End of Life Care

Objectives:
After you take this class, you will be able to:

  1. Use end of life care principles in your daily role as a nursing assistant.

  2. Detail the physical, mental, social, spiritual, financial and communication needs of patients and their family members as the end of life is near.

WHAT IS END OF LIFE CARE?

People of all ages go through the natural dying process unless they have had a sudden illness or accident. Babies and young children who are born with AIDS/HIV go through a dying process. Adults with cancer also go through the end of life process. The end of life requires special nursing care.

If a person is shot with a gun or is in a very bad car accident, they may die in an instant without the end of life process because their death was sudden. Their needs are not the same as those who died in a slower and more gradual way.

The years, months or days before death are often filled with more and more physical and mental problems for most people as they go through the end of their life. These people need special care as they go through the natural dying process.

WHAT DO PEOPLE NEED DURING THE END OF THEIR LIFE?

Some of the resident, patient and family member needs at the end of life are listed below.


  • Communication. Communication can be verbal, or spoken and it can be nonverbal. An example of verbal communication is saying, " Hello, Mrs. Rochas, how is your arm feeling today?" Communication can also be nonverbal. This communication is sometimes called body language. If you stand in a person's room and tap your foot WITHOUT saying a word, you are telling the person that you are in a hurry WITHOUT ever saying a word. Foot tapping is nonverbal communication.

  • Physical comfort. Many patients at the end of life are in pain. Some need pain medicine and other pain relief care. Many may be chilly, or feel cold. They may also lose control of their urine and feces. Patients at the end of life need physical care and comfort.

  • Mental comfort. Some people may be very sad, or depressed. Others may be afraid to be alone in their room. Many people accept the fact that they are dying. They accept the fact that death is near and they prepare for it. They may do certain things like taking care of their money matters, selling their house, giving their possessions away and writing a will, if not already done. All patients and residents must be treated with dignity and kind care at all times throughout their life, especially as the end of life comes. A lot of special care is needed during this time to make the person mentally comfortable.

  • Spiritual comfort. People may want to see a rabbi, priest or minister during the end of life. They may want to pray, go to church and read the bible. Others may not be spiritual or religious at all.

  • Social needs. Sadly, many old people and very ill people do not see or hear from their family or friends as much as they did in the past. They may feel lonely, unloved, and not useful or important.

  • Financial needs. Care in the home, hospital or nursing home costs a lot of money. During the end of life, many people worry about how they are going to pay for their funeral and their health care. Some need help from a social worker or community agency to meet these financial needs.

MEETING THE NEEDS AT THE END OF LIFE

Nursing assistants play a very important role in end of life care. They should observe and report all end of life needs to the charge nurse. They also provide end of life care. For example, a nursing assistant must report when a patient tells them that they would like to see a minister so that the minister can visit with the dying patient. They may also be asked to sit and talk to a resident so the resident will not fear being alone.

Nursing assistants also must care for the family. We must allow families to spend a lot of time with the loved one that is dying. Make the family comfortable. Give the family privacy.

Tell the family and other visitors where the telephones are. Show them the rest rooms and the coffee shop. Arrange for visitor meals to the patient's room if they want meals.

Other ways that nursing assistants can meet the needs of the dying patient and family.

Communication

  • Spend time with the patient and family.

  • Listen to what they have to say.

  • Speak in a kind and respectful way.

  • Answer their questions if you can. If you can't answer a question, ask the nurse to help them.

  • Use body language that shows caring and respect. A gentle touch, holding the person’s hand and just spending time shows caring. Do NOT cross your arms, tap you feet or show other signs of being hurried.

  • Communicate with patients that are in a coma or unconscious. Do NOT treat unconscious patients different from those that are awake and alert. Do NOT ever say anything that you do not want the patient or resident to hear. Hearing is the last sense to die at the end of life.

Physical Comfort

Patients during the end of life have physical care needs. Many patients at the end of life choose to NOT have some treatments, such as CPR, tube feedings and other things. This is their right. They can choose to have some nursing care and choose to NOT have other things. All patients, however, have a right to physical comfort.

  • Observe and report signs of pain. Tell the nurse if a person tells you that they are in pain or if you see an unconscious person with a look of pain on their face. Pain is now called the 5th vital sign. Patients should be checked for pain often.

  • Provide a quiet room, a backrub and even soothing music to patients that are in pain. Allow the person in pain to speak to you. Spend quiet time with them.

  • Give the person their bath and provide very good skin care. Keep them clean and dry at all times.

  • Turn and position the patient at least every 2 hours. Many dying patients are at risk for pressure ulcers.

  • Provide very good mouth care. The patient may be dehydrated and have a dry mouth. Use mouth swabs for unconscious patients that have a dry mouth. Give sips of water to patients that are conscious and able to swallow safely.

  • Keep the bed and the room neat.

  • Adjust the temperature in the room if the person is too warm or too cold. Give them lighter clothing to wear if they are hot. Give them a sweater or blankets if they are cold.

Mental Comfort

  • Listen to the patient, resident or family members. Spend time with them. Allow them to express their fears and concerns.

  • Keep the nurse call bell in reach of the person so they can call for help if they need it.

  • Answer the call bell immediately. Do NOT ignore any person or their needs when they need your help, especially at the end of life.

  • Allow the person to do their end of life tasks, like calling their family and speaking to their attorney or funeral director.

  • Make the person feel loved and cared for.

  • Report any signs mental distress, like crying, to the nurse.

Spiritual Comfort

  • Respect the need for spiritual support.

  • Do NOT force your own religious or spiritual beliefs on the patient. People have the right to choose their own beliefs. These beliefs must be respected. People also have the right to have no religious or spiritual beliefs at all.

  • Provide a quiet and private place to pray, read the bible, meditate and speak to their religious chaplain.

  • If a person wants to see their rabbi, priest, or other religious representative, report this to the nurse.


Social Needs

  • Welcome visitors. People at the end of life have a desire for closeness. Make visitors comfortable and welcome.

Financial Needs

  • Tell the nurse if the person is worried about their money or financial needs. Social workers often help them with these and other matters, such as writing a will or advance directives.

Post Mortem Care

  • Allow the family to cry, grieve and spend some time with the person who has died.

  • Follow your hospital or nursing home procedure for post mortem care.

  • Provide post mortem care with dignity and respect for the person that has died.

LEGAL & ETHICAL ISSUES AT THE END OF LIFE


The Right to Dignity

All patients and residents have a right to dignity throughout their life, especially when the end of life is near.

  • Provide privacy when bathing or caring for a patient.

  • Encourage the person to make choices and control their own life. If they want to wear a certain dress, let them wear it. If they want their bath in the evening instead of the morning, let them have their bath in the evening.

  • Allow the person to be as independent as possible.

  • Speak to the person with respect. Call the patient by their name. Do not call them “mom”, “honey” or “grandma”.

The Right to Make Decisions

All patients and residents that are capable of making a decision must be able to do so, even when the end of life is near.

  • A person can choose what they want and what they do NOT want. If a person refuses care, do NOT force them. Some people do not want a lot of medications or treatments like CPR at the end of life. Others choose to have CPR and medications. Know your patients and residents. Respect and carry out their wishes.

  • If a person has enough thinking ability (competence) to make a decision, their decision must be respected. Family members, nursing assistants and all others MUST respect these decisions, even if we do not agree with them.

The Right to Privacy & Confidentiality

Patients and residents have a right to have their medical information secret and private. NEVER discuss a patient or their condition with friends, neighbors, other patients or residents.

  • Do NOT discuss any information about the patient or resident unless the patient or resident asks you to.

  • Keep patient information confidential. It is against the law to tell your family member or neighbor that “Mr. B., my patient is dying with AIDS”.

  • Do NOT discuss any information about your patients with other patients or unknown people that have called the nursing station. You have no way of knowing who is at the other end of the phone.

A “Living Will”: Advance Directives

Patients and residents across the country are encouraged to write what treatments they do and do NOT want when they are at the end of life. These things are put in a “living will” or “advance directives”

  • Know your patients and residents.

  • Know what your patients and residents want and do NOT want. Do NOT do CPR, for example, on a patient who does NOT want it.

  • Respect these wishes even if you do not agree with them.

Medical Power of Attorney: Health Care Proxy

Some patients and residents choose to have others make decisions for them. These people may decide what treatments the patient or resident will and will not get when the person is no longer able to make a choice at the end of life.

  • Follow the decisions of the medical power of attorney or health care proxy

Summary

Nursing care does NOT stop when the end of life comes. All members of the health care team play a very important role in the end of life care. This care meets the person’s physical, mental, social, spiritual and financial needs.

Nursing assistants and others must be able to meet these needs. They must also be able to care for family members while they hold up the patient’s or resident’s rights to decision making, privacy, confidentiality and dignity.

Care at the end of life is a very rewarding part of nursing care.

References

Aging With Dignity. (2010). “Five Wishes”. [online] http://www.agingwithdignity.org/5wishes.html

American Association of Colleges of Nursing. (2001). “Peaceful Death: Recommended Competencies and Curricular Guidelines for End-Of-Life Nursing Care”. [online] http://www.aacn.nche.edu/Publications/ deathfin.htm

Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.

 

Eliopoulos, Charlotte. (1995). Manual of Gerontologic Nursing. St. Louis: Mosby –Year Book Inc.

 

Hockenberry, Marilyn J. and David Wilson. (2010).Wong's Essentials of Pediatric Nursing. 8th Edition. Elsevier Mosby.

 

Kee, Joyce LeFever and Evelyn Hayes. (2009). Pharmacology: A Nursing Process Approach 6th Edition. Saunders Elsevier.

 

Last Acts Campaign to End of Life Care. (2002). “Last Acts”. [online] http://www.lastacts.org/la_ala

 

Monahan, Frances Donovan and Wilma J. Phipps (2007). Phipps’ Medical-Surgical Nursing: Health and Illness Perspectives. 8th Edition. Elsevier Mosby.

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.

Wold, Gloria Hoffmann. (2008). Basic Geriatric Nursing. Elsevier Mosby.

 

 

Copyright © 2010 Alene Burke



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