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Nursing Care During the Last Weeks of Life

Nursing Care During the Last Weeks of Life. Meg Nobel RN, CHPN Hospice of Southern Maine Cindy Frost APRN, MMC. Objective. Participants will be able to outline key nursing interventions to relieve patient suffering and family distress when providing care at the end of life. .

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Nursing Care During the Last Weeks of Life

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  1. Nursing Care During the Last Weeks of Life Meg Nobel RN, CHPN Hospice of Southern Maine Cindy Frost APRN, MMC

  2. Objective • Participants will be able to outline key nursing interventions to relieve patient suffering and family distress when providing care at the end of life.

  3. When is a patient close to death? • Lose ability to perform ADLs without assistance • Lose interest in food and drink • Increased sleep • Begin to display altered mental status (delirium, confusion, lethargy)

  4. Imminent Death • Increased cognitive impairment • Unstable vital signs • No food or drink • Decreased urine/stool output • Pulmonary Congestion/increased secretions • Mottling/pallor/cyanosis • Edema/anasarca • Altered breathing • Cool extremities • Limited or no blinking Campbell, Margaret, 2009. Nurse to Nurse: Palliative Care Expert Interventions. McGraw Hill. New York

  5. Key Nursing Care Goals • Assess symptom burden. • Collaborate with patient, family and caregiver team. • Develop care priorities and symptom management plan. • Reassess frequently.

  6. Family As Unit of Care • Assessment of family members’ role in patient’s life. • Interdisciplinary care: involve patient, family, aide, volunteer, social worker, chaplain, clergy, physician, care coordination, others.

  7. Family Meeting Define goal of meeting. Rule: Listen twice as much as you talk. Listen to family concerns. Establish goals for each meeting: Consensus Specific care goals: management of pain, sleep, delirium, etc, Advance Directive Funeral plans Financial issues Schedule for caregivers Conclusion

  8. Symptom Prevalence Across Common Terminal Illnesses (All numbers represent a percentage) Solano JP, Gomes B, et al. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, COPD and renal disease. Journal of Pain and Symptom Management. Jan 2006; 31(1); 58-69

  9. Pain Management • Pain assessment • Numerical rating vs. Visual analog vs. Wong-Baker faces scale • Yes or no; mild/moderate/severe • Nonverbal behavior: grimacing, rigidity, moaning, clenching of fists, shutting eyes (Pain AD) • Pain treatment includes baseline and breakthrough pain management.

  10. Opioid Equianalgesic Dosing

  11. Fentanyl Transdermal PatchesBased on conversion of oral morphine to fentanyl patch

  12. Skin Care • Hygiene: • Frequency: Tailored to needs • Link with range of motion, massage, skin care inspection, compassionate touch • Avoid talc or powders

  13. Skin Integrity • Prevention of breakdown: • Use of high density foam, air or other specialty mattress • Repositioning • Protect bony prominences • Protective dressing on compromised skin • Consider Foley catheter

  14. Skin breakdown prevention…….. Positioning patient for comfort (weight shifting) • Keep dry, clean. • Family teaching: draw sheets, Dundee/pink pads, how to change bed linen.

  15. Skin breakdown treatment • Pressure wound healing is unlikely at end of life. • Goals: • Control of odor • Managing exudate • Improving comfort

  16. Oral Care Xerostomia: Sensation of oral dryness Incidence : 30-55% of palliative care • Increases with age • Etiology: • Reduced salivary secretions (surgery, radiation to head/neck, medication side effects, infections, hypothyroidism, autoimmune process, sarcoidosis • Buccal erosion: cancer/cancer treatment (chemo/radiation) • Local or systemic dehydration • Miscellaneous disorders: depression, mental health, anxiety, pain

  17. Oral Care • Assessment: • Symptoms: Thirst, discomfort of oral mucosa: burning, smarting, soreness, taste alteration, sleep disturbance. • Oral exam: • Dry cracked lips • Angular cheilitis • Oral mucosa: moisture, color, thrush • Tongue dry and fissured • Absence of salivary pooling. • Oral ulcerations, gingivitis, dentition • Salivary gland swelling, tenderness

  18. Oral Care • Frequent mouth care • Water • Ice chips • Magic mouthwash/Duke’s solution • Toothettes/mouthwash • Toothbrush/suction device • Lip care: balm, vaseline/chapstick • Artificial saliva

  19. Anxiety/Depression Factors: • Psychosocial issues influenced by individual, sociocultural, medical and family factors. • Emotional turmoil may occur at times of transition. • Anxiety and depression are common in persons with life-threatening illness.

  20. Psychological Distress • Patients near end of life are most vulnerable. • There is a relationship between perception of quality of life and presence of discomfort. • Quality of dying is very important to patient and family. Memory of death experience is life altering for survivors.

  21. Anxiety Symptoms Chronic apprehension Difficulty concentrating, restlessness Irritability Difficulty falling or staying asleep Trembling or shaking not otherwise explained Exaggerated startle response Recurrent and persistent ideas, thoughts, impulses Palpitations Panic

  22. Anxiety Management • Nonpharmacological: • relaxation techniques • imagery • hypnosis • psychosocial interventions

  23. Pharmacological Interventions • Benzodiazepines: Most widely used • Lorazepam: elimination half-life is 12 hours in adults, longer in renal disease. May suppress respiratory drive. • Clonazepam has longer half life (30-40 hours). • Neither is affected by concurrent use of SSRIs. • Use low doses in elderly. • Be alert for cumulative affect.

  24. Nausea • Assessment: establish cause of symptoms • Opiates • Gastric dysfunction (bowel obstruction, constipation, gastric paresis) • Anxiety • Chemo/radiation therapies • Vestibular

  25. Nausea treatment • Prochlorperazine (compazine) 10mg po or 25 mg pr q 6 hours • Decadron po, sq, IV (dosing varies) • Haldol 0.5-1mg po/pr/IV q 4-6 hours • Lorazepam 0.5-1mg po/pr q 4-6 hours • Metoclopramide 10mg po/IV q 6 hrs (gastric paresis) • Hyoscyamine 0.125mg po, SL (if abdominal spasms present) • ABHR suppository

  26. Incontinence/ Elimination • Incontinence is not universal. • Consider Foley catheter for urinary incontinence or care challenges related to toileting. • Consider using chux instead of bedpan for bowel movements.

  27. Constipation • Assess patient’s baseline and previous treatment. • If no BM in 2-3 days, assess bowel sounds, rectal exam for impaction. • Work with your institution's formulary.

  28. Constipation treatment • Senna • Lactulose • Miralax • Bisacodyl suppository or tablets • MOM • Milk and molasses enema

  29. Constipation…. • Disimpaction should be a one time event!! • When patient is unable to swallow, stop active constipation treatment.

  30. Anorexia/Decreased swallowing • Teach family natural progression of disease and dying process: little interest in food. • Change consistency of foods or fluid. • Assess ability to swallow pills and/or food bolus. • Change medication delivery form.

  31. Ascites • Def: Accumulation of vascular fluid in the peritoneal space resulting from altered capillary dynamics. • Etiology: • Portal hypertension • Heart failure • Pulmonary hypertension • Metabolic disease

  32. Ascites….. • Initial pharmacological treatment: Diuretics (spironolactone, lasix, bumex) • Eventually not responsive • Paracentesis: may be intermittent or placement of catheter • Comfort measures: • Small frequent meals • Positioning • Skin care

  33. Delirium: What is it? • Delirium: from Latin- “Off the track” • DSM-IV Criteria: -Disturbance in consciousness: attention -Change in cognition: memory, orientation, language (“word-finding”) -Develops over a short period of time (hours/days) and fluctuates during the day -Caused by general medical condition

  34. Delirium…. • A sign of significant physiological disturbance. • Occurs in up to 85 %of persons in last week of life. • Often involves multiple causes infection organ failure medication adverse effects Often not reversible Bretibart W, Yesne A 2008. Agitation and delirium at the end of life. JAMA Vol. 300.24 (2898-2910)

  35. Assessment of Delirium • Abbreviated CAM (Confusion assessment method) • 1. Acute and fluctuating course • 2. Inattention • 3. Disorganized thinking • 4. Altered level of consciousness: alert, hypervigilant, lethargic, stupor, coma

  36. Treatment of Delirium at end of life • Avoid benzodiazepines to manage psychosis, agitation or anxiety. • Avoid medications with anticholinergic properties. • Use antipsychotic agents: haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel) • “Start low, go slow, but go!” • Observe for extra-pyramidal side effects.

  37. Medications to treat delirium • Haloperidol: 0.5 to 1 mg IV or 1 to 2 mg po, repeat q6 hours with 1 to 2 mg q 2 hrs prn until agitation resolves or 20 mg given within 24 hours • Olanzapine 2.5 to 5 mg po BID and 2.5 mg po q 4 hours • For very agitated patient, may add lorazepam 0.5-1 mg q 1-2 hours; if IV needed: chlorpromazine 25-100 mg IV (or pr) BID to QID • Lorazepam alone can worsen delirium • For EPS: Cogentin 0.5-1 mg IV, PO TID prn

  38. Dyspnea • Subjective report by patient is only reliable indicator (similar to pain). • Is present in up to 70% of terminally ill, 90% in lung cancer before death. • Increased dyspnea is common in elderly: physiology, increased PE risk.

  39. Dyspnea….. • Assessment parameters: • Effect on functional status • Respiratory rate, depth, presence of apnea, agonal respirations • Use of accessory muscles, elevated JVP • Presence of pain with breathing • Breath sounds

  40. Dyspnea Management • Use oxygen only if symptom improvement noted. • Teach re: cognitive-behavioral skills, relaxation, pursed-lip breathing. • Personal energy conservation, fans, open windows, air conditioning • Elevate head, encourage forward sitting posture.

  41. Dyspnea management……. • Calm environment, music, smoke free • Thoracentesis for relief of pleural effusion, promote lung inflation • Paracentesis if severe ascites

  42. BREATHES Program for Management of Dyspnea in the Elderly Palliative Care Patient • B-Bronchospasm: Consider nebulized albuterol and/or steroids. • R-Rales /Crackles: If present, reduce fluid intake. Consider diuresis. • E-Effusion: Consider thoracentesis or chest tube. • A- Airway obstruction: Keep patient upright during and after meals for 1 hour.

  43. BREATHES…….. • T- Tachypnea /breathlessness: opioids reduce RR and breathlessness. • H-Hemoglobin: Consider blood transfusion if severe anemia. • E-Educate and support patient and family. • S-Secretions: If copious/death rattle, consider anti- cholinergics: atropine drops, hyoscyamine, glycopyrrolate, scopolamine patch. Ferrell B, Coyle 2006. Textbook of Palliative Nursing, 2nd edition. Oxford University Press, Oxford.

  44. Dyspnea Pharmacological Treatment • At end of life, benzodiazepines, opioids, corticosteroids are primary treatment. • Nebulized opioids have no benefit compared to oral/parenteral delivery. • Opioids are treatment of choice. • Typical opioid dose is 25-50% of stable, analgesic dose. If treating pain, increase dose by 25-50%. • If opioid naïve patient, use small doses of liquid oral morphine or oxycodone (as low as 3-5mg po q 1-2 hr prn in elderly). • Consider opioid infusion if actively dying with respiratory distress.

  45. Respiratory Secretions…… • Occurs commonly in last hours of life: decreased consciousness, decreased cough and swallow • Death rattle management: • Educate family and caregivers: patient unable to clear throat. • Elevate head of bed/change position. • Avoid suctioning (noxious). • Medicate for relief with anticholinergics. (see BREATHE slide) • Reduce or stop fluid intake/hydration.

  46. Myoclonus • Definition: Sudden, uncontrollable, nonrhythmic jerking, usually of the extremities • Causes: In palliative care, often related to opioid use: Prevalence 2.7-87% • Likely related to accumulation of neuroexcitatory opioid metabolites (morphine-3-glucouronide and hydromorphone-3-glucouronide) • Other causes: placement of intrathecal catheter, AIDS, dementia, hypoxia, paraneoplastic syndrome, withdrawal from barbiturates, benzodiazepines, alcohol, anticonvulsants

  47. Treatment of myoclonus • Opioid rotation, including dose reduction for incomplete cross tolerance • Benzodiazepines: clonazepam, diazepam, midazolam most commonly used sedatives • Education • Calm, relaxing environment

  48. Seizures • Seizures occur when a large number of neurons discharge abnormally. Generalized (primary) and partial (focal) • Etiologies include brain lesions, medications, metabolites, metabolic disorders, infection, stroke, HIV, hypoxia.

  49. Seizures…… • Treat with anticonvulsants. Diazepam, carbemazepine, lorazepam, valproic acid or phenobarbital can be given. • Route of administration: Lorazepam (SL, SQ, IV); Phenobarbital (SQ, IV, IM); Valproic acid (po), Valproate Na (IV), or diazepam (IV, IM, rectal suppositories); Carbemazepine (po) Prevention: Use of decadron, dilantin

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