Supplemental Ethics Points
DE Hierarchy of Decision-makers (If no POA-HC)
1. The spouse, unless a petition for divorce has been filed
2. An adult child
3. A parent
4. An adult sibling
5. An adult grandchild
6. An adult niece or nephew
Disqualified if pt. has a PFA or “no contact” order
If no one, Court of Chancery may appoint as guardian an adult who
exhibits special care +concern, + who is familiar w/ patient's values.
Do we need the Principle of the Double Effect to justify giving morphine at end-of-life?
– NO
– “Double Effect” is when there are 2 known, expected effects,
one good and one bad. (ex. Separating conjoined twins where
one will die)
– Morphine at end of life (at appropriate doses)
does not cause respiratory depression.
is not a meaningful factor in hastening death (many studies)
– So, we do not hasten death by treating pain or shortness of
breath with appropriate doses of opioids. (see handout)
Living Wills are inadequate
• Only 36% of Americans have a living will
• L.W’s often not available when needed
• Uncertainty about “qualifying conditions”
• DNR orders based on L.W.’s are not portable
TRADITIONAL ETHICS
Autonomy
Beneficence
Non-
Maleficence
Justice
Veracity
• Interdependence
• Preventing Harm
• Providing Care
• Communication
• Maintaining Relationships
ETHICS OF CARE
Feminist writers: Tong, Gilligan, Prendergast
“Autonomous Man”
vs.
“Communal
Woman”
CARE AT THE END OF LIFE:
One Chance
to Do It Right
Presented by: Sheila Grant, BSN, RN, CHPN
DISCLOSURES
• I am employed by Heartland Hospice, IV, and Homecare as a
Nurse-Liaison.
OBJECTIVES
1—Describe the concept “Convergence of Symptoms”.
2—Identify 7 common symptoms of the active phase of
dying.
3—Identify strategies for controlling each of those
symptoms.
4—Describe ‘terminal agitation”, its possible causes,
and options for treatment.
5—Explain the principles of communicating bad news.
Most People Die
After a prolonged illness
With gradual deterioration
With an active dying phase at the end of life
MOST CLINICIANS
Have little or
no formal
training in
managing
the dying
process.
Most Families
Have even
less
experience
or knowledge
of the dying
process.
FAMILIES WILL REMEMBER
A “good death”
OR a “difficult
death”.
A difficult death
may lead to
anger,
depression, or
complicated
grief
CARE PROVIDED DURING THE LAST DAYS
Affects not just
the patient, but
families and
everyone
involved in a
patient’s care.
THERE IS NO SECOND CHANCE TO GET IT RIGHT
of Symptoms
No matter what disease the person is dying
from, the symptoms begin to look the same
in the final stage.
The failure of one organ system affects all
the others. [“multi-system organ failure”]
In the final stage, you will treat the symptoms
(for comfort), NOT the disease (for cure).
Concerns in the last hours of life
Pain
Shortness of Breath
Secretions
Feeding and hydration
Changes in
Consciousness
Circulatory dysfunction
Delirium
PAIN
You may need to change the route and dose of
pain medicine, due to increased pain, inability
to swallow, or decreased metabolism.
LIQUID MORPHINE (Roxanol)
Often used in the last few days or when
patient is unable to swallow pills.
Partially absorbed by mucous membranes in
the mouth.
Begins to relieve pain/SOB in about 15-20
minutes.
PAIN MEDICINE IS BEST GIVEN ATC, not PRN
If allowed to
wear off, pain
becomes harder
to treat,
requiring higher
doses.
P.O Narcotics Peak in 1 hour
Half-life is 4 hours
Respiratory Depression + Opioids
Normal adult Resp. Rate = 12-20 [count for 60 sec.]
Respiratory depression ONLY occurs with the first few doses of an opioid and with new increases in dose. Tolerance to Resp. Dep. occurs quickly.
(stable dose w/RR>12—OK to give dose)
[Source: EPEC Pain Module]
Fact: Morphine Toxicity
Occurs in this sequence:
1. Drowsiness
2. Confusion
3. Loss of consciousness
ONLY after these will you see:
4. Respiratory drive significantly compromised
* If patient is AWAKE and COMPLAINING—OK to
give pain medicine.
GOAL is steady pain relief—don’t skip doses without a good reason.
When judging whether to hold dose, consider:
New or recently increased dose?
Is patient difficult to arouse?
Is Resp. rate < 12 ?
If yes, hold the dose. If no, give the dose.
HOSPICE NURSES
Are expert in
managing opioids for
pain relief
Have access to
Hospice Medical
Director
Can be a resource
*FENTANYL PATCH— NOT recommended at end-of-life
Pt’s. may not have enough SQ
fat stores to absorb the drug.
Poor absorption due to changes
in circulation and metabolism.
Rapid titration often necessary
as pain levels and LOC change
at the end of life. Patch takes
about 18 hours to reach peak
levels.
DYSPNEA—SOB
Increased respiratory
rate
Then, decreased rate
Apnea
Cheyne-Stokes
breathing
Agonal breaths
CHEYNE-STOKES BREATHING
If Patient Is Actively Dying w/ SOB
Avoid using an O2 mask (comfort)
Nasal Canula O2 may help
Fan may help, blowing air toward pt’s. face
Morphine is drug of choice for “air hunger”
Lorazepam, if anxiety is present
SECRETIONS
Due to oral and
tracheal secretions
Gurgling (“death rattle”)
No sign that this
bothers the patient
DEFINITELY bothers
those listening
Suctioning is NOT
recommended
TO DRY UP EXCESS SECRETIONS, GIVE:
• Hyoscyamine
(Levsin) or Atropine drops
• Transdermal Scopolomine
(Scop patch)
• Also, try repositioning the
patient
*All 3 equally effective in a recent comparative study, but Scopolamine takes 24 hrs. to reach steady state.
Decreased P.O. Intake
Decreased appetite,
weight loss, wasting,
weakness
Decreased fluid intake,
dehydration,
hypotension, dry mouth
Decreased P.O. intake is normal at end-of life.
Doesn’t bother patients.
They DO complain of dry mouth. Treat with frequent mouth care.
Educate families regarding decreased P.O. intake—Normal at end-of-life.
CHANGES IN CONSCIOUSNESS
Drowsiness
Difficulty
Awakening
Unresponsive
to stimuli
CIRCULATORY DYSFUNCTION
Cardiac
– Tachycardia
– Hyper/Hypotension
– Peripheral cooling and cyanosis/mottling
Renal
– Dark Urine (tea-colored)
– Oliguria (<400 ml./day)/ Anuria
EDUCATE FAMILY—Normal / No treatment needed
DELIRIUM—treat w/benzos, haldol, etc.
Symptoms:
– Confusion,
day/night reversal
– Agitation
– Purposeless,
restless
movements
– Moaning
– Acute onset
Terminal Agitation
Checklist
Medication review (polypharm.,
toxicity, side effects?)
Hx/ of substance abuse?
Retention or urine/stool?
Signs of fever or sepsis ?
Dyspnea ?
Assess pain/suffering
Non-Physical Causes of T.A.
Fear/Anxiety……
Environment……
Severe mental
anguish………….
IDT can offer support, treat
cautiously w/anxiolytics, consider
music tx., therapeutic touch
Reduce stimuli, involve familiar
faces @ bedside, consider
aromatx.
If recovery is impossible and
death is near, consider terminal
sedation
TWO ROADS TO DEATH
The usual road--easy
– Sleepy
– Lethargic
– Semi-comatose
– Death
The DIFFICULT ROAD
Restless
Confused
Hallucinations
Delirium
Myoclonic jerks,
seizures
Comatose
Death
PROGNOSIS AT END-OF-LIFE
Very difficult to be precise
Better to give a general estimate (“days to weeks”)
Always remind patients & families of the unpredictability of the dying process.
Unconscious Patients Near Death
May still hear, even if
they can’t respond.
Advise caregivers and
family members to
talk to the patient as if
he/she were
conscious.
WHEN DEATH OCCURS
Heart stops beating
Breathing stops
Pupils become fixed and dilated
Skin color becomes pale and waxen
Body temperature cools
Urine and stool may be released
Eyes may remain open
Jaw may fall open
Observers may hear trickling of internal fluids, even after death.
FAMILY MEMBERS OR CAREGIVERS
May want to spend time with the body after the death
A peaceful environment may facilitate grieving, so. . .
Staff should take time to position the body, remove tubes, disconnect machinery, and clean up any mess
LOVED ONES
May benefit from a recounting of events leading up to the death.
Staff may be able to help families understand and “frame” the events.
Families may need time alone with the body, or to observe customs & traditions.
Communicating the Bad News
1—Get the setting right
2—Provide a “warning
shot”
3—Tell the news
4—Respond to emotions
with empathy
5—Conclude with a plan
Remember . . .
We have only ONE CHANCE to get it right.
Your Expertise Can Provide a Smooth Passage for the Patient and Family
HOSPICE can HELP by offering
Expert symptom control
Education and support for your staff
Psycho-social support for pt. and family
Spiritual care
Volunteer services
Bereavement care for 13 months or longer
Coverage for medications and equipment
QUESTIONS/STORIES?