PALLIATIVE AND END OF LIFE CARE

BSN4│ LECTURE│HIRAYA

Palliative and End of Life Care in Critical Care Setting CARDIAC MONITOR
Learning Objectives:
• Comprehend and accept the guidelines,
requirements and grading system for their
success in the course.
• Comprehend the significance of the course to
the Nursing profession.
• Participate in the interactive discussions.
• Describe the three suggested phases relating
to the management of a patient in critical
care. - focuses on monitoring the vital signs including
• Identify the challenges of introducing and the blood pressure, oxygen saturation, heart
caring for palliative care patients in a critical rate, respiratory rate, and temperature.
care environment
MECHANICAL VENTILATOR
• Reflect on the support required for the
patient, family and critical care staff when
delivering palliative and end of life care.

CRITICAL CARE

- If the patient situation, cannot breathe on their

own. There is a supporting machine to be
attached to the patient to support their
breathing.
- Temporary machine only.

INFUSION PUMP AND SYRINGE PUMP

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- Infusion Pump - To monitor in detailed the IV
Fluids that are infused to our patients.
- Syring Pump – Medications that can be
administered in a slow IV push and includes
those High Alert Medications.
CRITICAL CARE SETTING
• The goal of critical care is ultimately to support
and treat reversible causes of critical illness,
maintaining life and relieving suffering.
However, it has taken a considerable time to
define what happens in ICUs because of
variation of patient criteria, reason for admission
and specialty.
• Patients in ICU or critical care units they nursed
and requires level 2 and 3 support. This is
because they need potentially life-saving
measures requiring staff with specialist skills and
knowledge, in addition to the use of medical
technology.
Levels of Care:
Level 0 – WARD CARE
• Patients whose needs can be met through a
normal ward setting.
o A patient with DKA who is on
appropriate treatment and was initially
very acidotic but is gradually improving
and requiring no organ support.
o A patient who was hypotensive in the
Emergency Department but who has
responded to intravenous fluids and is
now hemodynamically stable with a
lower risk of deterioration, such that
they can go to a medical ward.
o A patient with OSA who has their own
CPAP machine, knows how to use it and
does not have acute respiratory failure.
o A patient recently discharged from an
enhanced care unit or critical care unit
who is stable with a low risk of
deterioration.
Level 1 – ENHANCED CARE
• Patients at risk of their condition deteriorating,
or needing higher levels of care.
o A patient requiring close physiological
monitoring after major surgery – may
have additional monitoring devices in
situ e.g. arterial line.
o A patient requiring vasopressor support
(peripheral or central) but otherwise
stable and not deteriorating. E.g. post-
op patient with a “saggy” blood pressure
secondary to an epidural.
o A patient requiring NIV/CPAP for single
organ failure.
o A patient stepping down from level 2
critical care whose needs are greater
than those that can be met by ward level
care.
o Patients requiring ongoing interventions
from critical care outreach teams in their
active management.
Level 2 – CRITICAL CARE
• Patients requiring more detailed observation of
intervention or postoperative care, and higher
levels of care.
o A patient requiring NIV/CPAP who has
borderline blood pressure and also
needs vasopressor support.
o A complex post-op patient highly likely
to require one or more organ support.
e.g. Ivor-Lewis oesophagogastrectomy
or anterior resection in a patient
deemed high risk pre-operatively.
o An Emergency Laparotomy deemed high
risk of deterioration and the need for
organs support.
o A patient requiring Renal Replacement
Therapy in a non-renal setting.
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o A more unwell patient who look as
though they will deteriorate and require
organ support. E.g. severe pancreatitis.
o A patient weaning from mechanical
ventilation via a tracheostomy who is
spontaneously breathing via the
ventilator and is otherwise stable,
receiving on-going rehabilitation and
whose nursing needs are not high.
o A morbidly obese patient (BMI >40)
requiring NIV/CPAP or vasopressor
support.
o A patient who requires Level 1 care, who
is also suffering from hyperactive
delirium.
o A patient stepping down from level 3
critical care.
LEVEL 3 – INTENSIVE CARE
• Patients requiring advanced respiratory support
alone or basic respiratory support together with
support of at least two organ system.
o A patient requiring mechanical
ventilation.
o A patient requiring Renal Replacement
Therapy and vasopressor or respiratory
support.
o A patient requiring NIV/CPAP and
vasopressor support who is also
agitated/delirious.
o A patient who is requiring NIV/CPAP and
vasopressors who is at risk of requiring
additional or more advanced organ
support such as Renal Replacement
Therapy or mechanical ventilation.
o A morbidly obese patient (BMI >40) who
is requiring NIV/CPAP and vasopressor
support.
o A patient who requires Level 2 care, who
is also suffering from hyperactive
delirium.
PHASE OF CARE IN CRITICAL CARE
• In terms of planning and implementing holistic
patient-centered care, nursing patients in an ICU
is no different from other health care settings.
However, there are some differences that should
be recognized:
1. Medical technology and interventions
actively support and can even replace the
function of some organ systems during the
severe stages of organ failure.
2. It is often not possible to involve patients in
discussions about their care as they are
seriously ill, at times unconscious and may
be unable to communicate.
3. The serious illness may have developed
rapidly, within minutes or hours, and finally,
other services such as a hospice or palliative
care teams may have had more time to plan
end of life care with the patient and loved
ones.
PHASES OF CARE IN CRITICAL SETTING
1. PHASE 1 – HOPE OF RECOVERY
• Patients are admitted to the critical care
environment because they are looking forward
for the good management and fast recovery.
2. PHASE 2 – THE TRANSITION STAGE
• This involves recognition that the treatment is
not effective in the planned recovery of the
patient as interventions have not resulted in an
improvement of the patient’s condition.
3. PHASE 3 – A CONTROLLED DEATH
• The term “controlled death” could conjure up
different meanings, including helping someone
to die, which would be misconstruing.
NURSING THE DYING PATIENT IN CRITICAL CARE
• Importance of the design of ICU cannot be
underestimated and should include planning for
space and private rooms for a grieving family.
• These physical limitations can prove challenging
in maintaining dignity and support for the
relatives when providing palliative and end of life
care.
• Recognizing the need for privacy at this time
should be considered.
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• Relatives can understand the physical limitations
of the ICU, but staff need to reiterate this point
to them as a way of acknowledging how difficult
it might be for them not being close to the
patient.
• This can also enhances communication between
staff and relatives.
PAIN, DISTRESS, ANXIETY
- If patients are under palliative care, we are only
intervening their signs and symptoms instead of
their condition.
- Patient most probably feel Pain, Distress, and
Anxiety.
PHARMACOTHERAPY / SYMPTOM MANAGEMENT
HOSPICE / COMFORT CARE
- Assisting patient in their day to day activities
and routines.
ADVANCE CARE PLANNING
- Need to know how to assist in emergency
situations, if this occurs to our patients.
REMOVAL OF MONITORING EQUIPMENT
• When active therapy is withdrawn the audible
and visual alarm systems from the monitoring
systems may be switched off to enable the focus
of care to be on the patient and their family
rather than on the machines.
• Removing equipment and machinery from the
bedside seems to promote a peaceful and
dignified setting for the patient and family.
COMMUNICATION AND PALLIATIVE CARE IN
CRITICAL CARE
• Ensuring and maintaining excellent
communication between staff and relatives is
crucial when caring for the dying patient in
critical care.
• To improve communication, during meeting it
includes relative / family member, member of
nursing team and one doctor involve in the care
of the patient.
FIVE PRIORITIES OF CARE:
1. The possibility that a person may die within the
next few days or hours is recognized and
communicated clearly, decisions made and
actions taken in accordance with the person’s
needs and wishes and these are regularly
reviewed and decisions revised accordingly.
2. Sensitive communication takes place between
staff and the person who is dying and those
identified as important to them.
3. The dying person and those identified as
important to them are involved in decisions
about treatment and care to the extent that the
dying person wants
4. The needs of families and others identified as
important to the dying person are actively
explored, respected and met as far as possible
5. An individual plan of care, which includes food
and drink, symptom control and psychological,
social and spiritual support, is agreed,
coordinated and delivered with compassion.
INVOLVING THE FAMILY IN THE CARE
• Family of the patient want to be more actively
involve in some of the practical aspects of the
patient’s care.
• Family members can be involved in assisting in
administering some procedures for the patient
like personal hygiene routines.
• As a nurse, you play an important role also in
encouraging the family member to talk to the
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patient. By supporting relatives to talk to the

patient you can assist the family to feel a
connection with him or her.

CARING FOR YOURSELF

• A key aspect in terms of your personal well-
being and performance and in staff retention is
to have a supportive team.
• Critical Care Nurses require a continuous
education for skills and knowledge
enhancement.
1. Eat a nutritious diet
2. Get adequate sleep
3. Engage in exercise and relaxation activitieS
4. Establish a good work-family balance
5. Engage in regular non-work activities.
6. Develop coping skills
7. Allowing personal time for grieving
8. Focus on spiritual health
9. Find a mentor

ORGAN DONATION
• Good end of life care planning enables patients
to die with dignity, but it will inevitably involve
some difficult and sensitive decision being made.
• Organ donation should be considered as a usual
part of end of life care planning (guidelines
published by NICE 2016)

R.L.T.N. – 4NU06