END-OF-LIFE DOUBLE PATIENT
SIMULATION
:
AN EVALUATION OF PRIORITIZATION,
DELEGATION AND THERAPEUTIC
COMMUNICATION DURING AN END-OF-LIFE
SCENARIO IN THE ICU
STACEY LIEUX BSN, RN
JOYCE BRODNIK MSN, RN, CCRN
AMANDA KOEHLER BSN, RN
ANCC
Continuing Nursing Education
International Nursing Association for Clinical Simulation & Learning is
accredited as a provider of continuing nursing education by the
DISCLOSURES
Conflict of Interest
•
Stacey Lieux reports no conflict of interest
•
Amanda Koehler reports no conflict of interest
•
Joyce Brodnik reports no conflict of interest
•
Julia Greenawalt (INACSL Conference
Administrator & Nurse Planner) reports no conflict of
interest
•
Leann Horsley (INACSL Lead Nurse Planner) reports
no conflict of interest
Successful Completion
•
Attend 100% of session
OBJECTIVES
Upon completion of this educational activity, participants will
be able to:
1.
Prioritize the care of a two patient assignment in the ICU
2.
Demonstrate therapeutic communication techniques
ANALYSIS
What is the problem?!
•
Stressful environment in Critical Care
•
Lack of time for self-reflection
•
Managing multiple patients with complex
DESIGN &
DEVELOPMENT
How should we address the problem?
•
Simulation
•
Concept Mapping
IMPLEMENTATION
SIMULATION
•
Two 3G mannequins and two standardized wives are set up in
two separate rooms.
•
The participant gets “report” on both patients:
Patient A is a 37 year old male with GI bleed requiring
a blood transfusion.
Patient B is a 77 year old actively dying intubated
male with orders to terminally wean.
•
The participant chooses who to see first, and in either case, is
met by a wife with many questions and emotional needs. This
is the first touch point.
IMPLEMENTATION
SIMULATION
•
After the first touch point, the participant gets an updated set of
vital signs on both patients. Patient A has been extubated and
Patient B will be requiring a blood transfusion.
•
Again, the participant has an opportunity to prioritize which patient
IMPLEMENTATION
•
Depending on which patient the participant chooses, they will
either be interrupted by Patient A’s hysterical wife or by the
either be interrupted by Patient A’s hysterical wife or by the
participant is being pulled in two directions, requiring them to:
charge nurse with Patient B’s blood for transfusion. The
participant is being pulled in two directions, requiring them to:
* Think critically
* Provide emotional support
* Demonstrate empathy
* Think critically
* Prioritize care
Complete the Concept Map: Fill in each section to the best of your ability. Feel free to add boxes.
Expected Symptoms of Actively
Dying Patient during the Dying Process Nursing Interventions
Death has occurred… Now What??
Who to Notify Code Statuses and What
do they mean?? DNRcc: DNRccA: DNRspecified: Coroners Criteria Resources & Support for
Patient, Family & Staff:
Post-Mortem Care 1 2 3 4 6 5
CONCEPT MAP
Complete the Concept Map: Fill in each section to the best of your ability. Feel free to add boxes.
Expected Symptoms of Actively Dying Patient
•Decrease in activity, speech •Decreased responsiveness/LOC
•Confusion
•Decrease/stop eating & drinking
•Periods of restlessness
•Decrease in body temperature •Skin tone & nail beds have a
gray/blue hue
•Periods of apnea/irregular breathing/Cheyne Stokes
•Fluid in lungs causes rattling
sound in breathing
•Could “see” or speak to deceased
people they think are in the room
•Involuntary twitching
Nursing Interventions during the Dying Process
• Management of pain, N/V, dyspnea to relieve
symptoms and promote comfort (O2,
bronchodilators, diuretics, steroids, MSO4, Fentanyl, Ativan, Versed, Haldol)
• Suction secretions/Swabs • Comfort positioning
• Calm environment (silence alarms, limit activity in room, remove equipment, dim lights) “Code Calm”
• Emotional support to
family & pt. / therapeutic communication.
Encourage to verbalize feelings & talk to patient (hearing last sense to go)
• Cultural sensitivity
• Call LifeBank for possible
Organ Donation Cases
• Bereavement Cart
• “No one dies alone”
Death has occurred… Now What??
•Print a flat line strip
•Have physician
pronounce death and record time
•Turn off ventilator/pacer
•Talk to family
•Verify who will sign the death certificate (MD) Who to Notify •Family •Attending Physician •All consults •Pastoral Care •LifeBank •Funeral Home •Coroner, if applicable •Nursing
End of
Life
Code Statuses and What do they mean??
DNRcc: Only comfort care
before, during or after heart or breathing stops.
DNRccA: All life support
measures until the heart or breathing stops (meds, etc)
DNRspecified: Valid ONLY
at CCF- pt can modify DNR
*Ohio law recognizes 2 categories of DNR orders: DNRcc & DNRccA. CCF also allows for a DNRspecified (not recognized outside of CCF) Coroners Criteria • Recent fall • Recent procedure • < 24 hours in the hospital • Died in restraints • GSW, suicide • Call Coroner if
Resources & Support for Patient, Family & Staff:
•Pastoral Care/Spiritual Care/Chaplain
•Clergy member from
church •Extended family members •Code Lavender •Reiki/Healing Touch/Relaxation Techniques/Guided Imagery/Meditation •Concern/Caring for Caregivers •Hospice/Palliative Care •Ombudsman •Nursing Supervisor •Social Worker/Case Mgr. •Child Life Specialist
•Ethics Consult
•Comfort Care Order Sets
•Offer Family Conference
Post-Mortem Care
•Bathe patient and clean room
•Ice to eyes (if Lifebank)
•Place body in
body bag
•Secure ankles &
wrists w/pads & kerlix •Keep all belongings with body if no family available •What lines do we remove? (coroner case=none; non-coroner case=all) •Obtain morgue cart from morgue
•Transport body to
