Clinical Clips: End-of-Life Care Provides Comfort, Dignity
Monday March 10, 2008
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Palliative Care Resources
End-of-Life Care for Oncology
(EPEC Project) www.epec.net
End-of-Life Nursing Education Consortium (ELNEC)
www.aacn.nche.edu/elnec
Hospice and Palliative
Nurses Association (HPNA)
www.hpna.org
National Consensus Project for Quality Palliative Care (NCP) www.nationalconsensusproject.org
End-of-life care sometimes is called comfort care because it is focused on comfort rather than cure. Meg Campbell, RN, PhD, FAAN, president-elect of the Hospice and Palliative Nurses Association (HPNA), prefers the term palliative care. Campbell, a palliative care nurse practitioner at Detroit Receiving Hospital, defines palliative care as a team approach that “considers the range of responses the dying patient may experience: symptoms and emotional, psychological, and spiritual concerns.”
Palliative care does not necessarily result in the absence of all medical treatment, says Raeann Fuller, RN, CCRN, intensive care unit nurse manager, Condell Medical Center, Libertyville, Ill. A person who is struggling to breathe, for example, may want to use a ventilator as a comfort measure rather than a life-prolonging treatment.
Communication first
During the end-of-life phase, ongoing communication is vital, according to Fuller. “The process of dying and the patient’s needs change on a day-by-day basis,” she says. “You have to take your cues from patients.”
Fuller encourages nurses to talk to patients about death early in their dying process to learn about their final wishes and advance directives. Nurses can take advantage of these conversations to prepare patients and their families for the things to expect as the dying process progresses.
In their last days, patients may experience fatigue, weakness, and decreasing appetite. They may lose their ability to swallow, have insomnia and anxiety, and, most commonly, experience pain, dyspnea, and delirium. Cognitive failure, agitation, purposeless, repetitious movements, and moaning and groaning are signs of terminal delirium, according to Northwestern University’s EPEC (Education in Palliative and End-of-Life Care) Project. Nonverbal signs of pain include grimacing, wincing, facial rigidity, shutting the eyes, and clenching the fists.
Pain management
“Palliative care is more than following do-not-resuscitate orders,” says Lynn Juppe, RN, MN, CHPN, supervisor of the Hospice of Visiting Nurse Service in Akron, Ohio. An important component is managing pain, which is prevalent at the end of life but often goes undertreated.
HPNA maintains the position that patients should receive pain management therapies while they are dying. When opioid analgesics are used, doses should be adequate to relieve pain, according to HPNA’s position statement. The statement stresses that, contrary to what some believe, there is a lack of scientific evidence that opioid medications hasten death.
“Opioids remain the best agents for cancer pain or severe pain,” Campbell says. “Patients may need counseling from nurses about the safety and efficacy of opioids.”
Some patients choose to tolerate unrelieved pain to avoid side effects of opioid medications, Campbell says. Nurses should collaborate with patients to plan a pain regimen.
For optimal pain control, Juppe suggests:
• Thoroughly assess the cause or type of pain to ensure proper treatment.
• For patients with chronic pain, medicate on a schedule to prevent pain from returning.
• Check with the patient about the effectiveness of the pain management modality. Treat breakthrough pain with fast-onset, short-acting medications.
• Actively treat side effects as they occur. When using narcotics, start a regimen to manage constipation as soon as it begins.
• Don’t be concerned about potential for opioid addiction. Comfort is the goal during these final days.
Patient positioning in bed also contributes to comfort care, Fuller says. Moving a bedridden patient every two hours may cause pain, but not doing so could cause more painful complications, such as joint stiffness and bedsores. To minimize pain, Fuller recommends administering pain medication before moving patients. Nurses can make patients more comfortable with more pillows, proper body alignment, or a low-air-loss mattress overlay to reduce pressure.
A good death
Recent efforts to improve end-of-life nursing care have focused on the idea of providing a “good death.” A study published in the March 2006 American Journal of Critical Care surveyed intensive care nurses on care measures that help ensure the best-possible death for patients with life-limiting illness. Respondents recommend the following interventions in addition to managing pain and discomfort:
• Enhance the physical environment to promote dying with dignity. A private room with space for numerous family members and soothing background music are ideal.
• Be present. Sit with the patient, touch the person, and talk to him or her. Encourage family members to stay.
• Know and follow patients’ wishes for end-of-life care.
• Discontinue aggressive treatments or do not start them when there is little hope a patient will survive.
• Communicate effectively with physicians so all team members share a vision for a patient’s best plan of care.
While it may not be possible to have every variable in place to ensure every patient’s best death experience, any effort nurses can extend to increase comfort for dying patients and their familes goes a long way.
“Helping a patient die symptom-free and with dignity is a huge goal and a worthy one,” Juppe says.
Kathleen Louden is a freelance health writer. To comment, email editorDC@nursingspectrum.com
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