NSc 313- END OF LIFE CARE NURSING 7.pptx

END OF LIFE CARE
NSC:313
Nursing and end-of-life care
Setting of end-of-life care
Palliative care programs an hospice
Nursing care and the terminally ill patient
Nursing Care of patient who are close to death
Care of the dead and family
Coping with death and dying: Professional caregiver issues

Course Outline
• Course outline
• Learning objectives
• Definition of terms
• Nursing and End-of-Life care
• Setting for End-of-Life Care
• Approaches/systems of End of Life care
• Nursing Care of Terminally Ill Patients
• Nursing Care of Patients Who are close to Death
• Care of the dead and Family
• Coping With Death and Dying : Professional Caregiver
Issues

Learning Objectives
• After completing all the sections in this learning resource, you should:
• Define concepts used
• Have raised awareness on any socio-cultural, spiritual beliefs, legal and
ethical issues that might arise when providing care for the terminally ill
and dying patient.
• Determine settings and approaches suitable for the care of patients at
their end of life seasons
• Provide end of life care to an individual with a life limiting illness according
to the principles of nursing practice
• Describe Palliative and Hospice care
• Have improved understanding of the need for effective communication in
discussing end of life care with individuals reaching the end of life and
those close to them
• Keep accurate records and document summaries of conversation.
• Describe how care providers can cope with the physical and emotional
challenges of caring for patients at the end of life.

NURSING AND END OF LIFE CARE
(EOLC) ISSUES

INTRODUCTION
• Death is a necessary end of all mortals
• Good to prepare for death for self or loved ones to
enjoy physical and mental care at the end of life
• In advanced countries there are preparation for death
hours, days, weeks, month and even years before
death to avoid persons being admitted for
emergencies, seeking witch or native doctors help to
avoid death.
• Special care provided for persons with life threatening
condition is called End-of-Life Care (EoLC)

Definition of Terms/Concepts
• End-of life (EoL)-(1) issues relate to someone's death and
the time just before it, when it is known that they are likely
to die soon from an illness or condition (Cambridge English
Dictionary).
• (2) EoL usually refers to the last year of life, although for
some people this will be significantly shorter.
• End-of-life care (or EoLC) refers to health care, not only of
patients in the final hours or year of their lives, but more
broadly care of all those with a terminal illness or terminal
condition that has become advanced, progressive and
incurable.
• The term palliative care is often used interchangeably with
end of life care.

Definition of Terms/Concepts 2
• Palliative care- “Palliative care is specialized medical care
focused on identifying and relieving the pain and other
symptoms of a serious illness. Its goal is to improve quality
of life for such patients at any stage of illness regardless of
current treatment plans, and it is tailored to the needs of
the patient and the family (Strand, Kamdar & Carey, 2013,
p. 859).” •
• Palliative Care is focused on quality of life rather then
curing disease
• Hospice- “Hospice is a special concept of care designed to
provide comfort and support to patients and their families
when a life-limiting illness no longer responds to cure-
oriented treatments” (Hospice Foundation of America
[HFA], 2014

• Assisted suicide- is the aiding the patient to end his(er)
own life.
• Euthanasia 1. an easy or painless death.
2. the deliberate ending of life of a person suffering from an
incurable disease. (n.d.) Farlex Partner Medical Dictionary.
(2012)
• Caregiver - anyone who provides care.
– Formal caregivers are members of an organization and
accountable to defined norms of conduct and practice. They
may be professionals, support workers, or volunteers.
– Informal caregivers are not members of an organization. They
[usually] do not have formal training, and are not accountable to
norms of conduct or practice. They may be family members or
friends.

• Last few days of life- When death is expected
within the next few days or hours
• Terminally ill -A disease that cannot be cured and
that is reasonably expected to result in the death
within a short period of time is termed as
terminal illness. This term is more commonly
used for progressive diseases such as cancer or
advanced heart disease than for trauma. It
indicates a disease which will eventually end the
life of the sufferer.

• Death – There are several definitions and historical bases for the definition of
death.
• Traditionally death is defined as cessation of apical pulse, respiration and B/P
(Heart-Lung Death or cardiorespiratory death.)
• 1960s part two of the definition of death was introduced, absence of response to
painful stimuli, and, absence of pupillary response to light for clinical
confirmation of death.
• 1968, World Medical Assembly adopted guideline for physicians as indication for
death as Total lack of response to external stimuli, No muscular movement,
especially breathing, No reflexes, Flat encephalogram (Brain Waves) for at least 24
hours.
• The United Nations Vital Statistics Division defines death as the cessation of vital
functions without capability of resuscitation.
• With the introduction of life support defining death has taken a different
perspective considering also legal implications.
• 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)

Views about Death and Dying in Bayelsa State/ Africa
There are varied views among the different tribes, clans,
communities, families, social status, etc about death and
dying.
• Like other Africans, the Ijaws view death and dying, a
supernatural event caused by wicked spirits that work
through possessed persons.
• Death is not welcomed , but applauded when it affects an
enemy or an old person.
• They treat the dying with herbs and incantations.
• Recently, with increased application of Bible knowledge
and word of faith, Christians pray for God to intervene and
deliver the dying from death.
• In Africa, lifespan is short.

Views about Death and Dying in America
• Major cause of death in Africa is communicable
diseases.
• In advanced cultures causes of death include
old age, life threatening illness like CORPD,
cancer.
• Focus of care in the advanced nation is care for
their ageing population; manage persons with
life threatening and chronic illnesses, utilizing
advanced technology in healthcare to prolong
life.

Technology and End-of-Life Care
• There is no consensus when issue of technology
and end-of-life care is discussed globally.
• The shift in the environment for care of the dying
from home to the health institution was due to
the massive application of high tech equipment in
patients care, so families and friends involvement
reduced to almost nil.
• Families are no longer exposed to the dying and
death experience of relatives.

Technology and End-of-Life Care 2
• The high tech gadgets are used to prolong life which is
the goal of clinicians and desire of families, friends and
the patient.
• With the introduction of hospice and palliative care
there are debates on the implications of varied
methods of caring for the dying.
• The latest issue is that clinicians, family, friends, and
the patient are concerned about the appropriate
method to choose in end-of-life care.
• Other considerations are, how should families, friends
and clients prepare for end-of-life, and how they can
recover from the loss of a dear one.

Sociocultural Context and End
of Life Care
• Though dying and death experiences are unique
to the individual, the universal response is that
death is an enemy that must be fought with all
means available. (E.g. “fight against Cancer”)
• Consequently, the health care system is
structured, and technologically developed to
ensure cure of illnesses, and extend life when
possible.
• When a family or patient is not aggressive for
cure, they are diagnosed as “giving up”.

Sociocultural Context and End of Life Care 2
• In debates to consider which is more superior
between cure and care. The view in most cases
had been that cure is superior to care, that care
will be considered only best if cure is no longer
possible.
• So less emphasis is placed on care than cure.
• When cure is not achieved in the healthcare
institutions, clinicians and society will say nothing
more can be done, due to the disregard for care,
patient is sent home to die

Sociocultural Context and End of Life Care 3
• But, in a care-focused perspective, healing can take
place thorough physical, spiritual, emotional, and
social interventions.
• Among majority of Bayelsans and may be the rest of
Africa, the first point to seek healing is physical
intervention eg. (massaging), followed by or
complemented with spiritual intervention, the last
point of call could be the healthcare institutions.
• The social and emotional approaches to care in Africa
are usually massive, and could be distressing.

Sociocultural Context: Clinicians attitude towards
Death
• Kubler-Ross in her 1969 study titled On Death and Dying,
observed patients were usually uninformed about life
threatening illness like Cancer by clinicians. But her work
discovered that if patients were informed, though may be
difficult for patient initially, but, with time they go through
the process, accepting the diagnosis.
• Earlier, in 1965, 2 sociologists, Glaser and Strauss in their
study discovered that clinicians avoided direct communication
with patients on dying and death but believed patients will
discover on their own.

Sociocultural Context: Clinicians attitude towards
Death 2
• They identified 4 ‘awareness contexts’:
– Closed Awareness – pt is unaware because clinicians and
family keep the diagnosis as a secret for fear that patient
will not be able to cope.
– Suspected Awareness-pt suspect health situation due to
attitude of clinicians, family and non-improvement of
health, so they attempt find out what is wrong
– Mutual Pretense Awareness- Clinicians, family and patient
are aware that pt is dying but yet pretend that all is well.
– Open Awareness-Clinicians, family and patient is aware
that pt is dying and openly acknowledge it.

Sociocultural Context: Clinicians attitude
towards Death 4
• Though the study by Strauss et al was done more
than ½ a century ago its finding are still valid, but,
the emergence of hospice and palliative care is
addressing this attitude. Clinicians are now
informing patients about their diagnosis and
prognosis.
• In the developed nations, it has also been
observed that patients want to be informed of
their diagnoses and course of disease; the
situation may not be the same in Africa.

Clinicians Attitude and, Patient and Family Concerns
• It is asserted that patients and family denial of life
threatening illness is the reason clinicians are weary in
informing them of their life threatening illness.
• Research on the other hand opined that the denial stage is
useful in allowing to absorb the shock.
• Knowledge of diagnosis help patient and family to
collaborate with clinicians to make appropriate choice for
treatment.
• Lack of knowledge causes misconception of the course of
diseases for patients and family. Which is the reason for
seeking inappropriate alternatives and waste of fund.
• Other cultural consideration that may be difficult for some
culture to understand is assisted suicide,

Assisted Suicide
• Assisted Suicide involve the process in which
the physician assist the patient to terminate
his/her own life by providing a lethal dose of
medication for that purpose.
• Assisted suicide is quite controversial and has
a lot of implication in Nursing.
• Assisted suicide is an issue where the interests
of the individual cannot be separated from
those of society as a whole.

Assisted Suicide 2
Types of Assisted Suicide
• Euthanasia: Physician prescribes and directly administer the treatment to the
patient to relief suffering
• Physician-assisted suicide: Patient and not the physician administers the
treatment intended to terminate the patients life to relief suffering.
Types of Euthanasia
• Active: Administering the treatment to end life
• Voluntary: Patient ask to be assisted to die
• Passive: Withholding/withdrawing from treatment that will sustain life
• Involuntary: Patient is unable to consent to terminate his/her life because they are
in coma, so a relative takes the decision.
Legality of Assisted Suicide
• Physician-assisted suicide and Euthanasia not legal in Nigeria. Euthanasia is Illegal
in the United States and Canada, but Legal in Netherlands, Belgium. While
Physician-assisted suicide is Legal in Oregon, Washington, Montana, and the
Netherlands. Nurses should be aware of Oregon’s Death With Dignity Act

Assisted Suicide 3
Implication of Assisted Suicide Health Care Service Providers:
Healthcare and Human Service Workers (health care service
providers)
• Many healthcare and (health care service providers) would
be and be involved physician-assisted suicide cases against
their beliefs.
• Between 2010 and 2011, nursing organisations like ANA,
HPNA states that Nurses participating in assisted suicide is a
violation of nursing ethics, therefore oppose the motion of
its legalisation. Rather nurses should create therapeutic
environment to support effective symptom mx, that honors
the wishes of patients as well as identifying with their fears
and concern.

Assisted Suicide 4
• On the part of (Oncology Nurses society) ONS, it did not
specifically oppose the motion but calls for quality palliative
care and prompt discussion of request to hasten death.
• The American academy of Hospice and Palliative Medicine
advice clinicians to carefully assess cause of the request
and address findings instead of hastening death.
Patients
• In 47 states terminally ill patients cannot choose to end
their suffering
• In the 3 states that have legalized physician assisted suicide,
terminally ill patients are faced with a monumental
decisions.
• Decisions on end of life has legal and ethical implications

Legal And Ethical Issues Affecting End Of Life Care
• A) Advance Directives
• Nurses should be familiar with the laws concerning Advance
Directives, used mostly in advanced countries, and encourage
patients on admission to talk with family, significant others
and healthcare providers on treatment preferences.
• Eg of a popular directive is the Five Wishes
1.The person I want to make decision for me when I can’t,
2. the kind of treatment I want and don’t want,
3. how comfortable I want to be,
4. How I want people to treat me,
5. what I want my loved ones to know. Cont.

Legal And Ethical Issues Affecting End Of Life Care2
• Advance Directives cont.
• Is a general term advanced directive is used to describe the
documents that give instructions about future medical care
and treatment when the patient is no longer conscious to
make decisions. The document is generally made in
advance of serious illness, and may be completed when a
diagnosis of serious illness is made if the signer of a sound
mind. They include the living will, Do Not Resuscitate
(DNR), Withholding or withdrawing treatments-
• 1.The living will also called Medial Directive or Treatment
Directive. is a document that provide instruction on how
the signer is to be care for when the terminally ill and can
no longer communicate. It is usually accompanied by a
durable power of attorney for health care.

Legal And Ethical Issues Affecting End Of Life Care 3
• The Living Will- was the first advance directive,
now replaced by the following:
– Directive to Physicians (DTP)- is a written document
specifying the patient’s wish to be allowed to die
without extraordinary measures.
– Durable Power of attorney for Health Care (DPAHC)-a
document used to list the person(s) to make health
care decisions should a patient become unable to
make informed decision.
– Medical Power of Attorney (MPOA) is same as DPAHC.
The person(s) appointed may be called health Care
agent, Surrogate, Attorney-in-fact, or proxy

• 2. Do Not Resuscitate –Is a written physician’s order instructing health
care providers not to attempt CPR.
• Often requested by the family
• Must be signed by a physician to be valid
• Types
– Full code
– Chemical Code
– DNI (Do not intubate)
– DNR or “no code” (Do not resuscitate)
– Out-of-Hospital DNR
– Comfort Only
• 3. Withholding or withdrawing treatments- is putting in clear terms what
is to be or not to done for patient which may include withholding
hydration. . Decision may be made by patient or surrogate.

• B) Organ Donation -Under the Anatomical Gift Act and the
National Organ Transplant Act in the USA and the Human
Tissue Act in Canada, people 18 years and older of sound
mind may make a gift of all or part of their bodies for the
following reasons:
• Medical and Dental education, research, advancement of
medical and dental science, therapy, or transplantation.
• The donation is made in a will or by signing a card that is
carried all times by the intending donor.
• The will can be revoked by destroying the card or revoke
orally in the presence of two witnesses. Nurses may serve
as witnesses for donors.
• The nurse is to be abreast with the laws on donation and
educate patients.

Dying Person’s Bill of Rights
• I have the right to be treated as a living human until I die.
• I have the right to maintain a sense of hopefulness, however changing its focus may be.
• I have the right to be cared for by those who can maintain a sense of hopefulness, however
changing this may be.
• I have the right to express my feelings and emotions about my approaching death in my own
way.
• I have the right to participate in decisions concerning my care.
• I have the right to expect continuing medical and nursing attention even though “cure” goals
must be changed to “comfort” goals.
• I have the right to not die alone.
• I have the right to be free of pain.
• I have the right to have my questions answered honestly.
• I have the right to retain my individuality and not be judged for my decisions, which may be
contrary to the belief of others.
• I have the right to expect that the sanctity of the human body will be respected after death.
• I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt
to understand my needs and will be able to gain some satisfaction in helping me face my
death.

Setting for End-of-Life Care
End of life care is provided in a range of settings which include care in the community, a hospital, care
home, hospice etc.
• Regardless of care setting, the quality of care should be of the highest standard.
• Hospital Care: Families may choose to remain in the hospital to provide care in his unstable
condition and home care is not an option. -Then the setting should me made homelike as possible.
-for patient and the family’s comfort.
• Ambulatory/outpatient :
• Acute Care:
• Long term care:
• Home Care :Some families prefer home care agency.
– Periodic visits of nurses to administer medication, equipment or supplies are provided. -The health care
team promote this in the belief of providing hospice care
• Nursing Homes: focus more on medical care than the typical assisted living facility, but they also
provide personal care services like giving residents three meals a day and assisting with daily
activities. They may also have rehabilitation services, like physical and speech therapy, and
recreational activities, too.
• Hospice Care :Hospice is a community health care organization that specializes in the care of dying
patients by combining the hospice philosophy with principles of palliative care.

Setting for End-of-Life Care 2
• Hospice inpatient Care
• Management of physical, psychological, social and spiritual needs of child and
family.
• Care is provided by a multidisciplinary group of professionals in the patient’s
home. It is based on certain concepts.
• Board and care homes. Are residential facilities with fewer residents that provide
personal care and meals, including having their stall every day to assist .
• Assisted Living Facilities People in assisted living facilities typically have their own
apartments or rooms with shared common areas they receive some help with
their daily care (meals, medication, housekeeping, etc.) from 24-hour on-site staff,
but not as much as they’d usually get in a nursing homes. However, there may be a
few levels of care offered with people paying more for more intensive support,
they also provide activities to social and recreational activities.
• Continuing care retirement communities
• These usually offer different services in one spot, residents are usually admitted
into independent apartment, as condition detororirate they are moved to assisted
living care, and lastly into a nursing home equivalent on the same campus.

Goal Setting in Palliative Care at the End-of-Life
• When patient is not responding to treatment (cure) and
death is approaching, the goal of treatment then shifts from
cure towards care.
• Clinicians need to help patients and the families make
informed decision on appropriate option about seeking cure
(aggressive Rx and diagnostic testing) or care (comfort and
spiritual attention) when patient’s symptoms indicate
impending death.
Cure
Care

Palliative and Hospice Care
• There are two approaches or systems to End of life care, Palliative and
Hospice Care
• Palliative Care (PC) : PC is an approach as well as a structured system of
care for critically ill patients, initially used for cancer patients but is now
extended to noncancerous patients. The current comprehensive care
addresses the management of patients symptoms, psychosocial care, and
spiritual support to patient and families.
• WHO (2016), define Palliative care is defined as an approach that
improves the quality of life of patients (adults and children) and their
families who are facing problems associated with life-threatening illness. It
prevents and relieves suffering through the early identification, correct
assessment and treatment of pain and other problems. Palliative care is
the prevention and relief of suffering of any kind – physical, psychological,
social, or spiritual – experienced by adults and children living with life-
limiting health problems. It promotes dignity, quality of life and
adjustment to progressive illnesses, using best available evidence.

Palliative and Hospice Care2
• The terms palliative care and hospice are sometimes used
interchangeably, but the fact is that hospice care is rendered at
home or a special facility to a patient who may likely die within six
month.
• Palliative care is a broader concept, mainly to prevent and relieve
pain and suffering; provide quality life for patients and families,
regardless of stage of dx and the need for other therapies.
• In Palliative care, interdisciplinary collaboration is used to bring
about the desired outcome for patient and family, because there is
communication and cooperation among the various discipline,
unlike the multidisciplinary participation that has no coordination
and integration.
•

Palliative and Hospice Care 3
• Who is eligible for Palliative Care? •
• Patients of any age 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 is specialized medical care focused on identifying and
relieving the pain and other symptoms of a serious illness.
• Ideally it begins at the time of diagnosis of a life threatening or
debilitating condition and continues through cure, or until death and
into the family‘s bereavement period.
• Medical cases that commonly patronize palliative care are cancer,
progressive pulmonary disorders, renal disease, chronic heart failure,
and progressive neurological conditions.

• 2. Hospice (HC)
• Hospice is got from the root word hospis
meaning host.
• It is defined as a coordinated programme of
interdisciplinary services provided by professional
caregivers and trained volunteers to patients with
serious, progressive illness that are not
responsive to cure.
• Dame Cicely Saunders (1918 – 2005), nurse,
physician, writer, is the founder of world
renowned St. Christopher’s Hospice in London.

Principles of Hospice Care
• Death must be accepted
• The patient’s total care is best managed by an interdisciplinary
team whose members communicate regularly with one another
• Pain and other symptoms of terminal illness must be managed
• The patient and family must be treated as a single unit
• Home care of the dying is necessary
• Bereavement care must be provided to the family members
• Research and education should be ongoing

Key Components of Hospice
• Respect for the worth and dignity of each person.
• Dedication and commitment to the highest quality of compassionate
care.
• Neither the hastening nor the postponing of death.
• Quality of life as distinct from the length of life.
• Treatment of the patient, rather than of the disease.
• Alleviation of pain, rather than curative treatment.
• Patient care training and counseling support for the patient,
caregiver, and family.
• Hands-on care by the Registered Nurse and Certified Nursing
Assistant.
• Assistance from the interdisciplinary team on a 24/7 basis.
• Bereavement support for families and loved ones after a loss.

Hospice Care in the United State
• The concept of hospice as an alternative to depersonalized death in
institutions began in the early 1970s.
• The first hospice was founded in 1974.
• Hospice is not a place but a concept that end of life is a
developmental stage.
• The goal of hospice is to enable the patient die peacefully at home
surrounded by family and objects that have been valuable to the
person throughout life.
• That the patient and family are fully aware the person is dying and
embrace the reality of death.
• It also help relatives to appreciate life and live each moment to the
fullest.
• Hospice care does not hasten or prolong death.

Hospice care Eligibility and Benefits
• Hospice services began receiving Medicare and
Medicaid benefits in 1983, ten year after its
introduction in the US.
• Beneficiaries were expected to meet certain criteria.
• On meeting the criteria and if the patient decides to
use the benefit, a hospice certified program takes
responsibility for providing and paying the health care
services of the terminally ill.
• Four Levels of care are covered:
– Routine home care, inpatient care, continuous care, and
general inpatient 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
• Hospice care is a type of palliative care for people who are in their final
weeks or months of life
• Hospice is based on knowledge, communication and the cooperation of
interdisciplinary teams needed for the patients rely on.
• The hospice team collectively focuses on the care of the patient with a
unique focus on his or her individual wishes.
• Hospice care includes physical, psychosocial, spiritual, and emotional care
for both the patient and their family.
• Hospice care provides support, choices, and dignity during very difficult
time for patients and family.
• Hospice care allows individuals and families to take control of what in
many cases is an inevitable situation.

The similarities
• Hospice care and palliative care are very similar when it
comes to the most important issue for dying people: care.
• Most people have heard of hospice care and have a general
idea of what services hospice provides. What they don’t
know or what may become confusing is that hospice
provides “palliative care,” and that palliative care is both a
method of administering “comfort” care and increasingly,
an administered system of palliative care offered most
prevalently by hospitals. As an adjunct or supplement to
some of the more “traditional” care options, both hospice
and palliative care protocols call for patients to receive a
combined approach where medications, day-to-day care,
equipment, bereavement counseling, and symptom
treatment are administered through a single program..

The differences
Hospice
• Timing
You must generally be considered to be terminal or
within six months of death to be eligible for most
hospice programs or to receive hospice benefits
from your insurance.
• Location-at home, special hospice facility
• Payment: Is covered by Medicare, provided doctor
confirm patient has 6 months left to live.
• Eligibility for service (see slide 39 )
• Treatment
• Most programs concentrate on comfort rather than
aggressive disease abatement. By electing to forego
extensive life-prolonging treatment, hospice
patients can concentrate on getting the most out of
the time they have left, without some of the
negative side-effects that life prolonging treatments
can have.
Palliative Care
• Timing
There are no time restrictions. Palliative care can be
received by patients at any time, at any stage of
illness whether it be terminal or not.
• Location- Hospital
• Payment: care treatments are sometimes covered
by Medicare or private insurance, if you have it
• Eligibility for service (see slide 33)
• Treatment
Since there are no time limits on when you can
receive palliative care, it acts to fill the gap for
patients who want and need comfort at any stage of
any disease, whether terminal or chronic. In a
palliative care program, there is no expectation that
life-prolonging therapies will be avoided.

NEEDS OF TERMINALLY ILL
PATIENTS

Care by Interdisciplinary Team
• People who are diagnosed with a serious or life-
threatening illness, such as cancer, experience
many changes in their lives. These include
physical, psychosocial and spiritual changes
which should be treated as a unit.
• But, many patients and their families are
deprived of adequate care when they are not
managed by a interdisciplinary team set up to
care for such patient.
• Nursing Care Plan should be used for all
dimensions of care until after death.

Physiological Needs
• According to Maslow hierarchy of needs, Physiologic
needs must be met before other needs. The other needs
are: Safety and Security Needs, Love and belonging
Needs, Self-Esteem Needs, Self-Actualization Needs.
• If these needs are unmet it could result in emotional
distress.
• The physical needs that need to be relieved are:
pain, loss of appetite, fatigue, weakness, constipation,
difficulty breathing, confusion, nausea, vomiting, cough
and dry or sore mouth

Psychosocial Issues
• According to El, Hassan (2019),
• Fear and anxiety: about the process of death and the future,
resulting in sleeplessness, restlessness, agitation, fatigue, upset
stomach, muscle tension or even shortness of breath.
• Depression: because they feel scared, sad and anxious.
• Being a burden to others including financial burden, also not being
able to fulfill parental role, so, some pray for quick death.
• Familial relationships: due to inability to fulfill family responsibilities
it could create family dynamics thereby strengthen the bonds
between family members as they focus their efforts on providing
the care for their loved one. Or it could result in disagreements and
conflicts with time.

Spiritual Needs
• Spirituality refers to the way individuals seek and express
meaning and purpose and how they connect with
themselves, others, and what they consider to be bigger
than themselves. It is important therefore it should be
addressed and assessed in terminally ill patients.
• Some patients have difficulty with coming to terms with
their illness especially if they perceive it as inflicted or an
unjust punishment. They will frequently ask “Why me?”
• Therefore, the dying persons may experience confusion,
anger, at their God, crisis of faith, or other types of spiritual
distress.

Hope
• Hope is a multidimensional construct that provides comfort as a
person endures life threats and personal challenges.
• Clinicians and researchers have observed that hope may change
over time.
• Hope could be influenced by level of spirituality, quality of life, and
divine existence.
• Attributes that can hinder or foster hope in terminally patients :
– Hope-fostering categories
• Love of family and friends, spirituality/faith, setting goals and maintaining
independence, positive relationships with clinicians, humour, personal
characteristics, and uplifting memories.
– Hope-hindering categories
• Abandonment and isolation, uncontrollable pain/discomfort, and devaluation
of personhood.

USE OF NURSING CARE PLAN TO
NURSE TERMINALLY ILL PATIENTS

Assessment
• Assessment – Aside from the general nursing
assessment, information gathered in assessing
a dying client are:
– Client and family goals and expectation
– Client awareness that illness is terminal
– Identification of support systems
– History of positive coping skills
– Client’s perception of unfinished business to be
completed.

Assessment 2
• Symptoms should be carefully and systematically
assessed, and Treated based on patients goal.
• Assessing symptoms:
– How is the symptom affecting the patient’s life
– What is the meaning of the symptom to patient and family
– How is the symptom affecting physical functioning and
relationship
– What makes the symptom better or worse
– Is it worse at a particular time of the day
– What are the patient’s and family expectation and goal for mx
the symptom
– how is the patient coping with the symptom
– What is the economic effect of the symptom and mx

Nursing Diagnosis –
• Among other diagnosis, those applicable to dying
patients are:
– Powerlessness
– Hopelessness
– Pain (acute or chronic)
– Death Anxiety , “apprehension, worry, or fear related
to death or dying”
– Compromised Family coping
– Activity intolerance
– Anticipatory grieving

Planning/Outcome Identification-
• Planning/Outcome Identification- the major goals of nursing for a dying
client are the emotional, physical, psychosocial and spiritual needs of
clients. Plan towards meeting client and family needs based on the
patient’s Bill of Rights and be sensitive to the Dying Person’s Bill of Rights
• During the planning to ensure client is in a stable psychological state:
– Schedule time to spend with patient
– Identify areas of special needs and make referrals
– Promote and protect individual self-esteem and self worth
– Balance clients need for assistance and independence
– Meet physiologic needs of patient and family
– Respect client’s confidentiality
– Provide factual information to client and family and answer all questions
– Offer to contact clergy or other spiritual leader
• .

Implementation/Evaluation
• Implementation-
– Communicate comfort
– Establish rapport
– Create therapeutic environment
– Meet clients, physiological, psychosocial, spiritual,
environmental and learning needs
– Evaluate care

CRITICAL NURSING SKILLS FOR END OF
LIFE

Communication Skill
• The nurse must be empathic, be patient with patient and family and be
honest.
• Due to the dilemma this act may present, every nurse should learn the art
of therapeutic communication in order to disclose unpleasant information
to patient in a culturally and religiously acceptable manner
• to teach patient and family how to cope with the illness
• To be proficient in communication, the nurse must set aside her/his
cultural/religious assumptions to avoid conflicts.
• Be abreast with the latest information on care of patient through social
and legal evolution of advanced directives.
• The nurse also be abreast with info on healthcare financing and how
patient with terminal illness can receive care at minimal cost.
• And also learn the agency policy to help patient make informed choice and
receive comfort care

Communication Skill 2
• When all treatment seem to fail, and their seem no hope of living, this is
now the critical point to discuss how treatment can continue.
• Should be done by the multidisciplinary team, this helps to show concern
and respect to patient and family.
• Ask patient if he/she would like family member(s) to be present.
• It is a solemn occasion, all present must not be distracted, turn off
phones, use quite place, not the open ward.
• Give factual information and give time for family to absorb the news
• Make room for family to ask questions,
• The nurse must be sensitive to ongoing needs and process
• The most important nursing skill is listening empathically
• Be non-judgmental

Communication Skill 3
Responding with Sensitivity to Difficult Questions
• If a patient ask a difficult questions like “Am I dying” this
question may come at odd time and at an unexpected at the
time. Create time at least 5 minutes of interrupted time and
conducive atmosphere with patient.
• First, seek source of concern and encourage patient to open
up further
• Allay anxiety
• Plan follow up
• If information needed by patient is beyond scope of the
nurse, she/he must communicate with other team members
and refer pt to them.

Provide hands-on care
• Is the primary skill of nurses
• Keep pt relax and pain free
• Administer medication
• Read and report vital signs
• Wound management
• Hygiene care
• Feeding

Effective management of pain
symptoms
• Asses and manage pain

Health education
• Teach patient and relatives to understand and
deal with illness condition

Meeting Spiritual Needs
• Therapeutic Nursing intervention to meet
client’s spiritual needs include:
• Using Touch; playing Music; praying with
client; communicating empathy; contacting
clergy if requested by client; reading religious
literature aloud if requested by client

SIGNS & SYMPTOMS OF THE
TERMINALLY ILL PATIENT

Signs and symptoms the terminally ill
is approaching end of life
• Majority patients approaching the end of life
experiences many of the same symptoms
regardless of diagnosis.
• The symptoms are caused directly and
indirectly by the dx process or comorbidities.
• 12 common symptoms:
1. Pain
2. Dyspneoa (Shortness of breath)

is approaching end of life 2
3. Anxiety
4. Decreased appetite and thirst
5. Nausea and vomiting
6. Constipation
7. Fatigue
8. Drifting away from loved ones
9. Delirium and restlessness
10. incontinence
11. Cold hands and feet and skin mottling
12. The death rattle

End of class on the 20th of Jan 2023
Start next slide

Signs and symptoms of the terminally
ill in the last weeks of life
• Sleep more for prolonged periods
• Dysphagia, cannot tolerate solid food,
• No interest in loved ones, withdrawn,
• Awareness that death is near, patients use metaphor of travelling –
talk about people coming to take them etc
• Chronic fatigue
• Increased susceptibility to infection
• Fragile, and easily damaged skin
• General pain
• Prolonged, unexplained weight loss
• Untreatable nausea
• Oedema and ascites

Signs and symptoms the of terminally
ill days before death
• Lungs begins to degrade and become congested,
leading to ‘rattle of death’.
• Fluctuating respiration between 50 and 6 b/m
• While exhaling lips will be puffed
• More cough, no chest pain
• Hallucination
• Low BP, fluctuating temperature
• Blotchy skin
• Erratic sleep
• Fewer bowel movement and less urine
• Decreased appetite and fluid intake

24 hours before death
• Sleep and less interaction when awake, but
hearing intact
• S&S seen in the last days are pronounced with
increased restlessness due to nil supply of
oxygen to the limbs
• Sudden burst of energy that slowly fades
• Fluid secretion from the mouth and nose

Signs and symptoms of the terminally
ill final hours before death
• All systems in the body will be shutting down
• They may not see and become unresponsive to
communications, but hearing may be intact.
• Eyes will become glassy, teary and half opened
• Cold hands
• Weak pulse
• Increased hallucinations
• Sleepy and unable to wake up
• Gasping and then stop breathing

Signs when patient pass on
• No more breathing
• Eyes and mouth open
• Cannot be aroused
• Orifices open

NURSING AND MEDICAL
MANAGEMENT OF COMMON
SYMPTOMS

PAIN
Introduction
• Pain is a common symptom for patients at the final stage of life for
dx such as cancer, AIDS, heart dx, COPD, and renal dx.
• Pain is a subjective experience best assessed by the patient.
• It is the patient that can provide information on level and effect of
intervention of pain.
• Assessment of pain is now recognised as the 5th vital sign
• Multidimensional Objective Pain Assessment Tool (MOPAT) is a tool
undergoing trial to determine its reliability, validity, and feasibility in
assessing pain, especially if patient cannot verbalize the
information.
• Read up literature on pain assessment and mx for dying patients.

Definition of pain
• Nurse McCaffery, 1968 define Pain as what the person
says it is and exists whenever he or she says it does.
• Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage
International Association for the Study of Pain (2012).
• Pain is an individual and Subjective experience
modulated by physiological, psychological and
environmental factors such as previous events, culture,
prognosis, coping strategies, fear and anxiety

Types of pain
• Pain can be either acute or chronic; whilst
acute pain is temporary with a foreseeable
end and serves as a warning of injury or
disease, chronic pain is persistent and reminds
people of their disease.
• Chronic pain is a common problem for many
people receiving palliative care

Pathophysiology of Pain
• Read up, pls.

Assessment of pain
• It enables the nurse provide accurate diagnosis and effective pain relief
• Questions such as :-
• When did it start?
• What does it feel like?
• What words would you use to describe the pain?
• Does it go anywhere else?
• How often does it occur
• Is it there all the time?
• What makes it better?
• What makes it worse?
• What medications have you tried?
• What effects did the medications have/
• How does the pain affect your life?
• What do you think is causing the pain
• Can you rate the pain?
• Where is the pain?

Pain assessment tools
• Pain assessment tools are used in addition to
the questions asked. Some of them are:-
• The numerical rating scale (NRS):

Pain assessment tools 2
• The verbal rating score (VRS):
• Patients are asked to rate their pain in
association with a list of words that describe
pain increasing in intensity:
• 0 no pain
• 1 mild pain
• 2 moderate pain
• 3 severe pain

WHO Analgesic Ladder
• Once the type of pain has been identified there are central
principles that need to be adhered to, regardless of the medications
used to treat the pain.
• The three main principles of the WHO analgesic ladder are: “By the
clock, by the mouth, by the ladder”.
• By the clock: To maintain freedom from pain, drugs should be given
“by the clock” or “around the clock” rather than only “on demand”
(i.e. PRN). This means they are given on a regularly scheduled basis.
• By the mouth: The oral route is usually the preferred route for ease
of use in a variety of care settings. However, it may not be possible
for all patients (e.g. end-of-life, unconscious, swallowing issues).
When the oral route is not feasible, the least invasive route should
be considered (e.g. sub-lingual or sub-cutaneous before intra-
venous.). The intra-muscular route should never be used.

WHO Analgesic Ladder 2
• By the ladder: If pain occurs there should be
prompt administration of drugs in the
following order:
–

WHO Analgesic Ladder 3
• Analgesics should be administered based on severity of pain
• If pain is severe treatment should begin at the top of the
ladder with a strong opioid.
• When pain is controlled, the patient should be maintained on
the dose that is effective.
• If the cause of pain is resolved, then step down the ladder.
• Along any step in the ladder, additional drugs – “adjuvants”-
may be used.
• Opioids significantly impact the brain by reducing its ability to
sense pain, while non-opioids tend to play a role in addressing
chemical reactions at the site of tissue injury.
• Note side-effects of the analgesics and report appropriately

Anti-inflammatory Painkillers
(NSAIDs)
• The most popular over-the-counter anti-inflammatory painkillers:
• Aspirin (Ectorin, Aspir, Bayer, Durlaza, and Lo-Dose). This non-opioid
pain medication may also prevent blood clots due to its blood-
thinning capabilities.
• Ibuprofen (Advil). The active ingredient of this over the counter
painkiller is propionic acid, which blocks certain natural substances
produced by the body that cause inflammation.
• Ketoprofen. It reduces the hormones in the body that cause
inflammation and pain.
• Naproxen. It blocks the production of certain natural substances in
the body that cause inflammation and has a longer effect than
other anti-inflammatory drugs.
*NSAIDs= Nonsteroidal Anti-inflamatory drugs.

Non-opioid Painkillers
• Non-opioid painkillers do not pose many risks associated with opioid pain
meds. They are available as both prescription drugs and over the counter
pain medications. A non-narcotic pain meds list includes next
medications:
• Acetaminophen (Tylenol). The active ingredient in this non-narcotic pain
medication is Paracetamol, which increases the pain threshold of the
body.
• Steroids. Are beneficial in relieving chronic ache among cancer patients.
• Medical Marijuana and CBD oil. These substances often help to reduce
inflammation and relieve chronic pain, however it is strongly regulated by
the law in the U.S.
• Natural painkillers for severe pain, moderate pain, and inflammation.
Essential oils, herbal tinctures, magnesium, and other natural alternatives
may effectively cope with different types of ache if they are correctly
selected by the appropriate medical specialist

Strong too weak strength Opioids
• Carfentanil is 10,000 time stronger than Morphine
• Fentanyl is 50-100 time stronger than morphine
• Oxymorphine is 40 time stronger than morphine is medium
strength opioid
• Heroin is 2 to 5 time Morphine is medium strength opioid
• Morphine is lower strength opioid and commonly used
opioid
• Tramadol is 10% as strength of Morphine, lower strength
opioid
• Codein is 7 to 14 times lower than morphine is lower
strength opioid

Adjuvants
• antidepressants (e.g. amitriptyline),
• Anticonvulsants (e.g. gabapentin, carbamazepine,
phenytoin, sodium valproate, gabepentin),
• corticosteroids (e. g. dexamethasone), and
• anxiolytics (e.g. diazepam).
• Antispasmodics (baclofen )

Palliative radio/chemo therapy
• Palliative radio/chemo therapy is administered
to shrink tumours, thus relieving pain arising
from tumour pressure .

Non-pharmacological approaches to
pain relief
• Non-pharmacological interventions can be divided into the following
therapies.
• biological therapies including dietary supplements such as glucosamine,
chondroitin (for joint pain) and vitamins.
• mind-body medicine may provide distraction from the pain or introduce
the patient to new ways of dealing with the pain but the impact on pain
varies. This group includes prayer, relaxation, guided imagery, meditation,
creative therapies, hypnosis and cognitive behavioural therapies.
• manipulative and body-based practice including physiothera py,
occupational therapy, osteopathy, chiropractic techniques, massage and
acupuncture. Help with movement, positioning and flexibility may help
alleviate some of the pain. It is important that all of these therapies are
provided by trained practitioners.
• energy medicine including therapeutic touch, reiki and healing touch.

DYSPNOEA
• Breathlessness, otherwise known as dyspnoea, is a common
and persistent symptom for many people living with advanced
chronic disease.
• Breathlessness increases as diseases progress and end of life
approaches and can be very frightening.
• Seen in the following cases:
Primary lung tumors, Airway obstruction,
Lung metastasis, Intra abdominal process,
Pleural effusion, Restrictive lung dx, Anemia,
Muscle weakness,
Advance heart disease, Psychological

Assessment of Breathlessness
• As with pain, dyspnoea is a subjective experience,
therefore patient’s perspective should be the basis of the
assessment rather than professional judgment. The
experience of breathlessness tends to vary between
patients with different diagnoses but like a comprehensive
pain assessment there are key questions that should be
asked.
• Assessment should include physical, psychosocial, and
spiritual components.
• Findings during physical assessment may assist in locating
source dyspnea, symptom intensity, how much it
interference with activities, level of distress. It will enable
nurse determine the nursing intervention that will relieve
pain.

Assessment of Breathlessness 2
• Questions to be asked during assessment of breathlessness.
• When did this episode start?*
• When do you feel breathless?
• How would you describe your breathlessness?
• Can you rate your breathlessness? (best and worst)
• Do you have any other symptoms (cough)
• What drugs have you tried?
• What effect did they have?

Assessment of Breathlessness 3
Other Physical Assessment Parameters
i. Auscultation of lung sound
ii. Assessment of fluid balance
iii. Measurement of dependent oedema (measure
circumference of lower extremities and abdominal girth)
iv. Temperature
v. Skin colour
vi. Sputum quantity and character
vii. Cough

Pharmacological Management
• Any treatable exacerbating condition should
be addressed as appropriate (depending on
the patient’s prognosis), for example anaemia
or chest infection. Patients should continue
with their prescribed drugs if still beneficial.
These may include bronchodilators, ACE
inhibitors, and diuretics.

Pharmacological Management 2
• Opioids: eg Morphine titrated to the level of breathlessness that
the patient is experiencing opioids will not shorten patients’ lives
and may in fact prolong their life because of relief of symptoms.
• Oxygen via nasal canula is useful for patients whose breathlessness
is related to hypoxia and patients with sats of less than 92% when
breathing room air. if there is no improvement after 3-4day then
oxygen therapy should be stopped.
• Anxiolytics such as diazepam or lorazepam may be given to help to
relieve the anxiety associated with feelings of breathlessness.
• Steroids are useful if breathlessness is related to major airway
obstruction such as superior vena cava.
• Bronchodilators are likely to have already been prescribed for
cardio-pulmonary patients but may be introduced to overcome
airflow obstruction in patients with other diseases such as cancer.

Nursing Management of Dyspnoea
Nursing mx at the end of life consist of :
i. Administer medical treatment for underlying
pathology
ii. Monitor patient’s response to treatment
iii. Help patient and family manage anxiety which
further increases anxiety
iv. Alter the perception of pain
v. Conserve patient’s energy
vi. Alter perception of breathlessness by:

Nursing Management of Dyspnoea 2
• Helping the patient to find a position that is more comfortable,
• Elevate patient’s head and shoulders to make breathing easier.
• Reduce room temperature, maintain humidity, ensure adequate room
ventilation
• Avoid irritants, e.g. smoke, aerosol
• Open window and allow to see outside
• Limit people in room, be sensitive to sense of isolation
• Try not to ask questions that require long answers; use closed
questions
• Breathing exercises (will need to involve a physiotherapist)
• Administer Oxygen via nasal cannula as mask may not be well
tolerated.
• Periodic suctioning is necessary.
• Fan to provide cool, blowing air across the face.
• Behavioural strategies including breathing exercises, guided imagery,
relaxation, music

Nursing Management of Dyspnoea 3
vii. Medication may be prescribed to help
• Bronchodilators and corticosteroids.
• Limit volume of IV fluids, consider diuretics if fluid overload/
pulmonary oedema present
• Administer blood products
viii. Reduce Anxiety
• Administer prescribed anxiolytic
• Aromatherapy may help
• Provide patient with means to call nurses
ix. Reduce Respiratory Demand
• Educate patient and family to converse energy
• Place needed equipment and nourishment within patients reach
• Bedside commode

Gastro Intestinal Symptoms
These are:
• Nausea and vomiting
• Malignant bowel obstruction
• Constipation
• Cachexia
• Hiccups
• Ascites
• Anorexia
• Incontinence

Nausea and Vomiting
• The incidence of nausea and or vomiting is
acknowledged as one/two of the most
frequent physical symptoms in palliative care.
• Nausea is an unpleasant sensation of the need
to vomit, often accompanied by autonomic
symptoms – pallor, sweat, salivation,
tachycardia.
• Vomiting The forceful expulsion of gastric
content through the mouth.

Questions To Ask During An
Assessment Of Nausea And Vomiting
• What are you managing to eat and drink?
• What effect did the sickness drugs have?
• What sickness drugs have you tried?
• What drugs are you taking?
• What makes you feel better?
• Is there anything that sets the feeling off?
• When did you last have your bowels open?
• When did you start feeling/ being sick?
• Do you feel sick all the time?
• Do you feel sick before you are sick?
• How do you feel after you have been sick?
• What does your sick look like?
• Do you get any headaches

Non-Pharmacological Management of
Nausea and Vomiting
• provision of calm, peaceful and fresh, airy environment if possible;
• explanation of examinations, diagnoses and treatments;
• emotional support and attention to patient’s fears and anxieties;
• relaxation therapies;
• complementary therapies;
• appropriate preparation and presentation of food – if patient is able
to eat food prepared away from patient to prevent smells
stimulating nausea or vomiting response - offer small meals as
often as patient wants- upright position during and after meal
• ginger is a good antiemetic- drinks, biscuits or crystallised; regular
mouth care to keep mouth clean and fresh;
• acupuncture/acupressure- sea bands.

Pharmacological Management of
Nausea and Vomiting
• There are many drugs or combination of drugs
available to help prevent and control vomiting.
These may also control nausea. the
• The drugs are sometimes called anti-emetics.
Some of these drugs target the vomiting center in
the brain, while others work as rescue therapy if
the initial nausea medicine doesn’t work. Based
on this knowledge, physicians try a few different
drugs to find the ones that work best for patient.

Pharmacological Management of
Nausea and Vomiting 2
• Serotonin (5-HT3) antagonists block the effects of serotonin, a substance that commonly triggers
nausea and vomiting, usually given before chemo and then for a few days afterward. (Examples:
ondansetron, granisetron, dolasetron, palonosetron)
• NK-1 receptor antagonists block the effects of the NK-1 receptor, a receptor that is a part of the
vomiting reflex, often given with other anti-nausea medicines. (Examples: aprepitant, rolapitant,
fosaprepitant)
• Steroids are often given with other anti-emetic drugs to better prevent nausea and vomiting, given
before or after treatment. (Example: dexamethasone)
• Dopamine antagonists target dopamine to help prevent this substance from binding to areas in the
brain that trigger nausea and vomiting, given when nausea and vomiting is not well controlled by
other drugs. (Examples: prochlorperazine, metoclopramide)
• Benzodiazepines can help reduce nausea and vomiting by reducing anxiety and helping the person
feel more calm and relaxed. These drugs may be more helpful with patients who experience
anticipatory nausea and vomiting and are often used in combination with other anti-nausea drugs.
(Examples: lorazepam (Ativan), alprazolam)
• Cannabinoids contain the active ingredient in marijuana used to treat nausea and vomiting from
chemo when the usual anti-emetic drugs don’t work. They also may be used to stimulate appetite.
(Examples: dronabinol, nabilone)
• Olanzapine is a drug that has been shown to be helpful in reducing nausea and vomiting, especially
in combination with other anti-nausea and vomiting drugs. It can make one sleepy,.
• Combination anti-nausea medicines is a combination of a serotonin (5-HT3) antagonist with a NK-1
receptor antagonist. This combination is meant to help with both acute and delayed nausea and
vomiting.

Nursing Management of Nausea and
Vomiting
• Provide an emesis basin within easy reach of the
patient
• Educate and assist patient about oral hygiene.
• Assist the patient in diagnostic testing preparation
• Eliminate strong odors from the surrounding (e.g.,
perfumes, dressings, emesis)
• Maintain fluid balance in patients at risk
• Maintain fluid balance in patients at risk
• Dry food like crackers or toast
• Position the patient upright while eating and for 1 to 2
hours post-meal

Constipation
• Constipation is a common problem in many patients
living with advanced disease.
• Constipation is the passage of small, hard faeces
infrequently and with difficulty’.
• The aim of nursing care and management is to re-
establish an acceptable, comfortable bowel habit and
restore the patient’s independence
• ,Causes include immobility, weakness, fatigue, poor
diet, and lack fluid intake, anorexia, environment –
lacking in privacy and dignity, drugs – morphine,
diuretics, antidepressants, iron concurrent disease – for
example, diverticulitis hypocalcaemia

Assessment
When assessing the patient gain information about patient
perceptions of the problem;
• environment including privacy,
• accessibility of facilities;
• previous bowel habits,
• degree of change,
• current situation;
• frequency and difficulty of defecation;
• volume and appearance of stool- blood or mucus;
• sensation of rectal fullness/satisfaction after defaecation;
• medications regime;
• aperients tried, and effect.

Assessment2
• Tools such as the Bristol stool chart or the
Norgine constipation assessment tool can be
used to guide assessment.
• In addition abdominal examination will done
• Abdominal X-ray,
• blood sample to check blood chemistry to rule
out conditions such as hypercalcaemia.
• A rectal examination is also indicated, and it is
advised to adhere to the RCN (2012) guidance for
this intervention

Non-Pharmacological Management
• 1. Fiber High fiber diet
• 2. Water, lots of water
• 3. Changes in your Diet
• 4. Exercise
• 5. Sleep
• 6. Squatty Potty
• 7. Coffee
• 8. Plums/prunes
– Prune juices are rich in
insoluble fiber and sorbitol
• 9. Magnesium
• 10. Massage/ yoga poses
• 11. Meditation
• .12. Herbs
– Rhubarb
Cascara sagrada
Flaxseed oil
Triphala (aryuvedic)
Aloe vera
Persimmon
• 13. Diabetic Candy
• 14. Biofeedback Therapy
and Pelvic Floor Therapy
• 15. Acupuncture

Pharmacological Management
• Oral laxatives should be used in preference to
rectal interventions.
• Best regime is a combination of low doses of
softener and stimulant.
• If the patient does require rectal interventions
the following may be prescribed:
• Suppositories: glycerine – softens and lubricates;
bisacodyl – stimulates.
• Enemas: arachis oil – softens; phosphate –
stimulates;sodium citrate – microlax – stimulates.

Drugs used to relieve constipation.
• Milpar - 1–3 days Lubricates and softens stool to ease
passage and stimulates peristalsis
• Senna, bisacodyl- Stimulates bowel to increase
peristalsis
• Docusate - 1–3 days Increases penetration of water
into stool- softer so easier to pass
• Lactulose - 1–2 days Osmotic Laxative which draws
fluid into bowel thus increasing stool bulk to stimulate
peristalsis Can cause wind and colic and may be
unpalatable to patients because very sweet
• Co-danthramer Combination of softener a
• nd stimulant.

Nursing Management of Constipation
• Monitor patient’s bowel habits and
• intervening where necessary.
• Advise patient to increase their fibre and fluid intake or to increase their
activity.
• Administer prescribed drugs to promote regular bowel action.
• Ensure that patients are able to access toilet facilitis when they need to. If
patients wish to have their bowels open but are unable to get to the
bathroom unaided it is vital that they are assisted, if possible, to get there
to ensure maintenance of privacy and dignity.
• For patients who wish to use a commode; the commode can more often
than not be wheeled out.
• Scrupulous perineal hygiene is vital to prevent excoriation of skin or
development of pressure ulcers.
• If a dying patient is very restless it is advisable to check that a full bowel is
not the reason for his or her distress, if it is, then suppositories or an
enema may provide relief.

Anorexia and Cachexia
• Anorexia and cachexia are common in seriously ill resulting asthenia
(loss of energy).
• ‘Cachexia is a multifactorial syndrome characterized by severe
body weight, fat and muscle loss and increased protein catabolism
due to underlying disease
• Anorexia or loss of appetite is common in people with advanced
disease, but it is different from cachexia.It can cause a lot of stress
for the carers who spend time trying to make food attractive to
encourage the patient to eat.
• The lean appearance of the patient and lack of interest in food is
normally disturbing to the family.
• Anorexia, nausea, and vomiting are commonly seen in a dying
person. They are unable to take any form of food, nor, swallow
even the sips of water poured in their mouth, even if they do, they
are unable to retain the food.

Anorexia and Cachexia 2
– Cachexia is also defined as severe muscle wasting and
weight loss associated with illness.
– Although anorexia worsen cachexia, but it is not the
primary cause.
– Cachexia is associated with changes in metabolism
that include hypertriglyceridemia, lipolysis, and
accelerated protein turnover, leading to depletion of
fat and protein store.
– In cachexia, measures to improve appetite or improve
food intake even by using tube feeding or parenteral
nutrition will not reverse cachexia in the terminally ill.

Causes of Anorexia and Cachexia
• Etiologies not well understood, but, the
underlying disease process leads to metabolic
alteration which in turn causes early loss of
appetite and consequently disturbances in
carbohydrate, protein, and fat metabolism;
endocrine dysfunction; and anemia

Assessment of patients with Anorexia
and Cachexia
• Search for and treat specific causes
contributing to secondary cachexia:
– 1. Nausea/vomiting 2. Anxiety 3. Pain 4.
Constipation/diarrhea „
– Aside from the natural cause of anorexia, other
variables such as the social factors like the sick
eating alone in the hospital, progression of the dx,
side effect of treatment, and psychosocial distress
are likely causes of anorexia.

Pharmacological Treatment Management of
Anorexia and Cachexia
Cachexia is difficult to treat, drugs such as megace,
corticosteroids, cannabinoids non-steroidal anti-
inflammatories and thalidomide have been used
with varying success.

Medical and Nursing Management of Anorexia
and Cachexia
• Initiate measures to ensure adequate dietary intake without
adding stress to the patient at mealtimes.
• Assess the impact of medications (e.g., chemotherapy,
antiretroviral) or other therapies (radiation therapy, dialysis)
that are being used to treat the underlying illness.
• Administer and monitor effects of prescribed treatment for
nausea, vomiting, and delayed gastric emptying.
• Encourage patient to eat when effects of medications have
subsided.
• Assess and modify environment to eliminate unpleasant
odors and other factors that cause nausea, vomiting, and
anorexia.

Medical and Nursing Management of
Remove items that may reduce appetite (soiled tissues,
bedpans, emesis basins, clutter).
Assess and manage anxiety and depression to the extent
possible.
Position to enhance gastric emptying.
Assess for constipation and/or intestinal obstruction.
Prevent and manage constipation on an ongoing basis, even
when the patient’s intake is minimal. Provide frequent mouth
care, particularly following nourishment.
Ensure that dentures fit properly.
Administer and monitor effects of topical and systemic
treatment for oropharyngeal pain

Medical and Nursing Management of Anorexia and
Cachexia 3
– Patient And Family Teaching Tips
• Reduce the focus on “balanced” meals; offer the same food as often as
the patient desires it. Increase the nutritional value of meals. For example,
add dry milk powder to milk, and use this fortified milk to prepare cream
soups, milkshakes, and gravies.
• Allow and encourage the patient to eat when hungry, regardless of usual
meal times.
• Eliminate or reduce noxious cooking odors, pet odors, or other odors that
may precipitate nausea, vomiting, or anorexia.
• Keep patient’s environment clean, uncluttered, and comfortable.
• Make mealtime a shared experience away from the “sick” room whenever
possible.
• Reduce stress at mealtimes.
• Avoid confrontations about the amount of food consumed.
• Reduce or eliminate routine weighing of the patient.

Medical and Nursing Management of
- Patient And Family Teaching Tips 2
• Encourage patient to eat in a sitting position; elevate the head of the
patient’s bed.
• Plan meals (food selection and portion size) that the patient desires.
• Provide small frequent meals if they are easier for patient to eat.
• Ensure that patient and family understand that prevention of constipation
is essential, even when the patient’s intake is minimal.
• Encourage adequate fluid intake, dietary fiber, and use of bowel program
to prevent constipation.
• Assist the patient to rinse after every meal. Avoid mouthwashes that
contain alcohol or glycerin, which dry mucous membranes.
• Weight loss may cause dentures to loosen and cause irritation. Remove
them to inspect the gums and to provide oral care.
• Patient’s comfort may be enhanced if pain medications given on an as-
needed basis for breakthrough pain are administered before mealtimes

Artificial Nutrition and Hydration of the terminally ill
As patient is approaching end of life their bodies nutritional needs
change, the desire for drinks and food decreases as the body cannot use,
eliminate or store fluid and nutrient properly.
Clinicians therefore order artificial nutrition and hydration as treatment to
delay death,
but studies have shown that provision of food and drinks does not
improve patients condition that is terminally ill.
• Rather in patients close to death, studies have demonstrated that
withdrawing or withholding of food and drinks reduces urine output
and incontinence; decreased gastric fluids and emesis; decreased
pulmonary secretion and respiratory distress, decreased oedema
and pressure discomfort.
• Encourage family to concentrate on showing love rather than
concern for patients food.

Tips to promote nutrition for the terminally ill patient:
• Offer small portions of favorite foods.
• Be aware that cool foods may be better tolerated than hot foods.
• Offer cheese, eggs, peanut butter, mild fish, chicken, or turkey.
Because meat (especially beef) may taste bitter and unpleasant.
• Add milkshakes, meal replacement drinks or other liquid
supplements.
• Place nutritious foods at the bedside (fruit juices, milkshakes in
insulated drink containers with straws).
• Schedule meals when family members can be present to provide
company and stimulation.
• Offer ice chips made from frozen fruit juices.
• Allow the patient to refuse foods and fluids.

Delirium
Delirium
• is defined as a
state of mental confusion that develops quickly and usually fluctuat
es in intensity. It is also referred to as concurrent disturbances in
level of consciousness, psychomotor behavior, memory, thinking,
attention, and sleep-wake cycle.
• In some patients agitated delirium occurs before death, which often
make relatives to be hopeful as they perceive it as a sign of
recovery.
• Though in many patients may remain alert, arousable, and able to
communicate; but others may sleep for long intervals and awaken
only intermittently, with eventual somnolence until death.

Signs and symptoms of Delirium
• Patient may become hypoactive or
hyperactive
• Restless
• Irritable
• Fearful
• Insomnia
• Hallucination

Causes of Delirium
– Related treatable underlying conditions such as
• Full bladder
• Impacted stool
• Pain
• Hypoxia or dyspnoea
• Medication side effect or interaction
– Others are
• Brain metastases in case of cancer
• Metabolic changes
• Infection
• Organ failure
• Unmet spiritual need
• Fears about dying

Non-Pharmacological management of
Delirium
. Non-Pharmacological is to treat the underlying
factors contributing to these symptoms

Pharmacologic management of
Delirium
– neuroleptics or benzodiazepines may decrease
distressing symptoms. Haloperidol (Haldol) may
reduce hallucinations and agitation.
– Benzodiazepines (eg, lorazepam [Ativan]) can
reduce anxiety but will not clear the sensorium
and may contribute to worsening cognitive
impairment if used alone.

Nursing Management of Delirium
• Nursing interventions is to care in the following areas
– identifying the underlying causes of delirium,
– acknowledging the family’s distress over its occurrence,
– reassuring them about what is normal,
– teaching the family how to interact with and ensure safety for
the patient with delirium,
– and monitoring the effects of medications used to treat severe
agitation, paranoia, or fear.
– Spiritual intervention consist of the following, music therapy,
gentle massage, and therapeutic touch. Reduce environmental
stimuli, by avoiding harsh lighting or very dim lighting (which
may produce disturbing shadows),
– Encourage close relatives to visit

Depression
Depression a state of unhappiness and hopelessness. It is the most common affective
mood disorder of old age and is a normal l reactions to the losses associated with
impending death.
• Dying patients most times have electronic gadgets and tubes attached to them.
They feel anxious, scared, sad, frightened, isolated., hopeless and helpless
• Though regarded as normal process of dying, it should be treated.
• Patients and their families must be given space and time to experience sadness
and to grieve, but patients should not have to endure untreated depression at the
end of their lives.
• An effective combined approach to clinical depression includes relief of physical
symptoms, Attention to emotional and spiritual distress, by educating the client,
relatives and friends about what they can expect and talking through any
questions or helping the person to find the answers to questions can help alleviate
some of the stress.
• Pharmacologic intervention entails administration of psychostimulants, selective
serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants.

Nursing Care of Patients Who Are
Close to Death
• Nursing a patient who is close to death can be a rewarding experience for
the nurse, but for the patient and family their could be fear of the
unknown.
• There is no way to predict exactly when a terminally ill will take the last
breath, because some patients may present with signs of imminent death
but could live for more days.
• Some dying patients wait for a close relative to arrive for a last goodbye,
while others do not want anyone to be present, so as soon as they are
alone they take the last breath. And yet others request for permission to
die, so the relative may say, ‘I permit you ‘, then they take their last breath.
• Nurses should teach relatives what to expect and do about under listed
issues:
– signs of approaching death/expected physiological changes.
– Death pronouncement
– Postmortem care
– Body removal

Nursing Care of Patients Who Are Close to Death:
Expected Physiological Changes
• The person will show less interest in eating and drinking. This is an
indication that patient is ready to die.
• What you can do: Offer, but do not force, fluids and medication. If there
is pain administer concentrated oral analgesic solutions placed under the
tongue or by rectal suppository.
• Urinary output may decrease in amount and frequency.
• • What you can do: No response is needed unless the patient
expresses a desire to urinate and cannot. Call the hospice nurse for
advice if you are not sure.
• As the body weakens, the patient will sleep more and begin to
detach from the environment. He or she may refuse your attempts
to provide comfort. This is normal with the dying patient.
• What you can do: Allow your loved one to sleep. You may wish to sit
with him or her, play soft music, or hold hands.

• Mental confusion may become apparent, as less oxygen is
available to supply the brain. The patient may report
strange dreams or visions.
• What you can do: As he or she awakens from sleep, remind him
or her of the day and time, where he or she is, and who is present.
This is best done in a casual, conversational way.
• Vision and hearing may become somewhat impaired and
speech may be difficult to understand. • What you can do:
Speak clearly but loud enough for patient to hear. Keep the
room as light as the patient wishes, even at night. Even
when patient is unconscious carry on all conversations as if
they can be heard, since hearing may be the last of the
senses to cease functioning.

• Secretions may collect in the back of the throat and rattle or gurgle as
the patient breathes through the mouth. He or she may try to cough, and
his or her mouth may become dry and encrusted with secretions.
• • What you can do: if the patient is trying to cough up secretions and is
experiencing choking or vomiting, call the hospice nurse for assistance. Lie
patient on his or her side supported at the back with pillows, and let the
secretions drain from the mouth. Cleansing the mouth with moistened
mouth swabs will help to relieve the dryness that occurs with mouth
breathing. Offer water in small amounts to keep the mouth moist. A straw
with one finger placed over the end can be used to transfer sips of water
to the patient’s mouth.
• The Nurse will continue care, suction gently not deeply because it could be
distressing and the secretions will continue filling up. Transdermal or
sublingual anticholinergic drugs may be administered to reduce secretion
and provide comfort to patient and family.

Nursing Care of Patients Who Are Close to
Death: Expected Physiological Changes
• Breathing may become irregular with periods of no breathing
(apnea). The patient may be working very hard to breathe and may
make a moaning sound with each breath. As the time of death
nears, the breathing remains irregular and may become more
shallow and mechanical. The moaning sound does not mean that
the patient is in pain or other distress; it is the sound of air passing
over very relaxed vocal cords.
• What you can do: Raising the head of the bed may help the patient
to breathe more easily.
• As the oxygen supply to the brain decreases, the patient may
become restless. It is not unusual to pull at the bed linens, to have
visual hallucinations, or even to try to get out of bed at this point.
• What you can do: Reassure the patient in a calm voice that you are
there. Prevent him/her from falling by trying to get out of bed. Play Soft
music or a back rub may be soothing

• The patient may feel hot one moment and cold the next as the body loses its
ability to control the temperature. As circulation slows, the arms and legs may
become cool and bluish. The underside of the body may darken. It may be difficult
to feel a pulse at the wrist.• What you can do: Provide and remove blankets as
needed. Avoid using electric blankets, which may cause burns because
• the patient cannot tell you if he or she is too warm. Sponge the patient’s head with
a cool cloth if this provides comfort.
• Loss of bladder and bowel control may occur around the time of death.
• • What you can do: Protect the mattress with waterproof padding and change the
padding as needed to keep the patient comfortable.
• As people approach death, many times they report seeing gardens, libraries, or
family or friends who have died. They may ask you to pack their bags and find
tickets or a passport. Sometimes they may become insistent and attempt to do
these chores themselves. They may try getting out of bed (even if they have been
confined to bed for a long time) so that they can “leave.”• What you can do:
Reassure the patient that it is all right; he or she can “go” without getting out of
bed. Stay close, share stories, and be present.

The Death Vigil
• Just as individuals are unique, so is each person’s death is unique.
• Some patients may withdraw, sleep for longer intervals, or become
somnolent, while others may be chatting with family or health service
providers and pass on. Whichever mood that is presented family members
should be encouraged to be with the patient, to speak and reassure him or
her of their presence, to stroke or touch him or her, or to lie alongside him
or her (even in the hospital or long-term care facility) if they are
comfortable with this degree of closeness and can do so without causing
discomfort to the patient.
• Experienced Hospice personnel have observed that despite all efforts
made by clinicians and family members for patient not to die alone, it is
not unusual for patients to die when the family has stepped away from the
bedside just briefly.
• When the patient dies while the family is away from the bedside, the
family may express feelings of guilt and profound grief and will need
emotional support, the nurse should reassure the patient.

Summary of Expected Physiological Changes
• Signs of Imminent Death
• When death is near, bodily functions will slow and certain signs and
symptoms will occur, including:
• Respiration becomes irregular, rapid and shallow breath or very
slow
• Decline in blood pressure
• Rapid, weak pulse, Usually the pulsations are seen even after the
patient has stopped breathing
• Dyspnea and periods of apnea
• Slower or no pupil response to light
• The skin may become pale, cool and sweats lot (cold sweats),
• Ears and nose are cold to touch.
• .

Summary of Expected Physiological Changes
• Signs of Imminent Death (contd)
• Cold extremities
• Bladder and bowel incontinence
• Pallor and mottling of skin
• Loss of hearing and vision
• Hiccoughs,
• Nausea, Vomiting, abdominal distensions are seen. the patient
feels the inability to swallow.
• DEATH RATTLE”-A rattling sound heard in throat caused by
secretions that the patient cannot cough longer.
• Reflexes and pain are gradually lost. Patient may be restless due to
lack of oxygen
• Sight gradually fail. The pupil’s fails to react to light. Eyes are sunken
and half closed

After Death Care
• Clinical Signs of Death
• Clinical death is the medical term for cessation of blood circulation and breathing,
the two necessary criteria to sustain life.
• It occurs when the heart stops beating in a regular rhythm, a condition called
cardiac arrest.
• At the onset of clinical death, consciousness is lost within several seconds.
• Measurable brain activity stops within 20 to 40 seconds.
• Absence of pulse, heart beat and respirations
• Pupil becoming fixed and not reacting to light
• Absence of all refluxes.
• The body becomes dusky or bluish and cold
• The blood darkens and pools in dependent areas of the body like the sacrum and
back if the patient is in the supine position.
• Urine and stool is evacuated
• Rigor mortis sets in one hour after death. There is stiffing of the body, the arms &
legs cannot be bent or straightened, unless the tendons are torn

After Death Care
Care of the Body:
Screen the bed to protect other patients from unpleasant sights and sounds which could frighten
them.
• The physician or an authorized nurse has to pronounce death and legally
documented the death in the medical record. Care of the body is usually
performed by the nurse in a tenderly manner.
• Place the head on one or two pillows, straighten the limbs to make the body look
natural and prevent discoloration or deformity.
• Close eyes and mouth, remove dentures and place in its container without water
and send them with the body to the mortuary.
• Based on facility policy IV may be switched off but the cannula may be left insitu,
other tubes , catheter and wound dressing may be left or changed if soiled. This is
to protect the body from post mortem discharge
• Family members should be allowed and encouraged to spend time with the
deceased. Some members may wail, some sob and others may be quiet.
• An autopsy consent may be requested & obtained if required.
• If the patient is to be an organ donor, arrangements will be made immediately.
• If the patient had any valuables, they are handed over to the relatives

After Death Care
Care of the Body 2:
Consult close relatives before preparing the body for removal from the ward
to the mortuary where the relatives will receive the body.
Get the following articles:
• Articles for bath
• Extra bandages and cotton swabs
• Perineal pads
• Sheets
• Restraints for jaw, hands and legs.
• Pair of gloves
• Thumb forceps
• Patients own set of clothes.
• Name Tags
• Procedure
• Wash hands and put on glove

After Death Care
• Care of the Body 3:
• If the relatives require, the nurse should help them to sponge the patient
as necessary brush and comb hair.
• Apply perineal pads and plug the rectum & vagina (in females) with cotton
balls.
• Provide clean cloths(own).
• Take care of valuables and personal belongings by handing over to
members of family.
• Allow members of family to see the patient & remain in the room &
remember that the body is still dear to someone.
• Close the body from side to side and head to foot with the sheet.
• Prepare the identification slip and attach it to the body’s toe and wrist,
and pack sheet.
• Attach a special label if the patient had a contagious disease.
• Transfer the body to the mortuary.
• Remove contaminated articles from room

After Death Care
Identification Tag Should Contain
• Patient name
• Age
• Registration number
• Relatives name
• Address
• Ward number
• Bed number
• Date and time of death
• Cause of death

After Death Care
Care of the Family
• Hand over Death Certificate to the family.
• Nurses needed to listen & provide small acts of kindness that will
make families feel cared for.
• Allow the family to spend time with the patient. Stay with family to
provide support (or) if they wish, leave them alone with patient
• Involve the family in doing after death care according to cultural
needs
• If possible, hand over the personal articles & valuable to the family
of deceased one.
• Help the family with info regarding transportation.
• Where practiced provide drinks, tissue and light snacks.
• Walk with family to the front door of the hospital . The gentle
action of the nurse at the time of death can gently assist the family

After Death Care
Record & Report as appropriate :
• Vital signs & time of absence of same
• Events leading to the death
• Time when the physician declared death
• Any marks, wounds, bruises on the body before death (or)
made during care of the body
• Removal (or) securing of drains & tubes
• Time of notification of family
• Removal of jewelry (or) securing of items left on & removal
(or) replacement of dentures
• Consent forms, release forms signed
• Time when body was taken to the morgue

Grief, Mourning, and Bereavement
• Grief is the series of intense physical and psychological responses related
to loss, it is also defined as the personal feelings that accompany an
anticipated or actual loss.
• Grief is manifested in thoughts, feelings, and behaviours associated with
overwhelming distress or sorrow
• The responses are necessary, normal, and adaptive responses to loss.
• It is essential and good for mental health.
• Mourning is the behavioural process through which grief is eventually
resolved or altered, it reflects the individual, family, group, and cultural
expressions of grief and associated behaviors.
• Bereavement is the subjective response of the living after losing a valued
one, it is the period of time during which mourning takes place.
• Both grief reactions and mourning behaviors change over time as the
individual learns to live with the loss.

• Types of Grief
• Uncomplicated or Normal Grief has fairly predictable
course, though the person may have the symptom of
grieving.
• Anticipatory grief is experienced before the loss
• Dysfunctional grief is called either complicated,
unhealthy, pathological, inhibited, unresolved grief is
grieving beyond the expected time the demonstration
of a persistent pattern of grief,
• Disenfranchised grief is when it is not socially
acceptable to mourn the loss of a significant other
whom society do not value. Eg a pet

• Anticipatory Grief and Mourning
• Denial, sadness, anger, fear, and anxiety are normal grief reactions in the individual
with life-threatening illness and those close to him or her. Kübler-Ross (1969)
described five stages of emotional reactions to dying that are applicable to the
experience of any loss . These are:
• Denial: “This cannot be true.” Feelings of isolation. May search for another health
care professional who will give a more favorable opinion. May seek unproven
therapies.
• Anger: “Why me?” Feelings of rage, resentment or envy directed at God, health
care professionals, family, others.
• Bargaining: “I just want to see my grandchild’s birth, then I’ll be ready. . . .” Patient
and/or family plead for more time to reach an important goal. Promises are
sometimes made with God.
• Depression: “I just don’t know how my kids are going to get along after I’m gone.”
Sadness, grief, mourning for impending losses.
• Acceptance: “I’ve lived a good life, and I have no regrets.” Patient and/or family are
neither angry nor depressed.

• Anticipatory Grief and Mourning (Contd)
• Individual and family coping may not take the pattern
opined by Kobler-Ross. Because grieving process is
complex and could affect family cohesion, therefore,
the nurse should determine how the family is coping,
by assessing the characteristics of the family system.
• The nurse can encourage the family members to
verbalize their feelings and when necessary invite a
professional Grief Counselor to help patient, family and
community so that patient may enjoy a peaceful death.

Coping with Death and Dying:
Professional Caregiver Issues
• Whether practicing in the trauma center, intensive care unit or other acute care
setting, home care, hospice, long-term care, or the many locations where patients
and their families receive ambulatory services, nurses are closely involved with
complex and emotionally laden issues surrounding loss of life.
• To avoid symptoms of stress or burnout, the nurse should acknowledge the
difficulty of coping with others’ pain on a daily basis and put healthy practices in
place that will guard against emotional exhaustion by relying on interdisciplinary
colleagues for support, use meeting time to express your feelings.
• In many settings, staff members attend memorial services to support families
• and other caregivers, who find comfort in joining each other to remember and
celebrate the lives of patients. Finally, healthy personal habits, including diet,
exercise, stress reduction activities (such as dance, yoga, t’ai chi, meditation), and
sleep, will help guard against the detrimental effects of stress.

Grief and Mourning After Death
• After death of a loved one, the family members enter a new phase of grief
and mourning as they begin to accept the loss, feel the pain of permanent
separation, and prepare to live a life without the deceased.
• Grief is most intense if the death is premature and sudden.
• Even if the loved one died of protracted illness, grief will still be expressed,
but in conflicting manner that the loved one’s suffering
• has ended, compounded by guilt and grief related to unresolved
• issues or the circumstances of death. Grief will also be expressed
especially if the patient’s death was painful, prolonged, accompanied by
unwanted interventions, or unattended.
• Other aspect of grief is the preparation for burial and all other traditional
rights, financial implications.
• The period of mourning varies, based on how individuals adaptive
response, how close the person was and the culture of the environment.

Complicated Grief and Mourning
• Complicated grief and mourning are characterized by
prolonged feelings of sadness and feelings of general
worthlessness or hopelessness that persist long after
the death, prolonged symptoms that interfere with
activities of daily living (anorexia, insomnia, fatigue,
panic), or self-destructive behaviors such as alcohol or
substance abuse and suicidal ideation or attempts.
• Complicated grief and mourning require professional
assessment and can be treated with pharmacologic
and psychological interventions.

Assignment
• Debate on whether Nigeria should legalize Assisted Suicide ?
• Controversy
Against
• A cry for help
• Suicide intent is not permanent controllable
• Depressed
• Financial obligation to families
• Pain is controllable using symptom mx and psychological support
• Legalizing physician-assisted suicide would legalize euthanasia
• Murder
• Sin
For:
• Not all pain situations are controllable
• There are safeguards
• Patient Self-Determination on time and circumstances of death
• Humane
General and specific religious /cultural beliefs, preferences, practices regarding end-of –life, preparation for death, and after-death rituals among the
following
• Ijaws
• Hausa
• Ibo
• Yoruba
• Moslems
• Christians
• Pagans
Develop nursing care plan for all the 12 common S&S of the dying patient

• El, Hassan (2019) Rabab Cancer Foundation –

NSc 313- END OF LIFE CARE NURSING 7.pptx

Recommandé

Recommandé

Contenu connexe

Similaire à NSc 313- END OF LIFE CARE NURSING 7.pptx

Similaire à NSc 313- END OF LIFE CARE NURSING 7.pptx (20)

Dernier

Dernier (20)

NSc 313- END OF LIFE CARE NURSING 7.pptx