M/S End of Life

• Death


  Cessation of both breathing and the heartbeat
• Stages of the dying process

  1. Early stage

  2. Middle stage

  3. Late stage
• Early stage


  • Loss of mobility
  • Decrease in the ability or the desire to eat or drink
  • Cognitive changes- delirium or increased sleeping
• Middle stage


  • Continued decline in the client's mental status with periods of wakefulness
  • Noisy respirations due to pooling of mucus and saliva in the throat- "death rattle"
• Late stage


  • Fever with periods of apnea
  • Mottling of skin due to loss of peripheral circulation
• Clients go through stages at different rates from 24 hr to 14 days
• "Good deaths"


  Pain and distress free and occurring in the place of their choosing, surrounded by family and friends
• Each client and family will have varying needs and coping strategies as the stages of death are experienced; nurses must respect the client's dignity
• Manifestations of Impending Death

  • General Changes
  • Food and Fluids
  • Urinary Function
  • Skin Changes
  • Cardiac and Circulation Changes
  • Respiratory Changes
• General Changes


  • Profound weakness, fatigue, drowsiness, increase in sleeping, disorientation
  • Some clients may speak to individuals who have died previously or see things others cannot see
• Food and Fluids


  Decrease in ingestion of food and fluids, weight loss, dehydration, difficulty swallowing, choking or coughing when attempting to eat or drink
• Urinary Function


  Urinary output will decrease, urinary incontinence is possible, urine will often be dark and concentrated
• Skin Changes


  Mottling (a webbed pattern that is usually purple or dark pink on client's back and posterior arms and legs; in darker skin, mottling can appear brown), pressure injuries may develop
• Cardiac and Circulation Changes

  Decrease in cerebral perfusion (decreased level of consciousness, drowsiness, confusion, terminal delirium), decreased perfusion to other parts of the body, cyanosis (blueish discoloration of the skin or mucous membranes caused by lack of oxygen) and mottling in upper extremities indicate impending death; decrease in cardiac output and intravascular volume (hypotension, tachycardia, peripheral cooling of body)
• Respiratory Changes


  Secretions will pool in pharynx and upper respiratory tract, noisy respiration ("death rattle"), weak or absent cough reflex, changes in breathing patterns, dyspnea, Cheyne-Stokes respirations (type of breathing pattern with cyclical hyperventilation and apnea), respirations will be shallow and rapid progressing to periods of apnea
• Clinical death


  When the heart and lungs have ceased functioning, but brain is still viable
• Irreversible brain damage


  Starts after 4 min w/o oxygen & death as early as 4 to 6 min later
• Biological death


  Brain death
• Biological death


  • Lack of activity on an electroencephalogram or no blood flow to the brain
  • For provider to establish dx→ pt must have apnea, lack of brainstem reflexes, and be in a coma from a known cause
• Causes of biological death

  • Intracranial (subarachnoid hemorrhage or TBI)
  • Extracranial (CP arrest and inadequate CPR)
  • Head injuries from blunt trauma or gunshot wounds
  • Hanging
  • Drowing
  • Drug overdose
  • Stroke
  • Aneurysm
• Decrease in oxygenation of the brain


  • Leads to edema
  • Increase in fluid increases ICP→ leads to decrease in cerebral perfusion and subsequent herniation
• Lung and cardiac functioned maintained mechanically
• Patients but be declared brain dead to be eligible to be vital organ donors
• Palliative Care


  • Specially designed care for pt who have a serious diseases and their families
  • Receive medical care to improve quality of care
  • Controls manifestations but does not receive curative, or traditional treatments
  • Patients can also receive palliative care for symptom management while receiving curative medical care
  • Assists clients in understanding treatment choices
  • Provides support team to pts until death
• Hospice Care


  • Specializes in the care, quality of life and comfort of patients who have serious illnesses and heading towards end-of-life
  • Used when patients cannot be cured or chooses not to be treated
  • Provides comfort care for the clients and their family
  • Usually started when patient is anticipated to have fewer than 6 months to live but can be extended longer prn
  • Provided at home, facilities (hospital, hospice center, or nursing homes)
  • Interprofessional team
  • Provide medical, emotional, physical, spiritual, social
• Patients who would like to pass at home are cared for by family and friend with support of hospice
• Respite care


  Allows patients option to be admitted to a facility to give their caregivers a break in care lasting from hours to weeks
• Nurse works collaboratively with patient and family & other members of team to ensure pt wishes are integrated into the care and provides education
• Comfort Care


  • Any interventions to soothe and relieve suffering while respecting the client's final wishes
  • Managing shortness of breath, administering meds for pain, nausea, anxiety or constipation; limiting medical testing; and ensuring spiritual and emotional support
• Palliative Sedation


  • Used when distressing manifestations in patients that are terminally ill or actively dying
  • Indicated to provide relief from pain, agitation and anxiety to prevent unnecessary suffering
  • Not used to cause the death of the client or shorten their lifespan
  • Meds used to relieve the patient's respiratory distress, anxiety and agitation
  • Opiates, benzos, or antipsychotics
  • Dose and frequency increase risk of respiratory depression, aspiration, and increased agitation from delirium
• Patients, family and providers must be informed of the potential adverse effects of palliative sedation
• • If unable to communicate wishes, advanced directive should be followed
  • If none, consent from legal proxy should be obtained
• Cultural and Spiritual Needs of the Dying Client


  • Everyone has different view of illnesses and end of life based on culture
  • Important to complete cultural assessment to assist in planning end of life care→ improves quality of life when embracing pt culture
  • Use therapeutic communication during interactions
  • inability to find purpose and meaning in life affects their mental and physical health
  • Many facilities have chaplains or other religious personnel available from the prominent religious of the area to provide spiritual care
• Assessing spiritual needs


  • Use open ended questions to prompt the client to discuss specific needs and encourage to express feelings
  • Assess for manifestations of spiritual distress
  • Depression, feeling scared or worried, fear of loneliness
  • Fear of dying process and what follows post death are often voiced
• Important for nurse to approach patients using cultural humility and inclusive language and avoiding imposing personal values or religion→ can cause patient to feel misunderstood, judged or pressured
• Cultural humility


  Having self awareness and curiosity about others to assist healthcare personnel to build relationships and provide high quality care
• Assessments to determine spiritual needs of clients


  • HOPE
  • Hope:"What gives you a sense of hope, peace, comfort, or strength?"
  • Organized religion: "Do you have a religion you belong to? Is your religion important to you?"
  • Personal spirituality and practices: "What are your personal spiritual beliefs" What spiritual practices are most helpful for you?"
  • Effects of medical care and end-of-life issues: "Has your illness interfered with your ability to do things that give your life meaning and sense of purpose? What spiritual practices should we know about when we care for you"
• Many legal and ethical considerations that nurses will encounter during end-of-life care
• Goal of end-of-life care

  To decrease client suffering and respect the client's wishes
• Nurses are in a unique position to assist clients with advance directive planning to ensure these decisions are in line with the client's goals, beliefs, and wishes