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Course: Oncology Nursing

Topic: Nursing Care on Death and Dying

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the role of spirituality and cross cultural beliefs and practices surrounding death.
Identify the various aspects of providing support and comfort to the terminally ill patients.
Recognize common emergencies in oncology.
Describe actions to address common oncology emergencies.
Describe nurse’s role in end-of-life planning and Advanced Directives
Provide insights on Legacy and Life Review Projects.
Describe nurse’s role in respect to funeral practices, rituals, and legalities.

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Culture

Daher, 2012

“Culture is defined as a set of shared and socially transmitted ideas about the world that are passed down from generation to generation”

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Culture Myths and Cancer

Daher, 2012

The most common myths and perception of cancer are:

Death
Fear
Pain and suffering
Loss of control and independence
Helplessness
Isolation

Patients are often reluctant to undergo surgery because they believe ‘if they cut into the cancer, it will spread immediately all over the body’

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Culture and Perception of Cancer

Reasons that cancer is stigmatized in Middle East (ME) countries

People have belief that nothing can be done to prevent cancer and that cancer is always fatal.
It may be seen as a punishment.
Some perceived cancer treatment to be as bad as, or worse than, the disease itself.
Cancer symptoms or body parts affected by the disease can cultivate stigma:

For example, cervical cancer is highly stigmatized because the cervix is ‘part of the body people don't speak about’.

Daher, 2012

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Spirituality and Cancer Patients in ME Countries

“Spirituality is a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions”

Daher, 2012

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Spirituality and Cancer Patients in ME Countries

Many individuals rely on their spirituality and faith when coping with illness which has positive outcomes:

Less depression and longer survival
Fewer post-surgical complications
Delayed onset and slower progression of physical disability
Influence serotonin pathways in the brain that regulate mood and possibly less pain,
However,negative spirituality (e.g. ‘God is abandoning me’) is related to increased pain sensitivity

Overall, spirituality improves quality of life

Daher, 2012

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Providing Support and Comfort to Terminally Ill

The following characteristics of treaters are important in the care of dying patients:

Competence:

Skillful treaters allay anxiety and allow the best possible medical outcome.
Dying patients are greatly comforted when they feel that their physician is knowledgeable and has developed a comprehensive plan of care.

Huffman & Stern, 2003.

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Providing Support and Comfort to Terminally Ill

Concern:

True empathy and connection are necessary to provide good care for such patients.
Family members and patients may avoid talking about painful feelings of impending loss. However, by discussing their own feelings about the patient's loss and by asking how others are dealing with the impending loss during meetings with patients and families, can show their own concern and allow patients and families to grow closer.

Huffman & Stern, 2003

Contact info: info@nursesinternational.org

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Providing Support and Comfort to Terminally Ill

Comfort:

Physical discomfort can contribute to psychological distress and inhibit a healthy grief process.
Treatment of pain with narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), adjunctive agents, acupuncture, biofeedback, and other remedies is crucial in the care of the dying.
Treatment of low energy, shortness of breath, and psychiatric symptoms.

Huffman & Stern, 2003

Contact info: info@nursesinternational.org

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Providing Support and Comfort to Terminally Ill

Communication:

Communication with the dying should focus far more on the art of listening than on the art of speaking.
The conversation should be to help patients tell the story of their life (their accomplishments, their interests, their regrets, their hopes, the people in their life, and the details of their spiritual life).
Spend time with a patient, by listening intently, and by helping the patient make meaning of life and death.

Huffman & Stern, 2003

Contact info: info@nursesinternational.org

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Providing Support and Comfort to Terminally Ill

Huffman & Stern, 2003

The following are four ways in which a clinician can be helpful to a patient who is terminally ill:

1. Aid the psychological and spiritual coping process

2. Assess and treat psychiatric illness

3. Maximize comfort

4. Treat the treaters and family members

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What would the nurse do?

A nurse is caring 72 years old client with terminal cancer. The client is in last stage of his life. Which of the following actions taken by the nurse can help provide psychological support to her patient? (Select all that apply).

The nurse can spend quality uninterrupted time with the patient.
The nurse can actively listen to patients concerns
The nurse can encourage the patient to verbalize his feelings.
The nurse can tell the patient he needs to sleep as much as possible.

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Providing Support and Comfort to Terminally Ill

Huffman & Stern, 2003

Aid the psychological and spiritual coping process:

Engage in discussions that allow the patient to reveal the important psychological, social, and spiritual aspects of their life.
The nurse might ask about some of the following:

Life story
Relationship
Coping
Spirituality

Contact info: info@nursesinternational.org

life story:What are you proudest of? What legacy would you like to leave? What would you like your family to remember about you? Do you have any regrets? Is there anything you would like to accomplish with the remainder of your life?

Relationship:Whom do you cherish most? Have you been able to tell them? Is there anyone you would like to reconcile with? Are there any friends you hope to see? How can you help your family prepare for your death?

Coping:What are your biggest strengths? What difficult things have you gotten through in your life, and how did you get through them?

Spirituality:Are you a religious person? Do you believe in God? What is your relationship with God? Do you feel able to communicate with him? What do you imagine will happen to you when you die? Do you feel that God is happy with you, angry with you, or feels some other way? Why?

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Providing Support and Comfort to Terminally Ill

Assess and treat psychiatric Illness:

Psychiatric illness is common among patients with terminal illness.
Major depression is experienced by approximately one fourth of patients with cancer.
Furthermore, one quarter of terminally ill patients also experience significant anxiety symptoms.
Delirium is also common in patients with terminal illness and it often goes unrecognized.

Huffman & Stern, 2003

Contact info: info@nursesinternational.org

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Providing Support and Comfort to Terminally Ill

Maximize Comfort:

Pain control most importance in the care of the dying patient:

Higher doses of narcotics and adjuncts to narcotic medications (e.g., NSAID), tricyclic antidepressants, anticonvulsants, physical therapy, biofeedback, and massage) may be needed.

Discomfort from nausea, hiccups, or dyspnea must be treated
Adequate food, drink, and hygienic care can lead to significantly improved mood, self-esteem, and dignity

Huffman & Stern, 2003

Contact info: info@nursesinternational.org

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Providing Support and Comfort to Terminally Ill

Treat the treaters and family members:

Treaters can feel tremendous grief with the loss of a patient with whom they have had a long relationship or a strong alliance.
Psychiatric consultants can help treaters to identify their grief and can encourage them to share these feelings of loss with the patient, with other colleagues, and with supervisors.

Huffman & Stern, 2003

Contact info: info@nursesinternational.org

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Common Emergencies in Oncology

Mark et al., 2018

Metabolic Emergency:

Tumor lysis syndrome
Hypercalcemia of malignancy
Syndrome of inappropriate antidiuretic hormone

Hematologic:

Febrile neutropenia/sepsis/ septic shock
Hyperviscosity syndrome

Structural:

Superior vena cava syndrome
Malignant epidural spinal cord compression
Malignant pericardial effusions

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Actions to Address Emergencies in Oncology

The nurse’s role in oncology emergency are:

Understanding oncology emergency:

Recognize the signs and symptoms can be key to preventing serious problems.
Be aware of which cancers increase a patient’s risk for a specific oncologic emergency and understand the pathologic mechanisms underlying those complications.

Prompt identification and report their findings to the healthcare team

Frequent head-to-toe assessment from the RN is critical in quick identification.

Pirschel, 2018

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Actions to Address Emergencies in Oncology

Providing appropriate education and support to patients and caregivers:

Make sure they understand the possible signs and symptoms of pertinent oncologic emergencies, as well as the consequences of late recognition.

Provide written information of:

The disease
Treatment,
The potential complications
List of signs and symptoms along with when and where to call

Pirschel, 2018

Contact info: info@nursesinternational.org

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What would the Nurse do?

A nurse is in working in an emergency oncology ward. What are the different hematological oncology emergencies he/she may encounter? (Select all that apply).

Tumor lysis syndrome
Hypercalcemia
Septic shock
Hyperviscosity syndrome
Superior vena cava syndrome

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Advance Care Planning and Advance Directives

Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.
The goal of ACP is to help ensure that people receive medical care that is consistent with their values, goals, and preferences.

Silveira, 2021

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Advance Directive

“Advance directives (ADs) are the documents a person completes while still in possession of decisional capacity about how treatment decisions should be made on they behalf in the event they lose the capacity to make such decisions”

Silveira, 2021

Contact info: info@nursesinternational.org

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Advance Directive

Patient characteristics associated with a higher likelihood of completing an AD include:

Older age
History of a chronic disease, including AIDS and cancer
Higher socioeconomic status
Prior knowledge about AD and end-of-life care option
Higher level of education
Higher levels of functional impairment

Silveira, 2021

Contact info: info@nursesinternational.org

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Advance Directive

There are various kinds of ADs, but the types typically recognized by state law in the United States are:

The Living Will (LW):

A document summarizing a person’s preferences for future medical care.

The Durable Power of Attorney for Health Care (DPAHC):

Is a signed legal document authorizing another person to make medical decisions on the patient’s behalf in the event the patient loses decisional capacity.

Silveira, 2021

Contact info: info@nursesinternational.org

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Legacy and Life Review Projects

"Legacy work" is the process of transforming the thoughts into action

Act of sitting down and taking time to purposefully create something for the people you love and care about

Legacy project could take any form: elaborate or simple all are meaningful

A scrapbook (with pictures/keepsakes related to a particular time in patient life, a loved one, a favorite vacation destination, etc.)
A collection favorite recipe
A life review worksheet
A video montage
A poem or a song created specifically for the loved one

Griffith, 2011

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Critical Thinking Question

Which of the following statements best describe the reason healthcare team should address a terminally ill patient’s advance directives status?

The terminally ill patient may move to a condition where he can not make any medical decision that will support their personal values, life goals, and preferences regarding future medical care
The terminally ill patient will become sicker with each passing hour and then not be able to make his own decisions.
The terminally ill patient will be the best one to make decisions about his own healthcare, thus an advance directive is not necessary.
The terminally ill patient can only make decisions about his health care choices prior to a terminal diagnosis.

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Nurse’s Role in Dying Process

Cancer Council Victoria

Atmosphere

Use soft lighting
Have their favorite music playing in the background to create a gentle and peaceful atmosphere
Quietly read a favourite poem, passage from a book, or spiritual or religious text

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Nurse’s Role in Dying Process

Cancer Council Victoria

Comfort

Apply lip balm to dry lips, and keep the mouth moist with ice cubes.
Add incontinence sheets under the bed sheets.
Use a vaporiser in the room.
Keep the person warm with a blanket and use cushions to make them more comfortable.
Help the person change positions frequently.

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Nurse’s Role in Dying Process

Gentle presence

Sit with the person and talk or hold their hand. Often just being there is all that is needed so that they don’t feel alone.
Gently massage their hands or feet with a non-alcohol- based lotion.
Don’t force-feed even though you may be distressed by their loss of interest in eating.
Speak gently, and occasionally remind the person of the time, place and who is with them.

Cancer Council Victoria

Contact info: info@nursesinternational.org

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Nurse’s Role in Dying Process

Rituals

Ask the person whether a clergy member or other spiritual leader should be at the bedside and what rituals or ceremonies are important to perform.

Funeral home

Notify the chosen funeral home that a death is expected soon. Some people want to keep vigil after the person has died – you can have the body at home for up to five days, so let the funeral home know if this is your wish.

Cancer Council Victoria

Contact info: info@nursesinternational.org

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Nurse’s Role in Dying Process

Contact list

Ask the person who they would like to have visit in the final days and who to call after the death.

Ceremony

Find out what the person would like done with their body after death. Some people have strong views about whether they want to be buried or cremated, what sort of ceremony they want, and what type of memorial they would like.

Cancer Council Victoria

Contact info: info@nursesinternational.org

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What would the nurse do?

What techniques can the nurse use in providing comfort to a patient that is actively dying? (Select all that apply).

The nurse can sit with the person and talk or hold their hand
The nurse can play their favorite music in the background
The nurse can play a movie at medium volume.
The nurse can apply lip balm to dry lips, and keep the mouth moist with ice cubes

Contact info: info@nursesinternational.org

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Reference:

Cancer Council Victoria, n.d. Facing End of Life. Facing End of Life. https://www.cancervic.org.au/get-support/facing-end-of-life/caring-for-someone-nearing-the-end-of-life

Daher, M.,2012. Cultural beliefs and values in cancer patients.Annals of Oncology,Volume 23, Supplement 3,ISSN 0923-7534. Retrieved from:

https://doi.org/10.1093/annonc/mds091

Huffman, J. C., & Stern, T. A. (2003). Compassionate Care of the Terminally Ill. Primary care companion to the Journal of clinical psychiatry, 5(3), 131–136. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC406380/

Contact info: info@nursesinternational.org

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Reference:

Higdon, M.L., Atkinson, C.J., & Lawrence, K.V. (2018). Oncologic Emergencies: Recognition and Initial Management. American Family Physician, 97(11): 741-748. Retrieved from: https://www.aafp.org/afp/2018/0601/p741.html

Pirschel, C. 2018.Oncology Nurse’s Role in Recognizing and Addressing Oncologic Emergencies. ONS VOICE. Retrieved from:https://voice.ons.org/news-and-views/oncology-nurses-role-in-recognizing-and-addressing-oncologic-emergencies

Silveira, M. J. 2021.Advance care planning and advance directives.UpToDate. Retrieved from: https://www.uptodate.com/contents/advance-care-planning-and-advance-directives

Contact info: info@nursesinternational.org

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Reference:

Griffith, W. (2011). Making Memory Last: The Art of Legacy Work. MD Anderson Cancer Center. The University of Texas. Retrieved from: https://www.mdanderson.org/cancerwise/making-memories-last-the-art-of-legacy-work.h00-158673423.html

Contact info: info@nursesinternational.org

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