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Chapter 24: Palliative and End‐of‐Life Care

Chapter Highlights

Social trends in aging and dying

Palliative and hospice care for persons across the life span

Caring for a person at the end of life

Strategies for managing pain and common symptoms

Question #1

Is the following statement true or false?

Studies have documented that the American healthcare system has the best care in the world of seriously ill clients and their families.

Answer to Question #1

False

Rationale: Studies have documented that the American healthcare system has substantial shortcomings in the care of seriously ill clients and their families.

Nursing and Patients with Chronic Disease #1

Patient‐ and family‐centered care

Ethical behavior and consumer rights

Clinical excellence and safety

Inclusion and access

Organizational excellence

Nursing and Patients with Chronic Disease #2

Workforce excellence

Standards

Compliance with laws and regulations

Stewardship and accountability

Performance measurement

Death in the United States

Stages in the dying process

Specialized care at the end of life

Nursing Care When Death Is Imminent

Decisions about level of care

Comfort measures only

Advance directives

Artificial nutrition and hydration

CPR

Euthanasia and physician‐assisted suicide

Question #2

Is the following statement true or false?

It must be remembered that a dying patient will go through denial, anger, bargaining, and acceptance stages of dying.

Answer to Question #2

False

Rationale: A dying person may not exhibit all of these stages, or may move quickly through a stage, only to return to it at a later time.

Palliative Care

Interdisciplinary team‐based care that is focused on the relief of suffering for clients with serious illness

Best possible quality of life not only for clients but also for their families

Acute, serious, life‐threatening illness

Progressive chronic illness

Focus of Palliative Care

Controlling symptoms

Coordinating care

Reducing unnecessary tests and futile interventions

Ongoing conversations with the client and family

Hospice Care

Support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible

Hospice Care #1

Physician services

Nursing care

Physical therapy, occupational therapy, and speech‐language pathology services

Medical social services

Hospice aide services

Hospice Care #2

Homemaker services

Medical supplies, including drugs and biologic and medical appliances

Counseling, including dietary counseling, counseling about care of the terminally ill client, and bereavement counseling

Short‐term inpatient care for respite care, pain control, and symptom management

Caring for Patients at the End of Life #1

Death itself

Thoughts of a long or painful death

Facing death alone

Dying in a nursing home, hospital, or rest home

Loss of body control, such as bowel or bladder incontinence

Caring for Patients at the End of Life #2

Not being able to make decisions concerning care

Loss of consciousness

Financial costs and becoming a burden on others

Dying before having a chance to put personal affairs in order

Pain Management

Pain assessment

Types of pain in dying patients

Pain relief during the dying process

Pain Medications

Nonopioid analgesics

Opioids

Adjuvant analgesics

Oral

Oral mucosa

Rectal

Transdermal

Topical

Parenteral

Intraspinal

Question #3

Is the following statement true or false?

Short‐acting or immediate‐release agents are excellent prn medications, and their only use should be for control of breakthrough pain.

Answer to Question #3

True

Rationale: Short‐acting or immediate‐release agents are excellent prn medications, and their only use should be for control of breakthrough pain. Breakthrough pain is defined as “intermittent episodes of moderate to severe pain that occur in spite of control of baseline continuous pain.”

Preventing and Managing Adverse Effects

Constipation

Sedation

Respiratory depression

Nausea and vomiting

Myoclonus

Pruritus

Management of Distressing Symptoms at the End of Life

Secretions

Anorexia and dehydration

Skin integrity

Incontinence

Terminal delirium

Nursing Care of Clients Who Are Close to Death

Buildup of saliva and oropharyngeal secretions

Changes in respiratory patterns

Skin may appear dusky or gray and feel cold or clammy.

Eyes may appear discolored, deeper set, or bruised.

Nursing Care After Death

Postmortem care

Grief—emotion felt after the loss

Mourning—recovery from the loss

Grief

Numb shock

Emotional turmoil or depression

Reorganization or resolution

Caring for the Caregiver

What have you done to meet your own needs today?

Have you laughed today?

Did you eat properly, rest enough, exercise, and play today?

What have you felt today?

Do you have something to look forward to?

Complementary and Alternative Therapies

Acupuncture

Massage

Reiki

Chiropractic

Herbal medicine