End of Life Care
Lisa B. Flatt, RN, MSN, CHPN
Objectives
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Understand palliative care
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Compare and contrast settings where
palliative care and end of life care occur
Identify stages of grief,
uncomplicated grief and mourning
Describe legal, historical, social and
cultural aspects of palliative and end
of life care
Definitions to know
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Assisted suicide
Autonomy
Grief, Mourning & bereavement
Euthanasia
Terminal illness
Hospice
Medicare hospice benefit
Basic Concepts
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Loss –something/person and be
actual or potential no longer with
you, valued
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Sources of Loss – body image,
death, loss of independence,
brain ability, financial, memory
Grief Response
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Bereavement (subjective) and Mourning (process
follows bereavement, resolution of grief)
Normal grieving – essential for mental health
following a loss, steps are involved, helps you move
on
S/S of grieving – depression, sadness, isolation, wt
loss, sleep disturbances, ETOH, SA, fatigue, N&V,
HA, faint, palpitations
Variations of grief – anticipated or abbreviated
Dysfunctional grief – pathological, unresolved,
extended s/s of grief, stuck in a phase
Kubler-Ross’s (1969) Stages
of Grief
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Denial – shock, didn’t happen,
numb, disbelief
Anger – guilt, resentment,
sadness
Bargaining – pining, searching,
yearning
Depression – grieving
Acceptance - resolution
Engel’s (1964)Stages of Grief
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Shock & disbelief
Developing awareness – directed
anger, loss becomes real
Restitution – dealing with it all,
looking more
Resolving the loss – memories, talk
it out
Idealization – ‘the best at…..’
Outcome – acceptance, moving on
Sander’s (1998) Five Phases
of Bereavement
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Shock – confused, unreal,
disbelief
Awareness of loss – conflict,
stress, seperation anxiety
Conservation/Withdrawal –
despair, hopeless, isolation
Healing – identity, control
Renewal – acceptance,
revitalization
Influencing factors and
grieving
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Age – younger/children, acceptance as we age,
familiar, free from pain and poor quality of life
Significance of loss – how close, spouse, parents,
pets, kids, relatives
Culture – major, beliefs
Spiritual belief – influences outcome of death and
acceptance
Gender – woman disfigured with scar (idealization
of beauty), stoic
Socioeconomic – affordability of care and funerals
Support system - acceptance, after-care
Cause of death/loss – traumatic injury, extended
illness, unexpected death, suicide, drug OD
Death & Dying
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More accepted with age
Develops over time
Children – temporary state
Adults – frightening
Quality of life and lack of it can
determine a persons
perspective on death
Concept of Death and
Development
Age
Attitudes and Beliefs
0 to 5
Reversible; Sleep; Temporary ‘trip’’; immobility &
inactivity are part of death; separation forms basis for
undstg later
5-9
Death is final; own death avoidable; aggression &
violence; wishes/unrelated actions may be responsible
9 - 12
Inevitable end of life; understanding mortality = interest
in fear of death or interest in afterlife
12 – 18
Fear lingering death; doesn’t think much about; views in
religious/philosophic ways; emotionally difficult to
accept; fantasize it can be defied (acting out in reckless
behaviors)
18 – 45
Attitude is influences: religious and culture belief system
45 – 65
Accepting of own mortality; peaks of death anxiety;
emotional well being = decrease of death anxiety; death
of parents and peers occurs
65 +
Fear of prolonged illness, death of family and peers;
multiple meanings = reunion, free from pain
Definitions of Death
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With life support & medical
interventions, in 1968 World
Medical Assembly redefined
Clinical – absence of apical pulse,
respirations and BP
 Lack of OR NO response to:
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Eternal stimuli
 Reflexes
 Brain waves aeb flat encephalogram
 Respirations or muscular movement
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Dying Trajectories (Glaser &
Strauss 1965)
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Death and dying are unique
Series of graphs
Has limitations to ‘predictions’
Progression may be difficult to
predict
If someone knows outcome, this
may affect trajectory (sense of
control over dying process and
illness)
Types of Trajectories
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Expected trajectory – short duration,
steadily progressing downward
(terminal cancer)
Unexpected trajectory- episodes of
acute deterioration, recovery, decline
then unexpected death
Lingering/Prolonged – elderly
escaping cancer and MOF then die
later with dementia, Alzheimers, etc..
Physiologic Needs (pg 104)
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Maintain airway
Pain free
Positioning/comfort
Pastoral/spiritual care
Mouth care
ADL’s, brushing hair
Impending Death
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Muscle tone – decreased, relaxed
face, swallowing, speaking
Circulation – slows down, mottling,
cold
Respirations – rapid, shallow, noisy,
dry, mouth breathing, slows and
irregular
Sensory impairment
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Vision- blurred
Decreased smell/taste (or
hypersensivity)
Care Post-Mortem
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When appropriate, after they are
gone and family aware and in
agreement
Clean, covered
Remove tubes and lines
Dignity
Teeth, eyes closed
Rigor mortis
Hospice
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Cecily Saunders, MD founded
concept
Support and care of person &
family
Goal: peaceful and dignified
death
Holistic and interdisciplinary
Qualified if MD certifies within
the last 6 months of life
Where can hospice care
occur?
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Home
Facility
Hospital
ECF
Define Palliative Care
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Relief from symptoms of disease
Relief from pain
Support to patient and family, coping
mechanisms
Interdisciplinary team
Death not imminent
Allow pt and family to live as
‘normally’ as possible
The Nursing Process
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Assessment/Analysis
Planning
Rationale
 Factors influencing grief & dying
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Implementation
Evaluation