Overview
This lecture covers the dying process, differences between palliative and hospice care, cultural, legal, and ethical issues, and the nurse’s role in end-of-life care.
Dying Process and Manifestations
- Death is defined by the loss of breath and pulse; can be biological (irreversible) or clinical (potentially reversible).
- Early dying stage: loss of mobility, decreased appetite, increased sleep, cognitive changes.
- Middle stage: declining mental status, brief wakefulness, noisy respirations ("death rattle").
- Late stage: dyspnea with apnea, skin mottling, fever; progression varies by individual.
Palliative vs. Hospice Care
- Palliative care aims to improve quality of life by symptom management alongside curative treatments.
- Example: palliative surgery to relieve obstruction in cancer, even if cure is not possible.
- Hospice care provides comfort when cure is not possible or patient chooses no further treatment, usually with a prognosis of less than six months.
- Respite care offers temporary relief for caregivers by admitting the patient to a facility.
Cultural and Spiritual Considerations
- Nurses must assess and accommodate patients’ cultural and spiritual needs to enhance quality of life.
- Open-ended questions help assess spiritual needs (hope, organization, personal practices, effect on care).
- Chaplains and religious leaders should be available based on patient preferences.
Legal and Ethical Considerations
- Key principles: justice (fairness), nonmaleficence (do no harm), beneficence (acting in patient’s best interest), fidelity (honest information).
- Terminal sedation is for symptom relief, not to hasten death; requires specific criteria.
- Physician-assisted suicide is legal in some states under strict guidelines.
Advanced Directives and Code Status
- Advanced directives: living will (treatment wishes) and durable power of attorney (health care proxy).
- Every patient should have a code status: full code (all interventions), DNR (do not resuscitate), DNR-CC (comfort care only), DNR-CCA (treat until arrest but no CPR).
- Clarify code status before procedures and address misconceptions about DNR.
Withdrawing/Withholding Care
- Withholding/withdrawing interventions is ethically acceptable if aligned with patient wishes and when treatment burdens outweigh benefits.
- Nutrition/hydration decisions should be informed and respect autonomy.
Nursing Role in End-of-Life Care
- Assess and manage pain, dyspnea, skin integrity, GI symptoms, and fatigue.
- Use both pharmacological (opiates, non-opioids, medical marijuana) and nonpharmacological (music, massage) pain treatments.
- Routinely reassess and adjust interventions for effectiveness.
- Support families, ensure spiritual/cultural needs, and document all care accurately.
Key Terms & Definitions
- Palliative care — Symptom management to improve quality of life, often concurrent with curative treatment.
- Hospice care — Comfort-focused care at end of life when cure is not an option.
- Respite care — Temporary care to relieve family caregivers.
- Terminal sedation — Sedation for symptom relief at end of life when other measures fail.
- Physician-assisted suicide — Legal prescription for self-administered life-ending medication in certain states.
- Advanced directive — Legal documents stating patient wishes or proxy for health decisions.
- DNR (Do Not Resuscitate) — No CPR or resuscitation if patient’s heart stops.
- DNR-CC/C (Comfort Care/Arrest) — Specifies care before and after cardiac arrest.
Action Items / Next Steps
- Review advanced directives and code status documentation procedures.
- Prepare for spiritual assessments using open-ended questions.
- Complete any assigned reading on evidence-based end-of-life care practices.