PALLIATIVE CARE/ POST-MORTEM CARE

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PALLIATIVE CARE/POST-MORTEM CARE

• NUR 102 Lab
• Module F
• Fall 2006

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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

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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

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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.

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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.

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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.

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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.

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Comfort

• Management of symptoms of the disease and
  therapies
• Symptom distressthe 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

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Physical Changes of Death

• Rigor mortisstiffening of the body
• Algor mortisloss of skin elasticity
• Livor mortispurple discoloration of skin

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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

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Cultural Considerations Related to End-of-Life
Issues

• Chinesethe discussion of death is considered
  taboo and associated with bad luck and evil
• Muslimillness is a result of sin and death is
  part of life as destined by God
• Orthodox Jewsdo not leave the dying person
  alone have minyan praying at the bedside

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Continued

• Hindumay 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 clients forehead
• Catholicpriest will anoint the client and give
  Holy Communion

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Theories of Grief and Mourning

• Kubler-Rosss Stages of Dying
• Bowlbys Phases of Mourning
• Wordens Task of Mourning

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Kubler-Ross

• Elisabeth Kubler-Rossbehavioral theory
• 5 Stages
• Denial
• Anger
• Bargaining
• Depression
• Acceptance

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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.  Thats what dying patients teach you.
• Guilt is perhaps the most painful companion of
  death.

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Bowlby

• Dr. John Bowlbybehavioral theory
• 4 phases
• Numbing
• Yearning and searching
• Disorganization and despair
• Reorganization

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Worden

• J. William Wordenbehavioral theory
• 4 tasks
• Accept reality of loss
• Work through pain and grief
• Adjust to the environment
• Emotionally relocate the deceased

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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

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Continued

• Irregular pulse
• Decreased B/P
• Relaxation of jaw and facial muscles
• Cheyne-Stokes respiratory pattern

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Nursing Priorities

• Adequate pain control
• Maintain independence
• Prevent isolation
• Spiritual comfort
• Support the family

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Care of the Body after Death

• Post-mortemafter 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

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Continued

• DNRdo not resuscitate
• Omnibus Budget Reconciliation Act (OBRA) of 1986
• Autopsypostmortem exam to determine the exact
  cause of death
• Cultural considerations

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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

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Continued

• What can be donated?
• Organsheart, kidneys, pancreas, lungs, liver,
  intestines
• Tissuecornea, skin, heart valves, connective
  tissue
• Bone marrow
• Organ donation does not affect the
• appearance of the body an open casket is
• still possible

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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

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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

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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 Y-incision 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

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Continued
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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

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Continued
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Continued
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Continued

• Large organs are weighed on a grocers scale
• Smaller organs are weighed on a triple-beam
  balance
• Right lung 300-400 gm
• Left lung 250-350 gm
• Heart 250-300 gm

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Continued

• Liver 1100-1600 gm
• Adrenals 4 gm or so each
• Thyroid 10-50 gm
• Spleen 60-300 gm
• Brain 1150-1450 gm

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Continued
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Autopsy Room
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Cultural Considerations

• Refer to pg 181, Box 7-1

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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 IVs
• Reinsert dentures if possible. If not, place
  them in cup to stay with body

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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 clients
  religious preference
• Shave men unless family requests otherwise

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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

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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

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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/au
  topsy_steps.cfm