Group Members: Roshan Jan Muhammad Choi Jee Young Nesreen Abdulmannan Shalia Gregory

Theory PresentationPeaceful End of LifeCornelia M. Ruland and Shirley M. Moore

Describe the practice issue, its magnitude and significance.

Discuss relevance of the issue to nursing and potential consequences if the problem is not resolved.

Describe nursing theory used to solve the problem.

Evaluate theory using established criteria and discuss the limitations.

List solutions to the problem using identified nursing theory.

OBJECTIVES

What is Good death?What it means to individual patients and how do we

offer peaceful death in Intensive Care Setting?

Theory: Peaceful End of life

PROBLEM STATEMENT

• 540, 000 deaths occur per year in ICU, which corresponds to 20% of all deaths in USA.

• Approximately half of the patients who die in hospitals are cared for in ICU within 3 days of death.

(Montagani, 2012)

BACK GROUND

Death trajectories: (a) Sudden Death, (b) Cancer Deaths, (c) Death from advanced non-oncological disease (COPD, cardiac insufficiency, HIV-AIDS), (d) Death from dementia.

BACK GROUND

Fear and anxiety in patients confronting death. 1. Fear of death2. Fear of pain (physical, mental, social, psychological, spiritual)3. Fear of unpleasant experiences and appearance.4. Loss of self determination5. Fear of loneliness and isolation6. Quality of life during end of life7. Fear of becoming burden to the family and society8. Fear of death as a feeling that ones life tasks are still incomplete9. Loss of meaning10. Guilt/regret 11. Fear of death as a fear of extinction 12. Anxiety of death as anxiety towards unknown13. Fear of death as a fear of judgment and punishment after death

(Deeken, 2009),(Goldsteen, Houtepen, Proot, Abu-Saad, Spreeuwenberg, &

Widdershoven, 2006a),(Hayden, D. (2011)., (Lunder, Furlan, & Simonic, 2011)

LITERATURE REVIEW

GOOD DEATH Highly individualized experience

• Being in control• Being comfortable and free of pain• Having a sense of closure and completion of final responsibilities• Having trust in care providers• Recognizing the impending death• Avoid inappropriate prolongation of dying • Leaving a legacy.• Minimizing burden• Optimizing relationships with lovedones• Affirming/recognizing the value of the dying person• Living one’s life till end • Honoring beliefs and values• Caring for family• Acknowledging the level of appropriateness of the death

(Kehl, 2006)

LITERATURE REVIEW

DEATH IN ICUhttp://www.youtube.com/watch?v=F6xPBmkrn0g

Critical care environment does not adequately foster compassion that dying patients need. (Beckstrand, Callister, & Kirchhoff, 2006)

They continue to suffer pain and other distressing symptoms and receive aggressive therapies until the moment of death. Patient satisfaction with pain control is worse in ICU than other hospital setting. (Montagani, 2012)

High number of patients are unable to communicate their needs and wishes because of sedation, coma, delirium….. (Beckstrand, 2005)

In USA 60-80% time family members are involved in end of life care decisions. (Mularski, 2005)

ICU doctors lack skills to provide good palliative care.

Nurse patient ration, time constraint and assignment system pose challenge.

LITERATURE REVIEW

Quality of death and dying in ICU (QODD) 24% patients were not aware they were dying 34% patients were aware of dying only during last 7 days of life. Mean ICU QODD score = 60 (0-100) ICU as a place of death = 61 (0-100)

(Mularski, Heine, Osborne, Ganzini, & Curtis, 2005)

LITERATURE REVIEW

Variables Score P value

Pain under control 47 0.009

Saying goodbye to loved ones 47 0.006

Unafraid of dying 39 <0.001

Keeping dignity and respect 32 0.001

Feeling at peace with dying 30 <0.001

Control of events 8 <0.001

Patient

• Depression • Guilt

Family/significant

others

• Burnout•Syndrome of depersonalization •Emotional exhaustion • Lower sense of personal accomplishment• Moral residue and distress

Health Care Professional

s

•Financial ramification

Health Care System

CONSEQUENCES

Mularski, 2005)(Beckstrand & Kirchhoff, 2005, 2006)

Death is a common phenomena in nursing practice.

Focus of medical/ technical care digress broader efforts to improve care of those near death.

Terminally ill patients demand compassionate care not curative treatment.

Nurses can bridge the communication gap between patient, family and physician during end of life care decisions.

Promotes and advocates for rights of dying patient.

Play vital role in preparing patient and families for transition in treatment goal. (Fighting death ……seeking good death).

We have unique relational bond with the patient and family.

Sensitive to individualized patient’s needs.

Individualized care planning

Help terminally ill patients and families find closure and peace during the final time of life treat them with dignity, respect and empathy.

RELEVANCE TO NURSING

Developed by Cornelia M. Ruland and Shirley M. Moore.

Middle range theory: PEACEFUL END OF LIFE

Theoretical underpinning

(Alligood, Tomey, 2010)

Donabedian’s model (general system theory)

Preference theory of Brandt

standard of Care “End of life care”.

Empirical evidence from

direct experience.

Evidence based.

Peaceful end of

life

The occurrence and feelings at the EOL experience are personal and individualized.

Nursing care is crucial for creating a peaceful EOL experience.

Family that includes all significant others play important part in EOL care.

The goal of EOL care is to maximize treatment that is best possible care provided through judicious use of technology and comfort measure to enhance quality of life and achieve a peaceful death and not overtreatment.

(Alligood, Tomey, 2010)

ASSUMPTIONS:

Not Being in Pain

Monitoring and

administering pain

medication

Applying pharmacological and non pharmacolog

ical measures

Experience of Comfort

Preventing monitoring and

relieving physical

discomfort

Facilitating rest, relaxation and contentment

Preventing complications

Experience of dignity

and respect

Including patient and significant

others in decision making

Treating patient with dignity, empathy and

respect

Being attentive to patient’s

expressed needs, wishes and

preferences

Being at peace

Closeness of significant

others

PEACEFUL EOL

Providing emotional support

Monitoring patient’s needs for antii- anxiety

medications

Providing patient and significant others with guidance in

practical issues

Providing physical

assistance to another caring

person

Inspiring trust

Facilitating participation of significant

others in patients care

Attending to significant

others grief, worries and questions

Facilitating opportunities

for family closeness

(Alligood, Tomey, 2010)

1) Monitoring and administering pain relief and applying pharmacologic and nonpharmacologic interventions contribute to the patient's experience of not being in pain.

2) Preventing, monitoring, and relieving physical discomfort, facilitating rest, relaxation, and contentment, and preventing complications contribute to the patient's experience of comfort.

3) Including the patient and significant others in decision making regarding patient care, treating the patient with dignity, empathy, and respect, and being attentive to the patient's expressed needs, wishes, and preferences contribute to the patient's experience of dignity and respect.

4) Providing emotional support, monitoring and meeting the patient's expressed needs for anti-anxiety medications, inspiring trust, providing the patient and significant others with guidance in practical issues, and providing physical presence of another caring person if desired contribute to the patient's experience of being at peace.

5) Facilitating participation of significant others in patient care, attending to significant other's grief, worries, and questions, and facilitating opportunities for family closeness contribute to the patient's experience of closeness to significant others or persons who care.

6) The patient's experiences of not being in pain, comfort, dignity, and respect,being at peace, closeness to significant others or persons who care contribute to peaceful end of life

(Alligood, Tomey, 2010)

RELATIONAL STATEMENTS

Theory covers maximum aspects of peaceful end of life.

Derived from standard of Care that is grounded into core value of nursing “CARING”.

End of life care for terminally ill patients in acute care setting.

Relates patient’s personal definition of ‘quality of life’ and perspective of ‘Good death”.

Interventions are, measurable, attainable and based on scientific knowledge.

Patient and family centered care.

Developed by nurses and guides nursing practice.

REASONS FOR SELECTING

SIGNIFICANCE

Physical, psychological, social, spiritual dimension of care.

Individualized care planning

Standard of care as a source of theory development.

Focus of core value of nursing “Caring”.

Evidence based practice.

Guides nursing practice.

Provides avenue for research in related field.

High level middle range theoryFawcett, J. (2000)

Alligood, M.R., & Tomey, A.M. (2010)

CLARITY AND CONSISTENCY

Use of simple and uncomplicated terms and clear expression of ideas.

Setting and patient population is clearly defined.

All elements of theory (concepts, assumptions and relational statements) are stated clearly.

Constructs and philosophical claims are consistent and congruent.

Abstract concepts (dignity, peace) are operationalized well.

Fawcett, J. (2000)Alligood, M.R., & Tomey, A.M. (2010)

“I am not afraid of death, I just don't want to be there when it happens”

Woody Allen

ARE WE PREPARED?

What is Good death?What it means to individual patients and how do we

offer peaceful death in Intensive care setting?

PROBLEM STATEMENT

Anticipatory

Phase

STEP WISE APPROACH TOWARDS GOOD DEATH

Not Being in Pain

Monitoring and

administering pain

medication

Applying pharmacolo

gical and non

pharmacological

measures

Experience of Comfort

Preventing monitoring

and relieving physical

discomfort

Facilitating rest,

relaxation and contentment

Preventing complications

Experience of dignity

and respect

Including patient and significant others in decision making

Treating patient with

dignity, empathy and

respect

Being attentive to

patient’s expressed

needs, wishes and

preferences

Being at peace

Closeness of significant

others

PEACEFUL EOL

Providing emotional support

Monitoring patient’s needs for antii- anxiety

medications

Providing patient and significant others with guidance in

practical issues

Providing physical

assistance to another caring

person

Inspiring trust

Facilitating participation of significant

others in patients care

Attending to significant

others grief, worries and questions

Facilitating opportunities

for family closeness

COMMUNICATION

ADVANCED CARE DIRECTIVE (Code, Care limits, proxy)

ANTICIPATORY PHASE

DYING PHASE

Nurse

Pharmacist

Nutritionist

Respiratory therapist

Subspecialty Consultants

Intensivist

DYING PHASE

Nurse

Pharmacist

Nutritionist

Respiratory therapist

Others

Intensivist

Family/friends

Palliative Nurse

Social worker

Chaplain

Doctor

Nurse

Not being in

Pain

Experience of

comfort

Experience of dignity

and respect

Being at peace

Closeness to

significant others

NOT BEING IN PAIN EXPERIENCE OF COMFORT

  Conduct pain assessment every 1-2 hourly. Use behavioral pain scale and critical care pain observation tool to

quantify pain. Involve family members in assessing pain Morphine infusion for pain management. Discuss and define goal of pain management. Beware of double effect. Prophylaxis pain management before painful procedure, aggressive

physical activity like bathing, suctioning, wound care. Minimize invasive painful procedure. Physiotherapy and massage. Therapeutic touch Palliative sedation also known as total sedation, terminal sedation for

intractable suffering

  Symptoms management for dyspnea, agitation, delirium,

nausea, vomiting. Withdrawal of ineffective or burdensome therapy. Minimize invasive painful procedure. Hygiene care, positioning. Provide intermittent rest. Physiotherapy and massage. Music Care of wounds and devices Clean, odor free environment Undistracted calm environment Palliative sedation also known as total sedation, terminal

sedation for intractable suffering. 

EXPERIENCE OF DIGNITY AND RESPECT BEING AT PEACE

  Respect patient desires for aggressive treatment and resuscitation. Reassess patient ongingly for expressed wishes Involve patient in decision making if competent. Ongoing communication with patient to keep him informed. Shared decision making process with family. Visit patient frequently to avoid feeling of abandonment. Arrange sitter to avoid restraint. Coordinate organ donation as per patient’s desire. Observe moment of silence with family when patient die. Funeral arrangement as per patients desire.

 

  Provide emotional support and empathy. Wheel patient outside ICU in sunlight, fresh air. Share good memories Add sensitive humor to the care. Facilitate opportunities to forgive and being forgiven Care sensitive to their belief system Allow patient/family to offer prayers/hollywater offer

rituals. Involve chaplain or religious representative in care. Respect patient preference for place of death

 CLOSENESS OF SIGNIFICANT OTHERS

 

Flexible visiting hours. Involve family members in assessing pain. Undistracted calm environment Brief interruption of sedation or analgesia to allow interaction of patient and family if possible. Provide opportunity for private patient and family interaction Facilitate family complete unfinished business Remind family that hearing stays longer than any other sense and encourage them to continue talking to patient and offer prayer. Allow/encourage family to be with patient at the time of death. (Watts, T. (2012), (Beckstrand, 2006)

 

Respect and dignity for the body. Cultural and religion sensitive last

offices. Involve family members. Facilitating organ donation process. Support for family and friends.

CARE AFTER DEATH

Communication Competencies of

doctor and nurses

• Education of staff to improve communication skills and competencies related to EOL care.

Staffing and scheduling patterns

• End of life care pathway.• Involvement and family members into care.• Involvement of palliative care team.

Non-availability of advanced directives

• Institutional policy change.• Primary care physician and advanced care

practitioners propagate advanced care directive.

• Brochure for advanced care directive.

BARRIERS AND SOLUTION

Tune into what I’m going through here. Be present with me here and now.”

Beckstrand, R. L., Callister, L. C., & Kirchhoff, K. T. (2006). Providing a "good death": Critical care nurses' suggestions for improving end-of-life care. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses, 15(1), 38-45; quiz 46.

Beckstrand, R. L., & Kirchhoff, K. T. (2005). Providing end-of-life care to patients: Critical care nurses' perceived obstacles and supportive behaviors. American Journal of Critical Care : An Official Publication, American Association of Critical-Care Nurses, 14(5), 395-403.

Deeken, A. (2009). An inquiry about clinical death--considering spiritual pain. The Keio Journal of Medicine, 58(2), 110-119.

Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge. Nursing models and theories. Philadelphia: F. A. Davis.

Goldsteen, M., Houtepen, R., Proot, I. M., Abu-Saad, H. H., Spreeuwenberg, C., & Widdershoven, G. (2006a). What is a good death? terminally ill patients dealing with normative expectations around death and dying. Patient Education and Counseling, 64(1-3), 378-386. doi:10.1016/j.pec.2006.04.008

REFERENCES

Goldsteen, M., Houtepen, R., Proot, I. M., Abu-Saad, H. H., Spreeuwenberg, C., & Widdershoven, G. (2006b). What is a good death? terminally ill patients dealing with normative expectations around death and dying. Patient Education and Counseling, 64(1-3), 378-386. doi:10.1016/j.pec.2006.04.008

Hayden, D. (2011). Spirituality in end-of-life care: Attending the person on their journey. British Journal of Community Nursing, 16(11), 546-551.

Kehls, K. (2006). Moving towards peace: An analysis of the concept of good death. Americal Journal of Hospital Palliative Care, 23 (4), 277-286.

Kongsuwan,W. & Locsin R.C.(2009) Promotion peaceful death in the intensive care unit in Thailand international Nursing Review 56,116-122

Lunder, U., Furlan, M., & Simonic, A. (2011). Spiritual needs assessments and measurements. Current Opinion in Supportive and Palliative Care, 5(3), 273-278. doi:10.1097/SPC.0b013e3283499b20

REFERENCES

Alligood, M.R,& Tomey, A.M. (2010). Nursing theories and their work. Mosbey : Eleseiver.

Mazor, K. M., Schwartz, C. E., & Rogers, H. J. (2004). Development and testing of a new instrument for measuring concerns about dying in health care providers. Assessment, 11(3), 230-237. doi:10.1177/1073191104267812

Montagani, M, & Balisterieri. (2012). Assessment of self perceived End of life care Competencies of Intensive care unit providers. Journal of Palliative Care, 15(1).

Mularski, R. A., Heine, C. E., Osborne, M. L., Ganzini, L., & Curtis, J. R. (2005). Quality of dying in the ICU: Ratings by family members. Chest, 128(1), 280-287. doi:10.1378/chest.128.1.280

Thelen, M. (2005). End-of-life decision making in intensive care. Critical Care Nurse, 25(6), 28-37; quiz 38.

Watts, T. (2012). End-of-life care pathways as tools to promote and support a good death: A critical commentary. European Journal of Cancer Care, 21(1), 20-30. doi:10.1111/j.1365-2354.2011.01301.x; 10.1111/j.1365-2354.2011.01301.x

REFERENCES

THANKS