Dr. Hanan Youssef 371327-5
Critical care Nursing Taif University 1
Foundations of Critical Care Nursing Practice
Chapter 3
Palliative Care and End-of-Life Issues in Critical Care
Dr. Hanan Youssef 371327-5
Critical care Nursing Taif University 2
Objectives:
Describe how the integration of palliative care principles into
critical care is essential for providing end-of-life care in the
critical care setting.
Identify common symptoms experienced at the end of life and
appropriate measures to address them.
Explain the role of advance directives in facilitating end-of-life
care.
Explain how effective communication among caregivers,
patients, and family members can facilitate end-of-life care.
Explain aspects of family-centered care that are important
during the end-of life period.
Identify strategies caregivers can use for managing their own
grief.
Overview
This chapter focuses on:
The care of the dying patient and his or
her family,
Relevant research and suggestions for
advance care planning,
Specific management issues for both the
patient and the family,
and Care for the critical care nurse.
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Introduction:
Health care providers now recognize death inevitable and use of technology to prevent death is limited.
Recognize need for a quality death
Patients have died in ICU surrounded by health care providers, not family.
Critical care nurses are in position to help patients and families make transition to end-of-life care.
Being with patients and families in addition to doing things to them enables critical care nurses to provide the holistic care that is central to nursing.
WHO Definition of Palliative Care (2010):
Palliative care is an approach that improves
the quality of life of patients and their families
facing the problem associated with
life-threatening illness,
through
the prevention and relief of suffering
by means of early identification and impeccable assessment and treatment of
pain and other problems, physical, psychosocial and spiritual.
Introduction:
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End-of-Life Experience in Critical Care
For understanding human death, Increased attention and awareness regarding end-of-life issues:
SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments
Despite an intervention to improve communication, shortcomings identified.
Aggressive treatment was frequent
Only half of physicians knew their patients preferences regarding CPR
More than one third of patients who died spent at least 10 days in critical care
50% of conscious patients reported moderate to severe pain at least half of the time
Recommendations to Improve End-of-Life Care:
1. People with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skilful, and supportive care.
2. Physicians, nurses, social workers, and other health professionals must commit themselves to improving care for dying patients and to using existing knowledge effectively to prevent and relieve pain and other symptoms.
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Critical care Nursing Taif University 5
3. Because many deficiencies in care reflect system problems, policy makers, consumer groups, and purchasers of health care should work with health care providers and researchers to:
A. Strengthen methods for measuring the quality of life and other outcomes of care for dying patients and those close to them.
B. Develop better tools and strategies for improving the quality of care and holding health care organizations accountable for care at the end of life.
C. Revise mechanisms for financing care so that they encourage rather than impede good end-of-life care and sustain, rather than frustrate, coordinated systems of excellent care.
D. Reform drug prescription laws, burdensome regulations, and state medical board policies and practices that impede effective use of opioids to relieve pain and suffering.
4. Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have the relevant attitudes, knowledge, and skills to care well for dying patients.
5. Palliative care should become, if not a medical specialty, at least a defined area of expertise, education, and research.
6. The nations research establishment should define and implement priorities for strengthening the knowledge base for end-of-life care.
7. A continuing public discussion is essential to develop a better understanding of the modern experience of dying, the options available to dying patients and families, and the obligations of communities to those approaching death.
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Palliative Care
Medicare
Hospice
Benefit
Disease Progression
Diagnosis of serious illness Death
Life Prolonging Care
Hospice Care Life Prolonging Care
Old
New
Incorporating Palliative Care Throughout the Patients Illness
Palliative Care
Incorporating Palliative Care Throughout the Patients Illness
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What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)?
a. Clear communication is typical in the relationships between most patients and health care providers.
b. Critical care units often meet the needs of dying patients and their families.
c. Disparities exist between patients' care preferences and actual care provided.
d. Pain and suffering of patients at end of life is well controlled in the hospital.
C
Question:
Palliative Care in ICU:
Found to:
Improve symptom management
Provide family support
Reduce length of hospital stay
Increase discharges to home with hospice referrals
Reduce costs
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Question:
Is the following statement true or false?
Technology, urgency, and conflict in critical care practice may interfere with efforts aimed to provide good end-of-life care.
Answer:
True
Rationale: The advanced technology and urgency of care in a critical care unit are common. The focus is to save lives but can interfere with the quality of end-of-life care.
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The introduction of palliative care principles into critical care practice can provide a framework to address end-of-life issues.
Palliative care improves the quality of death and dying for patients and their families by addressing aspects of care that are unrelated to disease-specific treatments, cure, or rehabilitation.
According to the World Health Organization, palliative care includes the following interdisciplinary core principles:
Palliative Care:
Symptom management Advanced care planning Family-centered care Emotional, psychological, social, and spiritual care
Facilitating communication Awareness of ethical issues Caring for the caregiver
Common Symptoms Experienced at the End of Life:
Pain
Dyspnea
Anxiety and insomnia
Confusion/agitation
Depression
Nausea and vomiting
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Critical care Nursing Taif University 10
Some Statistics:
Pain occurs in 50 - 70 % of patients
88% of patients should have adequate pain
control using the WHO analgesic ladder
Cahexia occurs in 36 - 85% of patients (varies
with tumour)
Dyspnoea rises from 20-50% to 65-80% of
patients as death approaches
Nausea & vomiting - 15 - 45% occurrence
Constipation occurs in 30 - 50% of patients
approximately 80% will require laxatives
Pain:
Most prevalent symptom
Nursing interventions can be sources of pain.
Dose escalation () to treat severe pain is appropriate.
Bowel regimen essential to prevent constipation
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Critical care Nursing Taif University 11
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Dyspnea:
Different sources of dyspnea at end of life
Determine source of dyspnea to direct treatment
Accurate and frequent assessment of dyspnea
Tools to assess for dyspnea
Interventions include
Oxygen, opioids, anxiolytics, relaxation, cooling room, fan blow across face, close observation
Anxiety and Agitation:
Anxiety related to a number of causes
Assessment complex
Involves multidisciplinary approach
Pharmacological and non-pharmacological treatments
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Depression:
Depressive symptoms include
Anhedonia (loss of pleasure)
Loss of self-esteem
Pervasive despair
Thoughts of suicide
Feelings of helplessness, hopelessness
Depression may be normal and for a short period at end of life.
Prolonged depression requires appropriate treatment.
Delirium:
Terminal delirium is common in patients near death.
Daynight reversal
Management focused symptom control
Benzodiazepines or neuroleptics may be used to manage symptoms.
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Nausea and Vomiting:
Nausea common
Can be exhausting, debilitating, and frustrating
Determination of source important in determining appropriate intervention
Pharmacological management
NG tube
Surgery for intestinal obstruction or percutaneous endoscopic gastrostomy tube
Palliative End-of-Life Sedation:
Considered when all other interventions failed to control symptoms
Indication:
Unbearable and unmanageable pain
Approaching last hours or days of his or her life
Goal to produce a level of obtundation ( ) sufficient to relieve suffering without hastening death
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Question:
The critical care nurse should recognize that the most reliable indicator of pain in the unconscious patient is:
A. Observation of the patients behavior.
B. Physiological parameters, such as heart rate and blood pressure.
C. The patients self-report of pain.
D. Family input regarding the presence of pain. B
The patients wife is very concerned about the fact that her dying husband is vomiting. Because he has not had
any food in several days, this is confusing to her. The
nurse explains to her:
A. The nausea may be due to the medication he is taking. We should discontinue it for a while and see if that helps.
B. As the body shuts down, the organ systems slow their work, and sometimes this causes nausea and vomiting due to intestinal obstruction.
C. There is no medication he can be given that will make him feel better at this point.
D. Would you like to fix him a nice hot bowl of soup and see if that helps any?
Question:
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Recognizing that the patient is dying, the nurse
teaches the family what to expect as death
nears. This will include the possibility of:
A
A. Respiratory difficulty.
B. Increased hunger.
C. Excessive thirst.
D. Decreased swelling in the lower extremities.
Question:
Which of the following treatments is recommended for the management of delirium in the palliative care patient?
A.Application of restraints
B.Insertion of nasogastric tube
C.Administration of haloperidol
D.Blow cool air across the patients face
C
Question:
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Advanced Care Planning:
Decisions about treatment in the event that the patient is unable to make decisions or communicate wishes
More than advance directives:
Determines health care proxies
Preferences for goals of care during the end-of-life phase
Patient Self-Determination Act Supports the patients right to control future treatment
in the event the individual cannot speak for himself or herself
Also known as a living will or health care power of attorney
Encouraged to ensure patients receive the care they desire
Issues Underused (15% only, above 65 yo)
Desires not discussed with primary physicians
Applicability (is this a terminal illness?)
Advance Directives:
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Question:
Is the following statement true or false?
A health care proxy designated by the patient can make decisions based upon his or her own desires for the patient.
Answer:
False
Rationale: A health care proxy is designated by patients to make decisions for them in the event they are unable to make their own decisions. But the health care proxy should know the patients preferences and decisions need to be based upon those preferences, not his or her own wishes and desires.
Family Centered Care:
Society of Critical Care Medicine Guidelines
Recommend support of families during critical illness
These include
Shared decision making
Care conferences
Honesty
Spiritual support
Open flexible visitation
Family support
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Critical care Nursing Taif University 19
Question:
Which of the following is the most accurate statement
regarding family presence during resuscitation?
A. Families report more anxiety after the experience.
B. There are a greater number of litigations after
witnessing the resuscitation.
C. A dedicated staff member should attend to the
family during the resuscitation.
D. The experience has not been found to help the
bereavement process of the families.
Answer
C. A dedicated staff member should attend to the family during the
resuscitation.
Rationale: A dedicated staff member, who remains with the family
member during the resuscitation, can support, prepare, and inform the
family of the activities during the resuscitation. Family presence during
resuscitation has been found to help the bereavement process and
decrease anxiety and depression and has not been found to increase
number of litigations.
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Cultural and Religious Influences:
Attitudes and beliefs about death and dying differ dramatically
Satisfaction with care is linked to satisfaction with spiritual care
Cultural and religious assessment is needed to avoid assumptions: ensure that patients and families are able to follow tenets (beliefs) of particular culture or religion as they wish
Visitation During End-of-Life:
Open visitation
Cultivates trusting relationship
Period of closure
Cultural or spiritual ceremonies may take place.
Special situations
Visitation schedules as dynamics of family dictate
Uphold patients wishes on visitation
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Family Conferences:
Health care teams:
Provide information about condition of the patient and the patients prognosis
Review recommendations
Explore future care preferences of family
Careful planning and facilitation of the conference
Encourage families to become active participants
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Critical care Nursing Taif University 22
Nurses Role in Family Conference:
Before the conference
Obtain baseline information from family
Prepare family
During the conference
Set the tone, nonthreatening
Discuss end-of-life decisions
Discuss end-of-life management
Family Meetings:
Should be held within 72 hours of any ICU admission
Frequently held to formulate decision to withdraw life support
Discussing withhold and withdraw of life support (ethical and legal equality)
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Question:
When is the best time to approach the family regarding the patients prognosis?
A.When its time to withdraw life support
B.When the physician is convinced that the patient is going to die
C.When the family starts asking questions
D.Family meetings should be held within 72 hours of admission to the ICU
Answer:
D. Family meetings should be held within 72 hours of admission to the ICU
Discussions about the potential for impending death are never held early enough.
Often, the first discussions occur in conjunction with the topic of discontinuation of life support.
This is frequently some time after the health care team has concluded the prognosis is poor and there is a need to stop life support.
Family meetings should ideally be held within 72 hours of any ICU admission; however, they are frequently only held to formulate a decision to withdraw life support.
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Bereavement Care:
Multidisciplinary approach
Provide information to family regarding after death care
Allow time for familys bereavement
Facilitate Communication:
Establishing treatment goals and priorities;
The way presented can influence decisions.
Avoid ambiguous language.
Create proper setting for the discussion.
Determine what the family knows and understands.
Explore expectations.
Suggest realistic goals.
Use empathy.
Set a plan and revise as appropriate.
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Facilitate Communication (cont.)
Ensuring interdisciplinary communication
Clear and unified communication important
Assist with establishing consensus among providers
Delivering bad or serious news
Honest and open communication
Keep families up-to-date on changes in the patients status
Practice strategies for delivering bad news
Phrase bad news clearly but assure the team is doing best to help the patient
Death Notification:
Prepare
Be ready to answer questions.
Inform
Use the patients name.
Support
Be available.
Afterwards
Provide information about whats next.
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Providing Comfort:
Nursing management
Focus on provision of comfort
Avoid unnecessary vital signs, laboratory work, or other treatments
Position for comfort, not based on schedule to promote skin integrity
Dont make any unpleasant comments beside the patient the last sense lost is hearing sense
Near-Death Awareness:
Behaviors can be interpreted as delirium, acid-base imbalance, or metabolic derangement
Talking to family members who have died
Preparing for travel
Knowing death will occur
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Critical care Nursing Taif University 27
Principle of Double Effect:
The principle of double effect is an ethical principle that distinguishes between consequences a person intends and consequences that are unintended but foreseen and may be applicable in various situations where an action has two effects, one good and one bad.
Most commonly applied administering pain medications to patients who are dying
Focuses on intention of the opioid to relieve pain
Recognition that the patient may die but is morally and legally permissible to administer the opioid
Moral Distress:
Occurs when the nurse knows proper course of action but constraints make impossible to pursue it
Can arise when familys understanding or institutional policies differ from that of the nurse
Identified as a key issue affecting the work environment for nurses
AACN 4 As of moral distress
Ask, affirm, assess, and act
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Critical care Nursing Taif University 28
Caring for the Nurse:
Working in a critical care unit is demanding physically, intellectually, and emotionally.
Dealing with death on a consistent basis can take its toll on the nurses well-being.
It is important to be vigilant in recognizing signs and symptoms of unexpressed grief, burnout, and posttraumatic which include;
An increase in the number of sick days; indecision; difficulty with problem solving;
Isolation or withdrawal; behavioural outbursts;
Denial and shock ; a diminished capacity for experiencing pleasure;
To maintain emotional health, it is important to seek assistance in dealing with these issues.
Nurse leaders and human resources representatives can provide resources to assist with the stresses of working in critical care.
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Other Issues at End-of-Life:
Reduce suffering of the patient during withdrawing of life-supporting measures
Organ and tissue donation options
Supporting the nurses grief, preventing burnout and posttraumatic stress
Impact of Do Not Resuscitate (DNR) Order;
Should prevent initiation of CPR
Does not equate to Do Not Care
DNR should be written before withdrawal of life
support
Questions?
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Critical care Nursing Taif University 30
References
Urden L. D., Stacy K. M. & Laugh M. E. (2008): Priorities in Critical care
Nursing, (5th ed.,), Mosby, Elsevier, ISBN-13: 978-0-323-052559-7.
Morton P. G. & Fontaine D. K., (2013): Critical Care Nursing: A Holistic
Approach, (10th ed.,), Wolters Kluwer/ Lippincott Williams &
Wilikins, ISBN-13: 978-1-6054-7518-9.
Urden L. D., Stacy K. M. & Laugh M. E. (2008): Thelans Critical care
Nursing: Diagnosis and Management, (5th ed.,), Mosby, Elsevier,
ISBN-13: 978-0-323-03248-
Smeltzer S. C., Bare B. G., Hinkle J. L., & Cheever K. H., (2010):Brunner
& Suddarths Textbook of Medical-Surgical Nursing, (12th ed.,),
Walters Kluwer/Lippincott Williams & Wilkins Health, ISBN 978-1-
60831-080-7 (1 volume international ed.) ISBN 978-1-60831-088-3
(2 volume international ed.).
Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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