end of life care is very important to know something about it

2. End of Life Care for Older Adults
By the end of this lecture the student will be able to:
 Define end of life care.
 Identify Target population for better “End of Life Care”
 Identify the ten leading causes of death.
 Differentiate between Palliative Care and Hospice Care.
 List services provided by Hospice programs.
 Identify Nursing Skills needed to provide Palliative Care.
 Enumerates factors that influence attitude of people towards death.
 Understand decision making at the End of Life.
 List Barriers to Good End of Life Care.
 Apply Nursing Interventions for patients in End-Of-Life.
 Identify Signs of Imminent Death.
 Apply Postmortem Care.

3. Introduction:
End of life care is support for people who are approaching death. It helps
them to live as well as possible until they die, and to die with dignity. It also
includes support for their family or carers.
End of life care includes palliative care. If you have an incurable illness,
palliative care will help to make you as comfortable as possible by relieving
pain and other distressing symptoms, while providing psychological, social
and spiritual support for you and your family or carers. This is called a
holistic approach to care, as it deals with the ‘whole’ person rather than just
one aspect of their care.
 Thanatology: (i.e., the study of death and dying)
 Death: The United Nations Vital Statistics Division defines death as
the cessation of vital functions without capability of resuscitation.
 Dying: is regarded as a less specific, individualized process in which
an organism’s life comes to an end (i.e., the final portion of the life
cycle).
 When does the dying process begin?
People are considered to be dying when they are ill with a
progressive condition that is expected to end in death and for which
there is no treatment that can substantially alter the outcome
 The length of the dying process varies and depends on the
individual’s holistic situation. Its duration may be a matter of minutes,
hours, weeks, or months.
 The end of life is the period for patients when “there is little
likelihood of cure for their disease(s); further aggressive therapy is
judged to be futile; and comfort is the primary goal”
 This period can last from hours to months, and it encompasses
the time during which a person is actively dying.
 Palliation is defined as “the relief of suffering when cure is
impossible”
 Palliative care defined as the comprehensive management of the
physical, psychological, social, spiritual, and existential needs of
patients, particularly those with incurable, progressive illness.

4.  The goal of palliative care:
Focuses on comfort rather than cure, on the treatment of symptoms
rather than disease, on quality of life left rather than quantity of life
lived
Target population for better “End of Life Care”
1. Very sick (disabled, dependent, debilitated)
2. Generally getting worse
3. Will die without a period of being well again
4. Most likely will die from progression of current illness (es)
Primary cause of death
 10 leading causes of death account for 80% of all deaths in the
United States
1. Heart disease
2. Malignant neoplasms (cancer)
3. Cerebrovascular disease (stroke)
4. Chronic obstructive pulmonary disease
5. Pneumonia and Influenza
6. Diabetes mellitus
7. Alzheimer’s disease
8. Renal disease
9. Accidents
10. Septicemia
Palliative Care vs. Hospice Care:
• The core of Palliative care and Hospice care is the same: to
provide comfort and pain/symptom management and optimize quality
of life.
• Hospice patients receive Palliative care, but not every Palliative care
patient will enter Hospice.
• The goals of Palliative care and Hospice care are different, and
depend on what the patient wants to accomplish.

5. Palliative Care:
• Palliative care improves the quality of life for patients with serious
illnesses by relieving symptoms, pain and stress.
• Palliative care can happen at any point during a patient's illness.
• can even be provided at the same time a person is receiving curative
care for something else, such as receiving treatment for a bladder
infection while terminally ill with heart disease
Who is eligible for Palliative Care?
• Patients with life-limiting diseases who may still be seeking curative
treatment
• Sufferers of chronic conditions which require aggressive pain
management and symptom management
• May not have a terminal prognosis
Palliative Care Settings
• Hospitals
• Outpatient clinics
• Long-term-care facilities
• Home
Hospice Care:
• Hospice is a care program that provides assistance to those individuals
who have an incurable disease and have chosen not to carry out any
further aggressive treatment.
• Hospice considers the patient and family/caregivers as one unit of care
– provides support for all.
• The majority of hospice care is provided at home.
• Hospice care is a cost-effective alternative to the high costs associated
with hospitals and traditional institutional care.
Who is eligible for Hospice Care?
• An individual who has a life expectancy of six months or less if the
terminal illness runs its normal course, as determined by a physician,
and…
• …is no longer seeking aggressive treatment

6. Hospice Settings
 Freestanding
 Hospital
 Home health agencies with home care hospice
 Home
 Nursing home or other long-term-care settings
Hospice programs offer the following services:
● Physician and nursing care
● Home health aide
● Therapies such as music, art, and other supportive services
● Social work and counseling services
● Spiritual care
● Volunteer support
● Bereavement counseling, including support programs for1 year after death
● Medical equipment and supplies
● Drugs related to the disease
● Inpatient care for symptom management, caregiver respite, or both
Nursing Skills for Palliative Care:
The American Nurses Association’s Standards and Scope of Hospice and
Palliative Nursing Practice (2002) enumerates the special skills, knowledge,
and abilities needed by a nurse who provides end-of-life care:
1. Thorough knowledge of anatomy and physiology and considerable
familiarity with pathophysiological causes of numerous diseases
2. Well-grounded skill in physical assessment and in various nursing
procedures, such as catheterization and colostomy and traction care
3. Above-average knowledge of pharmacology, especially of analgesics,
narcotics, antiemetics, tranquilizers, anti-biotics, hormone therapy,
steroids, cardiotonic agents, and cancer chemotherapy
4. Skill in using psychological principles in individual and group
situations
5. Great sensitivity in human relationships

7. 6. Personal characteristics such as stamina, emotional stability,
flexibility, cooperativeness, and a life philosophy or faith
7. Knowledge of measures to comfort the dying in the last hours
Factors that influence attitude of people towards death:
Everyone has their own attitude toward death based on personal experiences,
age, and culture. As nurse aides, we need to respect these attitudes and care
for them the best we can.
1. Age
People of different ages have different attitudes towards death
 children see death as temporary
 Adults develop fears and sufferings of being alone
 elderly generally have fewer fears
2. Individuals reactions to death
 they may accept or completely deny death
 open and receptive
 they may talk about their uncertainties
 may be fearful or angry
 may be anxious
 hostile
 or thoughtful and meditative
3. Religion
Residents may have different attitudes toward death depending on
their religion, they may believe in:
 Life after death
 Reunion with loved ones
 Punishment for sins
 No afterlife
Decision Making at the End of Life:
 The adult has the ultimate authority to accept or reject medical care,
including the decision to leave off life-sustaining treatment, decisions
about dialysis, antibiotics, tube feedings, cardiopulmonary resuscitation

8. (CPR), and so on. Through the legislation related to the Patient Self-
Determination Act (PSDA).
1. Advance Directives
A legal document (as a living will) signed by a living competent person in
order to provide guidance for medical and health-care decisions (as the
termination of life support and organ donation) in the event that the person
becomes incompetent to make such decisions
Or
Are written instructions which communicate your wishes about the care
and treatment you want to receive if you reach the point where you can no
longer speak for yourself.
Forms of advance directive:
A. The durable power of attorney for health care.
(Also called the "medical power of attorney")
The patient chooses someone e.g. a relative or friend to make medical
decisions for him/ her when he/she is not able. Then this person is called an
agent, proxy, or surrogate.
B. Living will.
Called "instructions," "directive to physicians," or "declaration," states your
desires regarding life-sustaining or life-prolonging medical treatment. They
do not appoint a surrogate to make decisions for you.
2. Euthanasia called also mercy killing
The act or practice of killing hopelessly sick or injured individuals in a
relatively painless way for reasons of mercy. By not providing necessary
and ordinary care or food and water, or giving fatal dose of a medication
(usually secobarbital or phenobarbital)
Euthanasia is categorized in different ways, which include
A. Voluntary euthanasia: When the person who is killed has requested to be
killed.
Is legal in some countries, U.S. states, and Canadian Provinces

9. B. Non-voluntary euthanasia: When the person who is killed made no
request and gave no consent.
Is illegal in all countries. Involuntary euthanasia is usually considered
murder.
Barriers to Good End of Life Care:
1. Policies that prohibit families from freely visiting dying patients
2. Absence of pain and symptom management services
3. Absence of policies that promote adequate assessment and reporting
4. There are still patients, families, and professionals who feel there is
"nothing more to do" for a patient who has a life-threatening prognosis
5. Failure of healthcare providers to acknowledge the limits of medical
technology
6. Lack of communication among decision makers
7. Failure to implement a timely advance care plan
8. Unwillingness to be honest about a poor prognosis or telling bad news
9. Lack of understanding about the valuable contributions to be made by
referral and collaboration with comprehensive hospice or palliative care
services
Nursing Interventions in End-Of-Life Care
As healthcare providers, we become skilled in nursing and medical science,
but the care of the dying person encompasses much more. Certain aspects of
this care are taking on more importance for patients, families, and healthcare
providers. These include pain and other symptom management;
psychological, spiritual, and grief/bereavement support. To help the patient
die in comfort, with their dignity intact and their wishes and values
respected.
 Promoting Communication.
 Offering Spiritual Support.
 Managing Symptoms.

10. 1. Promoting Communication.
By using communication strategies and interpersonal skills, these
interventions include presence, compassion, touch, recognition of an
individual’s autonomy, and honesty.
 Presence: described as a “gift of self” in which the nurse is available
and open to the situation, valuing what the patient says, accepting the
patient’s meaning for things.
 Compassion: The nurse strives to be totally and compassionately with
the patient and family, allowing the most positive experience.
 Touch: A powerful therapeutic intervention, a means of
communicating genuine care and compassion.
 Recognition of autonomy: The nurse realizes and respects the
individual’s right to make all end-of-life decisions.
 Honesty: The nurse communicate/explain what can be expected
honesty and builds trust with the older adult facing death and his or
her family.
 Ability to communicate with the patient and family clearly and
supportively.
 Provide emotional support that facilitates the experience of self-transcendence
and a sense of win over death.
2. Help provide psychosocial and spiritual support
Be prepared to discuss spiritual matters if patient would like to.
 Learn to listen with empathy.
 Understand reactions to the losses in their life (the different stages of
grief).
 Be prepared to “absorb” some reactions, for example anger projected
onto the health worker.
 Connect with spiritual counselor or pastoral care according to the
patient’s religion and wishes.
 Do not impose your own views. If you share religious beliefs, praying
together may be appropriate.
 Protect your patient from over religious excitement.
 For some patients, it is better to talk about meaning of their life, rather
than directly about spirituality or religion.

11.  As human beings, we know how to care for each other. Reassure the
family caregivers that they already have much of the capacity needed.
 Give information and skills.
Managing Symptoms:
Fatigue (asthenia)
• Assess for associated conditions, including infection, fever, pain,
depression, insomnia, anxiety, dehydration, hypoxia, medication
effects.
• Inform older adult and family of the normality of fatigue at end of life.
• Pace activities and care according to tolerance.
• Exercise if tolerated.
• Promote optimal sleep, with regular times of rest, sleep, and waking.
• Corticosteroids, although generally contraindicated in older adults,
may decrease fatigue in patients with cancer.
• Treat associated conditions (e.g., with antibiotics, antidepressants).
Constipation
• Identify risks (e.g., chronic laxative users, medications).
• Perform abdominal assessment, including palpation for distention,
tenderness, or masses and auscultation of bowel sounds and pitch.
• Assess patients taking pain medications daily.
• Monitor the character of the bowel movements.
• Check the rectum if the older adult has not had a bowel movement in
more than 3 days or is leaking liquid stool (which can occur with an
impaction).
• Anticipate and prevent constipation with emphasis on fiber, fluid
intake, and activity, but recognize that patients may have difficulty
tolerating the optimal interventions.
• Promote regular routine. Strongest propulsive contractions occur after
breakfast; provide patient privacy at this time.
• Individualize laxative regimen based on the cause(s) of constipation,
history, and preferences.
• Use bulk-forming and stool-softening agents for patients with normal
peristalsis.

12. • A laxative regimen (with stimulant laxative) may be ordered for
patients taking a pain medication known to cause constipation.
• Stimulant laxatives are the most appropriate for opioid-induced
constipation.
Dyspnea
• Respiratory: Assess vital signs, including oxygen saturation, breathing
pat-tern, and use of accessory muscles.
• Auscultate breath sounds.
• Assess cough (type, if present).
• Check for tachypnea and cyanosis.
• General: Assess for restlessness, anxiety, and activity tolerance.
• Pace activities and rest.
• Provide oxygen; usually at 2–4 L per cannula (avoid using face mask
because of discomfort and sensation of smothering).
• Provide calm reassurance.
• Use a fan to circulate air and help reduce the feeling of breathlessness.
• Position for optimal respiratory function (e.g., leaning forward over a
table with a pillow on top is helpful for COPD; on the side with head
slightly elevated for unresponsive patient).
• Teach patient to use pursed-lip breathing, and encourage relaxation
techniques to reduce muscle tightness and associated sensation of
breathlessness.
• Treat symptoms with morphine or hydromorphone, which relieves the
breathless sensation in almost all cases.
• Use antianxiety agents or antidepressants if appropriate (and if
perception of breathlessness is exaggerated because of anxiety or
depression).
• Corticosteroids can be used for their anti-inflammatory effects in
certain conditions (e.g., COPD, radiation pneumonitis).
Nausea and vomiting
• Assess for potential cause (e.g., constipation, bowel obstruction).
• Palpate abdomen and check for distention.
• Assess vomitus for fecal odor.

13. • Assess heartburn and nausea, which may occur after meals in
squashed stomach syndrome.
• Assess pain (e.g., pain on swallowing may indicate oral thrush; pain
on standing may be caused by mesenteric traction).
• Hiccups occur with uremia.
• Offer frequent, small meals; serve foods cold or at room temperature.
• Apply damp, cool cloth to face when nauseated.
• Provide oral care after vomiting.
• Medications need to be specific to the cause:
● Use metoclopramide drug in Squashed stomach syndrome, gastritis,
and functional bowel obstruction: (contraindicated in full bowel
obstruction)
●Use haloperidol drug in chemical causes, such as morphine,
hypercalcemia, or renal failure:
● Use diphenhydramine in dysfunction of vomiting center (e.g.,
associated with mechanical bowel obstruction, increased intracranial
pressure, motion sickness): meclizine or
Dehydration
• Assess for clinical signs of hydration (e.g., skin turgor over the upper
chest or forehead).
• Assess buccal membranes for moistness.
• Assess vital signs: pulse, orthostatic blood pressure.
• Encourage fluids as tolerated; offer ice chips and popsicles if
swallowing.
• Provide frequent oral care; use swabs or moistened toothettes.
• Give intravenous fluids or administer clysis per advance directives.
• Discuss continued diuretic use with physician.
Anorexia and cachexia
• Assess for weight loss.
• Assess for levels of weakness and fatigue.
• Conduct physical examination for decreased fat, muscle wasting,
decreased strength.
• Assess mental status, including depression.

14. • Remove unpleasant odors.
• Provide frequent oral care.
• Treat pain optimally.
• Provide frequent, small meals.
• Provide companionship.
• Serve meals in a place that is separate from the bed area.
• Involve patient with meal planning.
• Collaborate with dietician for nutritional analysis and meal planning.
• Encourage culturally appropriate foods.
• Consider using an alcoholic beverage before meals.
• Medications that are used to stimulate appetite, promote weight gain,
and provide a sense of well-being: megestrol acetate, corticosteroids,
and mirtazapine.
• Metoclopramide is used to improve gastric motility and appetite.
Pain management:
• Assess present pain, including intensity, onset, location, duration,
characteristics, aggravating and relieving factors, and treatment (OLD
CART).
• Assess pain history, including prior injuries, illnesses, and surgeries;
pain experiences; and pain interference with daily activities.
• Assess patient's attitudes and beliefs about use of analgesics, adjuvant
drugs, and non-pharmacological treatments.
• Use a standardized tool to assess self-reported pain.
• Verbal Descriptor Scale, or (B) Numerical Rating Scale, or (C) Visual
Analog Scale
• Assess pain regularly and frequently to facilitate appropriate
treatment.
• Observe for nonverbal and behavioral signs of pain.
• Older adults with cognitive impairment experience pain but are often
unable to verbalize it. Such as:
 Moaning or groaning at rest or with movement
 Failure to eat, drink, or respond to presence of others
 Grimacing or strained facial expressions

15.  Guarding or not moving body parts
 Resisting care or noncooperation with therapeutic interventions
 Rapid heartbeat, diaphoresis, change in vital signs
• Work with the patient and his family to set realistic goals and
expectations because achieving these goals will promote a sense of
accomplishment.
• Give the patient an opportunity to express anger, frustration, sadness,
and concerns about living with pain. And show empathy.
• Educate patients, families, and other clinicians to use analgesic
medications prophylactically prior to and after painful procedures.
• Administer analgesics 30 minutes prior to activities.
• Educate patients and families about pain medications and their side
effects; adverse effects; and issues of addiction, dependence, and
tolerance.
• Use opioids for treating moderate-to-severe pain and nonopioid for
mild-to-moderate pain.
• Acetaminophen drug. Guidelines recommend not exceeding 4 g per
day (maximum 3 g/day in frail elders).
• Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with
caution in older adults. Monitor for gastrointestinal (GI) bleeding and
consider giving with a proton pump inhibitor to reduce gastric
irritation. Also monitor for bleeding, nephrotoxicity, and delirium.
• Monitor medication effects closely to avoid overmedication or under
medication and to detect adverse effects. Assess hepatic and renal
functioning.
• Educate patients, families, and other clinicians to use
nonpharmacological strategies to manage pain, such as relaxation,
massage, and heat/cold, deep-breathing, and diversionary activities.
• Provide opportunities for the patient to rest to increases pain tolerance
and provides energy for participation in other activities.
• Combination approaches that include both pharmacological and
nonpharmacological pain treatments are often the most effective.
• Pain characteristics in Cognitively-Impaired Older Persons

16. Signs of Imminent Death:
When death is near, bodily functions will slow and certain signs and
symptoms will occur, including:
 Decline in blood pressure
 Rapid, weak pulse
 Dyspnea and periods of apnea
 Slower or no pupil response to light
 Profuse perspiration
 Cold extremities
 Bladder and bowel incontinence
 Pallor and mottling of skin
 Loss of hearing and vision
Postmortem Care:
1. Needs to be done promptly, quietly, efficiently, and with dignity
2. Straighten limbs before death, if possible
3. Place head on pillow
4. Remove tubes
5. Replace soiled dressings
6. Pad anal area
7. Gently wash body to remove discharge, if appropriate
8. Place body on back with head and shoulders elevated
9. Grasp eyelashes and gently pull lids down
10. Insert dentures
11. Place clean gown on body and cover with clean sheet

17. References:
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constipation on patients near the end of life. Journal of Hospice and
Palliative Nursing, 12(1), 29–38.
 Murray, R. P. (2010). Spiritual care beliefs and practices of special
care and oncology RNs at patients’ end of life. Journal of Hospice and
Palliative Care, 12, 51–58.
 Menec, V. H., Nowicki, S., Blandford, A., & Veselyuk, D. (2009).
Hospitalizations at the end of life among long-term care residents.
Journal of Gerontology: Medical Sciences, 64A, 395–402.
 Munn, J. C., Dobbs, D., Meier, A., Williamsn, C. S., Biola, H., &
Zimmer man, S. (2008). The end-of-life experience in long-term care:
Five themes identified from focus groups with residents, family
members, and staff. The Gerontologist, 48, 485–494.
 Whitehead, P. B., Anderson, E. S., Redican, K. J., & Stratton, R.
(2010).Studying the effects of the end-of-life nursing education
consortium at the institutional level. Journal of Hospice and Palliative
Nursing, 12,184–193.
 Tayeb, M. A., Al-Zamel, E., Fareed, M. M., & Aboueillail, H. A.
(2010). A “good death”: Perspectives of Muslim patients and health
care providers. Annals of Saudi Medicine, 30, 215–221.
 Currow, D. C., Smith, J., Davidson, P. M., Newton, P. J., Agar, M. R.,
&Abernethy, A. P. (2010). Do the trajectories of dyspnea differ in
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