32.1 Palliation
- Palliation and palliative care are designed to reduce or relieve symptoms for patients with serious illnesses that are no longer responding to treatment.
- Curative care or life-prolonging treatments can be continued along with palliative care.
- Palliative care is performed in a variety of settings, including hospitals, long-term nursing facilities, specialized clinics, and home environments.
- Collaborative care by a team of health-care providers—such as primary care providers, nurses, social workers, dietitians, and social workers—is part of safe and effective palliative care.
- Frequent communication among the team members ensures continuity of care as well as quality care.
- As a case manager, a nurse should follow up on the efficacy of treatment, coordinate care with the interdisciplinary team, and regularly update the patient’s plan of care.
- A do-not-resuscitate (DNR) order means the patient does not want CPR as a life-saving measure; a do-not-intubate (DNI) order means the patient does not want to be placed on a ventilator.
32.2 End-of-Life Care
- End-of-life care includes palliative care, which relieves or reduces symptoms related to a serious illness to preserve a patient’s quality of life, and hospice care, which provides comfort measures during the last six months of life.
- The nurse often takes on the role of a case manager to coordinate with the patient, family, and the care team to provide safe and effective end-of-life care. Communication is essential to ensure the patient and their family are supported and informed through the entire process.
- Provider-assisted dying is legal in some states and jurisdictions; it involves a provider prescribing a lethal dose of medication for the patient to use to end their life.
- Euthanasia involves an act by a separate individual to cause death; it is illegal in the United States.
- Providers may find the use of medically assisted dying to present an ethical or moral dilemma. The nurse should conduct their own self-assessment to separate their personal beliefs from the care they provide to a patient in this situation.
32.3 Assessment
- An end-of-life assessment is an important time for the nurse to talk with the patient and family, while also observing and collecting physiological information, reviewing the treatment plan and directives, noting the family dynamics and conversation styles, determining the decision makers and caregivers, and ensuring spiritual, religious, and cultural beliefs are respected.
- Palliative care and hospice care patients may have pain, shortness of breath, fatigue, constipation, nausea, vomiting, loss of appetite, loss of cognition, and decreased level of consciousness (LOC).
- As death draws near, the nurse should observe for additional physiological changes and ensure the family understands what the changes signify and what to expect after the end of life.
32.4 Psychosocial Support
- Hope is an integral part of end-of-life care; it prolongs life and maintains quality of life, as patients still have hope for things they want to accomplish.
- According to psychologist C. R. Snyder, there are three conditions for hope to thrive: goals, pathways, and agency.
- Grief is the emotional state that follows the loss of a loved one, while mourning is the outward expression of grief. Bereavement is the time frame following the loss in which grief is experienced and mourning is expressed.
- The five stages of grief are denial, anger, bargaining, depression, and acceptance. However, everyone grieves differently and at their own pace.
- Families may also have learning deficits, inadequate coping mechanisms, and gaps in communication skills that cause them to feel off balance with the impending death of their loved one.
- The family’s method of coping with death may not coincide with the values and beliefs of the nurse and the care team, but it is imperative that the patient’s and family’s wishes be respected to the greatest extent possible.
- An important component in providing culturally competent care within the family is to use discretion about the appropriate time and setting for sensitive conversations to be conducted. It is also important to provide context for the discussion.
- Spiritual assessment is a key component for a terminally ill patient. A patient’s spirituality encompasses much more than their religious preference, affiliation, or beliefs.
- The nurse’s role is to teach the family members and assist them with obtaining the knowledge and resources they need to care for their loved one.
32.5 Special Considerations
- Nurses and other members of the health-care team encounter death and loss daily, making shadow grief and related anxiety common experiences.
- The negative impacts of working with the dying—such as associated grief, unresolved anxiety, and denial—can lead to illness and burnout among health-care workers, as well as create a barrier to effective patient care.
- Caregiver support is an essential part of end-of-life care, and nurses must encourage self-care measures for the primary caregiver so they can better provide effective and compassionate patient care and manage their own feelings about the patient’s end of life.
- Health-care professionals need support, education, and assistance to deal with the anxiety of working with grieving patients and families as well as to effectively process the death and dying of patients in their care.