End of Life Presentation

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End of Life Care
Rachel S. Hommersen
Mohawk College
Practical Nursing

Palliative Care

Transition from Acute to
Palliative Care
• Acute Care: “Short-term medical treatment,
usually in a hospital, for patients having an
acute illness or injury or recovering from
surgery” (Farlex, 2011).
• Palliative Care: Relieves suffering and
improves the quality of living and dying
when there are no longer “curative”
treatments/measures for illness or injury
(Potter & Perry, 2006).

Dying Person’s Bill of Rights
(Potter 2010) Adapted from Barbus, A. J. (1975)
The client has a right to:
 have a sense of purpose.
 be cared for by those who can maintain a sense
of hopefulness.
 participate in decisions about my care.
 expect continuing medical and nursing
attention even though “cure” goals must be
changes to “comfort” goals.

 die in peace and dignity.
 retain my individuality and not be judged for
my decisions that may be contrary to beliefs
of others.
 be cared for by caring, sensitive,
knowledgeable people who will try to
understand my needs and will be able to gain
some satisfaction in helping me face my
death.
Dying Person’s Bill of Rights
(Potter 2010) Adapted from Barbus, A. J. (1975)
(continued)

Principles of Palliative Care
Strives to help clients and families address
physical, psychological, social, spiritual
and practical issues, and their associated
expectations, needs, hopes and fears (CNO,
2009)
Prepares the client and others for managing
self-determined life closure and the dying
process. (P&P, 2006)

Principles of Palliative Care
Aims to relieve client suffering and
improve the quality of living and dying.
(Potter & Perry, 2006)
Strives to help clients and families address
physical, psychological, social, spiritual
and practical issues, and their associated
expectations, needs, hopes and fears (CNO,
2009)
Is appropriate for any client and/or family
living with, or at risk of developing, a life-
threatening illness due to any diagnosis,
with any prognosis, and whenever they
have unmet expectations and/or needs and
are prepared to accept care, regardless of
age (CNO, 2009)

Cultural Considerations
“Understanding the cultural background
of patients is fundamental to the
development of a trusting and supportive
relationship between patient, family and
health care professionals, and is essential
in developing a plan for health care that is
consistent with their cultural expectations
and health beliefs”
(Matzo & Sherman, 2010).

We as nurses need to:
Recognize the client’s culture, the nurse’s
culture and how both affect the nurse-client
relationship. (CNO, 2009)
 Realize cultural background and family
practices influence people’s interpretation of a
loss; expression of grief; attitudes toward life-
sustaining treatments. (Potter & Perry, 2010)
“There is no single right approach to all
cultures or all individuals with a similar
cultural background” (CNO, 2009).

(continued)
“The focus of care is always the client’s needs”
(CNO, 2009).
“Each client and each situation is unique and
requires individual assessment and planning”
(CNO, 2009).
The importance of these cultural elements is
emphasized in the College of Nurses of
Ontario’s (the College’s) practice standard
Therapeutic Nurse-Client Relationship,
Revised 2006” (CNO, 2009).

“A Guide to Nurses for Providing
Culturally Sensitive Care
To care for someone, I must know who I am.
To care for someone, I must know who the
other is.
To care for someone, I must be able to bridge
the gap between myself and the other.”
- Jean Watson
(CNO, Culturally Sensitive Care, 2009)

Therapeutic Care
Nurses Responsibilities:
 Create a bond and gain trust
 Show sensitivity to the cultural beliefs
and customs of the client
 Broaden our concept of social support
 Learn/understand/implement the
client/family’s wishes for end of life care
 Using communication and
implementation as our core theme in
assisting with client’s end of life care
 Develop plan of care by integrating
resources

Therapeutic Communication
Nurse Must:
 have an understanding of processes and
stages of grieving
 be physically and mentally present, listen
attentively and ask open-ended questions
 acknowledge the client’s feelings by using
touch and listening throughout the discussion
 show desire to start a therapeutic relationship
 convey a willingness to be available if client
initially chooses not to be open
 inform the client and family members that
anger towards individuals are normal
 learn to recognize the needs of patient

Providing Comfort for the
Terminally Ill Client

Symptom Control
Comfort for a dying patient requires management of
symptoms of disease and therapies. Through
assessment, specific nursing interventions can be
developed to address and treat each area of concern

Maintain Dignity and Self Esteem
When a patient is diagnosed with a terminally ill
condition, their dignity and self-esteem decrease. A
patient's personal dignity is individualized to them and
consists of their positive sense of self regard, extent to
which they feel valued, the treatment received by the
caregivers and links with their personal goals and social
contexts (Potter & Perry, 2010).

Prevent Abandonment and
Isolation
Many terminally ill clients are fearful of dying alone. It is
very important that you establish a presence with the
client, inquire about the client’s concerns, be available
to answer questions, even if data is not needed, no
further decisions are left to make, or no further curative
interventions are available (Potter & Perry, 2009 &
2010).

Provide Comfortable and Peaceful
Environment
Providing a comfortable and peaceful environment is
part of holistic healing. A comfortable, pleasant
environment helps clients to relax, which promotes
their ability to sleep and minimizes severity of
symptoms (Potter & Perry, 2010).

Address Fears of Dying and Death
People are afraid of dying and death for many different
reasons: the process of dying, with its associated
pain and loss of dignity; not knowing what will
happen after death; and dying before fulfilling
dreams and goals (Potter & Perry, 2010).

How to get Family Involved in Care
The family can:
 Be the primary caregiver for the client if
preferred (Matzo & Sherman, 2010)
 Discuss activities other family members are
involved in; reminisce about enjoyable
times
 Inquire about client’s concerns (Potter &
Perry, 2010)
 During final moments family can visit
frequently (Potter & Perry, 2010)
 Allow home-cooked meals, which may be
preferred by client and gives the family a
chance to participate in care (Potter & Perry,
2010)

How to get Family Involved in Care
(continued)
The family can:
 Find simple and appropriate care activities
for family to perform, such as feeding
client, washing client’s face, combing hair,
and filling out client’s menu (Potter &
Perry, 2010)
 Bring in pictures, cherished objects, cards or
letters from family members and friends,
plants and flowers (Potter & Perry, 2010)
 Offer client frequent back, lower leg, and
foot massages, or other forms of therapeutic
or complimentary care (Potter & Perry,
2010)

Nurse Teaching Strategies for
Family Involvement
 Describe/demonstrate feeding techniques,
bathing, mouth care, hygiene
 Enforce clients rest periods; create a visiting
schedule
 Discuss ways to support the dying person by
listening to the needs and fears of the client
 Demonstrate therapeutic touch
 Teach signs/symptoms of worsening
conditions

Physical Changes Nearing Death and
Associated Definitions

Definitions
 mottling - near death, circulation decreases
causing hands and feet to become blotchy
and purplish; mottling may slowly work its
way up the arms and legs, lips, nail beds,
and torso giving body a bluish or purplish
colour appearance (Lewis, et al, 2010)

Definitions
 rigor mortis - the stiffening of the body
prior to death (Barber, 1998); as end of life
approaches and undergoes metabolic
changes, process of rigor mortis includes
paralysis of jaw, loss of facial tone, reduction
of gastrointestinal motility and peristalsis,
cessation of bowel movement and decrease
of urinary function (Lewis, et al, 2010)

Definitions
 shroud - sheet like garment for wrapping a
corpse for burial; covers, conceals,
supports, and disguises the body for burial
(Potter, 2010)

Definitions
 Cheyne-Stokes - abnormal pattern of breathing
characterized by alternating periods of suspended
breathing and deep, rapid breathing or no breathing
at all; indicator that death is near (Lewis et al.,
2010)

Physical Changes
Sleep
Different Pace
Circulation
Bowel function/Bladder function
Eyes
Hearing and Touch

Breathing Changes
Rate will slow drastically with breaths
becoming farther apart
As death does approaches, breathing may
become laboured with the person gasping for
air
A death rattle may be present and sounds
like a low throat
Breaths will slow and come further and
further apart until the final breath is taken
(Roome, 2009)

Care of Body After Death
Nurses provide post-mortem care when a client dies.
Dignity and sensitivity to the recently deceased
individual should be maintained, and all post-mortem
care must be consistent with the client’s religious or
cultural background. It is important that care is
provided as soon as possible to prevent tissue damage
or disfigurement of body parts (Potter & Perry, 2010).

Procedural Guidelines
Care of the Body After Death (Potter & Perry, 2010)
Equipment:
Bath towels, washcloths, wash basin,
scissors, shroud kit with name tags, bed
linen, room deodorizer, documentation
forms.
Nurses:
Work with sensitivity to preserve client’s and
family’s dignity.
Check orders for any specimens or special
orders needed by physician.

Make arrangements for staff, spiritual
advisor, or others to stay with the family
while the body is prepared for viewing; find
out if the survivors have any special requests
for viewing (shaving, special gown, Bible in
hand, rosary at bedside, etc.)
Remove all equipment: tubes, supplies, and
dirty linens (according to agency protocol).
Exceptions: organ donation, coroner
involvement required (leave tubing and lines
in, cut near body and clamp).
Cleanse the body thoroughly, apply clean
sheets, remove trash from room.
Brush and comb client’s hair; apply personal
hairpiece (when present)
(continued)

Position according to protocol: eyes closed
by gently holding the eyelids closed for
several minutes; dentures should be in
client’s mouth to maintain facial alignment.
Cover body with a clean sheet up to the chin
with arms outside covers if possible.
Lower the lighting, spray deodorizer if
possible to remove unpleasant odours.
Give the family the option to view or not to
view the dead body, clarify that either option
is acceptable.
Go with the family to view the body if they
choose to do so.
(continued)

 Encourage family to say goodbye through
both touch and talk.
 Do not rush the goodbye process; once the
family is more comfortable, ask if they wish
to be left alone; remind them that they can
call you if needed.
 Clarify which personal belongings are to
stay with the body and who will take
personal items; documentation requires
descriptor of objects, name of each person
who received them with the date and time.
 Do not discard items found after the family
is gone; call family and tell them what was
found (with description); ask who might
pick it up.
(continued)

 Apply name tags according to protocol (wrist,
toe, outside shroud).
 Complete documentation in nursing notes;
documents vary depending on agency.
 Remain sensitive to other hospitalized clients
or visitors when transporting the body; cover
the body with a clean sheet, temporarily close
the door to client’s room, watch to avoid
visitors when moving the body to another part
of the hospital or to the exit for the funeral
home.
 Follow all protocol and policies to meet all
legal requirements in caring for the body.
(continued)

The following must be documented at the
end of a client’s life (Potter & Perry, 2010):
Time of death and actions taken to prevent,
or cardiac arrest record if applicable.
The name of the person that pronounced the
client’s death.
Make special preparation and type of
donation, including time, staff, and company.
The name of the family member or friend
who was called and who came to the
hospital: donor organization, morgue, funeral
home, chaplain, and individual family
members making any decisions.
Appropriate Documentation

Appropriate Documentation
 Personal articles left on the body and taped to
skin, or tubes left in.
 Personal items given to the family: specific
names and descriptors of items.
 Time of discharge and destination of the body
 Location of name tags on the body
 Special requests made by the family
 Any other statements that might be needed to
clarify the situation

Types of Grief and Grieving

Types of Grief
Normal Grief - consists of normal
behaviours, reactions to loss, and symptoms
Anticipatory Grief - process of “letting go”
before an actual death has occurred
Complicated Grief - an individual has
trouble progressing through the normal
(generally accepted) phases or stages of
grieving
Disenfranchised Grief - People experience
grief when a loss is experienced and cannot
always be openly acknowledged, socially
sanctioned, or publicly shared

Kübler-Ross 5 Stages of Grieving
1969 Theory
Denial Individual behaves as though they have not
experienced a loss
Anger Individual will try to cope by pushing away
the loss
Bargaining Individual will believe that there is a way to
prevent this loss
Depression Individual will finally feel the full force of
the loss
Acceptance Individual accepts the loss and starts to
think about the future

Bowlby 4 Phases of Mourning
1980 Theory
Numbing feeling “stunned” or “unreal”
can be interrupted by periods of
intense emotion
Yearning and searching full effects of acute distress;
emotional outbursts, and
uncontrollable crying
Disorganization and
despair
evaluation of loss; may become
angry at perceived person at
fault
Reorganization person begins to move forward
with life; roles, skills and
relationships

Worden’s Four Tasks of Mourning
1991 Theory
Task 1 To accept the reality of the loss
Task 2 To work through the pain and grief
Task 3 To adjust to the environment in
which the deceased is missing
Task 4 To emotionally relocate the deceased
and move on with life

“It has been said that to lose parents is to lose the past,
to lose a spouse is to lose the present, and to lose a
child is to lose the future”

Community Resources
Palliative Care/Hospice
 Good Shepherd
90 Stinson Street
• http://www.goodshepherdcentres.ca/Prog
rams/emmanuelhouse.htm
 Dr. Bob Kemp Hospice
277 Stone Church Road E.
• http://www.kemphospice.org

Community Resources
Grief/Bereavement
 Bereaved Families of Ontario
293 Wellington Street N.
• http://bereavedfamilies.net/index.htm
 Friends in Grief
1030 Upper James Street
• http://www.friendsingrief.ca/

Last Playlist
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
4. __________________________________________________
5. __________________________________________________
6. __________________________________________________
7. __________________________________________________
8. __________________________________________________
9. __________________________________________________
10. __________________________________________________
http://www.lifebeforedeath.com/bucketlist/index.shtml
Images retrieved from: http://www.learnersdictionary.com/search/bucket
Bucket List Before you “kick
the bucket”...Fill it with a list of things you’ve always wanted to do. And do them!
1. __________________________________________________
2. __________________________________________________
3. __________________________________________________
4. __________________________________________________
5. __________________________________________________
6. __________________________________________________
7. __________________________________________________
8. __________________________________________________
9. __________________________________________________
10. __________________________________________________
Put together your very own soundtrack
to celebrate your life with your Last Playlist
http://www.lifebeforedeath.com/lastplaylist/index.shtml
Images retrieved from http://www.read-and-play-piano.com/music-symbols.html

CNO Documents to Guide Your
Learning
 Complimentary Therapies
 Consent
 Culturally Sensitive Care
 Ethics
 Guiding Decisions About End-Of-Life Care
 Medications
 Therapeutic Nurse-Client Relationship

References
Barber, K. (1998). The Canadian Oxford Dictionary.
Toronto, ON: Oxford New York University Press
Canadian Hospice Palliative Care Association. (2002). A
model to guide hospice palliative care: based on national
principles and norms of practice. Retrieved from
http://www.chpca.net/norms-
standards/model_to_guide_hpc.html
CNO. (2009). Practice guideline: guiding decisions about
end-of-life care. Retrieved from
http://www.cno.org/Global/docs/prac/43001_Resuscitatio
n.pdf
CNO. (2009). Practice guideline: culturally sensitive
care. Retrieved from
http://www.cno.org/Global/docs/prac/41040_CulturallyS
ens.pdf

References
Egan, K.A., & Arnold, R.L. (2003). Grief and
bereavement care. American Journal of
Nursing,103(9), 42-52.
End of Life Harlows, M. (2010). Physical changes in
dying. Retrieved from
http://www.virtualhospice.ca/en_US/Main+Site+Navigat
ion/Home/Topics/Topics/Final+Days/When+Death+Is+N
ear.aspx
Kirk, P., Kirk, I., & Kristjanson, L. (2004). What do
patients receiving palliative care for cancer and their
families want to be told? A Canadian and Australian
qualitative study. British Medical Journal, 328, 1343-
1349

References
Matzo, M., & Sherman, D. (2010). Palliative Care
Nursing: Quality Care to the End of
Life. New York, NY: Springer Publishing Company.
Lewis, S., Heitkemper, M., Dirksen, S., & O’Brien, P.,
(2010). Medical-surgical nursing
in Canada: Assessment and management of clinical
problems. Toronto, ON. Elsevier Mosby.
Potter, P., Perry, A., Ross-Kerr, J., & Wood, M. (2006).
Canadian fundamentals of nursing. Toronto, ON.
Elsevier Mosby.
Potter, P., & Perry, A. (2010). Canadian fundamentals of
nursing. Toronto, ON. Elsevier Mosby.

References
Roome, D. (2009). Physical changes before death.
Retrieved from
http://www.bukisa.com/articles/105595_physical-
changes-before-death
Verosky, D. (2006). Good grief: assisting patients and
their loved ones in dealing with
death. Academy of Medical-Surgical Nurses Newsletter,
15 (6).

End of Life Presentation

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