Nursing Continuing Education

Palliative Care

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This is Your Course on Palliative Care or End of Life Care

Syllabus

Clients experience loss in many aspects of their lives. Grief is the inner emotional response to loss and is exhibited through thoughts, feelings, and behaviors. Bereavement includes both grief and mourning (the outward display of loss) as the individual deals with the death of a significant individual in their life.

Palliative or end‑of‑life care is an important aspect of nursing care and attempts to meet the client’s physical, spiritual, emotional, and psychosocial needs. End‑of‑life issues include decision‑making in a highly stressful time during which the nurse must consider the desires of the client and the family. Decisions are shared with other health care personnel for a smooth transition during this time of stress, grief, and bereavement.

Advance Directives

Advance directives: Legal documents that direct end‑of‑life issues

Living will: Directive documents for medical treatment per the client’s wishes

Health care proxy (also known as durable power of attorney for health care): A document that appoints someone to make medical decisions when the client is no longer able to do so on his own behalf

Types of Loss

Necessary loss: A loss related to a change that is part of the cycle of life that is anticipated but still can be intensely felt. This type of loss can be replaced by something different or better.

Actual loss: Any loss of a valued person, item, or status, such as loss of a job that can be recognized by others

Perceived loss: Any loss defined by the client that is not obvious or verifiable to others

Maturational or developmental loss: Any loss normally expected due to the developmental processing of life. These losses are associated with normal life transitions and help to develop coping skills (e.g., child leaving home for college).

Situational loss: Any unanticipated loss caused by an external event (e.g., family loses home during tornado)

Anticipatory loss: Experienced before the loss happens

Theories of Grief

Kübler-Ross Model

  1. Denial: The client has difficulty believing a terminal diagnosis or loss.
  2. Anger: The client lashes out at other people or things.
  3. Bargaining: The client negotiates for more time or a cure.
  4. Depression: The client is overwhelmingly saddened by the inability to change the situation.
  5. Acceptance: The client acknowledges what is happening and plans for the future by moving forward.

Stages might not be experienced in order, and the length of each stage varies from person to person.

Factors Influencing Loss, Grief, and Coping Ability

  • Individual’s current stage of development
  • Gender
  • Interpersonal relationships and social support networks
  • Type and significance of the loss
  • Culture and ethnicity
  • Spiritual and religious beliefs and practices
  • Prior experience with loss
  • Socioeconomic status

Factors That Can Increase an Individual's Risk for Dysfunctional Grieving

  • Being exceptionally dependent upon the deceased
  • A person dying unexpectedly at a young age, through violence or in a socially unacceptable manner
  • Inadequate coping skills or lack of social supports
  • Lack of hope or preexisting mental health issues, such as depression or substance use disorder

Assessment/Data Collection

Manifestations of Grief Reactions (ask Andrea about these headers - separate?)

Normal grief

  • This grief is considered uncomplicated.
  • Emotions can be negative, such as anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time.
  • Some acceptance should be evident by 6 months after the loss.
  • Somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue.

Anticipatory grief

  • This grief implies the “letting go” of an object or person before the loss, as in a terminal illness.
  • Individuals have the opportunity to start the grieving process before the actual loss.

Complicated grief

  • Unresolved or chronic grief is a type of complicated grief.
  • This grief involves difficult progression through the expected stages of grief.
  • Usually, the work of grief is prolonged. The manifestations of grief are more severe, and they can result in depression or exacerbate a preexisting disorder.
  • The client can develop suicidal ideation, intense feelings of guilt, and lowered self‑esteem.
  • Somatic complaints persist for an extended period of time.

Disenfranchised grief

  • This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide and abortion.

Nursing Interventions

Facilitate Mourning

  • Grant time for the grieving process.
  • Identify expected grieving behaviors, such as crying, somatic manifestations, and anxiety.
  • Use therapeutic communication related to the client’s stage of grief. Name the emotion the client is feeling. For example, the nurse can say, “You sound as though you are angry. Anger is a normal feeling for someone who has lost a loved one. Tell me about how you are feeling.”
  • Use active listening, open‑ended questions, paraphrasing, clarifying, and/or summarizing, while using therapeutic communication.
  • Use silence and personal presence to facilitate mourning.
  • Avoid communication that inhibits the open expression of feelings, such as offering false reassurance, giving advice, changing the subject, and taking the focus away from the grieving individual.
  • Assist the grieving individual to accept the reality of the loss.
  • Support efforts to “move on” in the face of the loss.
  • Encourage the building of new relationships.
  • Provide continuing support. Encourage the support of family and friends.
  • Assess for evidence of ineffective coping, such as a client refusing to leave the home months after his partner died.
  • Share information about mourning and grieving with the client, who might not realize that feelings, such as anger toward the deceased, are expected.
  • Encourage attendance at bereavement or grief support groups. Provide information about available community resources.
  • Initiate referrals for individual psychotherapy for clients who have difficulty resolving grief.
  • Ask the client whether contacting a spiritual advisor would be acceptable, or encourage the client to do so.
  • Participate in debriefing provided by professional grief and mental health counselors.

Palliative Care

  • The nurse serves as an advocate for the client’s sense of dignity and self‑esteem by providing palliative care at the end of life.
  • Goal is to learn to live fully with an incurable condition.
  • Palliative care improves the quality of life of clients and their families facing end‑of‑life issues.
  • Palliative care interventions are primarily used when caring for clients who are dying and family members who are grieving. Assessment of the client’s family is\ very important as well.
  • Palliative care interventions focus on the relief of physical manifestations (such as pain) as well as addressing spiritual, emotional, and psychosocial aspects of the client’s life.
  • Palliative care can be provided by an interprofessional team of physicians, nurses, social workers, physical therapists, massage therapists, occupational therapists, music/art therapists, touch/energy therapists, and chaplains.
  • Hospice care is a comprehensive care delivery system, that can be performed in a variety of settings, and can be implemented when a client is not expected to live longer than 6 months. Further medical care aimed toward a cure is stopped, and the focus becomes enhancing quality of life and supporting the client toward a peaceful and dignified death.

Assessment/Data Collection

  • Determine the client’s sources of strength and hope.
  • Identify the desires and expectations of the client and family for end‑of‑life care.

Characteristics of Discomfort

  • Pain
  • Anxiety
  • Restlessness
  • Dyspnea
  • Nausea or vomiting
  • Dehydration
  • Diarrhea or constipation
  • Urinary incontinence
  • Inability to perform ADLs

Manifestations of Approaching Death

  • Decreased level of consciousness
  • Muscle relaxation of the face
  • Labored breathing (dyspnea, apnea, Cheyne‑Stokes respirations), “death rattle”
  • Hearing is not diminished
  • Touch diminished, but client is able to feel the pressure of touch
  • Mucus collecting in large airways
  • Incontinence of bowel and/or bladder
  • Mottling (cyanosis) occurring with poor circulation
  • Pupils no longer reactive to light
  • Pulse slow and weak and blood pressure dropping
  • Cool extremities
  • Perspiration
  • Decreased urine output
  • Inability to swallow

Nursing Interventions

  • Promote continuity of care and communication by limiting assigned staff changes.
  • Assist the client and family to set priorities for end‑of‑life care.

Physical Care

  • Give priority to controlling findings.
  • Administer medications (such as morphine) that manage pain, air hunger, and anxiety.
  • Perform ongoing assessment to determine the effectiveness of treatment and the need for modifications of the treatment plan, such as lower or higher doses of medications.
  • Manage adverse effects of medications.
  • Reposition the client to maintain airway patency and comfort.
  • Maintain the integrity of skin and mucous membranes.
  • Provide caring touch (holding the client’s hand).
  • Provide an environment that promotes dignity and self‑esteem.
    • Remove products of elimination as soon as possible to maintain a clean and odor‑free environment.
    • Offer comfortable clothing.
    • Provide careful grooming for hair, nails, and skin.
    • Encourage family members to bring in comforting possessions to make the client feel at home.
  • If appropriate, encourage the use of relaxation techniques, such as guided imagery and music.
  • Promote decision‑making in food selection, activities, and health care to give the client as much control as possible.
  • Encourage the client to perform ADLs as able and willing to do so.

Psychosocial Care

  • Use an interprofessional approach.
  • Provide care and foster support to the client and family.
  • Use volunteers when appropriate to provide nonmedical care.
  • Use therapeutic communication to develop and maintain and facilitate communication between the client, family, and the provider.
  • Facilitate the understanding of information regarding disease progression and treatment choices.
  • Facilitate communication between the client, the family, and the provider.
  • Encourage the client to participate in religious practices that bring comfort and strength, if appropriate.
  • Assist the client in clarifying personal values in order to facilitate effective decision‑making.
  • Encourage the client to use coping mechanisms that have worked in the past.
  • Be sensitive to comments made in the presence of clients who are unconscious because hearing is the last sensation lost.

Prevention of Abandonment and Isolation

  • Prevent the fear of dying alone.
  • Make your presence known by answering call lights in a timely manner and making frequent contact.
  • Keep the client informed of procedure and assessment times.
  • Allow family members to stay overnight.
  • Determine where the client is most comfortable, such as in a room close to the nurses’ station.

Support for the Grieving Family

  • Suggest that family members plan visits to promote the client’s rest.
  • Ensure that the family receives appropriate information as the treatment plan changes.
  • Provide privacy so family members have the opportunity to communicate and express feelings among themselves without including the client.
  • Determine family members’ desire to provide physical care while maintaining awareness of possible caregiver fatigue. Provide instruction as necessary.
  • Educate the family about physical changes to expect as the client moves closer to death.
  • Allow families to express feelings.

Postmortem Care

  • Nurses are responsible for following federal and state laws regarding requests for organ or tissue donation, obtaining permission for autopsy, ensuring the certification and appropriate documentation of the death, and providing postmortem (after‑death) care.
  • After postmortem care is completed, the client’s family becomes the nurse’s primary focus.

Nursing Interventions

Care of the Body

  • Provide care with respect and compassion while attending to the desires of the client and family per their cultural, religious, and social practices. Check the client’s religion and make attempts to comply.
  • Recognize that the provider certifies death by pronouncing the time and documenting therapies used, and actions taken prior to the death.

Preparing the Body for Viewing

  • Maintain privacy.
  • Remove all tubes (unless organs are to be donated or this is a medical examiner’s case).
  • Remove all personal belongings to be given to the family.
  • Cleanse and align the body supine with a pillow under the head, arms with palms of hand down outside the sheet and blanket, dentures in place, and eyes closed.
  • Apply fresh linens with absorbent pads on bed and a gown.
  • Brush/comb the client’s hair. Replace any hairpieces.
  • Remove excess supplies, equipment, and soiled linens from the room.
  • Dim the lights and minimize noise to provide a calm environment.

Viewing Considerations

  • Ask the family whether they would like to visit with the body, honoring any decision.
  • Clarify where the client’s personal belongings should go: with the body or to a designated person.
  • Adhere to the same procedures when the client is an infant, with the following exceptions:
    • Swaddle the infant’s body in a clean blanket.
    • Transport the infant in the nurse’s arms or in an infant carrier based on facility protocol.
    • Offer mementos of the infant (identification bracelets, footprints, the cord clamp, a lock of hair, photos).

Postviewing

  • Apply identification tags according to facility policy.
  • Complete documentation.
  • Remain aware of visitor and staff sensibilities during transport.

Organ/Tissue Donation

  • Recognize that requests for tissue and organ donations must be made by specifically trained personnel.
  • Provide support and education to family members as decisions are being made. Use private areas for any family discussions concerning donation.
  • Be sensitive to cultural and religious influences.
  • Maintain ventilatory and cardiovascular support for vital organ retrieval.

Autopsy Considerations

  • The provider typically approaches the family about performing an autopsy.
  • The nurse’s role is to answer the family members’ questions and support their choices.
  • Autopsies can be conducted to advance scientific knowledge regarding disease processes, which can lead to the development of new therapies.
  • The law can require an autopsy to be performed if the death is due to homicide, suicide, or accidental death, or if death occurs within 24 hr of hospital admission.
  • Most facilities require that all tubes remain in place for an autopsy.
  • Documentation and completion of forms following federal and state laws typically includes the following:
    • Who pronounced the death and at what time
    • Consideration of and preparation for organ donation
    • Description of any tubes or lines left in or on the body
    • Disposition of personal articles
    • Who was notified, and any decisions made
    • Location of identification tags
    • Time the body left the facility and the destination

Care of Nurses Who are Grieving

  • Caring long‑term for clients can create personal attachments for nurses.
  • Nurses can use coping strategies:
    • Going to the client’s funeral
    • Communicating in writing to the family
    • Attending debriefing sessions with colleagues
    • Using stress management techniques
    • Talking with a professional counselor

References

  1. PN Mental Health Nursing REVIEW MODULE EDITION 10.0 2017 Assessment Technologies Institute, LLC. 
  2. Fundamentals for NursingREVIEW MODULE EDITION 9.0 2017 Assessment Technologies Institute, LLC.

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