Chapter 17

End-of-Life Care

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

End-of-Life Care
• An essential part of nursing practice and patient care.
• Care of the dying should include a comprehensive
approach that addresses:
– Respecting the patient’s goals, preferences, and
choices.
– Attending to the medical, emotional, social, and
spiritual needs.
– Using the strengths of interdisciplinary resources.
– Acknowledging and addressing caregiver concerns.
– Building mechanisms and systems of support.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Legislative Issues

• DNR orders
• Advance directives
– Living will
– Proxy directive
– Durable power of attorney
• Assisted suicide legislation

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Palliative Care

• Comprehensive care for patients whose disease is not

responsive to cure.
• Care also extends to the patient's family.

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Palliative Care and Hospice

• Palliative care emphasizes management of psychological,

social, and spiritual problems as well as control of pain
and other physical symptoms. The goal is to improve
quality of life. This is a comfort-focused approach to care
that may be used with cure-focused treatment.
• Hospice is associated with palliative care delivered at the
home or in special hospice facilities to patients who are
approaching the end of life.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hospice Care

• Concept of care in which the end of life is viewed as a

developmental stage.
• Founder of hospice care: Dr. Cicely Saunders (England)

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

Tell whether the following statement is true or false.

Hospice is associated with palliative care that is delivered
at home or in special facilities to patients who are
approaching the end of life.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

True.
Rationale: Hospice is a coordinated program of
interdisciplinary care and services provided primarily in
the home to terminally ill patients and their families.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Principles of Hospice Care
• Death must be accepted.
• The patient’s total care is best managed by an
interdisciplinary team whose members communicate
regularly.
• Pain and other symptoms must be managed.
• The patient and the family should be viewed as a single
unit of care.
• Home care of the dying is necessary.
• Bereavement care must be provided to family members.
• Research and education should be ongoing.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question

Which of the following would not be considered to be an

eligibility criterion for hospice?
a. Informed choice of palliative care
b. Progressive illness
c. Acute illness
d. Life expectancy of 4 months

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

c. Acute illness
Rationale: Criteria for hospice care include a serious,
progressive illness, limited life expectancy, and an
informed choice of palliative care over cure-focused
treatment.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Barriers to Improving End-of-Life Care

• Cure is the focus of the health care establishment.

• Financial criteria and reimbursement issues
• Cultural and social issues
• Discomfort with addressing the issues of death, both on
the part of the patient and family, and of health care
providers.
• Psychological and coping responses to death and dying
(such as denial)

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Communication

• Reflect on your own experiences and values concerning

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

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Communication

• Resist the impulse to fill “empty space.”

• Allow the patient/family sufficient time to reflect and
respond.
• Prompt gently.
• Avoid distractions.
• Avoid the impulse to give advice.
• Avoid canned responses.
• Ask questions.
• Assess understanding, both your own and the patient's
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Responding with Sensitivity
• Responding to difficult questions
• Discussing at the time the issue is addressed by the
patient. Make time.
• Using of open-ended statements or questions.
• Seeking clarification.
• Providing realistic reassurance.
• Dealing with grief processes.
• Assessing patient preferences, and spiritual and cultural
practices.

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Spiritual Care

• Spirituality includes religion but is not synonymous with

religion.
• Spiritual assessment mnemonic: SPIRIT
• Addressing spirituality is an important component of the
care of the dying patient.
• Maintaining hope

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Physiologic Responses

• The patient's goal should direct care management.

• Symptoms:
– Pain
– Dyspneas
See Chart 17-9
– Nausea
– Weakness
– Anxiety

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Signs of Approaching Death
• Refusal of food and fluids
• Urinary output decreases
• Weakness and sleep
• Confusion and restlessness
• Impaired vision and hearing
• Secretions in throat
• Breathing pattern
• Incontinence
• Decreased temperature control
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Grief and Mourning

• The 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, and
offer professional referral.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question

All of the following are signs of approaching death except:

a. Apnea
b. Increased sleep
c. Increased urinary output
d. Restlessness

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer

c. Increased urinary output

Rationale: Signs of approaching death include apnea,
increased sleep, decreased urinary output in amount
and frequency, and restlessness.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins