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

7. Disqualified if pt. has a PFA or “no contact” order 8. 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

AutonomyBeneficenceNon-

MaleficenceJusticeVeracity

• 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 RIGHTTHERE 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 * If patient is AWAKE and COMPLAINING—OK to give pain medicine.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

DrowsinessDrowsiness

Difficulty Difficulty AwakeningAwakening

Unresponsive Unresponsive to stimulito 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 AgitationTerminal 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.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--easyThe usual road--easy– SleepySleepy– LethargicLethargic– Semi-comatoseSemi-comatose– DeathDeath

The DIFFICULT ROAD

RestlessRestless ConfusedConfused HallucinationsHallucinations DeliriumDelirium Myoclonic jerks, Myoclonic jerks,

seizuresseizures ComatoseComatose DeathDeath

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 May want to spend time with the body after the with the body after the deathdeath

A peaceful environment A peaceful environment may facilitate grieving, may facilitate grieving, so. . .so. . .

Staff should take time Staff should take time to position the body, to position the body, remove tubes, remove tubes, disconnect machinery, disconnect machinery, and clean up any messand 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 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?