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N450 - Final Hours (1
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N450 - Final Hours (1
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N450 - Final HoursDying is an Individualized Personal Experience - ANS-- There is no typical death - all different
experiences
- Patient preferences
- Nurses advocate for choices - setting of death and support
- Psychological and emotional considerations
- don't assume every older adult is prepared for his/her death
Positive Influences of Death - ANS-- Older adults may accept what life has to offer - may have
had numerous encounters w/death and develop coping mechanisms for how to deal w/death
- May perceive death as developmentally appropriate
- May get support from religion/spirituality
Negative Influences of Death - ANS-- person has experienced multiple losses in a short period
of time (emotionally exhausted)
- death of significant other can make one's own dying much more difficult
- the assumption that they should accept death is negative
Open & Honest Communication - ANS-- Convey caring, sensitivity, compassion
- Provide information in simple terms, uncomplicated terms
- Patient awareness of dying
- Maintain presence
- May have to repeat b/c pt is anxious state
- Maintain hope until the very end
Two Roads to Death - ANS-Normal and Difficult
- always explain to the families as to what could happen, but not too much detail
- these roads don't always go in direct sequence
- we can't predict the exact time of death b/c of disease processes, patient's will to live and their
completion of life goals
Normal Road to Death - ANS-Sleepy --> Lethargic --> Obtunded --> Semicomatose -->
Comatose --> Death
- as pt. gets close to death the body starts shutting down - when they sleep or slip into a coma
encourage the family to talk to them and touch them
Difficult Road to Death - ANS-Restless --> Confused --> Tremulous --> Hallucinations -->
Mumbling --> Myoclonic Jerks --> Seizures --> Semicomatose --> Comatose --> Death
- this road is very difficult for the family to watch
- uncontrolled pain and bleeding are also very difficult to watch
, Cultural Considerations when Death is Imminent - ANS-- Death rites - last rites or sacrament of
the sick
- Rituals - special clothing etc.
- should get these things in place ahead of time
- Know things in advance so we can let family do what they need to do
What About Artificial Nutrition & Hydration at End of Life? - ANS-- Perceptions of "starving to
death"
- Enteral feeding does not reduce risk of aspiration or mortality
- Hydration does not decrease "dry mouth"
- Patients who fasted to end their lives experienced peaceful death
- Natural process of dying is for body to shut down - pt will have no appetite or thirst - body's
way of shutting down
- Natural process decreases secretions, decreases number of stools, decreases risk of
aspiration - protects the skin - drying out
- Many families feel with holding fluids or foods is cruel - need to explain the benefits and risks
of artificial feeding & hydration
Symptoms - Last 48 Hours - ANS-- Death rattle - noisy respirations - collection of secretions in
the back of the throat - seems like pt is suffocating to the family but just an accumulation of
fluids in back of throat
- Increase in pain
- Agitation
- Urinary Incontinence
- Dyspnea - feeling of can't breath
- May have buildup waste, toxins, which will trigger nausea vomiting
- Myclonus - can go into full seizures
Comfort Care Kit - ANS-- morphine (buccal absorption), ativan (anxiety, restless, agitation),
haldol (extreme agitation), atropine (dries up secretions), compazine or phenegran for N/V,
ducolax or fleet enema for constipation, valium (seizures)
Physical Symptoms can Vary - ANS-- Confusion, disorientation, delirium vs. unconsciousness
- Weakness and fatigue vs. surge of energy
- Drowsiness, sleeping vs. restlessness/agitation
- variations can cause artificial reassurance that the pt is getting better
- Possible to see visions or see or speak to someone who has already died
Additional Physical Considerations - ANS-- Fever - give Tylenol rectally
- Bowel changes
- Incontinence - keep pt. clean and dry & decrease intake to decrease incontinence
- Decreased intake
- Pain - increased even if they pt. is unconscious and if they had pain meds before going
unconscious they should still be medicated - don't want them going into withdrawal
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