2020 Review: End of Life Care
I know. I know, this is no way to end the year but 2020 has taught me more about death and end of life care than any other year.
Death is such a scary concept.
All of us dread the day we die. Most of us dread the dead. In healthcare however, you loose that dread. Or at least you are supposed to.
Believe it or not, until this year I still low key dreaded the dead. I hated doing last office and would avoid it at all costs. COVID had much more in store for me. At some point we had at least one death a day in my ward, this meant that I had to do last office one way or the other. But before we get here, I have come to learn that there is so much to end of life care (EOL).
So, when does EOL begin and what does it entail?
EOL begins when the medical team decides that any medical interventions made will have no consequences for the patient. At this point, physiologically, the body is shutting down. Organs are giving up. The spirit is done. Some will hold on, only to prolong the inevitable.
Usually, EOL is common for the elderly. However, sometimes young critically ill patients (commonly with a diagnosis of metastasized cancer) may be subject to EOL. These are all patients who have DNACPR/DNR directive in place, mechanical ventilation and other life supporting machines are not an option. Again, just prolonging the inevitable.
The fundamental goal of EOL is to a enable peaceful death. It also help the loved ones to anticipate and prepare for grief. This is not always practical though.
Proper EOL consists of the following:
Pain Management. As I mentioned above, the body is shutting down and pain is one of the major by-products. For a patient on EOL, the strongest analgesia is your go to. We are talking morphine and other opiates. As a nurse, your job is to determine that the patient is in pain. Remember, these patients cannot communicate. You must then monitor for other signs of pain which include restlessness, grunting and other sounds and facial expressions like wincing and grimacing.
Managing Breathing Difficulties. This is a common occurrence when a patient is dying. The patient may be dyspneic. Give oxygen for comfort. Also, sedation is a good way to minimize the work of breathing. Give some Midazolam or other prescribed sedative.
Maintaining Moisture. Dying patients get really dry in the mucus membranes, the lips and buccal cavity being the most pronounced victims. Do regular mouth care and keep the mouth moist. You may give some drinks for comfort. This, should however be given in very small amounts since most times, the patient is unconscious and cannot swallow properly.
Managing Digestive Problems. The most common digestive problem is nausea. Some dying patients may experience diarrhea or constipation. You will always have an antiemetic prescribed as part of the anticipatory medication, commonly cyclizine. Administer this as soon as your realize your patient is nauseated. Retching is a good indicator for nausea.
Spiritual Care. Just yesterday, one of my patient's relative called and informed me that their father is Roman Catholic and they would want a priest to perform the last rite in case he is dying. Spiritual care is an important part of EOL. Best practice is to provide this as soon as possible. However, spiritual care does not necessarily mean religion. I have come to learn that my hospital's chaplains offer a a variety of ministry to the dying.
Managing Emotional and Mental Needs. You may have dying patients who can still speak. I have had a patient who told me that she is afraid of dying. This can often put you in a tough position as a nurse. You know the clinical picture is horrible and you cant offer false hope. The best you can do is hold their hand and tell them that they are not alone. Allow their loved ones to come and be with them. If this is not possible, try to be with such patients as much as possible, constantly talking to them and reminding them that you are there.
EOL care is one of the components of care that can be draining. One thing I have learnt this is year is that dying peacefully is a major part of the care we provide.
Anytime you come a cross a dying patient, make sure they are at peace. It may be by giving them that morphine or calling the chaplain or having their relatives come by or by simply holding their hand.
As for my tweny tweny punchline: Death is inevitable. The sooner we accept this, the freer we live our lives.
Happy New Year guys!
Thank you all for the support.
To Bigger and Better!