End of Life Peace Without Pain

End of Life: Peace without Pain
Jacqueline R. Reviel
Loyola University New Orleans

End of Life Peace without Pain
Pain management during end of life care is crucial to the comfort and peace of the patient and their family. “With better pain control, dying patients live longer and better. Pain shortens life. Relief of pain extends life” (Zerwekh et al., 2006, p.317). The nurse must educate about (a) disease pathology, (b) signs & symptoms, (c) interventions, (d) medications, (e) alternative therapies, and (f) supportive care, related to end of life care. Pain management involves understanding the pharmacological issues, and management issues surrounding opioid drugs used for pain control. The identification of (a) nursing diagnosis, (b) implementation, and (c) education are essential in keeping the patient and family comfortable and at peace.
Pathology, Signs and Symptoms
End of life presents with specific pathology which can cause extreme pain and discomfort. The body’s organs begin to shut down as death approaches hypoventilation causes hypoxemia and hypercapnia in turn increasing the workload of the heart as it tries to oxygenate the vital organs. The kidneys and liver begin to fail and toxins begin to build up. The heart fails as it can’t keep up with the demand. Zerwekh (2006) lists specific signs and symptoms associated with death (a) reduced level of consciousness, (b) taking no fluids or only sips, (c) decreased urine output, (d) progressing coldness and mottling in legs and arms, (e) irregular labored breathing; periods of no breathing, and (f) the death rattle.
Diagnosis & Interventions
Diagnoses related to end of life care are (a) Ineffective tissue perfusion, (b) Alteration in comfort, (c) Activity intolerance, (d) Impaired gas exchange; (e) Ineffective breathing patterns, and (f) Decreased cardiac output. Interventions are attached to each diagnosis and a plan of care is established for the patient. Interventions for alternation in comfort include (a) spiritual, (b) pharmacological, and (c) alternative methods. Ineffective tissue perfusion involves (a) positioning, (b) O2, and (c) fluid management. Activity intolerance is managed by pacing periods of activity with rest. Impaired gas exchange is managed by decreasing fluid shifts with medication. Ineffective airway clearance is helped by (a) positioning and (b) suctioning to clear the airway. Disturbed thought processes interventions are (a) reorient the patient, (b) supporting family, and (c) visitors at times when the patient is most alert. Interventions are tailored specially to the patient’s needs and their disease process.
Pain management
“Dying does not need to be painful” (Moynihan et al., 2003 p. 1401). Holistic pain management is crucial during end of life care. Terminally ill patients can have (a) physical, (b) spiritual and (c) emotional pain. Providing comfort is important in decreasing suffering. Emotional pain can be addressed by (a) laughter, (b) memories, and (c) touch. Spiritual pain can be helped with (a) prayer, (b) meditation, (c) talking, (d) listening, (e) pastoral care, and (f) providing the last rights. Physical pain is managed pharmacologically and with alternative comfort measures. Opioids are given to treat severe pain at the end of life. Parlow (2005) used nitrous oxide to control incident pain in terminally ill patients with positive results.
Pharmacological issue related to pain management
Pharmacological issues surrounding pain management are (a) issues of addiction under medication, (b) legal repercussions, (c) respiratory effects, and (d) side effects. Zerwekh (2006) sums up the fallacy of addiction by stating persons with addiction take their opioids to escape life, whereas persons with pain take their opioids to live life more fully. These issues and lack of knowledge often cause Physicians to under medicate during end of life care. The nurse needs to have full understanding of how opioids work and how to adjust the medications to control severe pain and break though pain without entering into (a) legal issues, (b) respiratory depression and (c) side effects.
Complementary and alternative therapies
Along with the pharmacological methods to keep the patient comfortable there are many alternative method the nurse can use and teach the family to assist with; giving the family the gift of caring for their loved one and feeling like they are helping. The patient also benefits from the touch and interaction from his or her loved ones. Therapies such as (a) massage, (b) therapeutic touch, (c) guided imagery, (d) aromatherapy, (e) hypnosis and (f) relaxation, are just a few alternative therapies used.
Supportive nursing care
Often when a family member is dying their loved ones do not know what to say or do and often feel helpless. While providing care for the patient the nurse engages the family in the care and breaks down the fear that they can’t touch the dying patient. The nurse encourages the family to (a) gather, (b) share, and (c) grieve. The family and patient are educated to end of life care so they know what to expect and can recognize it. By giving the family these skills it is a gift so the family has time to say goodbye and to spend the last days in peace not in fear and chaos. The nurse manages symptoms so the patient and the family can concentrate on each other. O’Brien (2011) stated one of the best ways of providing spiritual support in this situation is to allow the patient and family to verbalize their feelings; for the dying person “one of the greatest spiritual gifts” a nurse can give is to listen (Burns, 1991, p. 51).
Patient & Family education
Education gives the patient and the family great power and strength to face the path ahead and not be fearful of the process. Discussion around key information such as (a) the patient’s wishes, (b) spiritual care, (c) visitation, (d) pain control, (e) disease process, (f) multi organ failure, (g) specific signs and symptoms, (h) interventions that can be provided, (i) interventions the patient may not want, (j) comfort care, and (k) funeral arrangements, must take place with the patient and their family. Patients may believe that pain is to be expected and education informing them that comfort will bring them quality time to spend with their loved ones and to not suffer in silences is vital. Encouraging the family to (a) hold their love ones hand, (b) stroke hair, (c) massage, and (d) talk to them until they take their last breath, is all education the nurse encourages. The nurses’ role is to (a) support, (b) pray and (c) answer question that might arise.
Conclusion
Caring for patients as they die involves (a) a great deal of knowledge, (b) compassion, and (c) caring, on the nurse’s part. Effective pain management decreases suffering in the terminally ill patient and can make all the difference in how the patient arrives at the end of life. The nurse must be versed and comfortable with the many issues surrounding end of life care so she or he can advocate for the needs of the patient and their family. The nurse’s role in (a) educating, (b) providing spiritual care, and (c) physiological care, to the patient and their family during this very important and stressful time plays a huge part in the comfort and peace that they experience as they journey down the path of loss and grieving.

References
Moynihan, T. J. (2003). Use of opioids in the treatment os severe pain in terminally ill patients-Dying should not be painful. Mayo Clin Proc., 1397-1401.
O 'Brien, M. E. (2011). Spirituality in nursing: Standing on holy ground. Sudbury, MA: Jones & Barlett Learning.
Parlow, J. L. (2005). Self-administered nitrous oxide for the management of incident pain in the terminally ill patient: A blind case series. Palliative Medicine, 19: 3-8.
Zerwekh, J. V. (2006). Nursing care at the end of life: Palliative care for patients and families. Philadelphia, PA: F. A. Davis Company.

LOYOLA UNIVERSITY NEW ORLEANS

NURS 384: End-of-Life Issues Paper

Student: _Jackie Reviel__________________________Semester:_Fall__Year:_2011__

Directions: The purpose of this paper is to examine end-of-life issues. Write a 4-5 page paper on one of the topics that are suggested in your syllabus. Focus the paper on the care of the terminally-ill patient; education of patient and family, and supportive nursing care. Use ast least 4 references (current text and articles) for this assignment and format paper in APA style.

Criteria: End-of-Life Issues Paper | Max. Points | Score | 1. Describes terminal Illness. Include pathology and signs and symptoms | 15 | | 2. Identify palliative care/interventions associated with illness | 15 | | 3. Address pharmacological issues related to terminal illness | 10 | | 4. Address complementary and alternative therapies | 15 | | 5. Describe supportive nursing care related to terminal Illness. | 15 | | 6. Discuss at least 5 nursing diagnosis taken from those listed in the North American Diagnosis Association. | 15 | | 7. Provide key information to be discussed with patients & families on terminal illness. | 15 | | Total
Comments:

Faculty Signature: _______________________________Date:_______________________

LOYOLA UNIVERSITY NEW ORLEANS Evaluation of Communication Skills

Student: ________________________________Semester: ____Year: _____

Skill in communication is defined as the ability to: (a) effectively express ideas through a variety of media, (b) use communication technology to enhance personal and professional functioning, and (c) use the group process for the purpose of achieving common goals.

Note: Your grade on Communication Skills will comprise 10% of your final course grade.

You will be rated using a scale of 0-10, where “0” indicates no credit and “10” indicates maximum credit for the item indicated. |

Writing Criteria: Nursing Research Critique Paper | Score | 1. Use appropriate language and terminology. | | 2. Use correct sentence structure and paragraphing. | | 3. Use correct grammar, spelling, and punctuation. | | 4. Demonstrate knowledge of relevant content areas. | | 5. Express ideas clearly and convincingly. | | 6. Organize ideas logically. | | 7. Use APA format correctly. | | 8. Overall effectiveness of the written work in meeting identified goals. | |

Communication Skills: Pts earned (_____)/ 80 pts = _____% Letter Grade:____

Percent of Final Course Grade: [Pts earned (____)/ 80 pts =___%] X 10 = ____%

Comments:

Faculty Signature:____________________________________Date:______________

References: Moynihan, T. J. (2003). Use of opioids in the treatment os severe pain in terminally ill patients-Dying should not be painful. Mayo Clin Proc., 1397-1401. O 'Brien, M. E. (2011). Spirituality in nursing: Standing on holy ground. Sudbury, MA: Jones & Barlett Learning. Parlow, J. L. (2005). Self-administered nitrous oxide for the management of incident pain in the terminally ill patient: A blind case series. Palliative Medicine, 19: 3-8. Zerwekh, J. V. (2006). Nursing care at the end of life: Palliative care for patients and families. Philadelphia, PA: F. A. Davis Company.