END-OF-LIFE CARE PART TWO JUNE 11, 2020 - ANDREA HUERTAS, MBA, BSN, RN

END-OF-LIFE CARE
   PART TWO
 JUNE 11, 2020
 ANDREA HUERTAS, MBA, BSN, RN

GOALS & OBJECTIVES

• JUNE 9TH
   • COMMUNICATING AT THE END OF LIFE
   • PAIN MANAGEMENT AT THE END OF LIFE

• JUNE 11TH
   • SYMPTOM MANAGEMENT AT THE END-OF-LIFE
   • CARE OF THE PATIENT AND FAMILY WHEN DEATH IS NEARING

PATIENT CARE: SYMPTOM MANAGEMENT & INTERVENTIONS
Symptoms                                        Interventions
Agitation                                       Administer benzodiazepines, provide music, massage, dim lighting, and a cool environment
Dehydration                                     Provide frequent oral care and ice chips as tolerated, consider initiation of hypodermoclysis or
                                                proctoclysis, if consistent with goals of care
Dry mouth                                       Provide frequent oral care and frequent application of lip balm. Offer ice chips and oral swabs as
                                                tolerated. Artificial saliva may be used
Dyspnea                                         Treat cause, if possible. Administer opioids as prescribed. Reposition patient for comfort. Use a fan to
                                                provide moving air and provide cool environment

Edema                                           Elevate extremities as tolerated, use diuretics as indicated, consider decreasing or discontinuing
                                                artificial nutrition and/or hydration if symptoms of fluid overload arise

Fever                                           Administer acetaminophen suppository as prescribed, use fan to circulate air, dress patient in light
                                                clothing, and apply cool washcloths to forehead

Incontinence                                    Use disposable briefs and change promptly. Provide skin care after each incident of incontinence.
                                                Reposition patient frequently to prevent decubiti

Pain                                            Administer oral medications until no longer tolerated. If patient is unable to swallow, provide pain
                                                medications subcutaneously or rectally. Use adjuvant medications as needed. Reposition patient for
                                                comfort, use distraction, massage, and/or heat/cold for comfort

Terminal secretions                             Reposition patient for comfort. Administer anticholinergic medications to dry excess secretions if
                                                necessary. Oral suctioning may be implemented but deep suctioning should be avoided

Decubitus ulcers                                Provide skin care with repositioning and when patient is incontinent. Provide appropriate wound care,
                                                and consider use of topical lidocaine to reduce pain

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NEUROLOGIC
• APHASIA
• DYSPHAGIA
• ALTERED LEVEL
• MYOCLONUS
• PARESTHESIAS AND NEUROPATHIES MANIFEST
• SEIZURES
• DYSKINESIA
• PARALYSIS
• INCREASED ICP

CARDIAC
• BLEEDING AND HEMORRHAGE
• DVT
• PE
• DIC
• ANGINA
• EDEMA
• LYMPHEDEMA
• SYNCOPE
• SUPERIOR VENA CAVA SYNDROME (SVCS)

RESPIRATORY
• COUGH
• DYSPNEA
• PE
• PNEUMOTHORAX
• TERMINAL SECRETIONS

GI
• CONSTIPATION
• DIARRHEA
• BOWEL INCONTINENCE
• ASCITES
• HICCUPS
• NAUSEA AND VOMITING
• BOWEL OBSTRUCTION

GU
•SPASMS
•INCONTINENCE
•RETENTION

MUSCULAR & SKIN

•MOBILITY
•XEROSTOMIA
•PRURITUS
•WOUNDS

PSYCHOSOCIAL
• AT THE END OF LIFE, PATIENTS MAY EXPERIENCE FEAR, DENIAL, ANGER, DEPRESSION, GRIEF, AND/OR
  HOPELESSNESS. PATIENTS MAY ALSO STRUGGLE WITH THE MEANING OF THEIR LIFE OR OF THEIR SUFFERING.
  MANIFESTATIONS OF THESE EMOTIONS ARE CULTURALLY BASED AND SHOULD BE ADDRESSED BY THE
  INTERDISCIPLINARY TEAM IN A COMPASSIONATE AND CULTURALLY SENSITIVE MANNER.
• NDA MAY OCCUR WITH THE PATIENT RELATING SPECIFIC INFORMATION ABOUT AN AFTERLIFE. THESE
  EXPERIENCES ARE OFTEN COMFORTING TO THE PATIENT AND SHOULD NOT BE NEGATED BY THE HEALTHCARE
  PROVIDER.
• SLEEP DISTURBANCES ARE VERY COMMON AT THE END OF LIFE. THE NURSE SHOULD PROMOTE GOOD SLEEP
  HYGIENE AND MANAGE SYMPTOMS THAT INTERFERE WITH RESTFUL SLEEP.
• SUICIDAL IDEATION MAY OCCUR IF PATIENTS BECOME FEARFUL OR DEEPLY DEPRESSED. THE NURSE SHOULD
  DETERMINE WHETHER THE PATIENT HAS A PLAN TO IMPLEMENT SELF-HARM AND THE MEANS TO DO SO. IF SO,
  INTERVENTIONS MUST BE TAKEN URGENTLY TO ENSURE THE PATIENT’S SAFETY.
• INTIMACY MAY BE AFFECTED BY SERIOUS ILLNESS. THE NURSE SHOULD ENCOURAGE PATIENTS TO EXPRESS
  THEIR CONCERNS AND NORMALIZE THEIR EXPERIENCE.

NUTRITIONAL
•ANOREXIA
•DEHYDRATION
•FATIGUE
•HYPERCALCEMIA

OTHER

•INFECTION
•MYELOSUPPRESSION
•CHANGE IN MENTAL STATUS

PRACTICE QUESTIONS

PATIENT AND FAMILY CARE, EDUCATION, AND ADVOCACY

• ESTABLISHING GOALS OF CARE
• SMART GOALS
• RESOURCE MANAGEMENT

• ADVANCE DIRECTIVES
• EXPERTISE IN DISCUSSING END-OF-LIFE CARE
• GOALS OF CARE
• IDT
• HOSPICE BENEFIT BY INSURANCE: MCR MA PRIVATE
• HOSPICE ELIGIBILITY
• LEVELS OF CARE
• CORE HOSPICE SERVICES INCLUDE PHYSICIAN SERVICES, NURSING SERVICES, MEDICAL SOCIAL
  WORK SERVICES, AND COUNSELING SERVICES.
• NONCORE HOSPICE SERVICES INCLUDE PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY;
  VOLUNTEER SERVICES; HOMEMAKER SERVICES; HOSPICE AIDE SERVICES; MEDICATIONS; AND
  MEDICAL SUPPLIES.
• PATIENTS ARE DISCHARGED FROM HOSPICE THROUGH DEATH, IMPROVEMENT IN CONDITION, OR
  BY REVOKING THE HOSPICE BENEFIT.

PRACTICE QUESTIONS
PATIENT & FAMILY CARE

PSYCHOSOCIAL, SPIRITUAL, AND CULTURAL

• KNOWLEDGE AND UNDERSTANDING NEED TO BE EXPLORED WHEN ADDRESSING
   • PSYCHOSOCIAL
   • SPIRITUAL
   • CULTURAL SIMILARITIES AND DIFFERENCES

PRACTICE QUESTIONS

GRIEF AND LOSS

•GRIEF
•LOSS
•BEREAVEMENT

PRACTICE QUESTIONS

CAREGIVER SUPPORT

• ACKNOWLEDGE AND IDENTIFY STRESS
• KNOWLEDGE IS POWER
• WHO AND HOW WE TEACH THE FAMILY
• BE A PATIENT ADVOCATE

PRACTICE QUESTIONS CARE GIVER SUPPORT

PRACTICE ISSUES
• INTERDISCIPLINARY TEAM
• NURSE
• PHYSICIAN
• SOCIAL WORKER
• CHAPLAIN
• AIDE AND/OR HOMEMAKER
• VOLUNTEER
• THERAPIST
• COUNSELING

CARE COORDINATION

SCOPE, STANDARDS AND GUIDELINES
• STRUCTURE AND PROCESSES OF CARE
• PHYSICAL ASPECTS OF CARE
• PSYCHOLOGICAL AND PSYCHIATRIC ASPECTS OF CARE
• SOCIAL ASPECTS OF CARE: FOCUSES ON LEVERAGING FAMILY STRENGTHS AND SOCIAL
  SUPPORT MECHANISMS TO ALLEVIATE FAMILY STRESS.
• SPIRITUAL, RELIGIOUS, AND EXISTENTIAL ASPECTS OF CARE
• CULTURAL ASPECTS OF CARE
• CARE OF THE PATIENT AT THE END OF LIFE
• ETHICAL AND LEGAL ASPECTS OF CARE

PRACTICE QUESTONS

ETHICS AT EOL
• AUTONOMY: THE RIGHT TO MAKE DECISIONS FOR ONESELF. AUTONOMY IS THE PRINCIPLE
  THAT UNDERPINS THE PRACTICE OF INFORMED CONSENT
• BENEFICENCE: THE PRINCIPLE OF DOING THE MOST GOOD; ACTING KINDLY AND CHARITABLY
• CONFIDENTIALITY: THE EXPECTATION THAT THE PATIENT’S PRIVATE INFORMATION WILL NOT BE
  DISCLOSED TO ANYONE WITHOUT THE PATIENT'S CONSENT
• JUSTICE: THE PROMOTION OF GOOD FOR ALL
• NONMALEFICENCE: DOING NO HARM
• PATERNALISM: RESTRICTING THE LIBERTY OR RIGHTS OF ANOTHER, SEEMINGLY FOR THE
  PERSON'S OWN GOOD
• TRUTHFULNESS: PROVIDING INFORMATION WITH HONESTY AND INTEGRITY

SELF-CARE & PROFESSIONAL DEVELOPMENT

• WHAT DO YOU DO TO TAKE CARE OF YOURSELF?
• TEACH, MENTOR, ENGAGE

QUESTIONS

• CONTACT INFO:

                  ANDREAVICKI@GMAIL.COM

                     484-635-5768 CELL