State of Nebraska Transition Grant

End-of-Life Care for the Newly Licensed Practical Nurse

Copyright 2011

Title: End of Life Care Learning Objectives: Upon completion of this education module, the newly licensed practical nurse will: Examine personal feelings concerning end of life care and death of a patient. Explain an advance directive and the patients code status. Describe physical changes that occur at the end of life. Describe the concepts of palliative care and end-of-life care. Discuss needs of a patient during palliative care and at the end of life. Prepare appropriate documentation at the end of life. Recognize needs of the patients family and caregivers during palliative care and at the end of life to include cultural traditions related to the dying process. Summarize care of the dying patient and after death. Interactive Exercises: 1. Review the information on end-of-life care that follows, with your preceptor. 2. With your preceptor, share your feelings and concerns about care of patients at the end of life and after death. 3. Develop a list of patient and family needs during palliative care, at the end of life and at death. If the facility has a palliative care or hospice coordinator, discuss these needs with this individual or your preceptor. 4. Review medications used for pain control in palliative care and at the end of life, to include: typical medications and the regimens used, routes, methods of administration, and documentation. 5. Prioritize the list of patient and/or family needs with your preceptor or the palliative care/hospice coordinator. 6. Discuss cultural traditions of ethnic groups in the community surrounding the dying process. 7. Explore the policy and procedure at your facility for care of the dying patient, his family and postmortem care. Discuss this with your preceptor. 8. Explore resources provided to the family of the dying patient. If the facility has a chaplain, discuss these materials with this individual. 9. Participate in postmortem care and practice documentation for a postmortem patient. 10. Explore the use of advanced directives at your facility. Obtain a copy of information about advanced directives given to the patient and his family and review this with your preceptor. 11. Review the policy and procedure for obtaining a patients code status. 2

End of Life Care 1. Take out a piece of paper and write down what you might observe during the assessment of a patient at the end of life. When you have completed reviewing this content, compare what you wrote with what you have learned. A. Signs of approaching death: 1) Drowsiness the patient may sleep more and may have decreased responsiveness 2) Disorientation may also be restless and have visions of places or people who are not present with them 3) Withdrawal caused by decreased blood flow and mental preparation for dying 4) Signs of approaching death 5) Loss of appetite will not be hungry due to the decreased ability of the body to utilize food and fluids 6) Loss of bladder and bowel control due to relaxation of the muscles in the pelvis 7) Decreased urine output and/or darker urine due to decreased fluid intake and decreased kidney function 8) Signs of approaching death 9) Cooler skin begins in the extremities; skin may become cyanotic due to decreased circulation 10) Audible rattling or gurgling breath sounds breathing often becomes shallow, irregular, and the respiratory rate decreases due to decreased circulation and congestion 11) Signs of approaching death 12) Turning of the head to a light source due to decreased vision 13) Increasing difficulty in controlling pain due to the advancing disease process 14) Involuntary movement and loss of reflexes in the legs and arms B. Nursing Interventions at the end of life: 1. Speak directly to the patient and talk as if the patient can always hear you. 2. Speak calmly and gently reorient the patient to time, place and person. 3. Do not restrain a patient at the end of life. 4. Let the patient choose if and when they want to eat and drink perform good oral care. 5. Keep the patient clean and dry provide a disposable pad on the bed. 6. Keep the patient warm use blankets. 7. The patient will probably rest easier on their side with pillows placed behind their back for support. 8. Provide pain medication as ordered and notify the physician for break- through pain. 9. Employ non-pharmacologic measures for pain control: Positioning Massage Therapeutic touch Application of heat or cold Music therapy Spiritual counseling C. Pain Management at the end of life: Collaboration among all health care team members as well as the patient and family or caregivers is very important. Joint participation is needed to provide adequate pain management at the end of life. Use a valid pain assessment tool and reassess pain 3

frequently. Complete accurate documentation. Many people in our society value stoicism. Many patients believe that asking for pain medication makes them appear weak and they may fear addiction. Health care professionals can educate patients and families regarding these beliefs. Most patients fear uncontrolled pain. Swallowing may be difficult at the end of life so it may be necessary to establish alternate routes of medication administration. There is no evidence that opioid use at the end of life will hasten death. D. World Health Organizations Pain Relief Ladder:

D. Family and Cultural Rituals: It is important for health care professionals to discuss cultural or religious rituals with the family that may be important to them. When death occurs, expressions of grief vary between family members and caregivers and the nurse should be sensitive to these expressions of grief. E. Family and Caregivers: Family and caregivers are often concerned about their ability to manage pain, nutrition and hygiene needs. Assess what the family and caregivers understand about end-of-life care. Refrain from using medical terminology use the words dying or death. Allow them opportunities to express their feelings, without making judgments. They often feel like they should always be doing something for the patient reassure them that just being there is appropriate. Teach them the signs of impending death and help them develop a plan for dealing with the moment of death. F. Palliative Care:

The goal of palliative care is to improve the patients and the familys quality of life by preventing and relieving suffering. This includes treating physical symptoms such as pain, and dealing with emotional, social and spiritual concerns. - National Cancer Institute G. World Health Organizations View of Palliative Care: 1. Provides relief from pain and other distressing symptoms. 2. Affirms life and regards dying as a normal process. 3. Intends neither to hasten nor postpone death. 4. Offers a support system to help the family cope during the patients illness and in their own bereavement. 5. Uses a team approach to address the needs of patients and their families, including bereavement counseling if indicated. 6. Will enhance quality of life, and may also positively influence the course of the illness. 7. Is applicable early in the course of illness, in conjunction with other therapies. H. The Team Approach: What team members are available in your facility to assist the patient and their family and caregivers at the end of life? Talk about this with your preceptor and do some In the State of Nebraska, the person who is appointed as a health care proxy cannot be the patients research.

physician or any employee of the physician not related to the patient, any owner of the patients health care provider not related While hospice a person unrelated to the patient a patient at home, they also I. Hospice Programs: to the patient, or programs are designed to keepwho is already a health care proxy to 10 or more people. Nebraska law requires that the patient has the power of attorney for health services provide service in hospice centers as well as hospitals and nursing home facilities. Hospice care witnessed. Thispeople accomplishedlonger benefit from curative your power of attorney for are available to can be who can no by a notary public (who is not treatment. The typical life health care) or by two witnesses less expectancy is 6 months or (unrelated to the patient and not the patients physician or your power of attorneyHospice programs patient may change their mind atnear timeend ofany of their decisions 1. for health care). A give care to patients who are any the about life. related to an advance directive. on quality of life. 2. Hospice care focuses

3. The goal of hospice care is to make the dying person comfortable, to relieve symptoms and include services to assist in physical care as well as emotional, social and spiritual needs of the patient and family. J. Advance Directives: The nurse should know the type (if any) of advance directive for each patient under his/her care. Advance directives are legal documents which allow patients to make their wishes known about end of life care: 1) Living will: a set of instructions documenting a persons wishes about medical care intended to sustain life 2) Durable power of attorney: a legal document that names a patients health care proxy 3) Health care proxy: a person appointed to make a medical decisions if the patient is unable to do so

K. Patient Rights: 1. Patients have the right to complete information about their illness and how it may affect their lives. 2. Patients have the right to share or withhold that information from others. 3. Patients have the right to make decisions about their treatment. 4. Patients have the right to change these decisions at any time. L. Care of the patient at the time of death: In some facilities, if the attending physician or designee is not present at the time of death, the RN in charge may pronounce the patient death (know your policy). However, the attending physician must complete and sign the death certificate as required by the state.

Note the exact time the patient ceases to breathe. Notify the physician/physicians assistant or nurse practitioner (know your facility policy regarding who will pronounce the death of a patient). Avoid unnecessary exposure of the body and treat the body with respect If family/caregivers are present, allow them time with the patient if they wish. M. Autopsy If an autopsy of the body is ordered, your facility will have a form that will need to be signed by the nearest relative or designee of the patient (look this up in your policy manual). Make sure the mortician is aware that an autopsy has been ordered. Do not remove any indwelling tubes if an autopsy has been ordered. N. Care of the body If necessary, bathe the body and make sure identification band (if present) is left in place. Close eyes or mouth, if open and replace dentures/glasses (or send with mortician). Place body in supine position with pillow under the head and cover with a clean sheet/blanket. Give all personal items to family or if family is not present, send with mortician. If a newborn dies, swaddle the infant in a clean blanket and transport the infant to the family in the nurses arms or an infant carrier. Assist the family to collect mementos of the infant such as the infants identification bracelet, cord clamp, lock of hair, footprints, photographs, etc. Allow parents/family.

O. Documentation at time of death -- Review forms/procedures required in your facility. Detailed assessment of the patient prior to death Time the patient stopped breathing or heart stopped Time the patient was pronounced dead and by whom When notification of physician, family, funeral home occurred, etc. Any specific instructions received from family or significant other List of personal items, etc. sent with family or mortician Name of mortician and time of departure with patient Most facilities will have a form to release the body that both a family member and the mortician must sign. Document any special postmortem care. Make sure each entry has your signature and title.

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