SEMINAR ON CARDIOPULMONARY RESUSCITATION AND END OF LIFE CARE

SUBMITTED TO: Mr. Shashidhara G.S., Assot. Professor, H.O.D. Community Health Nursing, College of Nursing, GGSMHT.

SUBMITTED BY: Ms. Jinsha Joseph I year M.Sc Nursing Student, Dept of OBG Nursing, College of Nursing, GGSMHT.

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Sl No
I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 II 1 2 3 4 5 6 7 8 9 10 11 12 III

INDEX Content
CARDIOPULMONARY RESUSCITATION Introduction Definition Purpose Indications for CPR Types of resuscitation Sequence of resuscitation in BLS Principles of resuscitation Techniques of BLS Methods of CPR Basic life support for adults CPR in children CPR in Infants After care of the patient Advanced cardiac life support ACLS team Complications of CPR Effectiveness of CPR Chest compression adjuncts Prevalence Equipments for assisting with cardiac resuscitation Conclusion END OF LIFE CARE Introduction Definition Concept of palliative care Palliative care and hospice Goals Principles of palliative care Different aspects of hospice care Signs of approaching death Signs of death Needs to be done after the patient has died Theories related to end of life care Conclusion BIBLIOGRAPHY

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3-22 3 3 3-4 4-6 6 6 6-7 7-9 9-11 11-13 13-14 14 14-15 15-16 16-17 18 18-19 19-20 20-21 22 22 23-32 23 23-24 24-25 25 25 25 26-29 29-30 31 31 32-33 34 35-36

CARDIOPULMONARY RESUSCITATION
INTRODUCTION: An emergency is the unforeseen events which call for prompt and quick action to save the life of a person or to prevent from further severe damage. When nurses are happened to be at the site when an

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emergency arises, nurses may have to deal with it promptly with knowledge and skill and also use confidentiality. Cardiopulmonary resuscitation is a life-saving technique to be performed with skill and practice. When a nurse comes across a victim with cardiopulmonary arrest, she is expected to have quick assessment of cardiopulmonary arrest because; it is the critical factor in time. Cardiopulmonary resuscitation is an emergency treatment that is provided without client consent. It is a procedure that is performed on an appropriate client unless a DNR (Do not resuscitate) order is written in the clients chart. It is vital that all nurses be trained to perform CPR so resuscitation measures can be initiated immediately when a cardiac arrest or respiratory arrest occurs. Nurses also can be instrumental in increasing community awareness of the need for CPR training and ensuring its availability. DEFINITION: Cardiopulmonary resuscitation (CPR) is a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilator action. Cardiopulmonary resuscitation is a combination of oral resuscitation (mouth-to-mouth breathing), which supplies oxygen to the lungs, and external cardiac massage (chest compression), which is intended to reestablish cardiac function and blood circulation. CPR is also referred to as basic life support (BLS. CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling into the patient (or using a device to simulate this) to inflate the lungs and pass oxygen in to the blood, called artificial respiration. The ABCs of cardiopulmonary resuscitation are to establish an Airway, initiate Breathing, and maintain Circulation. PURPOSES: CPR is unlikely to restart the heart; its main purpose is to maintain a flow of oxygenated blood to the brain and the heart, thereby delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage. Advanced life support and defibrillation, the administration of an electric shock to the heart, is usually needed for the heart to restart. This only works for patients in certain heart rhythms, namely ventricular fibrillation or pulseless ventricular tachycardia, rather than the 'flat line' asystolic patient although CPR can help induce a shockable rhythm in an arrested patient.

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For a patient with an advanced life-threatening illness who is dying, there are really no benefits. CPR may prolong life for patients with a better health status or who are younger. CPR may also prolong life if it's done within 5 to 10 minutes of when the person's heart stopped beating or breathing stopped. INDICATIONS FOR CPR: 1. Cardiac Arrest: A cardiac arrest is the cessation of cardiac function; the heart stops beating. Often a cardiac arrest is unexpected and sudden. When it occurs, the heart no longer pumps blood to any of the organs of the body. Breathing then stops and the person becomes unconscious and limp. Within 20 to 40 seconds of a cardiac arrest the victim is clinically dead. After 4 to 6 minutes the lack of oxygen supply to the brain causes permanent and extensive damage. The main causes of cardiac arrest are: a. Ventricular fibrillation b. Ventricular tachycardia c. Asystole d. Pulseless electrical activity Signs and symptoms of cardiac arrest: The three cardinal signs of a cardiac arrest are apnea, absence of a carotid or femoral pulse, and dilated pupils. The persons skin appears pale or grayish and feels cool. Cyanosis is evident when respiratory function fails prior to heart failure. Apnoea: Apnoea which indicates respiratory failure can be diagnosed by the absence of movements of the chest and abdominal muscles, by noting the retraction of the soft tissues in the patients suprasternal and intercostals spaces which indicates airway obstruction and not feeling the exhalations when the ear is placed next to patients face. Absence of a carotid or femoral pulse: Pulse in the large arteries close to the heart is palpable even when the peripheral pulse is absent. Carotid pulse can be checked easily. It is palpable by gentle pressure over the depression between the trachea and the sterno-cleido-mastoid muscle at the level with the adams apple. Absence of carotid pulse indicates cardiac arrest.

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Dilated Pupils: Cerebral hypoxia (lack of oxygen to the brain tissues) causes lose of muscle control in the entire body, including eyes. Pupils that are dilated and do not react to light indicate that the patient is having a cardiac arrest. It is because; the centers in the brain that controls the movements of the iris of eyes are not receiving enough oxygen to cause normal response (constriction of pupils) of the iris to light. The other signs and symptoms include cyanosis, unconsciousness, fit (grand mal seizure) and complete loss of muscle tone. Cyanosis: Cyanosis is developed due to the lack of oxygenation of blood resulting from hypoventilation of the lungs and circulatory failure. Unconsciousness: Hypoxia of the cerebral cortex causes unconsciousness. Brain cells are very sensitive to the paucity of oxygen than any other tissues of the body. To make sure whether the patient is sleeping or drowsy with alcoholism etc., call the patient by name shouting in his ears and then shaking him. Mild hypoxia leads to confusion and disorientation. Fit (grand mal seizure): This is also occurring due to cerebral anoxemia. 2. Respiratory arrest: A respiratory arrest (pulmonary arrest) is the cessation of breathing. It occurs as a result of a blocked airway, but it can occur following a cardiac arrest and for other reasons. A respiratory arrest may occur abruptly or be preceded by short; shallow breathing that becomes increasingly labored. The main causes of respiratory arrest are: a. Drowning b. Stroke c. Foreign body airway obstruction d. Smoke inhalation e. Drug overdose f. Electrocution/ injury by lightening g. Suffocation h. Accident/ injury i. Coma j. Epiglotitis TYPES OF RESUSCITATION:

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There are two types of resuscitation based on the setting and methods it is delivered. They are Basic life support, and Advanced cardiac life support

SEQUENCE OF RESUSCITATION IN BLS: When the victim appears unconscious, or lifeless the ABC of resuscitation needs to be performed in order to assess his/her most urgent needs. Once the nurse is sure that there is no danger carry out assessment on the basis of ABC rules. This should be done as quickly as possible following these steps: Check for consciousness - by shaking shoulders and asking him Open the airway (A) by removing blockages and lifting chin. Check breathing (B) by looking for chest movements, listening for sounds of breathing and feeling for breath for 5 seconds. Check for circulation (C) by feeling for the carotid pulse for 5 seconds.

PRINCIPLES OF RESUSCITATION: Resuscitation is defined as restoration to life or consciousness of the person whose respirations have ceased. It is an emergency technique used in cardiac disorders to re-establish heart and lung functions, until more advanced life support is available. It is vital to maintain a constant supply of oxygen to the brain. Tissue gets oxygen by the blood circulation. Heart maintains this circulation acting as a pump. If the heart stops functioning, death will result, unless an urgent action is taken. The flow of oxygenated blood is rapidly restored to the brain by means of artificial ventilation and chest compression. The victim is rushed to hospital for further care. Defibrillation is carried out immediately. The CPR bridges the gap between arrival of ambulance and casualtys collapse. The principles of resuscitation includes (i) Clear airway (ii) Review breathing (iii) Restore circulation

TECHNIQUES OF BLS:

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There are mainly to important technique are involved in basic life support procedure. They are Artificial respiration, and External cardiac massage.

ARTIFICIAL RESPIRATION The first step in CPR is to give artificial respiration. Artificial respiration is a lifesaving method used to restore breathing to a person whose breathing has stopped. If breathing has stopped, the victim will soon become unconscious. There will be no chest movement, and the skin will be pale or a slightly bluish colour. When breathing stops there is no oxygenation of the blood and irreversible brain damage or death may occur in as little as three to six minutes. Therefore it is important to start artificial respiration as soon as possible and continue until medical help arrives. If breathing restarts and becomes regular, the victim should be observed continuously until medical help arrives. The most common and efficient method of artificial respiration is mouth-to-mouth resuscitation. Mouth-to-Mouth Resuscitation

Assess the responsiveness of the patient by gently shaking the victim and shouting "Are you OK"? This precaution will prevent us from injuring during resuscitation someone who is not truly unconscious.

Ask someone nearby to call for Medical Help. Move the victim away from any dangerous location, that is, locations close to harmful gases, fire, etc. Place the victim face up on a firm surface, such as the floor or the ground. Open the Airway. One very important step in the resuscitation process is to immediately open the airway. Quite often the tongue may block the passage of air into the air passages. To open the airway, one hand must be placed on the victim's forehead and firm, backward pressure with the palm is applied to tilt the head back. If there is a suspicion of neck injury, the head should not be moved unless it is absolutely necessary to open the airway. Place the fingers of the other hand just under the chin and lift to bring the chin forward. If there is material like vomitus or any foreign body that appears to block the air passages it must be removed.

Ascertain whether the patient is breathing: With the airway open, look at the chest for signs of breathing. Put your ear next to the nose and mouth and listen for breathing. Feel for the flow of air. If there is no breathing, begin artificial respiration.

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Mouth-to-Mouth Resuscitation: Place one hand on the victim's forehead to pinch the victim's nose closed. Ensure that your breathing is regular. Take a deep breath and place your mouth tightly over the victim's mouth. If you wish you may place a thin handkerchief between your mouth and the victim's mouth. However, do not use a very thick cloth, as it may be difficult to blow through it. Blow until the victim's chest rises. Listen for air being passively exhaled. Repeat with breaths at the rate of 12 times per minute. Children should receive smaller breaths repeated at the rate of 20 times per minute.

EXTERNAL CARDIAC MASSAGE The aim of external cardiac massage is to cause the heart to pump blood to the other parts of the body. It should be started simultaneously with artificial respiration in a victim whose heart has stopped beating (as made out by an absent pulse in the neck or groin). The rescuer should place the heel of the palm of one hand parallel to and over the lower part of the victim's sternum (breastbone), 1 to 1.5 inches from its tip. The rescuer puts the other hand on top of the first and brings the shoulders directly over the sternum. The rescuer's fingers should not touch the victim's chest. Keeping the arms straight, the rescuer pushes down forcefully on the sternum. This action, called external cardiac compression, results in blood flow from the heart to other parts of the body. The rescuer alternately applies and releases the pressure at a rate of about 60 compressions per minute. Each time after 30 compressions, the rescuer gives the victim artificial respiration (two breaths). The ratio of 30 cardiac compressions to 2 breaths is commonly followed. If the victim is a small child, then the rescuer must use only one hand for the cardiac compression. For infants, the pressure is exerted using the index and middle fingers at the middle of the sternum. In all cases, the compressions must be accompanied by artificial respiration. Treatment should continue until medical help arrives. CPR is best performed by two trained persons. One should administer external cardiac compression, and the other should provide artificial respiration. The rescuers should position themselves on opposite sides of the victim so they can switch roles easily if either becomes fatigued. METHODS OF CPR: The methods include:

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ILCOR Compression only resuscitation Rhythmic abdominal compressions Internal cardiac massage Self-CPR hoax

International Liaison Committee on Resuscitation (ILCOR) In 2005, CPR guidelines were published by the International Liaison Committee on Resuscitation (ILCOR), agreed at the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. The primary goal of these changes was to simplify CPR for lay rescuers and healthcare providers alike, to maximize the potential for early resuscitation. The important changes for 2005 were:

A universal compression-ventilation ratio (30:2) recommended for all single rescuers of infant (less than one year old), child (1 year old to puberty), and adult (puberty and above) victims (excluding newborns). The primary difference between the age groups is that with adults the rescuer uses two hands for the chest compressions, while with children it is only one, and with infants only two fingers (index and middle fingers. While this simplification has been introduced, it has not been universally accepted, and especially amongst healthcare professionals, protocols may still vary.

The removal of the emphasis on lay rescuers assessing for pulse or signs of circulation for an unresponsive adult victim, instead taking the absence of normal breathing as the key indicator for commencing CPR.

The removal of the protocol in which lay rescuers provide rescue breathing without chest compressions for an adult victim, with all cases such as these being subject to CPR. Research has shown that lay personnel cannot accurately detect a pulse in about 40% of cases and

cannot accurately discern the absence of pulse in about 10%. The pulse check step has been removed from the CPR procedure completely for lay persons and de-emphasized for healthcare professionals. Compression only resuscitation The traditional International Liaison Committee on Resuscitation approach described above has been challenged in recent years by advocates for compression-only CPR, also known as cardiocerebral resuscitation (CCR). This technique is simply chest compressions without artificial respiration. The

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respiration component of CPR has been a topic of major controversy over the past decade. The CCR method has been championed by the University of Arizona's Sarver Heart Center. A study by the university claimed a 300% greater success rate over standard CPR. The exceptions were in the case of drowning or drug overdose. In March 2007, a Japanese study in the medical journal The Lancet presented strong evidence that compressing the chest, not mouth-to-mouth (MTM) ventilation, is the key to helping someone recover from cardiac arrest. An editorial by Gordon Ewy MD (a proponent of CCR) in the same issue of The Lancet called for an interim revision of the ILCOR Guidelines based on the results of the Japanese study, but the next scheduled revision of the Guidelines was not until 2010. However, on March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that compression-only CPR works as well as, and sometimes better than, traditional CPR. The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the blood flow moving without the interruption caused by MTM respiration. It has been claimed that the use of compression only delivery increases the chances of lay person delivering CPR. Rhythmic abdominal compressions Rhythmic abdominal compression-CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected to other sites, including the circulation around the heart. Findings published in the September 2007 issue of the American Journal of Emergency Medicine using pigs found that 60 percent more blood was pumped to the heart using rhythmic abdominal compression-CPR than with standard chest compression-CPR, using the same amount of effort. There was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. Avoiding mouth-tomouth breathing and chest compressions eliminates the risk of rib fractures and transfer of infection. Internal cardiac massage Internal cardiac massage is the process of cardiac massage carried out through a surgical incision into the chest cavity. This distinguishes the process from conventional, external cardiac massage, which is carried out by compression near the sternum during cardiopulmonary resuscitation. Self-CPR hoax

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A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled "How to Survive a Heart Attack When Alone" which wrongly cited "ViaHealth Rochester General Hospital" as the source of the technique. Rochester General Hospital has denied any connection with the technique. Rapid coughing has been used in hospitals for brief periods of cardiac arrhythmia on monitored patients. One researcher has recommended that it be taught broadly to the public. However, cough CPR cannot be used outside the hospital because the first symptom of cardiac arrest is unconsciousness in which case coughing is impossible, although myocardial infarction (heart attack) may occur to give rise to the cardiac arrest, so a patient may not be immediately unconscious. Further, the vast majority of people suffering chest pain from a heart attack will not be in cardiac arrest and CPR is not needed. In these cases attempting cough CPR will increase the workload on the heart and may be harmful. When coughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90 seconds. The American Heart Association (AHA) and other resuscitation bodies do not endorse "Cough CPR", which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a limited legitimate use of the coughing technique: "This coughing technique to maintain blood flow during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. In such cases the patients ECG is monitored continuously, and a physician is present." BASIC LIFE SUPPORT FOR ADULTS: Assess the unresponsiveness, observe for spontaneous respirations, palpate carotid pulse. Call for help and place the victim supine on firm, flat surface or use a back board. Kneel at victims side. A. Airway After unresponsiveness has been determined, the airway is opened using the head-tilt or chin-lift maneuver. A Guedal airway may be used to maintain patency of the airway until such time as endotrachial intubation occurs. To clear the airway, remove obstructing substance from the mouth with finger. - Use first finger as a hook to dislodge any material causing obstruction. - Hyperextend the neck to open the airway. - Place one hand under nape of neck. - Place other hand on forehead and tilt head back.

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- Lift chin up gently without closing mouth. - Check if breathing is restored. - If not, start mouth to mouth breathing. B. Breathing After airway is opened, assessment for respiration is conducted. Once absence of breathing is determined, artificial respiration using the mouth-to-mouth method is started. The rescuer is expected to act quickly and restore breathing by giving mouth-to-mouth resuscitation as follows: - Pinch and compress nose to close nostrils. - Take deep breathe. - Place your mouth around victims mouth, make an airtight seal.
- Quickly breathe into victims mouth two times.

- Refill your lungs by inhaling deep after stopping breathe. - Watch victims chest movements for rise and fall of chest. - Allow patient to exhale. In a hospital or clinic, resuscitation should be performed using a self-inflating (Ambu) bag attached to an oxygen source rather than mouth-to-mouth as a greater volume of oxygen is delivered under more controlled conditions. C. Circulation Circulation is checked by palpating the carotid pulse. If no pulse is found, external chest compression is started immediately. This consists of the regular application of vertical pressure at a point one-third up the sternum from its tip (xiphoid process). The rescuer is expected to act quickly and restore circulation by pericardial thump and/or external cardiac compression. First the rescuer should try pericardial thump by striking upper left-chest forcibly midsternum region with closed fist (except MI cases). This may result in resuscitation of normal heartbeat. If you are succeeding to get good results start external cardiac compression by following steps given below: - Place the victim on hard surface and kneel at victims side. - Locate heel xiphoid process, measuring 1-2 above xiphoid process. - Place heel of one hand at this point on the sternum. - Place the other hand on top of it. - Interlock the fingers to keep them off the victims ribs. - Keep elbows straight and lean forward.

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- Make dull use of your body weight when delivering downward compression.
- Apply steady smooth pressure to depress victims sternum 1.5-2 (2-4cm).

- Then relax pressure completely but do not let your hand leave victims chest or you may lose correct hand position. - Repeat or perform CPR for 1 minute as follows.
- After 30 chest compression give 2 quick lung inflation by mouth to mouth breathing and then two

more inflation if carotid pulse absent.

- Resume CPR by alternating lung inflations with chest depression.

If one rescuer is present, compressions are interrupted every 30 compressions for the lungs to be ventilated twice. Earlier, if two rescuers are present, one ventilation is delivered every five compressions. But now it is at the same rate, that is, 30:2. CPR IN CHILDREN: Sudden cardiac arrest is less common in children than it is in adults. It usually happens when there is a lack of oxygen caused by a breathing problem such as choking, near-drowning, or respiratory infections. Because oxygen often corrects the problem in a child, when an unresponsive, non-breathing child is found, CPR is performed for 1 minute before activating the EMS system. This may reverse the lack of oxygen and revive the child. Doing CPR on children aged one year to eight years is similar to doing CPR on adults. However, there are some minor differences. Most are due to the child's smaller size. Proper hand position: 1. 2.
3.

a.

Locate low margin of victims rib cage on side next to rescuer with middle and index fingers. Follow margin of rib cage with middle finger to notch where ribs and sternum meet. Place index finger next to middle finger. Place heel of hand next to point where index finger was located, with long axis of heel parallel to sternum. Rescuers other hand maintains childs head position.

4.
5.

b.

Compress sternum with one hand 1to 1 inch at the rate of 100 times/ minute. At end of every fifth compression, allow a pause for ventilation. (1-1 seconds). Reassess victim after 10 cycles (30 compressions, 2 ventilation each cycle). CPR IN INFANTS:

c.

d.

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An infant is defined as a child younger than one year of age. Because an infant is smaller than a child, the CPR technique for infants contains further changes. a. Proper hand position: 1. 2. Draw imaginary line between nipples over breast bone (sternum). Place index finger of hand farthest from infants head just under inframammary line where it intersects sternum. b. Using two or three fingers, compress to 1 inch at least 100 times/ minute. c. At end of every fifth compression, allow a pause for ventilation. 1 seconds.
d. Reassess victim after 10 cycles (30 compressions, 2 ventilation each cycle).

AFTER CARE OF THE PATIENT: 1. 2.

3.

Skilled after care of the patient who has suffered cardiac arrest is crucial for survival. The patient If the patient is not in the intensive care unit, shift him to the ICU for constant observation and Give oxygen continuously for 48 hours following resuscitation. This is necessary because Frequently check the victims head and jaw positions because his tongue may fall back and Assess the patients respirations by noting the rhythm, rate and depth of respiration. Check the colour of the skin. Persisting cyanosis indicates inadequate oxygen of blood. Watch for the signs of restored circulation and respiration. They are: Contraction of pupils Improved colour Change in the quality of pulse Free movements of the chest wall and no retraction of muscles over the intercostals space. Return of systemic blood pressure Struggling movements. Temperature is taken every hour. A high temperature usually indicates cerebral damage or cerebral Watch for convulsions. It may occur due to brain damage or acidosis.

should be continually watched by skilled persons over a period of 48 to 72 hours. expert care. respirations are depressed for some time after the cardiac arrest. 4. 5. 6.
7.

obstruct the airway.

e. f. g. h. i. j. 8. 9.

edema. Temperature should be brought under normal limits by appropriate methods.

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10. 11. 12. 13.

14.

Insert endotracheal tube, if not already in place. This maintains an open airway for the unconscious Insert Foleys catheter. Urine output is one of the measures of the cardiovascular status. Report if Start IV infusions to administer enough fluids in the patient. Blood gas and pH determinations are done to detect metabolic acidosis. Watch for the complications that might have occurred during the procedure. Record the procedure on the nurses record with date and time.

patient who can not clean secretions by coughing. the urinary output is below 30ml per hour.

15.

ADVANCED CARDIAC LIFE SUPPORT: Advanced life support and defibrillation, the administration of an electric shock to the heart, is usually needed for the heart to restart. This only works for patients in certain heart rhythms, namely ventricular fibrillation or pulse less ventricular tachycardia, rather than the 'flat line' asystolic patient although CPR can help induce a shockable rhythm in an arrested patient. Resuscitation challenges care providers to make decisions quickly and under pressure. Providers must occasionally limit their focus for a brief time to a specific aspect of the resuscitative attempt: getting the IV infusion line started, placing the tracheal tube, identifying the rhythm, and remembering the "right" medication to order. But rescuers constantly must return to an overall view of each resuscitative attempt. The flow diagrams or algorithms focus the learner on the most important aspects of a resuscitative effort: airway and ventilation, basic CPR, defibrillation of VF, and medications suitable for a particular patient under specific conditions. ACLS TEAM: The team leader should be decisive and composed. The team should stick to the ABCs (airway, breathing, and circulation) and keep the resuscitation room quiet so that all personnel can hear without repetitious commands. Team members should

State the vital signs every 5 minutes or with any change in the monitored parameters State when procedures and medications are completed Request clarification of any orders Provide primary and secondary assessment information

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The team leader should communicate her or his observations and should actively seek suggestions from team members. Evaluation of airway, breathing, and circulation should guide the efforts whenever the vital signs are unstable, when treatment appears to be failing, before procedures, and for periodic clinical updates. The Primary and Secondary ABCD Surveys: All who respond to cardio respiratory emergencies should arrive well trained in a simple, easy-toremember approach. The ACLS Provider Course teaches the Primary and Secondary Survey Approach to emergency cardiovascular care. This memory aid describes 2 sets of 4 steps: A-B-C-D (8 total steps). With each step the responder performs an assessment and then, if the assessment so indicates, a management. Conduct the Primary ABCD Survey: The Primary ABCD Survey requires your hands (gloved!), a barrier device for CPR, and an AED for defibrillation. The Primary ABCD Survey assesses and manages most immediate life threats:

Airway: Assess and manage the Airway with noninvasive techniques. Breathing: Assess and manage Breathing with positive-pressure ventilations. Circulation: Assess and manage the Circulation, performing CPR until an AED is brought to the scene. Defibrillation: Assess and manage Defibrillation, assessing the cardiac rhythm for VF/VT and providing defibrillator shocks in a safe and effective manner if needed.

Conduct the Secondary ABCD Survey: This survey requires medically advanced, invasive techniques to again assess and manage the patient. The rescuer attempts to restore spontaneous respirations and circulation to the patient and when successful, continues to assess and manage the patient until relieved by appropriate emergency professionals. In brief: resuscitate, stabilize, and transfer to higher-level care.

Airway: Assess and manage. Advanced rescuers manage a compromised airway by placing a tracheal tube. Breathing: Assess and manage. Assess adequacy of breathing and ventilation by checking tube placement and performance; correct all problems detected. Manage breathing by treating inadequate ventilation with positive-pressure ventilations through the tube.

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Circulation: Assess and manage the circulation of blood and delivery of medications by Starting a peripheral IV line Attaching ECG leads to examine the ECG for the most frequent cardiac arrest rhythms (VF, pulseless VT, asystole, and PEA) Administering appropriate rhythm-based medications

Differential Diagnosis: Assess and manage the differential diagnoses that you develop as you search for, find, and treat reversible causes.

The Resuscitation Attempt as a "Critical Incident": Code Critique and Debriefing: After any resuscitation attempt team members should perform a code critique. In busy emergency or casualty departments, carving out the necessary few minutes can be difficult. The lead physician, however, should assume responsibility to gather as many team members as possible for at least a pause to reflect. This debriefing provides feedback to prehospital and in-hospital personnel, gives a safe venue to express grieving, and provides an opportunity for education. COMPLICATIONS OF CPR: Pressing on the chest can cause a sore chest, broken ribs or a collapsed lung. Patients with breathing tubes usually need medicine to keep them comfortable. Some patients who survive may need to be on a breathing machine in the intensive care unit (ICU) to help them breathe for a while after they receive CPR. Few patients (less than 10%) in the hospital who have had CPR survive and are able to function the way they used to. Many patients live for a short time after CPR, but still die in the hospital. CPR may also prolong the dying process. Patients who have more than one illness usually don't survive after CPR. Almost no one with advanced cancer survives CPR and lives long enough to leave the hospital. Of the few patients who do, many get weaker or suffer brain damage. Some patients may need to live on a breathing machine for the rest of their lives. o Damage to the cervical spine due to hyper-extension of the neck. o Injuries such as fractures of the ribs or sternum o Laceration of the liver with internal bleeding and o Injury of the lungs causing pneumothorax and hemothorax. o Gastric distension with air and intra-abdominal hemorrhage.
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o Aspiration of vomitus in to lungs. These occurrences can be minimized by careful attention to proper techniques. To provide basic life support, air must enter the lungs and the heart must be compressed by a smooth, regular, and uninterrupted force. Effective CPR is mandatory, even if it results in complications, since the alternative is death. EFFECTIVENESS OF CPR: Used alone, CPR will result in few complete recoveries, and those who do survive often develop serious complications. Estimates vary, but many organizations stress that CPR does not "bring anyone back," it simply preserves the body for defibrillation and advanced life support. However, in the case of "non-shockable" rhythms such as Pulseless Electrical Activity (PEA), defibrillation is not indicated, and the importance of CPR rises. On average, only 5%-10% of people who receive CPR survive. The purpose of CPR is not to "start" the heart, but rather to circulate oxygenated blood, and keep the brain alive until advanced care (especially defibrillation) can be initiated. As many of these patients may have a pulse that is impalpable by the layperson rescuer, the current consensus is to perform CPR on a patient who is not breathing. Studies have shown the importance of immediate CPR followed by defibrillation within 35 minutes of sudden VF cardiac arrest improves survival. In cities such as Seattle where CPR training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as New York City, without those advantages, the survival rate is only 1-2 percent. In most cases, there is a higher proportion of patients who achieve a Return of Spontaneous Circulation (ROSC), where their heart starts to beat on its own again, than ultimately survive to be discharged from hospital (see table below). This is due to medical staff either being ultimately unable to address the cause of the arrhythmia or cardiac arrest, or in some instances due to other co-morbidities, due to the patient being gravely ill in more than one way. Type of Arrest Witnessed In-Hospital Cardiac Arrest Unwitnessed In-Hospital Cardiac Arrest Bystander Cardiocerebral Resuscitation No Bystander CPR (Ambulance CPR) ROSC Survival 48% 21% 40% 15% 22% 1% 6% 4% 2%

Bystander Cardiopulmonary Resuscitation 40%

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Defibrillation within 35 minutes ROSC = Return of spontaneous circulation CHEST COMPRESSION ADJUNCTS:

74%

30%

Several devices have become available in order to help facilitate rescuers in getting the chest compressions completed correctly. These devices can be split in to three broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especially depth and speed of compressions, and those which take over the process completely. Timing devices They can feature a metronome (an item carried by many ambulance crews) in order to assist the rescuer in getting the correct rate. The CPR trainer will have timed indicators for pressing on the chest, breathing and changing operators. Manual assist devices Studies have shown that audible and visual prompting can improve the quality of CPR and prevent the decrease of compression rate and depth that naturally occurs with fatigue, and to address this potential improvement, a number of devices have been developed to help improve CPR technique. These items can be devices to place on top of the chest, with the rescuers hands going over the device, and a display or audio feedback giving information on depth, force or rate, or in a wearable format such as a glove. Several published evaluations show that these devices can improve the performance of chest compressions. As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying the device with them, these devices can also be used as part of training programmes to improve basic skills in performing correct chest compressions. Certain defibrillation pads are capable of performing similar function, in that they may display rate and depth of compressions. Additionally, a certain algorithm may allow them to monitor electrical activity even during CPR. Automatic devices

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There are also some devices available which take over the chest compressions for the rescuer. These devices use techniques such as pneumatics to drive a compressing pad on to the chest of the patient. One such device, known as the LUCAS, was developed at the University Hospital of Lund, is powered by the compressed air cylinders or lines available in ambulances or in hospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusion pressure and return of spontaneous circulation. Another system called the Auto Pulse is electrically powered and uses a large band around the patients chest which contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studies showing increased successful return of spontaneous circulation. PREVALENCE: Chance of receiving CPR Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family members attempt CPR in between 14% and 45% of the time, with a median of 32%. This indicates that around 1/3 of out-of-home arrests have a CPR attempt made on them. However, the effectiveness of this CPR is variable, and the studies suggest only around half of bystander CPR is performed correctly. There is a clear correlation between age and the chance of CPR being commenced, with younger people being far more likely to have CPR attempted on them prior to the arrival of emergency medical services. It was also found that CPR was more commonly given by a bystander in public than when an arrest occurred in the patient's home, although health care professionals are responsible for more than half of out-of-hospital resuscitation attempts. This is supported by further research, which suggests that people with no connection to the victim are more likely to perform CPR than a member of their family. This is likely because of the shock experienced by finding a family member in need of CPR; it is easier to remain calm - and think clearly - when the person in need of CPR is a complete stranger, as in this case one will not be as frightened. There is also a correlation between the cause of arrest and the likelihood of bystander CPR being initiated. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medical cause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.

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Finally, it has been claimed that there is a higher chance of CPR being performed if the bystander is told to only perform the chest compression element of the resuscitation. Chance of receiving CPR in time CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops, because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 46 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 7243 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge. A notable exception is cardiac arrest occurring in conjunction with exposure to very cold temperatures. Hypothermia seems to protect the victim by slowing down metabolic and physiologic processes, greatly decreasing the tissues' need for oxygen. There are cases where CPR, defibrillation, and advanced warming techniques have revived victims after substantial periods of hypothermia. EQUIPMENTS FOR ASSISTING WITH CARDIAC RESUSCITATION: The following equipments are necessary for assisting with cardiopulmonary resuscitation and defibrillation: - Short or long spine board to provide rigid support during CPR efforts - An automated external defibrillator - A mechanical CPR compressor (eg., Thumper)-especially helpful for doing CPR for services with transports over 15 minutes to the hospital. - Artificial respiratory unit bag. CONCLUSION: Cardiopulmonary resuscitation (CPR) is an emergency procedure for people in cardiac arrest or, in some circumstances, respiratory arrest. CPR is performed in hospitals and in the community. CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling into the patient (or using a device to simulate this) to inflate the lungs and pass oxygen in to the

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blood, called artificial respiration. Some protocols now downplay the importance of the artificial respirations, and focus on the chest compressions only.

END-OF-LIFE CARE
When a patient's health care team determines that the cancer can no longer be controlled, medical testing and cancer treatment often stop. But the patient's care continues. The care focuses on making the patient comfortable. The patient receives medications and treatments to control pain and other symptoms, such as constipation, nausea, and shortness of breath. Some patients remain at home during this time, while others enter a hospital or other facility. Either way, services are available to help patients and their families with the medical, psychological, and spiritual issues surrounding dying. A hospice often provides such services. The time at the end of life is different for each person. Each individual has unique needs for information and support. The patient's and family's questions and concerns about the end of life should be discussed with the health care team as they arise. Hospice care and palliative care offer end-of-life care. DEFINITION:

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Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:

provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patients illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. Palliative care (from Latin palliare, to cloak) is any form of medical care or treatment that

concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. Non-hospice palliative care is not dependent on prognosis and is offered in conjunction with curative and all other appropriate forms of medical treatment. In the United States a distinction is made between general palliative care and hospice care, which delivers palliative care to those at the end of life; the two aspects of care share a similar philosophy but differ in their payment systems and location of services. Elsewhere, for example in the United Kingdom, this distinction is not operative: in addition to specialized hospices, non-hospice-based palliative care teams provide care to those with life-limiting illness at any stage of disease. Hospice care and palliative care both provide care during progressive illness, but hospice eligibility begin only when a patient has a life expectancy of 6 months or less. In contrast palliative care begins when the patient has been diagnosed with a life-limiting illness.

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CONCEPT: The term "palliative care" generally refers to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, a recent WHO statement calls palliative care "an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illness." Palliative treatments may also be used to alleviate the side effects of curative treatments, such as relieving the nausea associated with chemotherapy. The term "palliative care" is increasingly used with regard to diseases other than cancer such as chronic, progressive pulmonary disorders, renal disease, chronic heart failure, HIV/AIDS, and progressive neurological conditions. In addition, the rapidly growing field of pediatric palliative care has clearly shown the need for services geared specifically for children with serious illness. Although the concept of palliative care is not new, most physicians have traditionally concentrated on trying to cure patients. Treatments for the alleviation of symptoms were viewed as hazardous and seen as inviting addiction and other unwanted side effects. The focus on a patient's quality of life has increased greatly during the past twenty years. In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program, [3] and nearly one-fifth of community hospitals have palliative-care programs.[4] A relatively recent development is the concept of a dedicated health care team that is entirely geared toward palliative treatment: a palliativecare team. PALLIATIVE CARE AND HOSPICE: There is often confusion between the terms hospice and palliative care. In the United States, hospice services and palliative care programs share similar goals of providing symptom relief and pain management. Non-hospice palliative care is appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time, or to experience disease progression. In contrast, although hospice care is also palliative, the term hospice applies to care administered towards the end of life. GOALS OF PALLIATIVE CARE: While palliative care may seem to offer an incredibly broad range of services, the goals of palliative treatment are extremely concrete: relief from suffering, treatment of pain and other distressing symptoms,

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psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain and rehabilitate the individual's family. PRINCIPLES OF PALLIATIVE CARE: 1. Palliative care is an interdisciplinary team approach including experts from medicine, nursing, social work, the clergy, and nutrition. This team approach is needed to make the necessary assessments and to institute appropriate interventions.
2. The essential components of palliative care are relief of symptom distress, improved quality of life,

opening of communication on a regular basis with patients to provide appropriate care on their terms, and psychosocial support for patients and families.
3. The goal is not cure but to provide comfort and maintain the highest possible quality of life for as

long as possible.
4. The traditional focus on palliative care is not on death but on a compassionate, specialized care for

the living. It is based on a comprehensive understanding of patient suffering and focus on providing effective pain and symptom management to seriously-ill patients while improving quality of life.

DIFFERENT ASPECTS OF HOSPICE CARE: Hospice care and palliative care offer end-of-life care. Quality at end-of-life can be achieved by;
a. Enhancing physical well being through effective symptom management: pain, nausea, vomiting,

constipation, sleeplessness.
b. Enhancing psychological well-being through management of anxiety, depression, fear, denial,

hopelessness. Rather happiness, leisure and enjoyment are promoted. c. Enhancing social well being by addressing financial burden, caregiver burden, roles and relationships, affection and sexual function, and concern about appearance. d. Enhancing spiritual well being through minimization of suffering and instead focusing on religious beliefs, hope, and meaning. Team of Experts in Different Aspects of Patient Care:

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Hospice care is attended to by various professionals who coordinate their efforts to take the best possible care of the patient. So you will find, in addition to doctors and nurses, a host of others involved in hospice care - therapists, counselors, trained volunteers, members of the clergy, social workers and home health aides. Thus a patient and his or her relatives receive physical, mental, emotional, spiritual and social sustenance, in addition to the comprehensive palliative care provided to the patient. Control of Pain and Other Symptoms: This is, of course, a very important part of hospice care. When pain and discomfort are alleviated, the patient is better able to live a normal life. The hospice care professionals will see that patient is experiencing the least possible pain, without medicating the patient to such an extent that he is not mentally alert. Spiritual Care: This is another area covered by a hospice care programme. At a time like this, spitrual comfort is usually welcomed, and although people have varying faiths and levels of belief, attention to particular spiritual and religious requirements of the patient and his or her relatives is given as part of hospice care. Questions such as the meaning of life and death, bidding adieu to loved ones, or religious activities are covered by an expert in spiritual care. Home Care or In-Patient Care: Depending on the needs of the patient, hospice care could be offered at home, in a facility provided by the hospice programme, in a facility that offers long term care or in a hospital. Patient can get in-patient care arranged through the hospice programme, which will still take an active part in the care and in the support of patients family. And when it is feasible as far as the health is concerned, patient can return to receiving home care. Respite Care: The primary caregivers as well as the others involved in looking after you will sometimes require a rest period, since the work involved in looking after a seriously ill person, can be physically as well as emotionally draining. To give caregicvers a much-needed respite, hospice programmes often offer respite care services. Patient will be looked after in an in-patient set up, either in a hospital, or in the programmes' own in-patient care facilities, while his caregiver has a short holiday, or does something else that needs to

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be done, or attends a special occasion, or just get rest. This will refresh patients caregiver, and allows him or her care for him with renewed energy. Respite care is usually offered by hospice programmes in 5 day interludes for the caregiver. Emotional comfort: Everyone has different needs, but some emotions are common to most dying patients. These include fear of abandonment and fear of being a burden. They also have concerns about loss of dignity and loss of control. Some ways caregivers can provide comfort are as follows:

Keep the person companytalk, watch movies, read, or just be with the person. Allow the person to express fears and concerns about dying, such as leaving family and Be willing to reminisce about the person's life. Avoid withholding difficult information. Most patients prefer to be included in discussions Reassure the patient that you will honor advance directives, such as living wills. Ask if there is anything you can do. Respect the person's need for privacy.

friends behind. Be prepared to listen.

about issues that concern them.

Family Conferences: Meetings are regularly held with your relatives, so that they know what is going on and what is likely to happen in the near future. At such family conferences, friends and relatives of the patient get a lot of emotional support and a chance to express their feelings and concerns. These meetings can ease the minds of those concerned a lot. Bereavement Support: When the patient has succumbed to the illness, the relatives and friends of the patient will find it hard to deal with the grief and loss, even when the details of the illness have been understood and accepted. Bereavement care is part of the services offered by a hospice care programme, and assistance and support is offered by trained volunteers, spiritual and religious professionals, and counsellors, as well as by support groups. These people visit, call and write to the family of the patient and help them with getting care they themselves might require. This kind of care is given to families of patients for about twelve months after they have suffered their loss.

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Volunteers: In America, there are many people who voluntarily offer their services to a hospice programme. They could be trained in the fields of medicine or health, or they could be laypersons doing administrative work or work collecting money for the programme. Personnel Support: The staff who provide the actual hospice care generally have certain personal traits that are ideally suited to their work. They genuinely care about their patients, and are gentle with them. They listen well, too, and this is very important. However, looking after terminally ill people can be very stressful and upsetting, and it is essential for hospice care staff to have a support system of their own. Hospice care staff is trained in the process of death and how to deal with it. Integrated Services: The team of professionals that looks after you is coordinated and monitored as far as round the clock care is concerned. This interdisciplinary team sees that data about your care is shared among individuals and groups responsible, including doctors, nurses, pharmacists, therapists, psychologists, members of the clergy and funeral professionals. SIGNS OF APPROACHING DEATH: Certain signs and symptoms can help a caregiver anticipate when death is near. They are described below, along with suggestions for managing them. It is important to remember that not every patient experiences each of the signs and symptoms. In addition, the presence of one or more of these symptoms does not necessarily indicate that the patient is close to death. A member of the patient's health care team can give family members and caregivers more information about what to expect.
Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient's

metabolism). The caregiver and family members can plan visits and activities for times when the patient is alert. It is important to speak directly to the patient and talk as if the person can hear, even if there is no response. Most patients are still able to hear after they are no longer able to speak. Patients should not be shaken if they do not respond.

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 Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and

places that are not present; pulling at bed linens or clothing (caused in part by changes in the patient's metabolism). Gently remind the patient of the time, date, and people who are with them. If the patient is agitated, do not attempt to restrain the patient. Be calm and reassuring. Speaking calmly may help to re-orient the patient.
Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased

blood flow, and mental preparation for dying). Speak to the patient directly. Let the patient know you are there for them. The patient may be aware and able to hear, but unable to respond. Professionals advise that giving the patient permission to let go can be helpful.
Decreased need for food and fluids, and loss of appetite (caused by the body's need to conserve

energy and its decreasing ability to use food and fluids properly). Allow the patient to choose if and when to eat or drink. Ice chips, water, or juice may be refreshing if the patient can swallow. Keep the patient's mouth and lips moist with products such as glycerin swabs and lip balm.
Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).

Keep the patient as clean, dry, and comfortable as possible. Place disposable pads on the bed beneath the patient and remove them when they become soiled.
Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or

decreased fluid intake). Caregivers can consult a member of the patient's health care team about the need to insert a catheter to avoid blockage. A member of the health care team can teach the caregiver how to take care of the catheter if one is needed.
Skin becomes cool to the touch, particularly the hands and feet; skin may become bluish in color,

especially on the underside of the body (caused by decreased circulation to the extremities). Blankets can be used to warm the patient. Although the skin may be cool, patients are usually not aware of feeling cold. Caregivers should avoid warming the patient with electric blankets or heating pads, which can cause burns.
Rattling or gurgling sounds while breathing, which may be loud; breathing that is irregular and

shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).

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Breathing may be easier if the patient's body is turned to the side and pillows are placed beneath the head and behind the back. Although labored breathing can sound very distressing to the caregiver, gurgling and rattling sounds do not cause discomfort to the patient. An external source of oxygen may benefit some patients. If the patient is able to swallow, ice chips also may help. In addition, a cool mist humidifier may help make the patient's breathing more comfortable.
Turning the head toward a light source (caused by decreasing vision).

Leave soft, indirect lights on in the room.

Increased difficulty controlling pain (caused by progression of the disease).

It is important to provide pain medications as the patient's doctor has prescribed. The caregiver should contact the doctor if the prescribed dose does not seem adequate. With the help of the health care team, caregivers can also explore methods such as massage and relaxation techniques to help with pain.
Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the

legs and arms are additional signs that the end of life is near.

SIGNS OF DEATH: The traditional clinical signs of death were cessation of the apical pulse, respirations, and blood pressure, also referred to as heart-lung death.

Total lack of response to external stimuli. No muscular movement, especially breathing. There will be no pulse. The eyes do not move or blink, and the pupils are dilated (enlarged). The eyelids may be slightly open. The jaw is relaxed and the mouth is slightly open. The body releases the bowel and bladder contents. No reflexes. Flat encephalogram.

Rigor mortis: is the stiffening of the body that occurs about 2-4 hours after death. It results from a lsck of ATP, which is not synthesized because of a lack of glycogen in the body. Algor mortis: is the gradual decrease of the bodys temperature after death.
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Livor mortis: After blood circulation has ceased, the red blood cells break down, releasing hemoglobin, which discolours the surrounding tissues. This is referred as livor mortis. NEEDS TO BE DONE AFTER THE PATIENT HAS DIED: After the patient has passed away, there is no need to hurry with arrangements. Family members and caregivers may wish to sit with the patient, talk, or pray. When the family is ready, the following steps can be taken. Place the body on its back with one pillow under the head. If necessary, caregivers or family members may wish to put the patient's dentures or other artificial parts in place. If the patient is in a hospice program, follow the guidelines provided by the program. A caregiver or family member can request a hospice nurse to verify the patient's death. Contact the appropriate authorities in accordance with local regulations. If the patient has requested not to be resuscitated through a Do-Not-Resuscitate (DNR) order or other mechanism, do not call 911. Contact the patient's doctor and funeral home. When the patient's family is ready, call other family members, friends, and clergy. Provide or obtain emotional support for family members and friends to cope with their loss. THEORIES RELATED TO END OF LIFE CARE: Peaceful end of life theory: Cornelia M. Ruland and Shirley M. Moore
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Comfort theory: Catherine Kolcaba

COMFORT THEORY: Comfort is a positive outcome that has been linked empirically to successful engagement in health seeking behaviors and theoretically to positive institutional outcomes such as higher patient satisfaction and cost-benefit ratio. (Kolcaba-2003) The Theory of Comfort is a mid-range theory for nursing practice and research. It is a mid-range theory because of the limited number of concepts and propositions, low level of abstraction, and ease of application to actual practice (Kolcaba, 2003). Steps to use the theory:

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In order to use the theory, three steps are required: 1. understanding the technical definition of comfort and its origins, 2. understanding the relationships (propositions) between the general concepts entailed in the theory, and 3. relating the general concepts to specific problems/settings in order to enlighten practice and generate research questions. Meanings of Comfort Webster (1990) defined comfort in several ways: a) to soothe in distress or sorrow; b) relief from distress; c) a person or thing that comforts; d) a state of ease and quiet enjoyment, free from worry; e) anything that makes life easy; and f) the lessening of misery or grief by cheering, calming, or inspiring with hope. In these definitions, comfort can be a verb, noun, adjective, adverb, and it can be negative (absence of a recent discomfort), neutral (ease), or positive (inspiring hope). The origin of comfort is confortare, meaning to strengthen greatly (Kolcaba, 1992). This strengthening property associated with enhanced comfort is especially intriguing for nursing. By the very diversity of these definitions, we see that comfort is a holistic, complex term. The term comfort also is used in a variety of forms such as comfortable, in comfort, comforting, and comforter. Comfort is also a process ("The nurse comforted me") and a product ("The child felt comforted"). And, the state of comfort is more than the absence of discomfort. Clearly, for standards of care and clinical practice guidelines, a technical definition of comfort is needed so that all practitioners and researchers are "on the same page." Definition of Holistic Comfort for Nursing: Kolcaba (1994, 2001, 2003) has defined comfort as "the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental)" (2003, p. 251). The terms relief,

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ease, and transcendence are derived from the above dictionary definitions plus a review of the professional literatures in medicine, theology, ergonomics, psychology, and nursing (Kolcaba & Kolcaba, 1991). Types of Comfort:
Relief is the state of having a discomfort mitigated or alleviated. Ease is the absence of specific discomforts. To experience ease a child or family does not

have to have a previous discomfort, although the nurse may be aware of predispositions to specific discomforts (e.g., the tendency for shortness of breath in an asthmatic child or acute anxiety in family members). Many medical and psychological conditions disturb homeostatic mechanisms, and nurses must be aware of risk factors for depression, stressrelated illness, dehydration, bleeding, or vomiting to name a few examples.
Transcendence is the ability to "rise above" discomforts when they cannot be eradicated or

avoided (e.g., the child feels confident about ambulation although (s)he knows it will exacerbate pain). Transcendence, as a type of comfort, accounts for its strengthening property and reminds nurses to "never give up" helping their children and family members feel comforted. Interventions for increasing transcendence can be targeted to improving the environment, increasing social support, or providing reassurance as described below. Developmentally, the experience of feeling strengthened, empowered, or courageous may be more relevant to school-aged children and adolescents. Also, interventions to enhance transcendence may be more effective coming from parents/families, although nurses can certainly give encouragement and instructions for motivating messages. The three types of comfort occur in four contexts of experience: physical, psychospiritual, sociocultural, and environmental. These contexts were derived from an extensive review of the nursing literature on holism (Kolcaba, 1992). When the three types of comfort are juxtaposed with the four contexts of experience, a 12-cell grid is created, which is called a taxonomic structure (TS). Taken together, these cells represent all relevant aspects (defining attributes) of comfort for pediatric nursing and demonstrate the holistic nature of comfort as an important goal of care. CONCLUSION: Not all nursing activities can be directed toward promoting or restoring health, or preventing disease. Death is an inevitable consequence of life. Nurses have been active in promoting the respectful

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care of those who are terminally ill or dying. Nursing activities for the dying are designed to promote comfort, maintain quality of life, provide culturally relevant spiritual care, and ease the emotional burden of death. Nurses work with dying individuals, their family members and support persons, and with organizations that focus on the needs of the terminally ill.

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company; 1994. P. 868-72 21. Internet referances: http://www.webhealthcentre.com/HealthyLiving/first_aid_cpr.aspx http://www.susheewa.com/blog/uploads/CPRinfant.jpeg http://en.wikipedia.org/wiki/Cardiopulmonary_resuscitation http://www.emedicinehealth.com/cardiopulmonary_resuscitation_cpr/page2_em.htm http://www.cancer.gov/cancertopics/factsheet/Support/end-of-life-care http://www.cancer.net/patient/Coping/End-of-Life+Care http://www.eolc-observatory.net/ http://www.annals.org/content/121/10/822.full

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22. Journal references:

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