17.2 End-of-life care and palliative nursing

End-of-life care focuses on comfort and quality of life, addressing physical, emotional, and spiritual needs. It involves a collaborative approach, emphasizing symptom management and respecting patient autonomy. The goal is to alleviate suffering, provide support, and help patients achieve peace.

Assessment in end-of-life care covers physical, emotional, and spiritual needs. Interventions include pain and symptom management, emotional support, and spiritual care. Effective communication, shared decision-making, and ethical considerations like advance directives and DNR orders are crucial components of compassionate end-of-life care.

Principles and Goals of End-of-Life Care

Principles of end-of-life care

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• Focuses on quality of life and comfort rather than cure
• Takes a holistic approach addressing physical, emotional, social, and spiritual needs (pain management, counseling, family support, spiritual guidance)
• Provides patient-centered care respecting autonomy and preferences
• Involves a collaborative interdisciplinary team approach (physicians, nurses, social workers, chaplains)
• Emphasizes symptom management and pain relief
• Supports patients and families during the dying process

Goals of end-of-life care

• Alleviates suffering and promotes comfort
• Manages symptoms effectively (pain, dyspnea, nausea)
• Provides emotional and spiritual support
• Facilitates open communication and shared decision-making
• Assists patients in achieving a sense of closure and peace
• Supports families during the end-of-life process and bereavement

Assessment and Interventions in End-of-Life Care

Assessment of end-of-life needs

• Physical needs assessment
  • Evaluates pain and discomfort
  • Assesses fatigue and weakness
  • Monitors dyspnea and respiratory distress
  • Checks for nausea and vomiting
  • Assesses constipation or diarrhea
  • Examines skin integrity and pressure ulcer risk
• Emotional needs assessment
  • Evaluates anxiety and fear
  • Assesses depression and sadness
  • Identifies anger and frustration
  • Recognizes sense of loss and grief
  • Explores coping mechanisms and support systems
• Spiritual needs assessment
  • Discusses meaning and purpose of life
  • Explores religious or spiritual beliefs and practices
  • Identifies need for forgiveness, reconciliation, or closure
  • Addresses existential concerns and questions

Interventions for symptom management

• Pain management
  • Conducts comprehensive pain assessment using valid tools (numeric rating scale, FACES scale)
  • Administers pharmacological interventions (opioids, adjuvant medications)
  • Implements non-pharmacological interventions (relaxation, massage, heat/cold therapy)
• Symptom management
  • Dyspnea: provides oxygen therapy, positioning, opioids for air hunger
  • Nausea and vomiting: administers antiemetics, modifies diet, teaches relaxation techniques
  • Constipation: prescribes laxatives, stool softeners, dietary changes, encourages physical activity
  • Fatigue: teaches energy conservation, prioritizes activities, provides assistive devices (walkers, reachers)
• Distress management
  • Offers emotional support and active listening
  • Provides counseling and psychotherapy
  • Facilitates spiritual care and support
  • Incorporates complementary therapies (music therapy, art therapy, pet therapy)

Communication and Ethical Considerations

Communication in end-of-life care

• Effective communication strategies
  1. Practices active listening and empathy
  2. Uses clear, honest, and compassionate communication
  3. Addresses concerns and questions openly
  4. Provides information in understandable terms
  5. Respects cultural, religious, and personal beliefs
• Shared decision-making
  • Discusses goals of care and treatment preferences
  • Explores advance directives and end-of-life wishes
  • Involves patients and families in care planning
  • Facilitates family meetings and discussions
• Support for patients and families
  • Provides emotional and spiritual support
  • Offers practical assistance and resources (respite care, home health services)
  • Facilitates access to support groups and counseling services
  • Addresses anticipatory grief and bereavement needs

Ethics of end-of-life decisions

• Advance directives
  • Explains living wills specifying treatment preferences
  • Discusses durable power of attorney for healthcare decisions
  • Documents advance directives with patients
  • Ensures advance directives are accessible and honored
• Do-not-resuscitate (DNR) orders
  • Discusses DNR status with patients and families
  • Documents DNR orders clearly in medical records
  • Ensures healthcare team is aware of DNR status
  • Provides comfort care and symptom management for DNR patients
• Withdrawal of life-sustaining treatments
  • Assesses patient's decision-making capacity
  • Discusses benefits, risks, and alternatives of life-sustaining treatments
  • Respects patient autonomy and right to refuse treatments
  • Ensures comfort and support during the withdrawal process
  • Addresses family concerns and provides emotional support