End of Life
 Palliative Care
o Curative and restorative treatment to help prevent and relieve suffering
o Improve the quality of life for people who have serious life limiting illness
 Anyone with chronic disease, life limiting disease
 Cancer
 Alzheimer’s
 Heart failure
o “helps to reduce the severity of symptoms”
o Support the patients by helping them to live as actively as possible until their
time of death
o Help to decease the cost of health care associated with their conditions
 Make decisions such as not being put on life support which reduce the
cost
o Help to reduce the burden of the caregiver
 Decisions are made and not left up to the caregiver
o Palliative care does not hasten or postpone death
o How to optimize palliative care
 It should be started right when a patient is diagnosed with a life-limiting
illness (rarely is)
 collaborate with the interprofessional team
 Providers
 Nurses
 Chaplin’s
 Can be in many different settings
 Someone’s home
 Rehab facility
 Prison
o Often palliative care extends into end-of-life care
 Hospice care
o Can be initiated when the physician certifies that someone has less than 6
months to live
 Patient must have to have a terminal diagnosis
 If patient lives longer than 6 months, the physician can recertify, and the
patient is free to stay in hospice care
o The patient and team also agree to forgo curative treatment
o Hospice also has a team of care members and can take place in multitude of
settings
o Decision to start hospice can be very difficult for patient, family, and provider
 Doctors are trained to save lives and hospice care goes against that for
them
 Physicians can see this as a failure on their part which makes the decision
difficult
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Many people do not understand palliative care and hospice which makes
the decision even harder
o Main goal of hospice care: care for those during their last phase of a terminal
disease and to assist patient to live fully and comfortably as possible while dying
with dignity
 Symptom management
 Advance care planning
 Spiritual care
 Family support
End of life care
o End of life phase is when death is imminent
o End of life care is any issue in services related to death, physical and psychosocial
needs of the patient themselves, and the families and making sure the patient
dies a dignified death
o Physical manifestations at end of life
 Tachycardia
 Hypotension
 Dehydrated
 Irregular heart rhythm
 Increased respiratory rate
 Cheyenne stokes
 Very fast shallowed breathing followed by slow heavy breathing
with periods of apnea
 Difficulty clearing secretions and sound very congested and loud when
breathing
 Known as death rattle and terminal secretions
 Slowing or complete cessation of the GI system
 Distention
 Gas accumulation
 Suddenly become incontinent because lose sphincter control
 Incontinence
 Decreased urine output
 Retention
 Skin
 Modeled
o Purply in color
 Cool
 Clammy
o Not perfusing
 Waxy looking
 Nail beds may become cyanotic
 Difficulty swallowing
 Difficulty speaking
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o Physical care at end of life
 Assessments become more abbreviated and focused on symptoms
 Provide physical needs
 Oxygen won’t fix what is happening to them but may make them
more comfortable
 Nutrition
 Often times people truly have no desire to eat or drink
 Provide pain relief
 Clean them after they eliminate
 Very good skin care
 Often skin breakdown at end of life
 Good oral care
 Become mouth breathers
 Give morphine for dyspnea
 Morphine causes respiratory depression so if the patient is very
tachypneic (because of secretions they can’t clear) the morphine
can slow their breathing down making them more comfortable
 Restlessness
 Give antianxiety meds
 Morphine may help as well
 Truly focused on comfort
 Pain management
 Symptom management
 Death is not delayed or interrupted as a result of our care
Death
o Definition: The irreversible sensation of cardiovascular, respiratory, and brain
function
o Brain death: irreversible loss of all brain function
o Declaring death
 Check pupillary reaction for brain function
 Look for cessation of respiratory effort
 Listen to lungs for full minute
 Listen to heart for full minute
 Won’t check a radial pulse because skin becomes modeled and
the blood all travels to the center to try and protect the vital
organs
 Weak peripheral pulses
 Listen to apical pulse
 If all three are absent then that is time of death
Bereavement
o Period of after the death of a loved one where people experience grief or
mourning
 Grief is a normal reaction to loss
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Very dynamic
Involves anger, sadness, anxiety, depression, despair
Can become physiologic
o Sleeping problems
o Changes to appetite
o Develop illness themselves
o Through hospice and palliative care there are bereavement and grief counseling
Spirituality
o Relationship to a higher being may not equate to a religious belief which may
cause people to question their spirituality at the time of death
o Or can turn to spirituality as a form of guidance during this time
 Perform a complete spiritual assessment
Culturally competent care
o Consider cultural and ethnic backgrounds
 This can affect decision making about life
o Some cultures can perform certain rituals that it is necessary for nurses to let
them do
 Assess preferences to avoid any stereotyping and allowing for these
rituals to be accommodated
Legal and ethical issues
o Organ and tissue donations
 Contacting the organ donation company is the first step in determining if
a patient is eligible in donating
 Eligibility is not up to us
 The organization (gift of hope in Illinois) makes the assessment and
speaks with the family
o Advance directives
 Written documents that provide us information about the patient’s
wishes
 Can designate a spoke person
 In Illinois have a physician order for life-sustaining treatments
 1st: CPR attempt or do not attempt
 2nd: medical interventions
o Where everything will be done for the patient
 Selective treatment is more for comfort where we wouldn’t
intubate the patient
o Not as aggressive
 Comfort focus is truly based on keeping the patient comfortable
 Medically administered nutrition is asking about enteral or
parenteral nutrition being administered
o DNR
 Is a natural death by comfortable measures only
o Euthanasia
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 Deliberate hastening of death
 Direct violation of the code of nurses
 Cannot participate
o Physician assisted suicide
 Legal in some states
 Nurses cannot participate in it
Use of opioids at the end of life
o Misunderstood by patients and families so often they refuse
o Often believe that giving them an opioid can quicken the death which is not true
 Used for comfort
 Medication will not make them die
 Do not want patients unnecessary suffering
o Family education important
Post-mortem care
o After the patient passes
o First and foremost, call the family in
 Try to get them there before the patient has died
o Clean the patient up
 At time of death the patient will release their bowels and/or bladder
 For the family and the patient, themselves
 Wash the body, hair if doesn’t look nice, oral care, change the gown,
change linens
 The may still continue to leak so place a pad
o Close the jaw
o Close the eyes
o Dentures
 Put them in to prevent the mouth from caving in
o Comb the hair
o Remove lines, drains, tubes
 Only time not done if coroner believes they need to do an investigation
on the cause of death
o Keep the body as straight as possible
o Put a pillow under the head
o Once the family is done:
 Place the body in the body bag with the appropriate identification tag
 3 tags
o Toe tag
o Zipper of body bag
o Any belongings that you’d send down to the morgue if no
family/friends take personal belongings home
EOL Special needs for nurses
o Important to do self-care
o Have a support system
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Hospice companies can have monthly memorial services to let nurses
mourn the loss of their patients together