For patients who are nonverbal or cannot answer questions because of cognition or mentation status, clinicians must still assess for pain (ANA & HPNA, 2021). Using tools such as FLACC or PAIN-AD scales can be helpful in addition to clinical observation. The FLACC (Face, Legs, Activity, Cry, Consolability) tool is used to assess pain for children between the ages of two months and seven years or individuals that are unable to communicate their pain (Merkel et al., 1997). The PAIN-AD (Pain Assessment in Advanced Dementia) tool is used to assess pain in older adults who have either suspected or diagnosed dementia or other cognitive impairment and are unable to reliably communicate their pain (Warden et al., 2003). Once the assessment of pain is completed, clinicians must include the patient, family, and caregivers in choosing the pain management plan that is most acceptable and inform them that it is possible to control their pain. Interventions should then be implemented as soon as possible to decrease or avoid increasing the time the patient must tolerate the pain (ANA & HPNA, 2021). Frequently, pain management includes a combination of treatments. Most frequently, opioid analgesics are used to treat pain associated with advanced illness. Opioid analgesics such as fentanyl, hydrocodone, morphine, and oxycodone are the most commonly used pain-relief medications in hospice and palliative care (American Society of Clinical Oncology, 2017). In combination with pain medication, patients may also benefit from complementary and alternative medicine, incorporating massage, animal-assisted therapy, or mind–body interventions in their symptom management plan (Urden et al., 2018). Physical, psychological, spiritual, and existential pain can be treated with biofeedback, relaxation techniques, transcutaneous electrical nerve stimulation, supportive counseling, and spiritual care (ANA & HPNA, 2021). Treatments for pain may also include radiation therapy, nerve blocks, and surgery. Notably, changes in breathing such as dyspnea, coughing, and congestion caused by the patient’s inability to clear secretions can be managed by frequent mouth care, positioning the patient on their side, elevating the head of bed, and/or providing medications such as a opioids and anticholinergics (CCH, 2021). Self-Assessment Question 4 What is the most important aspect of delivering hospice and palliative care? a. Alleviating pain and providing comfort care b. Ensuring the family can make decisions for the patient c. Alleviating both physical and psychosocial symptoms to ensure the best quality of life d. Allowing the patient to die at home The correct answer is c. Rationale: Both hospice and palliative care delivery center around quality of life and working toward relief of physical and psychosocial symptoms. As mentioned in Table 1, the prevention and management of skin tears and pressure wounds are very important to the care of the immobile patient and pain management. Pressure wounds are defined as localized injury “to skin and underlying tissue resulting from prolonged pressure on the skin” (Mayo Clinic, 2021, p. 1). These types of wounds most often occur on the bony prominences of the body, including heels, ankles, Care at the Time of Death The pronouncement of death is a moving and profound time for family members and clinicians. It is typically defined as the opinion or determination that, based on a physical assessment, life has ceased (National Conference of Commissioners on Uniform State Laws, 1980). Determination of death does not require consent from the patient’s family or a surrogate decision maker (Pope, 2018). In most instances, especially in the acute care environment, a physician is responsible for the death pronouncement. If the patient’s physician is unable to be
hips, and sacrum/coccyx (Mayo Clinic, 2021). Management of wounds can vary; however, regardless of treatment choice, the goal of palliative care is comfort. Pain is often the most frequent complaint for patients with wounds; therefore, selection of the type of dressing and analgesic (systemic or topical) is essential in pain control. Second, managing the wound exudate is also important for patient comfort and to diminish odor, which can cause patients and families anxiety. Therefore, treatment choice is important in regard to the selection of a wound dressing— one that does not need to be changed frequently, can help with pain and anxiety, and can absorb odors is preferred. Other interventions for odorous wounds include Metronidazole (systemic and topical), silver dressings, and honey as per provider order. Regardless of wound type, hospice and palliative care teams should consider consulting with a wound, ostomy, and continence nurse (WOCN) and, according to Tilley and colleagues (2016), “preferably [a WOCN] with a palliative care background and certification in the hospice and palliative care specialty” (p. 516). Finally, as families wait for their loved one to die, they may ask clinicians how much time is left because of the symptoms they are witnessing. It is important for the clinician to provide clear, factual, and supportive information during this time that includes noting the signs and symptoms of nearing death (see Table 1). As death approaches, patients will often have a dramatic drop in blood pressure and a drop in overall body temperature, and their extremities may become mottled (reddening and pooling of blood in spaces in the body) and/or feel very cold to the touch. The patient may experience severe unconsciousness, agitation, hallucinations, and urinary and/or bowel incontinence, and the jaw will drop as the body is held in a rigid and unchanging position (ANA & HPNA, 2021). Hearing and vision may decrease until death (CCH, 2021). Once death occurs, a person no longer breathes and has no heartbeat. There may be minimal movements from the arms and/or legs because of involuntary muscle movement, and there may be the release of a small amount of urine or stool (CCH, 2021). After a few minutes, the skin turns pale, waxen, and cool to the touch. Within 30 minutes of a patient’s heart stopping, the blood supply will stop moving through the body, and any part of the body that is on a firm surface will show signs of lividity, which looks like a dark purple discoloration against the skin (AMBOSS, 2021; Harle, 2017). Approximately two to six hours after the death, rigor mortis occurs and is first seen in the small muscles around the eyes, neck, and jaw (Shivpoojan, 2018). Self-Assessment Question 5 3. The Center to Advance Palliative Care (CAPC) provides action items for nurses and other healthcare professionals and organizations to support equity and access to hospice and palliative care among vulnerable populations. These include: a. Collaborating with the social worker on your team about any unmet needs in the population you serve. b. Developing a vision and mission statement that encompasses reducing health inequity. c. Listening to patients and families about what matters most to them, and about their greatest worries. d. All the above. present within a reasonable time and the death is because of natural causes or the patient is being cared for in the home, the RN employed by hospice can pronounce death (Brent, 2016). Many states have passed laws that allow registered nurses and/ or advanced practice registered nurses to pronounce death; different hospitals and care facilities may have their own policies regarding the death pronouncement.
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Book Code: PYFL4024
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