1. Chapter 44 End-of-Life Care
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2. End-of-Life Care
End-of-life care describes the support and care given during the time surrounding death.
End-of-life care may involve days, weeks, or months.
Sometimes death is sudden, but often it is expected.
Your feelings about death affect the care you give.
You must understand the dying process.
Then you can approach the dying person with caring, kindness, and respect.
You will help meet the dying person’s physical, psychological, social, and spiritual needs.
Health team members see death often. Many are unsure of their feelings about death.
Review Teamwork and Time Management: End-of-Life Care on p. 666.
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3. Terminal Illness
An illness or injury for which there is no reasonable expectation of recovery is a terminal illness.
Hope and the will to live strongly influence living and dying.
Types of care
Palliative care involves relieving or reducing the intensity of uncomfortable symptoms without producing a cure.
Hospice care focuses on the physical, emotional, social, and spiritual needs of dying persons and their families.
The goal is to improve the dying person’s quality of life.
Many people have died for no apparent reason when they have lost hope or the will to live.
Persons with terminal illnesses can choose palliative care or hospice care. The person may opt for palliative care and then change to hospice care.
The intent of palliative care is to improve the person’s quality of life and provide support for the family. This type of care is for anyone with a long-term illness that will cause death.
Often the person in hospice care has less than 6 months to live. No attempts are made to cure the person. Hospice care is not concerned with cure or life-saving measures. Pain relief and comfort are stressed.
Hospice also provides support for the health team to help deal with a person’s death.
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4. Attitudes About Death
Experiences, culture, religion, and age influence attitudes about death.
Attitudes about death often change as a person grows older and with changing circumstances.
Practices and attitudes about death differ among cultures.
Many adults and children never have had contact with a dying person. They have not seen the process of dying and death. Therefore it is frightening, morbid, and a mystery.
The family is often involved in the person’s care. They usually gather at the bedside to comfort the person and each other.
When death occurs, the funeral director is called. He or she takes the body to the funeral home to prepare it for funeral practices.
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5. Culture, Spiritual Belief, and Age
Culture and spiritual needs
Practices and attitudes about death differ among cultures.
Attitudes about death are closely related to religion.
Reincarnation is the belief that the spirit or soul is reborn in another human body or in another form of life.
Many religions practice rites and rituals during the dying process and at the time of death.
Age affects a person’s attitudes and feelings about death.
Spiritual needs relate to the human spirit and to religion and religious beliefs.
Religion can provide comfort for the dying person and the family.
Review Caring About Culture: Death Rites on p. 667.
Review Focus on Communication: Culture and Spiritual Needs on p. 668.
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6. The Stages of Dying
Dr. Elisabeth Kübler-Ross described five stages of dying.
Denial is the first stage.
Anger is the second stage.
Bargaining is the third stage.
Depression is the fourth stage.
Acceptance of death is the last stage.
Dying persons do not always pass through all five stages.
A person may never get beyond a certain stage.
Some move back and forth between stages.
Some people are still in denial when they die.
Anger is normal and healthy. Do not take the person’s anger personally.
Often the person bargains with God or a higher power for more time. Bargaining is usually private and spiritual.
The person mourns things that were lost and the future loss of life. The person may cry or say little.
Reaching the acceptance stage does not mean death is near.
A person may never get beyond a certain stage. Some people stay in one stage.
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7. Comfort Needs
End-of-life care involves addressing physical, mental, emotional, and spiritual needs.
Comfort goals are to:
Prevent or relieve suffering to the extent possible
Respect and follow end-of-life wishes
Dying persons may want to see a spiritual leader.
Provide privacy during prayer and spiritual moments.
Be courteous to the spiritual leader.
Handle the person’s religious objects with care and respect.
Comfort is a basic part of end-of-life care.
You do not need to say anything. Being there for the person is what counts.
Touch shows caring and concern when words cannot.
Review Focus on Communication: The Person’s Needs on p. 669.
Review Residents With Dementia: The Person’s Needs on p. 669.
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8. Physical Needs Dying may take a few minutes, hours, days, or weeks.
To the extent possible, independence is allowed.
Every effort is made to promote physical and psychological comfort. The person is allowed to die in peace and dignity.
The person may depend on others for basic needs and activities of daily living.
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9. Physical Needs (Cont’d)
Pain
Skin care, personal and oral hygiene, back massages, and good alignment promote comfort.
Frequent position changes and supportive devices promote comfort.
Breathing problems
Vision, hearing, and speech
Vision blurs and gradually fails.
Hearing is one of the last functions lost.
Speech becomes difficult.
Pain management is important. Always report signs and symptoms of pain at once (see Chapter 24, p. 407). Pain-relief medications are ordered by the doctor and given by the nurse.
Shortness of breath and difficulty breathing are common end-of-life problems. Semi-Fowler’s position is usually best for breathing problems.
The person naturally turns toward light. A darkened room may frighten the person.
Explain what you are doing to the person or in the room.
Always assume that the person can hear.
Anticipate the person’s needs.
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10. Physical Needs (Cont’d)
Mouth, nose, and skin
Oral hygiene promotes comfort.
Crusting and irritation of the nostrils can occur.
Circulation fails and body temperature rises as death nears.
Nutrition
Elimination
Urinary and fecal incontinence may occur.
Constipation and urinary retention are common.
Give mouth and nose care as needed. A lip balm may help dry lips.
Carefully clean the nose. Apply lubricant as directed by the nurse and the care plan.
Good skin care, bathing, and preventing pressure ulcers are necessary.
Nausea, vomiting, and loss of appetite are common. The doctor can order medications for nausea and vomiting. Report refusal to eat or drink to the nurse.
Use incontinence products or bed protectors as directed.
Give perineal care as needed.
Provide catheter care according to the care plan.
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11. The Room The person’s room 11
The person’s room should be comfortable, pleasant, well lit, and well ventilated.
Unnecessary equipment is removed.
Equipment upsetting to look at is kept out of the person’s sight if possible.
The person and family arrange the room as they wish.
Mementos, pictures, cards, flowers, and religious items provide comfort. Arrange them within the person’s view. This helps meet love, belonging, and esteem needs.
The room should reflect the person’s choices.
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12. Mental and Emotional Needs
Mental and emotional needs are very personal.
Some persons have specific fears and concerns, such as:
Severe pain
When and how death will occur
What will happen to loved ones
Dying alone
The doctor may order medications for anxiety or depression.
Simple measures may soothe the person.
Measures such as touch, holding a hand, back massage, soft lighting, or music at a low volume may help.
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13. The Family This is a difficult time for the family.
The family usually is allowed to stay as long as they wish.
You must respect the right to privacy.
You cannot neglect care because the family is present.
The family goes through stages like the dying person.
They need support, understanding, courtesy, and respect.
A spiritual leader may provide comfort.
The family may be very tired, sad, and tearful.
To show you care, be available, courteous, and considerate.
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14. Legal Issues The Patient Self-Determination Act and OBRA:
Give persons the right to accept or refuse medical treatment.
Give the right to make advance directives.
Nursing centers must inform all persons of the right to advance directives on admission.
Living wills
Durable power of attorney for health care
“Do Not Resuscitate” (DNR) orders
Even if you do not agree with care and resuscitation decisions, you must follow the person’s or family’s wishes and the doctor’s orders.
Some people make end-of-life wishes known.
An advance directive is a document stating a person’s wishes about health care when that person cannot make his or her own decisions.
The medical record must document whether or not the person has made advance directives.
A living will is a document about measures that support or maintain life when death is likely. A living will may instruct doctors not to start measures that prolong dying and to remove measures that prolong dying.
If the person has DNR or “No Code” orders, the person will not be resuscitated. The person is allowed to die with peace and dignity. The orders are written after consulting with the person and family.
If care decisions are against your values, discuss the matter with the nurse. You may need an assignment change.
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15. Signs of Death Signs that death is near may occur rapidly or slowly.
Movement, muscle tone, and sensation are lost.
Peristalsis and other gastro-intestinal functions slow down.
Body temperature rises.
Circulation fails.
The respiratory system fails.
Pain decreases as the person loses consciousness.
The signs of death include no pulse, no respirations, and no blood pressure.
A doctor pronounces the person dead.
The facial expression is often peaceful.
Abdominal distention, fecal incontinence, nausea, and vomiting are common.
The person feels cool or cold, looks pale, and perspires heavily.
The pulse is fast or slow, weak, and irregular. Blood pressure starts to fall.
Slow or rapid and shallow respirations are observed. Mucus collects in the airway. This causes the death rattle that is heard.
Some people are conscious until the moment of death.
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16. Care of the Body After Death
Care of the body after death is called post-mortem care.
It begins when the doctor pronounces the person dead.
It is done to maintain a good appearance of the body.
The right to privacy and the right to be treated with dignity and respect apply after death.
Within 2 to 4 hours after death, rigor mortis develops.
An autopsy is the examination of the body after death to determine the cause of death.
A nurse gives post-mortem care. You may be asked to assist.
Rigor mortis is the stiffness or rigidity of skeletal muscles that occurs after death. The body is positioned in normal alignment before rigor mortis sets in.
The body should appear in a comfortable and natural position for viewing.
Moving the body can cause remaining air in the lungs, stomach, and intestines to be expelled. When air is expelled, sounds are produced. Do not let these sounds frighten you. They are normal and expected.
Review Delegation Guidelines: Care of the Body After Death on p. 674.
Review Promoting Safety and Comfort: Care of the Body After Death on p. 674.
Review the Assisting With Post-Mortem Care procedure on p. 674.
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17. Care for the Caregiver
Nursing assistants and staff grow close to the people they care for.
When death takes a person you are close to, it can be a very sad time.
Sometimes just talking can be helpful.
Healing comes with time.
It is also important to consider the feelings of other residents.
Some nursing centers may have a chapel where a memorial service takes place.
Nursing assistants who experience these losses for the first time may find it somewhat frightening. If this happens to you confide in a nurse or other staff member.
Others may not realize the sadness you are experiencing.
This might offer an opportunity for residents and caregivers to socialize and share memories with each other and the person’s family.
For some persons a private service for family members only is held.
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18. Quality of Life
Quality of life is important to dying persons and their families.
A person has the right to die in peace, with dignity.
The dying person has these rights under OBRA:
To privacy before and after death
To visit others in private
To confidentiality before and after death
To be free from abuse, mistreatment, and neglect
To be free from restraint
To have personal possessions
To a safe and home-like setting
To personal choice
Review Box 44-1 on p. 675.
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