PALLIATIVE CARE/
POST-MORTEM CARE
NUR 102 Lab
Module F
Fall 2006
Essential Goals of Palliative Care
• Prevention, relief, reduction, or soothing of
symptoms
• Allow clients to make informed choices
• Achieve better relief of symptoms
• Allow clients the opportunity to work on
end of life issues
• Allow client to experience a “good death”
Hospice
• Multidisciplinary, family centered program
of care designed to assist the terminally ill
through the phases of dying (pg. 167)
• Physician, RN, LPN, aide, and chaplain
are available to assist the client and family
• Provide many services, such as respite
care, medical equipment, medication
• Services based on need, not ability to pay
ELNEC
• End-of-Life Nursing Education Consortium
(ELNEC)-a national education initiative to
improve end-of-life care in the United States.
• Assist client and family through the grieving
process
• February 2000--funded by a major grant from
The Robert Wood Johnson Foundation and has
received additional funding from the National
Cancer Institute, the Aetna Foundation, the
Archstone Foundation, and the California
Healthcare Foundation.
Facts About ELNEC
• Death often is seen as a failure of the health care system
rather than a natural aspect of life. This belief affects all
health professionals, including nurses. Despite their
undisputed technical and interpersonal skills,
professional nurses may not be completely comfortable
with the specialized knowledge and skills needed to
provide quality end-of-life care to patients. The ELNEC
project gives nurses the knowledge and skills required to
provide this specialized care and to positively impact the
lives of patients and families facing the end of life.
Continued…
• ELNEC-Core content is divided into nine
modules: Nursing Care at the End of Life; Pain
Management; Symptom Management;
Ethical/Legal Issues; Cultural Considerations in
End-of-Life Care; Communication; Loss, Grief,
Bereavement; Achieving Quality Care at the End
of Life; and Preparation for and Care at the Time
of Death. Achieving Quality Care at the End of
Life; and Preparation and Care for the Time of
Death.
Continued…
• Trainers represent each state and the District of
Columbia. The states with the highest number of
Trainers are California, Ohio, Pennsylvania and Texas
with over 50 each. Thirteen other states have twenty or
more ELNEC Trainers.
• The American Journal of Nursing (AJN) published a
bimonthly continuing education series on palliative
nursing care in 2002 that featured the ELNEC project.
The series used actual case studies to improve the way
nurses care for dying patients, both physically and
psychologically. The series can be viewed online at
www.aacn.nche.edu/ELNEC/ajn.htm or
www.ajnonline.com.
Comfort
• Management of symptoms of the disease
and therapies
• Symptom distress—the experience of
discomfort or anguish related to the
progression of a disease
• Anxiety related to “fear of the unknown”
• Worry or fear can increase ability to
control pain
Physical Changes of Death
• Rigor mortis—stiffening of the body
• Algor mortis—loss of skin elasticity
• Livor mortis—purple discoloration of skin
EBP Trends
• Several research topics have been done
to address palliative and end-of-life care
• Barriers to a “good death” include differing
expectations, lack of advanced directives
or living wills, and clinicians ineffective
communication skills
• Pain control is a major concern
• Clients do not want to be a “burden” and
want to maintain sense of control
Cultural Considerations Related to
End-of-Life Issues
• Chinese—the discussion of death is
considered taboo and associated with bad
luck and evil
• Muslim—illness is a result of sin and death
is part of life as destined by God
• Orthodox Jews—do not leave the dying
person alone; have “minyan” praying at
the bedside
Continued…
• Hindu—may refuse food and pain
medication because of belief in
transmigration; head will face east with a
lamp near the head; family will chant
(mantra) and pray; they may spread
incense and apply ash to the client’s
forehead
• Catholic—priest will anoint the client and
give Holy Communion
Theories of Grief and Mourning
• Kubler-Ross’s Stages of Dying
• Bowlby’s Phases of Mourning
• Worden’s Task of Mourning
Kubler-Ross
• Elisabeth KublerRoss—behavioral
theory
• 5 Stages
–
–
–
–
–
Denial
Anger
Bargaining
Depression
Acceptance
Quotes
• “We run after values that, at death,
become zero. At the end of your life,
nobody asks you how many degrees you
have, or how many mansions you built, or
how many Rolls Royce's you could
afford. That’s what dying patients teach
you.”
• “Guilt is perhaps the most painful
companion of death.”
Bowlby
• Dr. John Bowlby—
behavioral theory
• 4 phases
– Numbing
– Yearning and
searching
– Disorganization and
despair
– Reorganization
Worden
• J. William Worden—
behavioral theory
• 4 tasks—
– Accept reality of loss
– Work through pain and
grief
– Adjust to the
environment
– Emotionally relocate
the deceased
Physical Signs and Symptoms of
Impending Death
• Hands, arms, feet, and legs become cool and
pale
• Increase in sleeping
• Disorientation to time, place, or person
• Incontinence
• Lung congestion
• Restlessness
• Decreased nutritional intake
– Refer to pg 179, table 7-2
Continued…
•
•
•
•
Irregular pulse
Decreased B/P
Relaxation of jaw and facial muscles
Cheyne-Stokes respiratory pattern
Nursing Priorities
•
•
•
•
•
Adequate pain control
Maintain independence
Prevent isolation
Spiritual comfort
Support the family
Care of the Body after Death
• Post-mortem—after death
• The Uniform Determination of Death Act
(UDDA)—defines death as “irreversible
cessation of circulatory and respiratory functions
or irreversible cessation of all functions of the
brain, including the brainstem” (pg. 180)
• Post-mortem care must be done soon after
death because of the changes the body
undergoes
Continued…
• DNR—do not resuscitate
• Omnibus Budget Reconciliation Act
(OBRA) of 1986
• Autopsy—postmortem exam to determine
the exact cause of death
• Cultural considerations
Organ Donation
• Client must be on life-support to support
vital organs
• Family must understand that client is
brain-dead
• No age limit although parents must
consent when client is under 18 years old
• Indicate on drivers license request to be
organ donor, although family makes the
final decision
Continued…
•
What can be donated?
– Organs—heart, kidneys, pancreas, lungs,
liver, intestines
– Tissue—cornea, skin, heart valves,
connective tissue
– Bone marrow
Organ donation does not affect the
appearance of the body; an open casket is
still possible
Nursing Interventions
• Provide private place for family discussion
• Be sure that the decision is made by the
appropriate person
• Contact local donor registry
• Inform family that body will be cared for
• Be sure family understands that there is
no cost for organ donation
Autopsy
• External Procedure
– Body is brought to the morgue and
photographed and x-rayed as indicated
– Body is cleaned, weighed, and placed on
autopsy table
– The body is placed face up on the table, and
a body block is placed under the patient's
back.
– A general description of the body is made and
all identifying features are noted
Continued…
• Internal Examination
– A large, deep, Y-shaped incision that is made
from shoulder to shoulder meeting at the
breast bone and extends all the way down to
the pubic bone.
– When a woman is being examined, the Yincision is curved around the bottom of the
breasts before meeting at the breast bone.
– The next step is to peel back the skin, muscle,
and soft tissue
Continued…
Continued…
– The chest flap is pulled up over the face,
exposing the ribcage and neck muscles.
– Two cuts are made on each side of the
ribcage, and then the ribcage is pulled from
the skeleton after dissecting the tissue behind
it with a scalpel.
– A series of cuts are made and organs are
removed and weighed
Continued…
Continued…
Continued…
• Large organs are weighed on a grocer’s
scale
• Smaller organs are weighed on a triplebeam balance
• Right lung: 300-400 gm
• Left lung: 250-350 gm
• Heart: 250-300 gm
Continued…
•
•
•
•
•
Liver: 1100-1600 gm
Adrenals: 4 gm or so each
Thyroid: 10-50 gm
Spleen: 60-300 gm
Brain: 1150-1450 gm
Continued…
Autopsy Room
Cultural Considerations
• Refer to pg 181, Box 7-1
Post-Mortem Care
• Always follow agency policy and
procedure
• Ensure that correct identification is on the
body
• Remove foley catheters, ET tubes,
oxygen, and peripheral IV’s
• Reinsert dentures if possible. If not, place
them in cup to stay with body
Continued…
• Position body in natural position, avoid
placing one hand over the other
• Place small pillow under head and elevate
the head of the bed 10-15 degrees
• Close eyes, unless contraindicated by
client’s religious preference
• Shave men unless family requests
otherwise
Continued…
• Wash body to remove blood, feces, and
other drainage
• Place pad under bottom
• Remove any soiled dressings and replace
with clean gauze.
• Use only paper tape
• Put on a clean gown and brush or comb
hair
Continued…
• Gather all personal belongings into bag for
family
• For family viewing of the body, remove all
unnecessary equipment, turn down lights,
and provide seating for the family
• Do not rush the family through this
process
• Transport body to morgue per agency
policy
References
• US Department of Health and Human
Services website at www.organdonor.gov.
• http://health.howstuffworks.com/autopsy4.
htm
• http://www.deathonline.net/what_happens/
autopsy/autopsy_steps.cfm