End-of-Life/Palliative Care (Organ/Tissue Donation, Advance Directives, Care Withholding, Family Presence)

Palliative care:

• A comprehensive approach to a life-threatening or terminal condition – focus is to alleviate physical, psychological, emotional, and spiritual suffering and promote quality of life

Advance directives:

• A guide to patient wishes with end-of-life care
• Unique applications in various states, be familiar with laws where you practice
• Written when patient is competent – becomes effective when patient loses decision-making capacity
• Flexible documents that can be changed or revoked

Types of Advanced Directives:

• Living will – declaration of wishes regarding treatment does and does not want
• Durable power of attorney for healthcare – designates a surrogate decision maker when an individual is unable to make own decisions, may include limits or parameters for what types of medical treatment must be followed by surrogate
• Durable power of attorney for finance – identifies a person to manage financial matters including health insurance and medical bills
• Physician orders for life-sustaining treatment (POLST) formerly do not resuscitate (DNR) – order that addresses what lifesaving measures should NOT be initiated, may limit CPR or intubation, but DOES NOT include withholding or limiting comfort measures such as pain relief, oxygen administration, or other measures to decrease or limit discomfort

Tissue and Organ Donation:

• CMS rules (1998) require notification of organ procurement
• Only organ procurement organization staff or trained hospital staff may approach family about donation
• Uniform Determination of Death Act (1978)
• Criteria – Irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brain stem
• Emergency nurses help families to understand brain death is not a recoverable state
• Notification of medical examiner; may not exclude donation – Homicide, suicide, unintentional injury, death within 24 hours of admission, patients admitted in comatose state, death of minor
• Once declared dead, care is not directed by emergency physician – orders written by Organ Procurement Officer (OPO) are valid and should be followed
  Procurement can occur up to 10 hours after asystole
• Keep body refrigerated
• If donating eyes – elevate head 20 degrees, tape eyelids shut with paper tape

Death Notification:

• Ideally, physician and nurse together
  • Be free of distractions
  • Sit down, introduce selves and identify family members
  • Ascertain family’s understanding of situation
  • Provide synopsis of what occurred and result of actions
  • Use simple, clear terms (e.g., died or dead)
• Viewing – inform families what they will see (tubes, activities, medications, physical condition of body), offer families to touch, talk with deceased
  Encourage family presence throughout

Postmortem Care:

• In medical examiner cases, leave required tubes in place
  • follow local/state/facility regulations in re: ME (may be required in some cases for example)
• Cover large wounds with gauze
• Place clean sheets, gown on body
• Be sensitive to needs of the family
• Before releasing the body, assure proper identification