endoflifecare-180224144308.pdf

END OFLIFE CARE,
DEATH AND GRIEVING
SHAMMA KAUSAR
1ST YEAR M.SC NURSING

Manifestation of approaching and impending
death
Grief
Palliative care
Hospice care
Legal and ethical issues
Critical thinking
Nursing management
Care after death
REVIEW

Loss: an aspect of self no longer
available to a person
Death : cessation of life
Grief : pattern of physical and emotional
responses to bereavement
End of life : final phase of a patient’s
illness when death is imminent
TERMINOLOGIES

Death rattle : a sound that is
something heard coming from a
dying person’s throat or chest
Palliative care: it is a specialized
medical care for people with
serious illness
Hospice : a place that provides
care for people who are dying

Primitive societies: unnatural, accidental
occurrence
Preliterate societies: living either
honoured or feared the deceased
Early Greek history: spirits of the dead
continued to live after death
Western culture (6th through the early 12th
century): collective destiny of all human
beings
HISTORIC PERSPECTIVE

END OF LIFE CARE:
End of life care refers to health
care, not only of patients in the
final hours or days of their lives,
but more broadly care of all those
with a terminal illness or terminal
disease condition that has become
advanced, progressive and
incurable.

DEATH:
Death can be defined as the
cessation of all vital functions of
the body including the heartbeat,
brain activity (including the brain
stem) and breathing.

More than 2.5 million people die
in the United States each year.
25% of all deaths take place at
home, with about 50% occuring in
hospitals. Remaining 25% occur in
nursing homes.
INCIDENCE

GOALS FOR END OF LIFE CARE:
Control symptoms
Identify client needs
Promote meaningful
interactions between the client
and significant others
Facilitate a peaceful death

INDICATIONS OF DEATH:
Total lack of response to
external stimuli
No muscular movement,
especially breathing
No reflexes
Flat encephalogram (brain
waves)

DEVELOPMENT OF THE
CONCEPT OF DEATH:
Infancy to 5 years
5 to 9 years
9 to 12 years
12 to 18 years
18 to 45 years
45 to 65 years
65+ years

IMPORTANCE OF CARE OF A DYING
PATIENT:
1. Care of the whole person
2. Support meaningful living
3. Supports the family to cope with
loss and grief
4.Respect personal, cultural and
religious values
5. Value ethical principles

PHYSICAL MANIFESTATIONS OF
APPROACHING DEATH
SYSTEM MANIFESTATIONS
SENSORY Decreased sensation, decreased perception,
blurring of vision, sinking and glazing of
eyes, blink reflex absent, eyelids remain half
opened
INTEGUMENTARY Mottling on hands,feet,arms and
legs;cold,clammy skin;cyanosis on nose,nail
beds,knees;wax like skin when very near to
death
RESPIRATORY Increased respiratory rate; Cheyne-stokes
respiration;inability to cough or clear
secretions resulting in
granting,gurgling;irregular breathing

URINARY Decreased urinary output, urinary
incontinence, unable to urinate
GASTROINTESTINAL Accumulation of gas, distension and
nausea, loss of sphincter control
MUSCULOSKELETAL Inability to move, sagging of jaw,
difficulty speaking, difficulty in
swallowing, difficulty maintaining
body posture and allignment, loss of
gag reflex, jerking
CARDIOVASCULAR Increased heart rate , slower and
weakening pulse, irregular rhythm.
Decreased in blood pressure, delayed
absorption of drugs
Cont…

PSYCHOSOCIAL MANIFESTATIONS
OF APPROACHING DEATH
 Altered decision making
 Anxiety about
unfinished business
 Withdrawal
 Decreased socialization
 Fear of loneliness
 Fear of meaninglessness
of one’s life
 Fear of pain
 Helplessness
 Life review
 Peacefulness
 Restlessness
 Saying goodbyes
 Unusual
communication
 Vision like experiences

1. Loss of muscle tone:
 Relaxation of facial muscles
 Difficulty speaking
 Difficulty swallowing and gradual loss of gag
reflex
 Decreased activity of the gastrointestinal
system
 Urinary and rectal incontinence
 Diminished body movement
IMPENDING CLINICAL DEATH

2. Slowing of the circulation:
Diminished sensation
Mottling and cyanosis of the
extrimities
Cold skin
Slower and weaker pulse
Decreased blood pressure

3. Changes in respiration:
Rapid, shallow, irregular or abnormal
slow respirations
Noisy breathing
Mouth breathing, dry oral mucous
membrane
4. Sensory impairment:
Blurred vision
Impaired senses of taste and smell

Grief is defined as the
emotional process of coping
with a loss
GRIEF

1. Normal grief: complex
emotional,cognitive,social,physical,
behavioural and spiritual responses to loss
and death
2. Anticipatory grief: associated with the
normal grief response before the loss
actually occurs
3. Delayed or inhibited grief: absence of
evidence of grief when it ordinarily would
be expected
TYPES OF GRIEF

4.Distorted (exaggerated) grief:
symptoms associated with normal
grieving are exaggerated
5.Chronic or prolonged grief: maintaining
personal possessions aimed at keeping a
lost loved one alive
6. Disenfranchised grief: when
relationship to the deceased person is not
socially sanctioned

7. Ambiguous loss: when the lost person is
physically present but not psychologically
available,e.g- severe dementia
8. Complicated grief: prolonged or
significantly difficult time moving forward
after a loss
9. Masked grief: disruptive behaviour due
to loss and ineffective grief resolution

Human development,
Personal relationship,
Nature of the loss,
Coping strategies,
Socioeconomic status,
Culture and ethnicity,
Spiritual and religious belief
FACTORS INFLUENCING GRIEF

The Dual Process Model
of coping with loss,
adopted from Stroebe
(1998)

Loss oriented
Grief work
Intrusion of grief
Breaking
bonds/ties
Denial/avoidance
of restoration
change
Restoration oriented
Attending to life
changes
Doing new things
Distraction from
grief
Denial/avoidance of
grief
New roles/identities/
relationships
Everyday life
experience

PHYSIOLOGIC AND PSYCHOLOGIC
RESPONSES TO GRIEF
Physiologic
• Crying
• Sighing respiration
• Shortness of breath ,
palpitation
• Fatigue , weakness,
exhaustion
• Insomnia
• Loss of appetite
• Choking sensation
• Tightness in chest
• GI disturbances
Psychological
• Intense loneliness and
sadness
• Anxiety or panic
episodes
• Difficulty concentrating
and focusing
• Disorientation
• Anger
• Ambivalence and low
self esteem

NORMAL GRIEF REACTIONS VERSUS
SYMPTOMS OF CLINICAL
DEPRESSION
 Self esteem intact
 Accepts comfort and
support from others
 Openly express anger
 May experience
transient physical
symptoms
 Self esteem is
disturbed
 Does not respond to
social interaction and
support from others
 Does not directly
express anger
 Express chronic
physical complaints

Palliative care is any form of care or
treatment that focuses on reducing the
severity of disease symptoms , rather
than trying to delay or reverse the
progression of the disease itself or
provide a cure.
PALLIATIVE CARE

endoflifecare-180224144308.pdf

GOALS OF PALLIATIVE CARE:
Provide relief from symptoms
Regard dying as a normal process
Affirm life and neither hasten nor
postpone death
Support holistic patient care and enhance
quality of life
Offer support to patients to live as
actively as possible until death
Offer support to the family

The palliative care team is an
interdisciplinary collaboration
involving physicians, social
workers, pharmacists, nurses,
chaplains and other health care
professionals.

HOPE: THE HEART OF
PALLIATIVE CARE

Hospice is not a place but a
concept of care that provides
compassion, concern and support
for the dying.
HOSPICE CARE

GOALS OF HOSPICE CARE
To ensure that every moment
counts, in the last six months of
life.
To make the patient comfortable,
ease pain and other troublesome
symptoms and support the family
through a sad and difficult time.

HOSPICE ELIGIBILITY REQUIREMENTS:
Certified as being terminally ill by a
physician and having a prognosis of 6
months or less if the disease runs its
normal course.

HOSPICE CARE BENEFITS:
Offers a familiar environment.
Provides a comprehensive plan,
competent professionals.
Offers personalized care and
support.
Gives patient a sense of dignity.
Respect a patient’s wishes.
Lessens financial burdens.
Provide family counselling.

Palliative
care
End
of life care
Hospice
care

LEVEL 3: COMPLEX/SPECIALIST
BEREAVEMENT- COUNSELLING
LEVEL 2: INTERMEDIATE/SPECIALIST
BEREAVEMENT CARE
LEVEL 1 : GENERALIZED
BEREAVEMENT-SUPPORT
BEREAVEMENT CARE: Levels of
Intervention

LEGAL, ETHICAL AND
COMMUNICATION ISSUES
AFFECTING END OF LIFE
CARE

ADVANCE DIRECTIVE:
Documents that give
instructions about future medical
care and treatments and who
should make them in the event the
person is unable to communicate.
2. LEGAL DOCUMENTS USED
IN END OF LIFE CARE:

DIRECTIVE TO PHYSICIANS:
A written document specifying
the patients wish to be allowed
to die without heroic or
extraordinary
measures.

DO NOT RESUSCITATE (DNR):
A written physicians order
instructing health care providers
not to attempt CPR , often
requested by family ,
must be signed by a
physician to be valid.

DURABLE POWER OF
ATTORNEY FOR HEALTH CARE:
A document used for listing the
person or persons to make
health care decisions when a
patient become unable to make
informed decisions for self.

LIVING WILL:
Documents that give
instructions about future
medical care and treatments or
the wish to allowed to die
without heroic or extraordinary
measures when the patient is
unable to communicate for self.

MEDICAL POWER OF ATTORNEY:
A document used for listing the
person or persons to make
health care decisions when a
patient become unable to make
informed decisions for self.

Physician assisted suicide
involves the prescription by a
physician of a lethal dose of
medication for the purpose of
ending someone’s life.
ASSISTED SUICIDE

Informatics tools
Telecommunications
Computers
and internet
TECHNOLOGY AND END
OF LIFE CARE

CLINICIANS
ATTITUDE
TOWARDS DEATH

Culture
Ethnicity
Rituals
Beliefs
Values
CULTURALLY COMPETENT
CARE AT THE END OF LIFE
CARE

Should I begin/continue/discontinue a
particular treatment?
Should I make plans to receive care in a
place other than my home?
Should I discuss my wishes for care and
treatment planning with my family?
Should I appoint someone to be my
substitute decision maker?
NURSES ROLE IN END-OF-LIFE
DECISION MAKING

O’ Conner (2008) suggested the
following as typical signs of decisional
conflict:
Being unsure about what to do
Concern about negative
outcomes
Distress or upset
Preoccupation with the decision

Wavering/vacillation
Delay making the decision
Questioning what is
important
Physical signs of stress

Provide information about options and
the benefits and harms associated with
each option
Assess in individual’s understanding of
information about options
Helps individuals build skills in
deliberation and communication
Assess support needs
Screen for implementation needs
NURSES CAN-

Right to be treated
Right to be in control
Right to maintain a sense of hopefulness
Right to be cared for by those who can
maintain a sense of hopefulness
Right to have a sense of purpose
Right to express feelings and emotions
A DYING PERSON’S BILL OF
RIGHTS

Right to participate in decision about care
Right to expect continuing medical and
nursing attention even through ‘cure’
goals must be changed to ‘comfort’goals
Right not to die alone
Right to be free from pain
Right to have a respected spirituality
Right to have questions answered
honestly
Right not to be decieved

Right to have help from and for family
Right to die in peace and dignity
Right to retain individuality and not be
judged for decisions
Right to discuss and enlarge religious
and/or spiritual experiences
Right to expect that the sanctity of
human body will be respected after death
Right to be cared for by caring, sensitive,
knowledgeable people

NURSING
MANAGEMENT OF A
PATIENT AT END OF LIFE

Physical examination
Medication profile
Allergies
Coping abilities
ASSESSMENT

A. PSYCHOSOCIAL CARE:
Anxiety and
depression
NURSING
IMPLEMENTATION

Fear of loneliness and
abandonment

B. COMMUNICATION:
Elements of communicating
Bad-News, the P-SPIKES
Approach

P- Preparation
S- Setting of the
interactions
P- Patient’s
perception and
preparation

I- Invitation and
information needs
K- Knowledge of the
condition

E- Empathy and
exploration
S- Summary and
strategic planning

Skills for communicating with
the seriously ill
Responding with sensitivity to
difficult questions

D.PROMOTION OF DIGNITY
AND SELF ESTEEM

E.PROTECTION AGAINST
ABANDONMENT AND
ISOLATION

1. Opioid analgesics: morphin, fentanyl
etc.
2. Non-opioid analgesics: paracetamol,
aspirin, ibuprofen etc.
3. Adjuvant analgesics : NSAID, tricyclic
antidepressant, anticonvulsants,
anticholinergic etc.
PHARMACEUTICALS
INTERVENTIONS

4. Anti anxiety agents:
benzodiazepines etc
5. Bronchodialators
6. Corticosteroids
7. Oxygen therapy
8. Haloperidol for delirium
9. Laxatives

Euthanasia is the practice of intentionally
ending a life in order to relieve pain and
suffering.
EUTHANASIA
Voluntary
Non voluntary
Involuntary

1. Relaxation and guided imagery
2. Massage and other touch-based
therapies
3. Aromatherapy
ADVANTAGES AND
DISADVANTAGES
COMPLEMENTARY MEDICINE IN
PALLIATIVE CARE

CULTURAL ASPECTS OF CARE OF
THE BODY AFTER DEATH
POSTMORTEM CARE
 DOCUMENTATION OF END OF
LIFE CARE

PROCEDURAL
GUIDELINES FOR CARE
OF THE BODY AFTER
DEATH
CARE OF CARE GIVERS

1. Physician assisted suicide and
euthanasia: can you even imagine
teaching medical students how to end
their patients’ lives?
2. Assisted suicide and the killing of
people? May be, physician-assisted
suicide and the killing of patients? No:
the rejection of Shaw’s new perspective
on euthanasia.
JOURNAL ABSTRACT

3. Parents perspective on the end of
life care of their child with cancer:
Indian perspective
4. Significance of end of life dreams
and visions experienced by the
terminally ill in rural and urban India.
5. The complexity of nurses attitudes
toward euthanasia : a review of the
literal.

SUMMERY
CONCLUSION
JOURNAL REFERENCE
BIBLIOGRAPHY

endoflifecare-180224144308.pdf

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