3-D Approach to end of life care3-D Approach to end of life care

By: Joseph Ramsubhag, RNBy: Joseph Ramsubhag, RN1

Presentation ObjectivePresentation ObjectiveIdentifying & Meeting the Needs of Patient/familyIdentifying & Meeting the Needs of Patient/family

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Spiritual

CriteriaCriteria forfor End of Life End of Life CareCare

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Unable to Stop the Trajectory of the Terminal Illness

“The train has left the station”

Treatment GoalsTreatment Goals Physical ComfortPhysical Comfort

Palliating distressful symptomsPalliating distressful symptoms

Emotional ComfortEmotional Comfort Terminating Personal relationships in a positive Terminating Personal relationships in a positive

wayway Preparing family for deathPreparing family for death Offering bereavement services after deathOffering bereavement services after death

Spiritual ComfortSpiritual Comfort Finding Meaning and significance at the level Finding Meaning and significance at the level

of spiritof spirit

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Accomplishing Unfinished Accomplishing Unfinished BusinessBusiness

Patient’s unfinished business may not be that Patient’s unfinished business may not be that of the family’sof the family’s

Family members or others assisting pt.Family members or others assisting pt.

Taking over the dying pt.’s RolesTaking over the dying pt.’s Roles

A husband does not cease to be a husband A husband does not cease to be a husband when he is dying….vice versa….when he is dying….vice versa….

The pt.’s role & responsibilities do not ceased The pt.’s role & responsibilities do not ceased to exit when they are dying to exit when they are dying

Family can assist pt. taking over rolesFamily can assist pt. taking over roles

Rembrandt’s Return of Rembrandt’s Return of Prodigal SonProdigal Son

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Finishing Unfinished Finishing Unfinished Business PhysicallyBusiness Physically

Taking care of financial business Taking care of financial business Wills, power of attorneysWills, power of attorneys

Telling your storyTelling your story Completing books, videos, or musicCompleting books, videos, or music Writing letters to loved onesWriting letters to loved ones

Advanced directivesAdvanced directives Do not resuscitate Do not resuscitate

Funeral arrangements Funeral arrangements Preferential religious practices/customsPreferential religious practices/customs

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Taking Care of Emotional Taking Care of Emotional Unfinished Business Unfinished Business

For all those who are close and important to the patient For all those who are close and important to the patient (pt.):(pt.):

Thank each other for the journeyThank each other for the journeyGive unconditional love and Give unconditional love and forgiveness to the pt.forgiveness to the pt. More importantly, ask the same for More importantly, ask the same for yourselfyourselfAllow your loved one to make their Allow your loved one to make their journey and for them to be able to say journey and for them to be able to say goodbye (Tasks of the Dying by Dr. Ira goodbye (Tasks of the Dying by Dr. Ira Byock)Byock)

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Taking Care of Spiritual Taking Care of Spiritual Unfinished Business Unfinished Business

Accomplishing unfinished goals according Accomplishing unfinished goals according to patient’s philosophyto patient’s philosophy Most people's philosophy is tied in Most people's philosophy is tied in

with their religionwith their religion Examples: Catholic pt. will want Examples: Catholic pt. will want

anointing of the sick, the Buddhist anointing of the sick, the Buddhist pt. visit from the monk, or pt. who pt. visit from the monk, or pt. who is close to nature wanting to be in is close to nature wanting to be in naturenature

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Stages of Grief Stages of Grief Experienced by Both Experienced by Both Patient and FamilyPatient and Family

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Dr. E. KÜBLER-ROSS

Family DynamicsFamily Dynamics Importance of advanced directives done Importance of advanced directives done

by patientby patient

Death of a loved one is hard, but it can be Death of a loved one is hard, but it can be healing eventhealing event

It is important for healthcare staff to It is important for healthcare staff to identify where patients and family are in identify where patients and family are in the grieving processthe grieving process

The heavy stress of a dying loved one The heavy stress of a dying loved one widens the cracks in the family dynamicswidens the cracks in the family dynamics

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Physical Signs & Physical Signs & Symptoms of Impending Symptoms of Impending

DeathDeath Delirium Delirium

Insomnia, restlessness (unable to find a Insomnia, restlessness (unable to find a comfortable position), and frightful visual comfortable position), and frightful visual hallucinationshallucinations

This is high-risk area for fallsThis is high-risk area for falls

Anorexia Anorexia Food doesn’t taste the same Food doesn’t taste the same

Dysphagia Dysphagia Moving from meat & rice to soups & puddings, Moving from meat & rice to soups & puddings,

then to only liquids then to only liquids Pocketing of food noticeablePocketing of food noticeable

GI system is winding downGI system is winding down Tube fed pts. will have increased residuals & Tube fed pts. will have increased residuals &

increased lung secretionsincreased lung secretions11

Physical Signs & Symptoms Physical Signs & Symptoms of Impending Deathof Impending Death

Vital Signs: BP, O2 Sat., HR, Resp. Vital Signs: BP, O2 Sat., HR, Resp.

Change in respiratory system Change in respiratory system Labored, cheyne stoking, & argonal breathingLabored, cheyne stoking, & argonal breathing Breathing with all accessory musclesBreathing with all accessory muscles

Change in thermoregulation: fever, diaphoresis, & chills (parts of Change in thermoregulation: fever, diaphoresis, & chills (parts of body hot & parts cold) body hot & parts cold)

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Physical Signs & Symptoms Physical Signs & Symptoms of Impending Deathof Impending Death

Changes in Elimination Excretion Changes in Elimination Excretion Urinary retention, constipation, & bowel & Urinary retention, constipation, & bowel &

bladder incontinencebladder incontinence Decreased urine outputDecreased urine output, , color changes from color changes from

light yellow to a tea color, apple juice color or light yellow to a tea color, apple juice color or coco cola colored (hematuria) coco cola colored (hematuria)

Changes in Respiratory Status Changes in Respiratory Status Rhonchi, wheezing, rales, coughing, Rhonchi, wheezing, rales, coughing,

congestion (gurgling & rattling, sounds)congestion (gurgling & rattling, sounds)

Increasing fatigue & sleepIncreasing fatigue & sleep Decreased LOCDecreased LOC

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Emotional & Mental Emotional & Mental SignsSigns

Pt. is first to know they are dying:Pt. is first to know they are dying: “ “I am dying” or “I want to go home”I am dying” or “I want to go home”

Pt. is self-absorbed and pensive:Pt. is self-absorbed and pensive: Detaching from surroundings, including familyDetaching from surroundings, including family In order to leave, you have to disconnectIn order to leave, you have to disconnect Staring into space, looking at you but looking Staring into space, looking at you but looking

through youthrough you Reaching or grabbing invisible things from the air Reaching or grabbing invisible things from the air

or from their bodyor from their body

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“Wherever your heart is, there is where you

will be. In order to leave, you have to

detach”

Mental & Spiritual Signs Mental & Spiritual Signs Pts. Often See & Speak to the DeceasedPts. Often See & Speak to the Deceased

Maybe deceased relatives or even petsMaybe deceased relatives or even pets Gives hope to patientGives hope to patient Pt. moving from physical to Pt. moving from physical to

metaphysical realmmetaphysical realm Confusion frequently occurs as a resultConfusion frequently occurs as a result

Pts. Experience Surge of EnergyPts. Experience Surge of Energy Commonly mistaken for the pt. getting Commonly mistaken for the pt. getting

betterbetter Taking one day at a time may be Taking one day at a time may be

expedientexpedient May be for the transition from this world May be for the transition from this world

to the otherto the other15

“The mountain tops are shorter and the valleys,

deeper”

Final Gift Final Gift

Pts. sometimes choose the people in Pts. sometimes choose the people in whose presence they want to die. whose presence they want to die.

If you are not there when your loved on If you are not there when your loved on passes, don’t beat up on yourself passes, don’t beat up on yourself

This may be their final gift to you.This may be their final gift to you.

When a pt. dies they discard their physical When a pt. dies they discard their physical body made from the dust of the earth and body made from the dust of the earth and they put on their spiritual body made from they put on their spiritual body made from lightlight

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ReferencesReferences Byock, I. (1997). Byock, I. (1997). Dying Well. Dying Well. New York, NY: Riverhead New York, NY: Riverhead

Trade.Trade.

Coyle, N. & Ferrell, B.R. (2010). Coyle, N. & Ferrell, B.R. (2010). Oxford Textbook of Oxford Textbook of Palliative Palliative NursingNursing. (3. (3rdrd ed). New York, NY: Oxford ed). New York, NY: Oxford University Press.University Press.

Hallenbeck, J.L. (2003). Hallenbeck, J.L. (2003). Palliative Care Perspectives. Palliative Care Perspectives. New New York, York, NY: NY: Oxford University Press.Oxford University Press.

Kubler-Ross, E. (1997). Kubler-Ross, E. (1997). On Death and Dying. NOn Death and Dying. New York, NY: ew York, NY: Scribner.Scribner.

Matzo, M.l. & Witt, D. (2009). Matzo, M.l. & Witt, D. (2009). Palliative Care Nursing: Palliative Care Nursing: Quality Care to the End of LifeQuality Care to the End of Life. (3. (3rdrd ed.). New York, NY: ed.). New York, NY: Springer Publishing Company. Springer Publishing Company.

Myss, C. (2003). Myss, C. (2003). Sacred Contracts: Awakening Your Divine Sacred Contracts: Awakening Your Divine Potential. Potential. Carlsbad, CA: Three Rivers Press.Carlsbad, CA: Three Rivers Press.

Patt, R. (1993). Patt, R. (1993). Cancer PainCancer Pain. Philadelphia, PA: . Philadelphia, PA: Lippincott Lippincott Williams & Wilkins.Williams & Wilkins.

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Presentation dedicated to Presentation dedicated to Mrs. Lucile RamsubhagMrs. Lucile Ramsubhag

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Email Address : josephramsubhag@yahoo.com

Office (281)894-6499 Cell (832)353-7787