End-of-Life Care


Chapter 55

End-of-Life Care



Objectives





E nd-of-life care describes the support and care given during the time surrounding death. Sometimes death is sudden. Often it is expected. Some people gradually fail. End-of-life care may involve days, weeks, or months.


Most people die in hospitals or nursing centers. Hospice care is a common option. You may see death and dying often. Death and dying cause staff discomfort because they mean helplessness and failure to cure. They also remind us that our loved ones and we will die.


Your feelings about death affect the care you give. You will help meet the dying person’s physical, psychological, social, and spiritual needs. Therefore you must understand the dying process. Then you can approach the dying person with caring, kindness, and respect.


See Teamwork and Time Management: End-of-Life Care.



Teamwork and Time Management


End-of-Life Care


Dying persons need a lot of time from nurses. Often it is a busy time before and after someone dies. Offer to take equipment and supplies to and from the room. Also help with other patients or residents.



Terminal Illness


Many illnesses and diseases have no cure. The body cannot function after some injuries. Recovery is not expected. The disease or injury ends in death. An illness or injury from which the person will not likely recover is a terminal illness.


Doctors cannot predict the time of death. A person may have days, months, weeks, or years to live. People expected to live for a short time have lived for years. Others have died before expected to do so.


Modern medicine has found cures or has prolonged life in many cases. Research will bring new cures. However, hope and the will to live strongly influence living and dying. Many people have died for no apparent reason after losing hope or the will to live.



Types of Care


Terminally ill persons can choose palliative care or hospice care. The person may opt for palliative care and then change to hospice care.



• Palliative care. Palliate means to soothe or relieve. Palliative care involves relieving or reducing the intensity of uncomfortable symptoms without producing a cure. The focus is on relieving symptoms and treating the illness. The intent is to improve quality of life and provide family support. This care is for anyone with a long-term illness that will cause death. Settings include hospitals, nursing centers, and home settings.


• Hospice care. The focus is on the physical, emotional, social, and spiritual needs of dying persons and their families (Chapter 1). Often the person has less than 6 months to live. Cure or life-saving measures are not concerns. Pain relief and comfort are stressed. The goal is to improve quality of life. Hospital, nursing centers, and home care agencies offer hospice care. A hospice may be a separate agency. Follow-up care and support groups for survivors are hospice services. Hospice also provides support for the health team to help deal with a person’s death.



Attitudes About Death


Experiences, culture, religion, and age influence attitudes about death. Many people fear death. Others do not believe they will die. Some look forward to and accept death. Attitudes about death often change as a person grows older and with changing needs.


The family is often involved in the person’s care. They usually gather at the bedside to comfort the person and each other. When death occurs, the funeral director is called. The body is taken to the funeral home to prepare for funeral practices.


Many adults and children have had no contact with a dying person. Nor have they been present at the time of death. Some have not attended a visitation (wake) or funeral. They have not seen the process of dying and death. Therefore it is frightening, morbid, and a mystery.



Cultural and Spiritual Needs


Practices and attitudes about death differ among cultures. See Caring About Culture: Death Rites. In some cultures, dying people are cared for at home by the family. Some families prepare the body for burial.



image Caring About Culture


Death Rites


In Vietnam, dying persons are helped to recall past good deeds and to achieve a fitting mental state. Death at home is preferred. In some areas, a coin or jewels (a wealthy family) or rice (a poor family) is put in the dead person’s mouth. The belief is that they will help the soul go through encounters with gods and devils and the soul will be born rich in the next life.


The Chinese have an aversion to death and anything concerning death. Autopsy and disposal of the body are not prescribed by religion. Donating body parts is encouraged. The eldest son makes all arrangements. The body is buried in a coffin. After 7 years, the body is exhumed and cremated. The urn, with the ashes, is buried in the family tomb. White, yellow, or black clothing is worn for mourning.


In India, Hindu persons are often accepting of God’s will. The person’s desire to be clear-headed as death nears must be assessed in planning treatment. A time and place for prayer are essential for the family and the person. Prayer helps them deal with anxiety and conflict. The Hindu priest reads from Holy Sanskrit books. Some priests tie strings (meaning a blessing) around the neck or waist. After death, the son pours water into the mouth of the deceased. Blood transfusions, organ transplants, and autopsies are allowed. Cremation is preferred.


From D’Avanzo CE: Pocket guide to cultural health assessment, ed 4, St Louis, 2008, Mosby.


Spiritual needs relate to the human spirit and to religion and religious beliefs. They involve finding meaning in one’s life. Some people need to resolve issues with family and friends. Many people strengthen their religious beliefs when dying. Religion provides comfort for the dying person and the family.


Attitudes about death are closely related to religion. Some believe that life after death is free of suffering and hardship. They also believe in reunion with loved ones. Many believe sins and misdeeds are punished in the afterlife. Others do not believe in the afterlife. To them, death is the end of life.


There are also religious beliefs about the body’s form after death. Some believe the body keeps its physical form. Others believe that only the spirit or soul is present in the afterlife. Reincarnation is the belief that the spirit or soul is reborn in another human body or in another form of life.


Many religions practice rites and rituals during the dying process and at the time of death. Prayers, blessings, scripture readings, and religious music are common sources of comfort. So are visits from a cleric.


See Focus on Communication: Cultural and Spiritual Needs.



Focus on Communication


Cultural and Spiritual Needs


Your cultural or religious practices and beliefs about death may differ from those of patients and residents. Do not judge the person by your standards. Do not make negative comments or insult the person’s beliefs. Respect the person as a whole. This includes his or her beliefs and customs.



Age


Adults fear pain and suffering, dying alone, and the invasion of privacy. They also fear loneliness and separation from loved ones. They worry about the care and support of those left behind. Adults often resent death because it affects plans, hopes, dreams, and ambitions.


See Focus on Children and Older Persons: Age.



Focus on Children and Older Persons


Age





Children


Infants and toddlers do not understand the nature or meaning of death. They know or sense that something is different. They sense a caregiver’s absence or a different caregiver. They also sense changes in when and how their needs are met. They may feel a sense of loss.


Between 2 and 6 years old, children think death is temporary. It can be reversed. The dead person continues to live and function in some ways and can come back to life. These ideas come from fairy tales, cartoons, movies, video games, and TV. Children this age often blame themselves when someone or something dies. To them, death is punishment for being bad. They know when family members or pets die. They notice dead birds or bugs. Answers to questions about death often cause fear and confusion. Children who are told “He is sleeping” may be afraid to go to sleep.


Between 6 and 11 years, children learn that death is final. They do not think they will die. Death happens to others, especially adults. It can be avoided. Children relate death to punishment and body mutilation. It also involves witches, ghosts, goblins, and monsters. Understanding increases as children grow older and have more experiences with death.


By age 11, death is more fully understood. Death is still viewed as something that happens to other people. One’s own death is an event in the distant future. Without correct information, they may have some wrong ideas.



Older Persons


Older persons know death will occur. They have more experiences with dying and death. Many have lost family and friends. Some welcome death as freedom from pain, suffering, and disability. Death also means reunion with those who have died. Like younger adults, many fear dying alone.



The Stages of Dying


Dr. Elisabeth Kübler-Ross described 5 stages of dying. They also are called the “stages of grief.” Grief is the person’s response to loss.



• Stage 1: Denial. The person refuses to believe that he or she is dying. “No, not me” is a common response. The person believes a mistake was made. Information about the illness or injury is not heard. The person cannot deal with any problem or decision about the matter. This stage can last for a few hours, days, or much longer. Some people are still in denial when they die.


• Stage 2: Anger. The person thinks “Why me?” There is anger and rage. Dying persons envy and resent those with life and health. Family, friends, and the health team are often targets of anger. The person blames others and finds fault with those who are loved and needed the most. It can be hard to deal with the person during this stage. Anger is normal and healthy. Do not take the person’s anger personally. Control any urge to attack back or avoid the person.


• Stage 3: Bargaining. Anger has passed. The person now says: “Yes, me but…” The person may bargain with God or a higher power for more time. Promises are made in exchange for more time. The person may want to see a child marry, see a grandchild, have another Christmas, or live for a special event. Usually more promises are made as the person makes “just one more” request. Bargaining is usually private and spiritual.


• Stage 4: Depression. The person thinks “Yes, me” and is very sad. The person mourns lost things and the future loss of life. The person may cry or say little. Sometimes the person talks about people and things that will be left behind.


• Stage 5: Acceptance. The person is calm, at peace, and accepts death. The person has said what needs to be said. Unfinished business is complete. This stage may last for many months or years. Reaching the acceptance stage does not mean death is near.


Dying persons do not always pass through each stage. A person may never get beyond a certain stage. Some move back and forth between stages. For example, Mr. Jones moves from acceptance back to bargaining. Then he moves forward to acceptance. Some people stay in 1 stage.



Comfort Needs


Comfort is part of end-of-life care. It involves physical, mental and emotional, and spiritual needs. For spiritual needs, see “Cultural and Spiritual Needs” on p. 852. Comfort goals are to:



Dying persons may want family and friends present. They may want to talk about their fears, worries, and anxieties. Some want to be alone. Often they need to talk during the night. Things are quiet, distractions are few, and there is more time to think. You need to listen and use touch.



Some people may want to see a spiritual leader. Or they want to take part in religious practices. Provide privacy during prayer and spiritual times. Be courteous to the spiritual leader. The person has the right to have religious objects nearby—medals, pictures, statues, writings, and so on. Handle them with care and respect.


See Focus on Communication: Comfort Needs.


See Focus on Children and Older Persons: Comfort Needs.



Focus on Communication


Comfort Needs


You may not know what to say to the dying person. That is hard for many health team members. Unless you have been near death yourself, do not say: “I understand what you are going through.” The statement is a communication barrier. Instead you can say:



Tags:
Apr 13, 2017 | Posted by in NURSING | Comments Off on End-of-Life Care

Full access? Get Clinical Tree
Get Clinical Tree app for offline access