Palliative Care at End of Life

KEY POINTS

PALLIATIVE CARE
Palliative care is a holistic approach to care or treatment that focuses on reducing
the severity of disease symptoms, rather than trying to delay or reverse the progression of
the disease itself or provide a cure. Treatment should align with the patients preferences
for care and cultural beliefs and values.
The overall goals of palliative care are to (1) prevent and relieve suffering and (2)
improve quality of life for patients with serious, life-limiting illnesses.
Palliative care includes curative care, hospice, end of life, and bereavement
following death.

HOSPICE CARE
Hospice is not a place but a concept of care that provides compassion, concern,
and support for the dying.
Hospice care is provided by an interprofessional team of professionals and
volunteers in a variety of locations including the home, inpatient setting, and long-term
care facilities.
Hospice care can be on a part-time, intermittent, on-call, regularly scheduled, or
continuous basis. Hospice services are available 24 hours a day and 7 days a week to
provide help to patients and families in their homes.
Admission to a hospice program has two criteria: (1) The patient must desire the
services and (2) two physicians must certify that the patient has 6 months or less to live.
Patients must not be receiving curative, life-prolonging treatments.

DEATH
Death occurs when all vital organs and body systems irreversibly cease to
function.
Brain death is an irreversible loss of all brain functions, including the brainstem.
Brain death is a clinical diagnosis.

END-OF-LIFE CARE
End-of-life care (EOL care) is the term currently used for issues related to death
and dying, as well as services provided to address these issues.
The goals for EOL care are to (1) provide comfort and supportive care during the
dying process, (2) improve the quality of the patients remaining life, (3) help ensure a
dignified death, and (4) provide emotional support to the family.
Certain symptoms are more prevalent at the EOL, including respiratory distress
and shortness of breath (dyspnea). The sensation of air hunger results in anxiety for the
patient and family.
 Noisy, wet-sounding respirations, termed the death rattle or terminal secretions,
are caused by mouth breathing and accumulation of mucus in the airways.
Cheyne-Stokes respiration is a pattern of breathing characterized by alternating
periods of apnea and deep, rapid breathing.
Most terminally ill and dying people do not want to be alone and fear loneliness.
Grief is a normal reaction to loss. It is dynamic and includes both psychologic and
physiologic responses following a loss.
Priority interventions for grief must focus on providing an environment that
allows the patient to express feelings.
Bereavement is the period following the death of a loved one during which grief is
experienced and mourning occurs.
The objective of a bereavement program is to provide support and to assist
survivors in the transition to a life without the deceased person.
People who are dying deserve and require the same physical care as people who
are expected to recover.
To meet the holistic needs of the patient, collaborate with the social worker,
chaplain, physical therapist, occupational therapists, unlicensed assistive personnel
(UAP), and physician.
Spirituality is defined as those beliefs, values, and practices that relate to the
search for existential meaning and purpose and that may or may not include a belief in a
higher power.
The patients and familys preferences related to spiritual guidance or pastoral
care services should be noted.
Culture affects decision-making with regard to life support and withholding and
withdrawing of treatments.
Legal issues that should be discussed prior to death are the choice for (1) organ
and tissue donations, (2) advance directives (e.g., medical power of attorney, living
wills), and (3) resuscitation.
Advance directives are written statements of a persons wishes regarding
medical care, including the desire to withhold or withdraw treatments.
A DNR is a written medical order that documents a patients or familys
wishes regarding resuscitationmost importantly, the desire for the use of CPR.

NURSING MANAGEMENT: END OF LIFE

Patients and families need ongoing information of the disease, signs and
symptoms of the dying process, and any care that will be provided.
Assessment of the terminally ill or dying patient varies with the patients
condition and proximity of approaching death.
As death approaches, you need to respond appropriately to the patients
psychosocial manifestations, including fear, anxiety, anger, powerlessness, and
hopelessness.
 Physical care at the end of life focuses on oxygen, nutrition, pain relief,
elimination, and skin care. People who are dying deserve the same physical care as
people who are expected to recover.
It is important not to delay or deny pain relief measures to a terminally ill patient.
Skin integrity is difficult to maintain at the end of life because of immobility;
urinary and bowel incontinence; dry skin; nutritional deficits; anemia; friction; and
shearing forces.
The patient near death may seem to be withdrawn from the physical environment,
maintaining the ability to hear while not able to respond.
After the patient is pronounced dead, prepare or delegate preparation of the body
for immediate viewing by the family with consideration for cultural customs and in
accord with state law and agency policies and procedures.

SPECIAL NEEDS OF CAREGIVERS IN END-OF-LIFE CARE

The role of caregivers includes working and communicating with the patient,
supporting the patients concerns, helping the patient resolve any unfinished business,
working with other family members and friends, and dealing with the caregivers own
needs and feelings.
An understanding of the grieving process as it affects both the patient and family
is of great importance.
Recognizing signs and behaviors among family members who may be at risk for
abnormal grief reactions is an important nursing intervention.
Caring for dying patients is intense and emotionally charged. It is important to
consider interventions that help to ease physical and emotional stress for you.

SPECIAL NEEDS OF NURSES

Caring for patients and their families at the end of life is challenging and
rewarding, but also intense and emotionally charged.
It is common to feel helpless and powerless when dealing with death. It is
important to recognize your own values, attitudes, and feelings about death.
Focus on strategies to decrease stress. Get involved in hobbies or other interests,
schedule time for yourself, ensure time for sleep, maintain a peer support system, and
develop a support system beyond the workplace.