Chapter 3 Palliative Care & End of Life

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



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.



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:



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.



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.



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



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



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.



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



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



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



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.



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



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:



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:



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:



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



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.



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



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



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)



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.



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.



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.



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



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



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.



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?



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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Chapter 3 Palliative Care & End of Life

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