Comfort Care and End of Life

Comfort Care and End of Life

Promoting Comfort and Sleep

Research has shown that frequent sleep disturbances, such as getting up to go to the bathroom, may affect the body's natural pain inhibitors and cause more pain. This is especially so with women. You are responsible for helping all residents feel as comfortable as possible and get enough sleep. The techniques listed in Box 8-1 can

NONDRUG THERAPIES FOR PAIN

Heat/cold application involves using dry or moist heat or cold on a specific area to relieve pain or increase the resident's comfort.

Vibration can be used to promote comfort or help relieve pain. This form of electrical massage is applied lightly or with pressure on various body areas. Different types of vibrating devices are available for different parts of the body.

Massage is a method of relaxation that can be used to help residents relax both physically and mentally. A three-minute backrub using slow, rhythmic strokes is a safe and effective way to decrease pain and promote relaxation.

Acupuncture is an ancient Chinese healing method. The acupuncturist inserts very thin needles in specific body sites. Acupuncture is said to allow energy to flow to or from areas that do not have enough energy or have too much energy. Acupuncture is believed to help restore and regulate the body's energy balance.

Distraction is a technique used to direct a resident's attention away from pain. With distraction, the resident deliberately focuses on something other than the pain and thus responds less to it. Talking, books, movies, and social activities are all distractions.

Humor is an enjoyable and often effective form of distraction that can be used to get the resident's mind off their pain.

Relaxation techniques are methods that help reduce anxiety, muscle tension, and pain. Such techniques include meditation, music, massage, and deep breathing.

Guided imagery is a healing technique that uses words and sometimes music to bring the body and mind to a relaxed and focused state.

Animals provide relaxation and companionship and help distract a resident's attention from pain.

be used to help promote comfort and sleep in addition to relieving pain.

It is helpful to encourage residents to use the bathroom before going to bed at night.

You may also want to encourage them to rest during the day. This can mean quiet time reading or listening to music. Understanding how each resident likes to relax and prepare for sleep will help you know what to do to assist them.

You can also help control the resident's environment to keep them comfortable and promote sleep:

Make sure that the room it is not too hot or too cold. Ask the resident how the room temperature feels to them. Remember that what you consider a comfortable temperature may be different from what the resident finds comfortable.

Be sure there are extra blankets nearby in case they get cold during the night. If residents cannot pull up additional covers on their own, be sure to check on them throughout the night.

Limit noise at night. Do not talk to others in the resident's room or outside their door.

Lower the lights in the hallways. Close the resident's door, if appropriate.

Be sure to pull window shades and close curtains at night so outside lights do not shine in the resident's window.

Pay attention to any odors. Empty bedpans, change soiled linens, and manage incontinence in a timely manner.

End of Life

Facing the end of life is a very difficult time for the resident and their loved ones. Your role as a temporary nurse aide is to support them through this phase with as little pain and discomfort as possible. People nearing the end of life generally have comfort needs in these areas:

Physical comfort

Mental and emotional needs

Spiritual issues

Practical tasks

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Physical Comfort

There are things that can be done to help a dying person be more comfortable. Some residents may be uncomfortable due to pain, breathing problems, skin irritation or breakdown, digestive issues, temperature sensitivity, or fatigue. Always reinforce the importance of the resident reporting the first sign of increased pain so measures can be taken to help control it. Some breathing problems can be relieved with positioning, fans, and oxygen therapy. Dryness in the eyes and mouth are a source of discomfort and can easily be relieved with lip balms, damp cloths, moistened cotton swabs, or ice chips (as tolerated).

Skin irritation and breakdown occur when the ability to move is limited. Constant pressure can result in pressure sores. Changing position and providing proper skin care help to relieve the pressure. Additional pads, mattresses, and protectors can be used to help relieve the pressure and prevent skin damage.

Common digestive problems are constipation, nausea, vomiting, and loss of appetite. The cause and treatments for these symptoms are individualized and may be a combination of interventions. Adjustments may be made in diet and medications to try to alleviate the problem. Loss of appetite is a normal part of the dying process. Forcing food when the resident does not want it may cause the resident more discomfort than not eating.

People who are dying may not be able to communicate their needs. It is important to observe the resident for clues. Repeated attempts to push back the blanket may indicate that they are too hot. Shivering, hunching shoulders, and pulling up covers may indicate that they are cold. Your role is to recognize the clues and intervene.

Fatigue is common in people nearing the end of life. Keep activities simple and provide convenient alternatives such as a bedside commode and shower chairs.

Mental and Emotional Needs

Death is a natural stage in life, but most people do not like to talk about it. When we face the death of another person, we are reminded that we, too, will die someday. Many people fear death because they are afraid of the unknown. The dying person realizes that they will have no more chances to do things they wanted to do. At this time, people ask themselves many questions, such as "What is the meaning of life?" or "What have I done that has made a difference or that will be remembered after I'm gone?" You as a temporary nurse aide can help residents face their fears and deal with negative emotions such as regret or sadness.

Spiritual Issues

People at the end of life may have spiritual needs that are as important as their physical needs. Finding meaning and peace in the process are very important. You will need to inform the charge nurse if arrangements need to be made for a social worker, spiritual counselor, or clergy member to visit the resident. Many people find solace in their faith or spiritual beliefs at the end of life. It is important to honor their wishes and beliefs.

Practical Tasks

Residents at the end of life may worry about practical tasks. They may be concerned about what will happen to loved ones left behind and who will take over the daily chores and tasks that they have been responsible for. Final wishes and details of responsibilities should be discussed to provide reassurance and comfort to the dying person.

Advance Directives

An advance directive is a legal document communicating a person's wishes in regard to health care decisions in the event he or she becomes unable to make those decisions. There are two general types of advance directives: the living will and the durable power of attorney for health care. The federal Patient Self-Determination Act requires all health care facilities to inform residents of their right to make such a directive and of the form(s) they need to complete. Different states use different forms, but all have the same purpose.

A living will states the resident's wishes about withdrawing or withholding life-sustaining procedures if the person becomes terminally ill. The document also specifies which medical treatments the person accepts or rejects. A living will must be written while the individ-ual is mentally competent. The resident can revoke it at any time by notifying the physician or other health care provider or by destroying the original document.

A durable power of attorney for health care is a legal document that designates someone, usually a family member, close friend, or an attorney, to make health care decisions if the person becomes incapacitated and unable to make decisions for themselves.

You do not need to understand all the legal issues related to these documents, but you should know your facility's general policy about advance directives. You should also know which residents in your care have them.

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Feelings About Dying

Elderly residents have experienced the death of loved ones and friends. Because of this, they may think more about life and death. Their spiritual needs often become more important as they review their lives. How people feel about their approaching death varies greatly. These feelings are usually based on their life experiences and spiritual beliefs. Cultural background also plays a role in what a person believes and how they respond to dying. Some welcome death as a release from pain and suffering. Many have positive expectations based on their religious beliefs. Following are some common beliefs:

There is a life after death that is free of pain and hardship.

One will be reunited with loved ones who have already died.

One will be reincarnated into another body or form.

To support a resident throughout the dying process, you need to understand their beliefs about death. For example, some dying residents fear dying alone, even though they may accept death as positive or freeing. If a resident seems fearful of being alone, develop a plan to be with them as needed. Be sure to respond when they ask for you. Many people fear a painful death. Ask the charge nurse to discuss pain management with the resident. Residents may also have concerns related to how they lived their lives. For example, they may:

Feel that they have unfinished business, such as resolving a dispute with a family member.

Feel unhappy about how they lived their lives. They may feel they failed to achieve all they wanted.

Feel guilty about something they did or did not do. For example, they may feel that they were not supportive enough of a family member or friend.

The process of life review is very important. Be supportive, open, and nonjudgmental. Always listen to the resident. Think about basic human needs as you care for a dying resident, and try to meet as many of their needs as possible. Be sure to report to the charge nurse any information the resident communicates to you so that other members of the team can also provide support.

Stages of Grief

Regardless of individual differences in attitudes and spiritual beliefs, most dying people go through similar feelings about the process. Dr. Elisabeth K?bler-Ross, a psychiatrist who worked with many dying patients, described five stages of grief or loss. These stages apply to the dying person and to those experiencing loss, such as the loss of a loved one. The five stages are denial, anger, bargaining, depression, and acceptance. While called "stages," these emotional states do not necessarily occur in a linear order. They may overlap, and people may move back and forth between several stages for a period of time.

Denial -- When people first learn that they are dying, most experience a "not me" reaction. They may refuse to talk about death or to acknowledge physical evidence that they are dying.

Anger -- The person asks, "Why me?" They may lash out at family members, caregivers, or even at God. Often they are looking for someone to blame.

Bargaining -- The person may try to bargain with physicians or a higher power to gain time to complete unfinished business.

Depression -- This occurs when the individual acknowledges that death is coming. They experience sadness and are beginning to mourn their loss of self.

Acceptance -- The dying person has worked through most of their earlier feelings and reached a state of calm or peacefulness. Typically, a person who has reached the acceptance stage focuses on living each day to its fullest. A dying resident may work to help friends and family work through their feelings of grief and loss over their approaching death.

Residents may ask you to help their loved ones accept that they are dying. They may evaluate their lives and come to accept both the good and bad aspects. Letting a dying resident talk and being an active listener are key to caregiving at this time. Make sure the resident knows it is all right to talk to you about their feelings.

Almost everyone who is terminally ill knows that their death is inevitable. You may hear family members or staff say that a resident hasn't been told about their approaching death. This does not mean that they do not know. Often it means only that the person is not yet ready to talk with loved ones about their feelings. You may need to tell family members and other staff about clues you notice about the resident's attitude. Encourage them to listen carefully to what the resident says.

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DISCLAIMER: AHCA/NCAL has created this course to assist providers to recruit and train temporary staff during the national emergency caused by the coronavirus pandemic. Federal and/or state requirements may need to be waived to permit individuals under this training program in your location. Employers should check with their state survey agencies and their state occupational licensing agencies where applicable to ensure individuals trained under this program are permitted to assist with care in your location.

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