, to individualize interventions, and to use a variety of methods, including interprofessional approaches, to relieve pain. Pharmacologic treatment of pain includes the use of both nonopioids and opioids. Palliative care guidelines suggest that a three-step ladder be used when administering these pain management medications). According to this three-step ladder, pain control begins with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), which are nonopioid medications. If the client’s pain is unrelieved or increases in intensity, codeine or tramadol is recommended. When the client’s pain is rated as moderate to severe, morphine is prescribed. Nurses are responsible for supporting nonpharmacologic interventions in managing pain, including the use of psychological approaches, physical measures, integrative therapies, and interventional techniques. Nonpharmacologic interventions include diversion, relaxation exercises, or imagery; massage therapy; breathing exercises; music therapy; spiritual practices; changes in lighting or noise; repositioning; and the use of heat or cold therapy. As the client nears death, the nervous system’s ability to regulate body temperature diminishes, causing the client to experience episodes of both increased and decreased temperature. Other causes of temperature changes may include infection, cancer, and cancer therapy. In a client who has an infection, sweating is normal, especially if a fever is present. Chemotherapy decreases the immune system’s ability to respond to an infection, which can lead to sepsis. The cancerous tumor itself can also cause the client to have an elevated temperature. Likewise, the use of opioids, blood transfusion reactions, pain, hypoxia, fear and anxiety, and a warm environment result in temperature changes. The client’s body temperature can be managed with cold or hot compresses, warm sponge baths, hypothermia blankets, adjusting the air conditioning, using a fan, and antipyretic medications, including acetaminophen, ibuprofen, naproxen, or aspirin. Mottling of the skin is an expected and ordinary physical change that occurs hours or days before death. The upper and lower extremities become cool to the touch, accompanied by purple or reddish marbling of the skin. This is a result of the heart’s inability to pump blood effectively, leading to decreased blood perfusion throughout the body. Mottling often begins in the feet and moves up the legs. It is an indication of impending death. The client does not feel any discomfort from mottling, but may feel cold. Interventions to keep the client comfortable include providing warm blankets. Clients may experience hallucinations, a sensation that something is there when it is not, including hearing and seeing those who have already died. Hallucinations can include all the senses: hearing, sight, taste, touch, and smell. The client may hear voices or see an item or person unseen by others. For example, the client may be seen speaking with a family member who has already died or see places that others do not see. When a client experiences a hallucination, avoid contradicting what the client believes to be true. Denying the occurrence of hallucinations can cause distress and aggravate the client who is actively dying. As clients can hear even if they are in a deep comatose state, talk to them and provide reassurance—this can help those who are experiencing hallucinations. Reorientation approaches are of little benefit at this time. If the family is at the bedside, provide support and reassurance, as they may become unsettled when the client experiences hallucinations. Interventions are aimed at ensuring client safety and preventing client injury. A number of physiological alterations commonly unfold as a client nears the end of their life. Providing care at the end of life can be both physically and emotionally demanding, but preventing or relieving suffering is an essential part of medical care for clients who are dying. Click through the following alterations for descriptions and management strategies. The absence of social contact leads to social isolation, which can cause loneliness and adversely affect health. Loneliness is described as an emotional condition in which there is a perception of insufficient love, closeness, and social communication with others. Social isolation refers to inadequate contact or relationships with people. Constant tiredness, pain, and other factors can influence a client’s ability to socially interact act with others. Because people rely upon their social environment to give meaning to their life, separation from family, the community, or the religious or spiritual support system can increase client suffering. Numerous palliative care services have been designed to facilitate social support for clients whose lives are limited by disease. These services can be provided through home visits, the telephone, or the Internet. If possible, in-person face-face connections will be the most beneficial to the client, but other methods of facilitating social support include social media platforms and texting to help the client who is actively dying stay in touch with friends and family. Members of online support groups can validate feelings of isolation and offer encouragement, as they understand what it is like to experience loneliness. Volunteers through a hospice organization can visit with clients and family members and develop enduring relationships for those who have found their social contacts decreasing near the end of life. In addition, support groups can assist family members and caregivers who have recently lost a loved one to meet others who are also experiencing conflict, pain, or loss. As a nurse, you can assist in having visitors come at a time when the client’s pain management and other adverse physical manifestations are controlled, which should enable the client to be more comfortable when interacting with others. The American Nurses Association’s Code of Ethics for Nurses states, “the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person”. Dignity is regarded as an everyday necessity that is essential to the well-being of all clients. Most concerns related to nursing care at the end of life are associated with a breakdown in communication and lack of attention or consideration, which in turn diminishes the client’s sense of dignity. Nurses can support their clients’ dignity by managing client manifestations, including pain and respiratory issues; advocating independence, privacy, and social assistance; providing care with an optimistic attitude; listening; providing correct information; and demonstrating caring behaviors including empathy. Other needs that must be met to preserve client dignity include spiritual and everyday concerns. Spiritual needs center on the client’s need to be acknowledged as a person until they die as well as the client’s need to be told the truth about their illness. Spirituality is more than religion; it is attempting to be present, to acknowledge the client’s viewpoint sincerely, and to provide holistic care that emphasizes dignity before everything else. As clients near the end of life, illness contributes to a loss of control, which lessens their sense of dignity. Control refers to the client’s perception of and their ability to take care of life situations. As a nurse, it is essential to involve clients in the decision-making process by asking for their input about how they desire to be cared for and how they would like to die. Nurses should advocate for the client when the client is unable to handle matters themselves, which includes being truthful with family members and caregivers. Spirituality is difficult to define because a universally recognized definition is lacking. Although the terms “religion” and “spirituality” are often used interchangeably, they mean different things. Religion is based on specific beliefs and values that are shared within a community in the worship of a higher power. For some people, religion includes spirituality and a relationship with God or a higher power; for others, it does not. Spirituality speaks to a person’s existence, centered on the significance and purpose of life. It is about the relationship with others, nature, and a higher power. Spiritual happiness has several benefits for clients, including improved quality of life; better handling of illness, diagnosis, and manifestations; and averting depression, hopelessness, and the wish to hasten death. It is not uncommon for clients at the end of life to revisit their faith and spirituality as they make happiness a priority while looking forward to a peaceful death. Spirituality can offer clients an approach to coping with impending death, as it provides hope for life after death. If clients do not believe in the afterlife, they may experience worldly or horizontal hope, which is founded on people or things that offer meaning in assisting the person in reaching end-of-life goals. For example, clients may hope to be pain-free when they die or to repair damaged relationships before they die. As the end of life becomes imminent, it is not unusual for clients to change what they hope for as they are actively dying. Providing spiritual care is a part of the nurse’s role in delivering holistic, client-centered care. When assessing the spiritual needs of a client, the nurse must be sensitive to avoid offending the client and maintain the client–nurse relationship. Before offering spiritual care, it is essential to ask clients if they desire spiritual care. The nurse should demonstrate understanding, warmth, and compassion in caring for the client and family; this approach improves the relationship and communication between the nurse and the client, both of which are critical when providing spiritual care. If clients identify a religious affiliation with their spirituality, it is essential to accommodate their religious beliefs. Accommodating religious beliefs includes making contact with religious figures and other followers within their religious group. Nonreligious spiritual care should be offered to those clients who do not identify religious beliefs with spirituality. Although nurses can provide spiritual care, in-depth spiritual counseling should be provided by spiritual leaders. When a client is actively dying, health care providers, family, and caregivers are instrumental in providing a “good death” for the client. The definition of “dying well” is different for every client, as various factors influence the perception of a “good death”. Nevertheless, studies have identified some fundamental aspects of a “good death” and core elements that influence the perception of a “good death.” Fundamental aspects relate to recurring topics that many clients believe to be essential for a “good death” and are unique to each individual—for example, pain management, planning for death, closure at the end of life, clear decision making, and contributing to others. Elements that influence clients’ perception of death include culture, religion, age, life events, illness, and financial concerns. Nurses can affect the lives of dying people by applying their personal views of what constitutes a “good death.” Nurses should recognize their personal beliefs and the risk of using them in forming their perception of good or bad death.