Ch.
13 Palliative and End of Life Care SETTINGS FOR PALLIATIVE AND
END-OF-LIFE CARE
PALLIATIVE CARE • Institution-based
Interdisciplinary collaboration (single plan of - Hospital
integrated care) - Long-term care facility
Comprehensive symptom management, • Outpatient-based
psychosocial care, and spiritual support - Outpatient clinic
needed to enhance the quality of life for any - Ambulatory setting
person with advanced illness • Community-based
Appropriate for patients at any age and at • Hospice care
any state in a serious illness even while
pursuing disease directed or curative therapies INSTITUTION-BASED PALLIATIVE CARE
and extending into illness • Interdisciplinary consultation for pain
management, symptom management, goals of
INSTITUTE OF MEDICINE 2014 care discussions, end-of-life issues,
• Dying in America: Improving Quality and psychosocial distress, spiritual or existential
Honoring Individual Preferences Near the End distress
of Life. • Most common patients are often older with a
serious illness other than cancer and typically
• Recommendations for improving end-of-life have a full code status
care • In 2011, The Joint Commission launched
- Widespread and timely access certification program for palliative care
- Comprehensive coverage
- Improved clinician–patient OUTPATIENT-BASED PALLIATIVE CARE
communication • Provide palliative care services and support
- Greater emphasis on advance care to patients and families who opt not to, or are
planning not eligible for, home hospice but could benefit
- Professional education and from comprehensive palliative care in the
development community
- Stronger public education and
engagement COMMUNITY-BASED PALLIATIVE CARE
• Home-based primary care has increased in
NATIONAL CONSENSUS PROJECT popularity and incorporates palliative care
• Guidelines for a more comprehensive and skills, and specialty palliative care home
human approach to the care of the seriously ill programs that were developed with the goal of
patient at any state, age, setting, or prognosis. managing symptoms and providing support in
• 2018 update the home.
• Covered by The Affordable Care Act
HOSPICE CARE C. Hospice will follow the patient’s choice for
• All hospice care is palliative care “DNR” status
• Focus is on quality of life and includes D. Hospice is provided in the home and will
realistic emotional, social, spiritual, and allow the family to be involved in the decisions
financial preparation for death for care
• Coordinated program of interdisciplinary - B. Hospice assists the family and patient
services provided by professional caregivers to prepare for death Rationale: Hospice
and trained volunteers to patients with serious, is an interdisciplinary team approach
progressive illnesses that are not responsive to that provides services to the patient and
cure family to prepare for death. Hospice
• Recognized by Medicare in 1983 care would include pain control, but
• Goal is patient remains at home complete pain control cannot be
guaranteed. A patient’s “DNR” status is
PRINCIPLES OF HOSPICE CARE respected for all patients in any setting,
• Death must be accepted not just hospice. Hospice care can be
• Patient’s total care best managed by provided in the home, hospital, nursing
interdisciplinary team whose members home, or hospice home settings; as with
communicate regularly all practice areas of health care, family
• Pain and other symptoms must be managed involvement is encouraged if the patient
• Patient/family should be viewed as single chooses this.
unit of care
• Home care of dying necessary COMMUNICATION
• Bereavement care must be provided to • Tenet of palliative and end-of-life care
family members • Nurses must be able to assess patient and
• Research and education should be ongoing family responses to serious illness and support
their values and choices throughout the
4 LEVELS OF HOSPICE CARE continuum of care
• Routine home care • First, nurses must consider their own
• Inpatient respite care experiences and values regarding illness and
• Continuous care death
• General inpatient care
CRITICAL POINTS FOR COMMUNICATION
MOST COMMON HOSPICE DIAGNOSIS • Time of diagnosis
• Dementia • When treatment fails
• Heart disease • Effectiveness of interventions
• Lung disease • Consideration for hospice care
Q1: A family is asking why their father with
end-stage COPD is being referred to hospice
care. Which of the following would be the best
response from the nurse?
A. Hospice care provides complete pain control
B. Hospice assists the family and patient to
prepare for death
NURSING APPROACH TO SYMPTOM ASSESSMENT AND
COMMUNICATION MANAGEMENTS
• Patience • Physiologic changes
- Open-ended questions to allow patient - Pain
and family to voice concerns - Dyspnea
• Empathy - Impaired secretions
- Respond to emotion - Anorexia and cachexia
• Honesty - Anxiety and depression
- Explore misconceptions and need for - Delirium
information - Time of death
• Time of death
Q2: A patient recently diagnosed with a
terminal illness tells the nurse, “I am afraid to HOPE AND MEANING IN ILLNESS
die but I don’t want to hang on with a bunch of • Hope:
tubes and medications keeping me alive.” - a multidimensional construct that
Which of the following is the most appropriate provides comfort as a person endures
way for the nurse to respond? A. “There is life threats and personal challenges
nothing to fear, you can stop treatment at any • Hope-fostering
time.” B. “Don’t worry, your family can make - Spirituality/faith, relationships with loved
those decisions later.” C. “Have you signed a ones, humor, positive memories
Do Not Resuscitate Order?” D. “You can • Hope-hindering
complete an advance directive; has anyone - Isolation, uncontrollable pain/discomfort,
explained that option to you?” abandonment
D. “You can complete an advance directive; NURSING INTERVENTIONS FOR HOPE
has anyone explained that option to you?” • Answer questions honestly and accurately in
Rationale: The patient, while of sound mind, ways the patient can understand
can make decisions now about future • Listen attentively
interventions. An advance directive • Support patient choices
communicates patient preferences regarding • Facilitate communication with family
end-of-life care for when the patient is
terminally ill and unable to verbally state their CULTURALLY SENSITIVE AND SPIRITUAL
wishes, providing the patient control over their CARE
future health care decisions should they • Assess values, preferences, beliefs,
become incapacitated. The nurse should never expectations and practices.
disregard a patient’s fear of dying nor ask the • Nurse must set aside own assumptions and
patient to wait to make a decision about their attitudes toward death and dying
care • Spirituality contains features of religiosity;
however, the two concepts are not
interchangeable
GRIEF, MOURNING, BEREAVEMENT
• Grief SPECIAL ISSUES FOR NURSES AT END OF
- refers to the personal feelings that LIFE
accompany an anticipated or actual loss ● Ethical dilemmas
• Mourning ● Care/cure dichotomy
- refers to individual, family, group, and ● Resiliency
cultural expressions of grief and
associated behaviors
• Bereavement
- refers to the period of time during which
mourning for a loss takes place
UNCOMPLICATED GRIEF AND MOURNING
• Grief is not a linear process
• There is no right way to cope
• Nurse must promote family cohesion during
grief and mourning
• Provide opportunities after death for social
and cultural rituals to facilitate acceptance of
death and loss as permanent
Q3: Which actions by a surviving family
member indicate uncomplicated grief and
mourning? A. Soon after death speaking of the
deceased loved one in the past tense B.
Refusing to discuss funeral arrangements C.
Reluctance to attend a survivors’ support group
D. Avoiding family gatherings
- A. Soon after death speaking of the
deceased loved one in the past tense
Rationale: Acceptance of death begins
with reconciliation of the fact that the
deceased is gone and will not return.
Some choose to preplan funerals with
the soon to be deceased to provide the
means for patient and family to begin to
accept the reality and f inality of death.
Those adjusting to life after the death of
a loved can recognize the permanence
of loss and move forward with the help
of support groups, and other family
members. Attending support groups and
family gatherings is a healthy response
by a survivor with uncomplicated grief.