Chapter 16

End-of-Life Care

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End-of-Life Care #1

❖ Essential part of nursing practice, patient care

❖ National Consensus Project for Quality Palliative Care
(2004)
o Structure, processes of care
o Physical aspects of care
o Psychological, psychiatric aspects of care
o Social aspects of care

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End-of-Life Care #2

❖ Essential part of nursing practice, patient care

❖ National Consensus Project for Quality Palliative Care
(2004)
o Spiritual, religious, existential aspects of care
o Cultural aspects of care
o Care of imminently dying patient
o Ethical, legal aspects of care

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Awareness Contexts (Glaser & Strauss,
1965)

❖ Closed awareness
❖ Suspected awareness
❖ Mutual pretense awareness
❖ Open awareness

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Legislative Issues

❖ DNR orders
❖ Advanced directives
o Living will
o Proxy directive
o Durable power of attorney
❖ Assisted suicide legislation

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Question #1

Which awareness context occurs when the patient, family,

and the health care professionals are aware that the
patient is dying and openly acknowledge that reality?
A. Closed
B. Suspected
C. Mutual pretense
D. Open

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Palliative Care

❖ Comprehensive care for patients whose disease is not

responsive to cure; care also extends to patients’ families

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Question #2

Is the following statement true or false?

Palliative care is the use of pharmacologic agents at the
request of the terminally ill patient to induce sedation
when symptoms have not responded to other
management measures.

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Palliative Care and End-of-Life Settings

❖ Hospital setting
❖ Long-term care facility

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Hospice Care

❖ Coordinated program of interdisciplinary care, services

provided primarily in home to terminally ill patients and
their families

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Principles of Hospice Care

❖ Death must be accepted

❖ Patient’s total care best managed by interdisciplinary
team whose members communicate regularly
❖ Pain, other symptoms must be managed
❖ Patient, family should be viewed as single unit of care
❖ Home care of dying necessary
❖ Bereavement care must be provided to family members
❖ Research, education should be ongoing

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Question #3

A family is asking why their father with end stage COPD is

being referred to Hospice care. The best response from
the nurse would be:
A. Hospice care provides complete pain control.
B. Hospice assists the family and patient to prepare for
death.
C. Hospice will follow the patient’s choice for “DNR” status.
D. Hospice is provided in the home and will allow the
family to be involved in the decisions for care.

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Barriers to Improving End-of-Life Care

❖ Cure = focus of health care establishment

❖ Financial criteria, reimbursement issues
❖ Cultural, social issues
❖ Discomfort with addressing issues of death (both patient,
family), health care providers
❖ Psychological, coping responses to death, dying (denial)

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Four Levels of Hospice Care

❖ Routine home care

❖ Inpatient respite care
❖ Continuous care
❖ General inpatient care

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Communication #1

❖ Reflect on your own experiences, values concerning

illness, death
❖ Deliver, interpret technical information without hiding
behind medical terminology
❖ Realize best time for patient to talk may be least
convenient for you
❖ Be fully present during all communications
❖ Allow patient, family to set agenda regarding depth of
conversation

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Communication #2

❖ Resist impulse to fill “empty space”

❖ Allow patient, family sufficient time to reflect, respond
❖ Prompt gently
❖ Avoid distractions
❖ Avoid impulse to give advice
❖ Avoid canned responses
❖ Ask questions
❖ Assess understanding, both your own and the patient‘s

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Question #4

A patient who is dying wants to talk to the RN about fears

of dying. The patient tells the RN, “I know I am dying,
aren’t I?” What is an appropriate nursing response?
A. “This must be very difficult for you.”
B. “Tell me more about what’s on your mind.”
C. “I am sorry. I know exactly how you feel.”
D. “You know you are dying?”

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Responding with Sensitivity

❖ Responding to difficult questions

❖ Discussing at time issue is addressed by patient—make
time
❖ Using open-ended statements or questions
❖ Seeking clarification
❖ Providing realistic reassurance
❖ Dealing with grief processes
❖ Assessing patient preferences as well as spiritual and
cultural practices

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Spiritual Care

❖ Spirituality includes religion

o But is not synonymous with religion
❖ Spiritual assessment mnemonic—FICA
❖ Addressing spirituality: important component of care of
dying patient
❖ Maintaining hope

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Hope #1

❖ Listening attentively
❖ Encouraging sharing of feelings
❖ Providing accurate information
❖ Encouraging, supporting patient’s control over his or her
circumstances, choices, environment whenever possible
❖ Assisting patients to explore ways for finding meaning in
their lives

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Hope #2

❖ Encouraging realistic goals

❖ Facilitating effective communication within families
❖ Making referrals for psychosocial, spiritual counseling
❖ Assisting with development of supports in home or
community when none exist

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Physiologic Responses

❖ Patient’s goal should direct care management

❖ Symptoms
o Pain
o Dyspnea
o Nausea
o Weakness
o Anxiety

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Question #5

What is one of the most common and feared responses by

patients to terminal illness?
A. Anorexia
B. Cachexia
C. Dyspnea
D. Pain

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Answer to Question #5

D. Pain
Rationale: Prevalence of pain is as high as 50% in
patients with cancer of any type as well as in
terminally ill patients. Dyspnea is an uncomfortable
awareness of breathing that is common in patients
approaching the end of life. Anorexia and cachexia are
common in the seriously ill.

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Signs of Approaching Death

❖ Refusal of food, fluids

❖ Urinary output decreases
❖ Weakness, sleep
❖ Confusion, restlessness
❖ Impaired vision, hearing
❖ Secretions in throat
❖ Breathing pattern
❖ Incontinence
❖ Decreased temperature control

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Grief and Mourning

❖ Grief process
❖ Nursing diagnosis—anticipatory grief
❖ Interventions
❖ Support expression of feelings
❖ Assess social support
❖ Assess coping skills
❖ Assess for signs of complicated grief and mourning, offer
professional referral

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