Essentials in Hospice and Palliative Care:A PRACTICAL RESOURCE FOR EVERY NURSELEARNING ACTIVITIES Katherine Murray RN, BSN, MA, CHPCN(C), FT
Essentials in Hospice and Palliative Care:A PRACTICAL RESOURCE FOR EVERY NURSELEARNING ACTIVITIES RAEevsisPesdReEAdnitCitoTniaIClsAiLnHREoSsOpUicReCaEnFdOPRalElViaEtRiYveNCUaRrSeE:This companion book of Learning Activities is the ideal tool to help you, a Katherinenurse, acquire the knowledge, skills, and attitudes for integrating a palliative RN, BSN, MA,approach into care. It is linked to the competency-based text, Essentials inHospice and Palliative Care: A Practical Resource for Every Nurse. Each activityis designed to help you develop your practice using dynamic explorations ofpalliative care topics, strategically organized to maximize comprehension inthese three categories: • Understanding Your Beliefs and Baggage • Solidifying Concepts • Integrating into Practice Murray CHPCN(C), FTCompleting the Learning Activities will you to: • Identify the common symptoms, possible causes, and • Recognize and describe common patterns of dying pharmacologic and non-pharmacologic strategies to • Articulate the process of providing care help manage symptoms • Describe what is meant by integrating a palliative approach • Distinguish between grief and loss, identify ways to • Develop personal characteristics of best practice, and provide support to a grieving person, and factors that best practice interactions increase a person’s need for extra support • Explain the need for self awareness and therapeutic boundaries • Reflect on your personal response to participating in • Demonstrate strategies for developing self awareness assisted dying and therapeutic boundaries • Become familiar with standardized tools used in • Explain the process for requesting medical assistance in hospice and palliative care and how to use them when dying or physician assisted dying assessing and communicating with the person, family and health care team. • Identify and support the physical and psychosocial • Identify and implement the six steps of providing care needs of the dying person and family in the last days when working with the person and family and hours • Explain the need for self-care and implement strategies that you find nurturing • Identify indicators of compassion fatigue and strategies for preventing compassion fatigueKatherine Murray, RN, BSN, MA, CHPCN(C), FT has a love for hospice and palliative care and a pas-sion for education. She creates exceptional resources that help nurses, health care workers andpersonal support workers provide excellent care for the dying person and their family. Kath’sresources also provide caregivers with strategies to sustain themselves by finding meaning andvalue in the process of providing care. Printed in U.S.A.www.lifeanddeathmatters.ca 1.888.788.6781 [email protected] @LDMatters facebook.com/LifeAndDeathMatters
Essentials in Hospice and Palliative Care:A PRACTICAL RESOURCE FOR EVERY NURSELEARNING ACTIVITIESKatherine MurrayRN, BSN, MA, CHPCN(C)Life and Death MattersVictoria, BC www.lifeanddeathmatters.ca
Copyright © 2017 Life and Death Matters September 2017 All rights reserved. No part of this publication may be reproduced in any form, or by any means, electronic or mechanical, including photocopying, recording, or any information browsing, storage, or retrieval system, without permission in writing from the publisher. Published by Life and Death Matters, Victoria, BC, Canada www.lifeanddeathmatters.ca Illustrations by Joanne Thomson Editing by Ann-Marie Gilbert Design by Greg Glover ISBN 978-1-926923-13-0DisclaimerThis book is intended only as a resource of general education on the subject matter. Every effort has been madeto ensure the accuracy of the information it contains; however, there is no guarantee that the information willremain current beyond the date of publication. The information and techniques provided in this book should beused in consultation with qualified medical health professionals and should not be considered a replacement,substitute, or alternative for their guidance, assessment, or treatment. The author and publisher accept noresponsibility or liability with respect to any person or entity for loss or damage or any other problem caused oralleged to be caused directly or indirectly by information contained in this book.
Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Understanding the Dying Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Integrating a Palliative Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Preparing to Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Using Standardized Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Enhancing Physical Comfort Part 1: Principles of Symptom Management. . . 23 Enhancing Physical Comfort Part 2: Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . 30 Anorexia and Cachexia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Changes in Bowel Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Providing Psychosocial Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Caring in the Last Days and Hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Caring for You!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Answers to physical care and comfort measures puzzle. . . . . . . . . . . 89 Learning Activities – Contents iii
PrefaceThe changes in the number of people dying, the older average age at death, and the decrease in the numberof available caregivers are creating a need for health care providers able to care for the dying person and theirfamily. This primary care team is able to meet this need for the majority of people by integrating hospice andpalliative care into caregiving. Palliative care is no longer only the specialist’s responsibility. Palliative care is everynurse’s responsibility. This is known as “integrating a palliative approach.” To integrate a palliative approach is to integrate the principles, practices, and philosophy of hospice and palliative care into the care of people with any life-limiting illness, early in the illness trajectory, across all care settings. — Kath MurraySupporting nurses to integrate a palliative approach into care is crucial to providing excellent care for thedying. These learning activities, which are based on the text Essentials in Hospice and Palliative Care: A PracticalResource for Every Nurse, are intended to support every nurse to learn the knowledge, skills, and attitudes forintegrating a palliative approach and providing excellent care for the dying. Learning Activities – Preface v
Understanding the Dying Process 1Understanding Your Beliefs and Baggage1. Reflect on the four different patterns (trajectories) of decline and place them in order of your most pre- ferred to least preferred way of dying. Draw and name each pattern on the “flip chart” below. On the right-hand side of the chart, write two reasons why you placed them in the order you did. Learning Activities – Chapter 1: Understanding the Dying Process 1
2. Reflect on the trajectories of decline. a. Which trajectory would you choose for a loved one? b. Is the trajectory you chose for your loved one different from the one you chose for yourself? Explain your answer. c. Is it harder or easier to imagine and choose a path for someone else? Why? Would you choose more or less aggressive interventions for a loved one? Solidifying Concepts3. The 2016 CARES 1 document from the American Association of Colleges of Nursing (AACN) has indicated that new nurses must be able to “identify the dynamic changes in population demographics, health care economics, service delivery, caregiving demands, and financial impact of serious illness on the patient and family that necessitate improved professional preparation for palliative care.” Choose two areas of dynamic change and explain why these changes will require nurses to be better pre- pared to provide palliative care. 1 Ferrell, B, Malloy P, Mazanec P, Virani R. (2016). CARES: AACN’s New Competencies and Recommendations for Educating Undergradu- ate Nursing Students to Improve Palliative Care. Journal of Professional Nursing 32(5), 327–333.2 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
4. Using the stories from the “Common Trajectories of Dying” section in Chapter 1 of the text, complete the table below.Pattern of decline Effects on the person Effects on the family Ways that you as a nurse can 1. 1. support the person and family 1.Sudden death 2. 2. 2. 1. 1. 1.Steady decline 2. 2. 2. 1. 1. 1.Stuttering decline 2. 2. 2. 1. 1. 1.Slow decline 2. 2. 2. Learning Activities – Chapter 1: Understanding the Dying Process 3
5. One principle of hospice and palliative care is that care is person and family centered. Why might this be especially important as a person’s condition declines and as death nears? Integrating into Practice6. Discuss the unique challenges associated with each pattern of decline, and how your awareness of these challenges might help you as a nurse to provide better care for the dying person and family. 4 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Integrating a Palliative Approach 2Understanding Your Beliefs and Baggage1. One key message of the text is that the principles of hospice and palliative care can be integrated into care early in the dying process. Reflect on and write about this idea. Consider whether this is a new concept for you. Describe any aspects of hospice and palliative care that you are already integrating early into care. 2. Dame Saunders’s goal in the 1960s was to provide better care for people who were dying. In your personal and professional experience, what do you think is needed now to provide better care for people who are dying? What steps need to be taken now to effect these changes? How might you, a nurse, advocate for these changes? Learning Activities – Chapter 2: Integrating a Palliative Approach 5
3. Ethics principle 2.2 of the CCPNR states that the nurse’s responsibility is to “advocate for the client to re- ceive fair and equitable access to needed and reasonably available health services and resources.” Describe ways that you advocate and ways that you can incorporate advocacy into your practice. Solidifying Concepts4. Consider the definitions of the following terms and how the terms are used in the community, area, and country where you work or study. a. Palliative care b. Hospice c. End-of-life care d. Integrating a palliative approach 6 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
5. Describe how a dying person and family might benefit when a palliative approach is integrated into their care. 6. Explain how the current model of hospice and palliative care is responsive to the needs of the person and family. 7. Give examples of open-ended questions that might help you identify how to best share information with the person and family about health-related matters. Example: “How do you like to receive information? Alone? In a family meeting?” 8. List the eight Common Issues / Domains of Care identified in the CHPCA Square of Care (see Figure 3 on page 17 in the text). 1. 5. 2. 6. 3. 7. 4. 8. Learning Activities – Chapter 2: Integrating a Palliative Approach 7
9. Choose three Common Issues / Domains of Care from the CHPCA Square of Care and for each one identify four things you might assess. Common Issues / Domains of Care 1. 2. 3. i. i. i. ii. ii. ii. iii. iii. iii. iv. iv. iv.10. Less than 15% to 30% of dying people access hospice and palliative care services. Describe five common barriers to accessing hospice and palliative care services that may affect people in your area. 11. Explain the purpose of the Surprise Question and how it is best used in hospice and palliative care. 8 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Integrating into Practice12. Describe something that you can do in your personal or professional life to help reduce the barriers to ac- cessing care that dying people encounter. 13. Describe five actions you can adopt to integrate a palliative approach into your nursing practice. 14. What might a person be experiencing or what challenges might a team be facing that would or should prompt a referral to a hospice and palliative care team specialist? Learning Activities – Chapter 2: Integrating a Palliative Approach 9
10 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Preparing to Care 3Understanding Your Beliefs and Baggage1. Reflect on an early experience you had related to death, dying, or grief. a. Describe the experience. b. Describe any support you received at the time of this experience. c. How do you feel this experience affected you? Learning Activities – Chapter 3: Preparing to Care 11
2. The baggage that everyone carries includes their personal beliefs and biases about what constitutes a “good” and “bad” death. a. List on the chart below what you consider to be characteristics of a “good” and “bad” death.12 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
b. Where do your beliefs about a “good” and “bad” death originate (e.g., family, culture, personal experi- ences, religion, other influences)? c. Explore with colleagues the similarities and differences in the characteristics of what you consider to be a “good” and “bad” death. 3. Reflect on and write about the value of excellent hospice and palliative care. Learning Activities – Chapter 3: Preparing to Care 13
4. Circle the faces in the illustration below that reflect some of your feelings about working with people who are dying. interested worried afraid ill unsure eager to learn meditative concerned glad I can nervous honoured other offer support5. Describe how compassion can be helpful when providing palliative care. 6. Explain how the personal characteristics and ways of being, which Davies and Steele2 identify as part of best practice, align with the Ethical Responsibilities identified in Canadian Nurses Association Code of Eth- ics for Registered Nurses, “Part 1-A: Providing safe, compassionate, competent and ethical care.3 2 Davies, B., Steele, R., Krueger, G., Albersheim, A., Baird, J., Bifirie, M., Cadell, S., Doane, G., Garga, D., Siden, H., Strahlendorf, C., & Zhao, Y. (2016). “Best practice in provider/parent interaction.” Qualitative Health Research, 1–15. doi:10.1177/10497323166647123 Canadian Nurses Association (2008). “Canadian Nurses Association’s Code of Ethics for Registered Nurses. Centennial Edition.” https://www.cna-aiic.ca/~/media/cna/page-content/pdf-fr/code-of-ethics-for-registered-nurses.pdf?la=en14 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
7. Using a full sheet of paper, organize the 13 components of best practice interactions on the page in a way that will help you to remember them. Consider using mind-mapping, thought diagrams, or organization process charts, and integrating color or shapes to help solidify these strategies in your mind. Use any meth- od that works for you. Identify strategies that you already use and those that interest you or in which you want to increase your competence.8. Explain why therapeutic boundaries are essential for nurses and why boundaries might improve care of the person and family. 9. In pairs or small groups, discuss the following: a. Similarities and differences between your definitions of self-awareness b. Experiences you have had related to death, dying, or grief c. Feelings you have about working with people who are dying d. The concept of baggage that you carry and the need to put your baggage aside when you care for others10. Discuss in pairs or small groups what you might notice about a nurse or other member of the health care team whose therapeutic boundaries are not well defined. Consider what you might notice about yourself if your therapeutic boundaries were not clear. Learning Activities – Chapter 3: Preparing to Care 15
11. Using your own words, describe the concepts of cultural competence and cultural humility. Work in pairs or small groups and discuss the roles of cultural competence and cultural humility in providing excellent care for the dying person and family. Brainstorm ways for nurses to develop their capacity for cultural compe- tence and providing care with cultural humility. Present your ideas to the larger group. 16 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
12. Write your response to the Dignity Question, “What do I need to know about you as a person to give you the best care possible?” or ask the Dignity Question of a friend or family member. Reflect on this experience. Share your answer within a small group. Write about the experience. Describe any difficulties. Did any answers surprise you? Learning Activities – Chapter 3: Preparing to Care 17
18 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Using Standardized Tools 4Solidifying Concepts1. Describe the rationale for using standardized tools. 2. Caregivers in many work settings use the Palliative Performance Scale (PPS) to identify a dying person’s current level of functioning and care needs. List five abilities that are measured on the scale. a. b. c. d. e. 3. Describe the level of functioning and care needs of a person with a PPS of 40%. 4. Describe the level of functioning and care needs of a person with a PPS of 10%. 5. What does each letter in the mnemonic “OPQRSTUV” of the Symptom Assessment Tool represent? Learning Activities – Chapter 4: Using Standardized Tools 19
6. Explain why a tool such as the SBAR is important when working with a health care team. Integrating into Practice7. Explain the benefits of using a screening tool for integrating a palliative approach into acute and long-term care. Consider the screening tools for integrating a palliative approach (GSF PIG, SPICT, tools for prognos- ticating one-year mortality). Identify which one is used at your location, or, if one is not currently in use, which one you might consider using. 20 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
8. Use the IDEA Ethical Decision-Making Framework on page 93 in the text to help you address the ethical issue in this case study. Case Study Mr. Wu is a 73-year-old Chinese-Canadian man in whom lung cancer was diagnosed approximately one year ago. At the insistence of his family, however, Mr. Wu has been told only that he has “lung disease.” He does not know his diagnosis or prognosis. Mr. Wu’s wife died eight years ago, and he has lived alone since then. His disease is clearly advancing, he has lost weight (13 pounds in the past six months—he now weighs 143 pounds), and he is experiencing increasing back pain and difficulty swallowing. He recently was admitted to your nursing facility. His two sons and daughter are married and live in the area. He does not practice any religion or faith. Because Mr. Wu’s family does not want him to know the truth about his illness or his prognosis, he cannot participate in decision making and care planning, a situation that the health care team finds frustrating. Learning Activities – Chapter 4: Using Standardized Tools 21
22 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Enhancing Physical Comfort 5Part 1: Principles of Symptom ManagementUnderstanding Your Beliefs1. Reflect on your experiences of pain. Reflect on experiences of pain that you have witnessed in your family, friends, and other people you know. Consider your beliefs about pain management. Did you grow up in a home in which family members were comfortable with using medications to manage pain, or do you come from a home in which family members opposed the use of medications for pain management? Write about your responses to these questions. Learning Activities – Chapter 5: Enhancing Physical Comfort 23
Solidifying Concepts2. Complete the crossword puzzle on physical care and comfort measures below. 1 23 45789 10 11 613 15 12 17 18 14 16 19 20 21 2224 25 23 2627 28 29Across 2. Sustained-release opioids may be administered using this method involving a ____________________ patch. 4. Constipation is the number one __________________________ that people express about using opioids. 8. __________________________ a medication to the most effective dose. 13. There is no ceiling to the dose of this opioid. 14. A person taking opioids who drifts off to sleep during a conversation, may be experiencing respiratory __________________________. 16. Breakthrough doses are used to manage breakthrough pain, to help with titration, and to __________________________ pain. 17. The principles of symptom management indicate that the focus is on the person’s ________________ of care. 20. People may fear becoming __________________________ on regular doses of opioids.24 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
22. A __________________________ of medications may be more effective than a single medication. 23. The range of serum levels of medication that meet the person’s goals of care for symptom relief is the __________________________ window. 24. Checking a person’s __________________________ function before starting opioids is one step in preventing opioid toxicity. 26. Because it is cleared easily through the kidneys, this is the opioid of choice for people with renal disease. 27. It is advisable to use this method for writing names of medications when the names are similar and could be confused. 28. When opioid prescriptions or medications make their way to the illegal market, this is called __________________________. 29. __________________________ may indicate opioid toxicity. Down 1. One principle of symptom management is to __________________________ the symptom before it escalates. 3. Managing ongoing symptoms requires medications to be administered around the clock, and __________________________. 5. A weak opiate that works well when combined with acetaminophen. 6. This synthetic opioid is 1000 times more potent than morphine, and is used to treat severe pain. 7. If a person begins to __________________________ partially digested food when they are taking opioids, it may mean that the medication has slowed their GI tract. 9. A person with poor __________________________ function may not be able to tolerate morphine. 10. Opioids are used for treating pain and __________________________. 11. The naturally occurring compound found in the resin of poppy plants is an _____________________. 12. When using medications, nurses need to be familiar with three parameters of the medication: onset of effect, time to peak effect, and __________________________ of effect. 15. This opioid is 80 to 100 times more potent than morphine. 18. Morphine, 10 mg PO is equivalent to 5 to 7 mg __________________________. 19. __________________________ pain can occur spontaneously or predictably (e.g., in response to a dressing change). 21. __________________________ is an initial side effect of starting opioids, and may disappear after a few days. 25. Anticipating __________________________ changes in medications includes arranging for common medications to be kept in stock in a variety of different forms. (Answer key is on page 89.) Learning Activities – Chapter 5: Enhancing Physical Comfort 25
3. Circle the principles of palliation that guide the health care team when managing symptoms. a. Focus on the person’s goals of care. b. Use nonpharmacological comfort measures when possible. c. Use medications to manage symptoms only when death is imminent. d. Monitor, record, and report the person’s responses to medications and other comfort measures4. Circle the principles that guide the ordering and administration of medications in hospice and palliative care. a. The health care team determines the goal for pain relief. b. Medications should be given only after pain occurs, not on a regular schedule. c. Breakthrough doses are used when a symptom recurs or continues between regularly scheduled doses. d. A combination of medications may be necessary to control a symptom and any side effects. e. Side effects and fears or concerns about medications should be recorded and reported. f. Nonpharmacological comfort measures may help improve comfort.5. Explain the value of understanding opioid equianalgesia and titration calculations even though nurses are not responsible for ordering opioids. 6. Why are opioids provided regularly, around the clock? 7. Identify guidelines to follow when providing nonpharmacological comfort measures. 26 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
8. Discuss the side effects of using opioids and why a person might be concerned about taking opioids. Alternatively, work in small groups and explore one common side effect associated with taking opioids. Brainstorm ways of communicating with the family when they express concerns about the side effect. Each group can present their findings to the larger group. 9. The family of a dying person is concerned that their loved one is receiving morphine every four hours! And sometimes their loved one receives an extra dose of morphine before bathing. Discuss, in small groups, how to teach family about the need for medication regularly, around the clock, and the use of break- through doses. You may want to use diagrams to support your discussion. Learning Activities – Chapter 5: Enhancing Physical Comfort 27
10. Common myths about opioids can pose significant barriers to opioid use for some people. Identify three common myths and how you might help the person and family to understand the facts. 11. Angela is currently taking morphine 60 mg po, every 4 hours. a. Calculate her 24-hour oral dose of morphine. b. Calculate the following equianalgesic doses for Angela: i. Morphine long acting po q12h ii. Morphine subcutaneous q4h 12. Michael has advanced esophageal cancer and has been taking morphine 60 mg long acting po q12h. He is no longer able to swallow the tablets. The physician/nurse practitioner has ordered a medication change. Calculate equianalgesic doses of these medications. a. Oxycodone rectal q4h b. Dilaudid subcutaneous q4h 28 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
13. Daniel rates his pain at 6/10. His current dose of morphine is 30 mg po q4h. He also received four break- through doses (15 mg po morphine) in the past 24 hours. What might be an appropriate new dose for Daniel? 14. The physician has ordered morphine 50 mg po q4h and morphine 5 mg po for a breakthrough dose. a. What is the problem with the breakthrough dose? Why? b. Calculate the appropriate breakthrough dose (show calculations). Learning Activities – Chapter 5: Enhancing Physical Comfort 29
Enhancing Physical ComfortPart 2: SymptomsAnorexia and CachexiaUnderstanding Your Beliefs1. Imagine that you look in the mirror and you have lost so much weight that you do not recognize the person who stares back at you. Reflect on and write about your feelings. 2. Describe how the following two experiences might feel different and have different meanings: “I have the flu and I am nauseated” versus “I have cancer and I am nauseated.” 30 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
3. Reflect on the role of food in nurturing your family. Hypothesize and describe reasons why a decreasing appetite could be a difficult symptom for your family to witness. Solidifying Concepts4. Describe the similarities and differences between anorexia, cachexia, and anorexia-cachexia syndrome that may occur in a person with life-limiting illnesses. 5. Describe the differences between anorexia-cachexia syndrome and starvation. Learning Activities – Chapter 5: Enhancing Physical Comfort 31
Integrating into Practice6. Family is concerned about their loved one’s weight loss. What information would you share to address their concerns and help them to understand the normal decline in appetite and in intake? 7. Discuss nonpharmacological comfort measures for supporting a person who is experiencing anorexia and cachexia. 32 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Changes in Bowel FunctionUnderstanding Your Beliefs1. Describe your thoughts from the last time you felt constipated or experienced diarrhea. Did you share what you were experiencing with family? Friends? How is sharing information about changes in bowel function different from sharing information when you have a common cold or flu? Solidifying Concepts2. a. List three causes of constipation and provide examples of each. b. What causes diarrhea? What factors may cause this change in bowel function? Learning Activities – Chapter 5: Enhancing Physical Comfort 33
3. When using the Victoria Bowel Performance Scale to assess a person, it is important to know what is nor- mal stool consistency and frequency for that person. Why? 4. Will it be helpful to increase the intake of dietary fiber in the last weeks or days of a person nearing end of life? Explain your answer. 5. Identify five nonpharmacological comfort measures to implement “in the moment” when a person is ex- periencing diarrhea. 6. List five pharmacological treatments that can reduce constipation and increase comfort. 34 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
Integrating into Practice7. Consider the case study on page 132 in the text. Describe the information you would share with Mr. Johnson and his family regarding his constipation. What strategies might you recommend to increase his comfort? Learning Activities – Chapter 5: Enhancing Physical Comfort 35
DeliriumUnderstanding Your Beliefs1. What are your beliefs about delirium? What are your personal or professional experiences with the symp- tom of delirium? 2. Why might delirium be frightening to the person or family? Solidifying Concepts3. a. What is the definition of delirium? b. How would you describe delirium to family? 36 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
4. Identify causes of delirium on the diagram below. Use a highlighter pen to indicate causes that are normal changes in the dying process.5. What are the differences between dementia and delirium? 6. Delirium is more likely to be reversed if it is _______________ ___________ , acted on ______________ , and if the causes are _______________ and can be _____________________. Learning Activities – Chapter 5: Enhancing Physical Comfort 37
Integrating into Practice7. Case Study Marion Beck is a frail 87-year-old woman with moderate dementia. She rates 7, severely frail, on the CSHA Clinical Frailty Scale (she is completely dependent on others for activities of daily living). She has a history of osteoarthritis, back pain, and knee pain. For the past four months, she has taken morphine long acting, 15 mg po q12h. In the last several days, she became very agitated, refusing food and resisting care. Marion no longer rec- ognizes health care providers whom she used to know. She is paranoid that someone is coming to get her and has refused medications, saying they are poison. a. Explain the potential implications of these changes in her behavior. b. Write notes for a verbal report that you will provide to the physician/nurse practitioner, using the SBAR format. c. Identify nonpharmacological comfort measures you could implement immediately. d. What concerns might the family have about Marion, her condition, and the care that the team provides? 38 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
e. If you identify that Marion is experiencing a delirium, would it be appropriate to investigate the cause? Why or why not? 8. What is the significance of Marion’s level of frailty for her prognosis, and how might her frailty affect the decision to investigate or not investigate? 9. In a group, consider Marion’s case and discuss the importance of involving the family in decision making and care planning as much as possible. 10. Why might delirium be an especially difficult symptom for families to witness? Learning Activities – Chapter 5: Enhancing Physical Comfort 39
DyspneaUnderstanding Your Beliefs1. Complete the dyspnea exercise described in the video “Dyspnea—the Feeling of Breathlessness” or as de- scribed in the activity on page 145 of the text. In the space below, answer the reflection questions listed in the activity in the text. 40 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
2. Answer the questions in the first Ethics Touchstone on page 154 in the text. Solidifying Concepts3. Define dyspnea. Learning Activities – Chapter 5: Enhancing Physical Comfort 41
4. Identify in the diagram below the causes of dyspnea.5. The words a person uses to describe their dyspnea may provide insight about the cause of their dyspnea. Identify the three causes of dyspnea that research has linked to the terms “air hunger,” “work,” and “tightness?” 6. What words or phrases might trigger you to assess a person for dyspnea? 42 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse
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