End Of Life Care

Presented by:- Meenakshi Soni

M.sc.(N)1st Year
Introduction:-
• Every year more than half a millions people die and
most of these deaths occurs in hospitals.

• Some deaths occur suddenly, the majority of deaths

occur after a period of chronic illness, with three
quarters of all deaths being expected. During this
time people often require ongoing care which may
include end of life care.

• End of life care helps them to live as well as possible

until they die, and to die with dignity. It also
includes support for their family or careers.
Definition:-
• End-of-life care refers to the medical care not only of
patients in the final hours or days of their lives, but
more broadly, medical care of all those with a
terminal illness or terminal condition that has
become advanced, progressive and incurable.

• End of life care is the term currently used for issue

related to death and dying, as well as the service
provided to address these issues.
Goals of End of Life Care:-
 To improve the quality of the remaining life.

 To give mental support to the patient and their

families.

 To provide comfort and supportive care during the

dying process.

 To ensure a dignified death.

Palliative Care:-
 Palliative care is derived from the Latin word ;
palliare which means “to cloak”

• It is a multidisciplinary approach and specialized

medical care for people with serious illness.

• Its mainly focused on providing patients with relief

from the symptoms, pain, physical stress, or mental
stress of a serious illness.
Hospice care:-
• Hospice care is a special kind of care that focuses on
the quality of life for people and their caregivers who
are experiencing an advanced , life limiting illness.

• Hospice care provides compassionate care for

people in the last phase of incurable disease so that
they may live as fully and comfortably as possible.
Benefits Of Hospice Care:-
• Better quality of life - patient and care-giver.

• Lower risk of major depressive disorder in bereaved

caregivers.

• Allows many patients to go home.

Principles:-
• Recognition of the requirements, complications.

• Meet any emergency.

• Prepare the until by all necessary equipments for

smoothing running.

• Provide quality care and necessary and appropriate

action to prevent complications.

• Collaborative practice between physician and nurse

for giving end of life care.
Physical Manifestations at
End of life:-
• Death occurs when all vital organs and systems
cease to function. Death is an irreversible cessation
of circulatory and respiratory functions or the
irreversible cessation of all functions of the entire
brain, including the brainstem. Trauma and disease
process can affect physical manifestations at the end
of life.
• Generally, respirations cease first. Then the heart
stops beating within few minutes. Physical
manifestations of approaching death are listed
below:
Sensory System:-
 Hearing
• Usually last sense to disappear

 Touch
• Decrease Sensation
• Decrease perception of Pain
 Taste and Smell
• Taste is decreased with disease progression

 Sight
• Blurring of vision
• Blink reflex absent
• Eyelid remain half open
• Patient appears to stare
Integumentary System

• Mottling on hands, feet, arms, and legs.

• Cold and clammy skin.

• Cyanosis on nose, nails , Knees.

• “Wax like” skin when very near to death.

• Extremities become pale.

Respiratory System:-
• Increased respiratory rate.

• Irregular breathing, gradually slowing down to

terminal gasps.

• Rapid breathing.

• Dysponea

• Inability to cough or clear the secretions resulting in

grunting or noisy congested breathing.
Urinary system:-
• Gradual decrease in urinary output

• Incontinence of Urine

• Unable to urinate
Gastrointestinal System:-
• Accumulation of gas

• Distension of nausea

• Loss of sphincter control may produce incontinence

• Slowing of gastrointestinal tract and possible

cessation of function.
• Lack of appetite

• Constipation

• Diarrhea
Musculoskeletal System:-
• Gradual loss of ability to move

• Difficulty in speaking

• Swallowing can become more difficult

• Difficulty maintaining body posture and alignment

• Loss of gag reflex

• Jerking seen in patient on large amounts of opioids

Cardiovascular System:-
• Increase heart rate, later weakening and slowing of
heart rate

• Irregular rhythm

• Decrease in blood pressure

• Delayed absorption of drugs administered

intramuscularly or Subcutaneously
Nursing Management:-
 Nursing Assessment:-
• Assessment of the terminally ill or dying patient
varies with the patient’s condition and proximity of
approaching death.

• In general assessment is limited to essential data.

The patient’s medical diagnoses, medication profile
and allergies are recorded.
1. If the patients is alert, a brief review of the body
system to detect important signs and symptoms
should be completed. Discomfort , pain, nausea
and dysponea are carefully assessed so that prompt
interventions can be implemented.

2. Coping abilities of the patient and family should be

assessed.

3. As death approaches, neurological assessment is

especially important and includes the level of
consciousness, presence of reflexes, and pupil
responses.
4. Evaluation of vital signs, skin color, and
temperature indicates changes in circulation.

5. Respiratory status, character, and pattern of

respiration and characteristics of breath sounds are
monitored.

6. Monitoring fluid and nutritional intake, urinary

output, and bowel functions provides assessment
data for renal and gastrointestinal functioning.

7. Skin conditions must be assessed on an ongoing

basis because the skin become fragile and may
easily breakdown.
 Psychosocial care:-

1. Anxiety and depression

2. Fear
 Fear of pain
 Fear of shortness of breath
 Fear of loneliness and abandonment
 Fear of meaninglessness

3. communication
Physical Care:-
 Pain:
• Assess the pain thoroughly and regularly to
determine the intensity, location, and contributing
factors.

• Minimize possible irritants such as skin irritations

from wetness, heat, cold, and pressure.

• Administer medications around the clock in a timely

manner and on a regular basis to provide constant
relief rather than waiting until the pain is unbearable
and then trying to relieve it.
• Provide complementary and alternative therapies
such as guided imaging, massage, acupressure, heat,
cold, therapeutic touch, distraction, and relaxation
techniques as needed.

• Evaluate the effectiveness of pain relief measures

frequently to ensure that the patient is on a correct,
adequate drug regimen.

• Do not delay or deny the pain relief measures to

terminally ill patients
 Restlessness
• Assess for spiritual distress as a cause of restlessness
and agitation.

• Do not restrain.

• Use music, slow, soft touch, and voice.

• Limit the number of persons at the bedside.

 Dysphasia
• Identify the least invasive alternative routes of
administration for drugs needed for symptom
management.

• Suction orally.

• Include the likes and dislikes of the patient.

• If patient is able to eat then offer the food in an

attractive manner.
 Dehydration

• Assess condition of mucus membranes frequently to

prevent excessive dryness, which can lead to
discomfort.

• Maintain complete, regular, oral care to provide for

comfort and hydration of mucus membrane.

• Do not force the patient to eat or drink.

• Encourage consumption of ice chips and sips of
fluids or use moist cloths to provide moisture to the
mouth.

• Use moist cloths and swabs for unconscious patients

to avoid aspiration.

• Apply lubricant to the lips and oral mucus

membranes as needed.
 Dysponea
• Assess the respiratory status regularly.

• Elevate the head and/or position on side to improve

chest expansion.

• Use a fan or air conditioner to facilitate movement of

cool air.

• Administer supplementary oxygen as ordered.

• Administered drugs such as opioids, sedatives, diuretics,

antibiotics, corticosteroids, and bronchodilators as
ordered to relieve congestion and coughing.
 Weakness and Fatigue
• Assess the patient’s tolerance for activities.

• Assist the patient to identify and complete valued or

desired activities.

• Provide support as needed to maintain position in

bed or chair.

• Provide frequent rest periods.

 Bowel pattern
• Assess bowel functions

• Encourage movement and physical activities as

tolerated.

• Encourage fiber in the diet if appropriate.

• Encourage fluids if appropriate.

• Use stool softeners, laxatives, or enemas if ordered

 Urinary incontinence

• Assess urinary functions.

• Use absorbent pads for urinary incontinence.

• Prevent the skin irritation and breakdown from

urinary incontinence.
 Anorexia, Nausea, and Vomiting

• Assess the patient for complaints of nausea and

vomiting.

• Assess the possible contributing causes of nausea or

vomiting.

• Advice the family members provide the patient’s

favorite foods.
• Provide frequent mouth care, especially after
vomiting.

• Provide antiemetic before meals if ordered.

• Offer culturally appropriate food.

 Preventive oral care for all patients
• Assist in oral care as per the condition of the patient.

• Use soft toothbrush to gently brush teeth, tongue,

palate, and gums to remove debris.

• Use diluted sodium bicarbonate (baking soda) or

toothpaste.

• Rinse mouth with diluted salt water after eating and

at bedtime (usually 3-4 times daily).
 Prevent bedsores in all bedridden
patients

• Remember that prevention of bedsores is better than

cure.

• Help the bedridden patient to sit out in a chair from

time to time if possible.

• Lift the sick person up the bed—do not drag as it breaks

the skin.

• Encourage the sick person to move his or her body in

bed if able.
• Change the sick person’s positions on the bed often,
if possible every one or two hours—use pillows or
cushions to keep the position.

• Keep the beddings clean and dry.

• Look for damaged skin (change of color) on the

back, shoulders, and hips every day.

• Put extra soft material such as a soft cotton towel

under the sick person.
 Instructions for bathing

• Provide privacy during bathing.

• Dry the skin after bath gently with a soft towel.

• Oil the skin with cream, body oil, vegetable oil.

• Use plastic sheets under the bed sheets to keep the

bed dry when one cannot control urine or faeces.
• Massage the back and hips, elbows, ankles with
petroleum jelly.

• If there is leakage of urine or stool, protect skin with

petroleum jelly applied around private parts, back,
hips, ankles and elbows.
 To prevent pain, stiffness and
contractures in muscles and joints

• Exercise the elbow by gently bringing the hand as

close as possible to the shoulder.

• Exercise the wrist doing the full ROM (range of

motion)

• Exercise the shoulder by lifting the arm up and

bringing it behind the head and laterally as far as
possible.

• Exercise the knee by lifting the thigh up and bringing

it close to the chest and laterally as far as possible.
 Moving the Bedridden Patient
• When transferring from the bed to a chair:

• Roll the patient on one side

• Move the patient to the side of the bed. Ask the

patient to bend legs and to prop on the same side
elbow

• Hold your hands on the patient’ pelvis, ask to raise

him/her buttocks. Sit patient on the edge and with
feet flat on the floor.
• Stand in front of the patient and hold both
shoulders. Keep patients feet flat on the floor.

• Help patient raise bottom from the bed and rotate

him/her towards the chair.

• Transfer from bed to chair. Hold patient by

shoulders and knees.
Responsibilities:-
• Death of a patient in the hospital the nurse needs to
provide respect and care to the dead body.

• The nurse must be assisted to clean the body ,by

sponging ,usually in India practice of bathing the
dead body is common .But the family often performs
these rituals at home.

• The nurse must completely wrap the body and

handover the body along with relevant documents to
the family.
Summarize:-
• Introduction
• Definition of End life care
• Palliative Care
• Hospice Care
• Physical Manifestation of end life care
• Nursing Management
• Responsibilities
References:-
• Potter Patrica A., Perry Anne Griffin (2006),
“Fundamentals of Nursing”, 6th edition, published by
Elsevier, Pp 775-800

• Delaune Sue C. (2002), “Fundamentals of Nursing

Standards and Practice” 3rd edition, Pp:- 669-700.

• Phipps Monahan Sands Mareks Neighbors (2003)

“Medical Surgical Nursing” 7th edition, published by
Mosby, Pp :-90-108.
• Suzanne C. Smeltzer Brenda Bare (2004) “Medical
Surgical Nursing” 10th edition, published by Lippincott
Williams Wilkins, Pp 369-388.

• Lewis Heitkemper Dirksen O’ Brien Bucher (2007)

“Medical Surgical Nursing” 7th edition, published by
Mosby Pp :-151-163.

• The Nightingale Nurses Vol. 5, No.5 August 2009 Pp :-

12-16.
•
• The Nightingale Nurses Vol. 6, No.5 August 2010 Pp :-
24-27.
• www.medicinenet.com

• http://www.suite101.com/content/end-of-life-care-i
n-nursing-a29142#ixzz15GHezsem

• www.makna.org.my/artofhealing.asp

• http://www.cancer.gov/cancertopics/coping