End of Life Discussion Summary

End of Life Care – Discussion Summary GOC: C1 or C2 *Goal is to keep the patient as comfortable as possible *No VS, thorough head to toe assessments, labs or diagnostic investigations *Medications for comfort purposes only Comfort Care * Goal: keep the patient as comfortable as possible • Airway – monitor minimum q1h • Keep mouth and upper airway clear of secretions - wipe mouth, suction PRN • Breathing – monitor minimum q1h • “Air hunger” • Accessory muscle usage/increased WOB • Can apply O2 for comfort • Monitor minimum q1h • Body temperature – monitor minimum q1h o Cold cloths if hot o Warm blankets (especially to peripheries) • Hygiene – minimum q1h-2q2h • Wipe their face and eyes • Wipe away any sweat • Check incontinence brief, ensure they are clean and dry • Positioning – minimum q2h • Position in manner which patient is/appears comfortable, especially for WOB • Position in manner that family can visit comfortably • Pain – assess and intervene minimum q1h • Ask patient (if able to), pay attention to nonverbal cues (facial expression, WOB) • Administer analgesic as ordered • Non pharmacological interventions • If applicable, insert or advocate for the patient to have a Cleo or SC butterfly in place to administer frequent SC medication, so that they don’t have to be poked every time • Hydration o PO if able o IV fluid maintenance or hydration therapy via clysis • Eating o PO if able o “Eat at risk” Order – order from physician that allows patient to eat or drink what they choose even if they are normally ordered a modified texture diet due to dysphagia Common Medications Ordered for Comfort • Opioids ATC SC + PRNs (e.g. Dilaudid 0.25-1mg SC Q1H, sometimes IV) *most commonly ordered o Ensures regular and consistent pain control o Can also help ease WOB when it is laboured (as narcotics decrease respiratory drive) o Advocate for patient to have a Cleo or SC butterfly in place to administer the medication so that they don’t have to be poked every time • Anxiolytics, benzodiazepines 1 J. Valenzuela, RN U of A Faculty of Nursing • Glycopyrollate o Helps diminish or reduce excess saliva/secretions in the mouth and upper airway o Helpful for those who are unable to cough or clear their own secretions independently Family Involvement • Allow family to be as involved and present as possible (pay attention to visitor rules re: pandemic/site or unit specific rules) • May leave the side rails down for family to visit, as long as it is safe (keep the bed lowered) • Explain what you are doing to both the patient and the family every time you are in the room • Offer Spiritual Care services, Aboriginal Cultural Helper services • Take into consideration any requests/customs from the family and/or patient • Family is permitted to spend as much time as they would like Final Moments • Breathing – agonal patterns, apneic periods • Mottling of the skin • Cooler/cold peripheries compared to skin temperature centrally • Urine output – dark, concentrated; minimal to none Pronunciation of Death • Once you have observed that the patient has passed away, contact the physician to pronounce death • The physician will come to assess the patient (it is valuable to observe this if you have never seen it before) - they will auscultation for heart sounds, breath sounds, perform corneal reflexes, palpate for pulse, etc. • Time of death is when the physician pronounces death – not when it has been observed by nursing staff Post Mortem Care • Perform after the family is finished visiting • Wash patient; be aware of potential secretions/drainage (e.g. Mouth, peri area) due to all muscles relaxing) • Lines, drains, dressings – leave as-is if patient is a Medical Examiner’s case, remove if not • Insert dentures (try to do this ASAP – even if family is still visiting) • Take into consideration any requests or practices from family due to religious or cultural background related to post mortem care • Patient will be placed in a post-mortuary bag and labelled as per policy • UAH site: Contact Protective Services to transfer patient to the morgue, they or a porter will come to the unit with a covered stretcher to transport the patient (each site has a different protocol) Code Blue Event – Family Presence • Studies have shown that it is beneficial for family members to remain present during a code blue event – while the events are traumatic, it can help family members gain closure in their grieving process later on, as they see “everything being done” for their loved one. It also helps family members understand the invasiveness and aggressiveness involved in a full resuscitation • A staff member should take on the role to remain with family members 2 J. Valenzuela, RN U of A Faculty of Nursing • • • Ensure the family members are out of the way and not interrupting or disrupting the resuscitation process, but are in a place where they can see what is going on Explain to the family member events as they unfold Remove family members from situation to a comfortable place if it is not appropriate for them to be witnessing the events; stay with the family members and answer their questions, provide comfort MAID vs. De-escalation of care vs. Withdrawal of care • MAID o Healthcare option that allows an adult (must be capable), who is suffering from a terminal medical condition, to voluntarily request medication that will bring about their death o This allows patients with terminal prognoses the autonomy to decide how to deal with or “take on” their inevitable outcome. It can prevent any further suffering that the patient is expecting due to their terminal medical condition o Patients go through an evaluation of their capacity, and Ethics is involved • De-escalation of care o Decreasing Goals of Care (not always necessary for end of life purposes, but also occurs to align with patient and/or family wishes, align treatment plan and goals with patient prognosis) o Reducing treatments and therapies • Withdrawal of care o Removal of life-sustaining treatments and therapies (e.g. in ICU, removing a patient from the ventilator) 3 J. Valenzuela, RN U of A Faculty of Nursing