8 Palliative and end-of-life care
Nursing diagnoses related to information needs
Nursing diagnosis:
Deficient knowledge
related to unfamiliarity with progressive disease process and expectations as death approaches
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s/family’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs. | This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate. |
| Assess patient’s/family’s understanding of disease progression: including appetite loss, changes in respiratory status, mental status, and pain levels. | Understanding physiologic changes may alleviate patient/family fear or anxiety as changes occur. |
| Assess patient’s/family’s understanding of palliative approach to care and clarify misconceptions. | This promotes understanding that palliative care is not “giving up” but rather focuses on achieving the best possible quality of life for patient and family when the disease is no longer curable. |
| Discuss interventions for managing symptoms as death approaches. | Aggressive symptom management and ensuring best quality of life are very active treatments that can be provided. For example, “You should not feel ‘there is nothing more to be done’ because curative treatment is no longer effective.” |
| Refer patients to palliative care or hospice care providers, while maintaining relationships with family/primary care physicians, community, and specialist care providers as appropriate. | This ensures that patient and family do not feel abandoned as care shifts to a palliative focus. |
| Understand practical insurance and financial issues related to hospice care vs. home care. | There is a wide variation of reimbursement for hospice and palliative care provided by private insurers and health maintenance organizations (HMOs). |
| Provide information for hospice or palliative care team for home visit and/or symptom management suggestions when death is imminent | Hospice should be the first call for patients dying at home who will be receiving hospice support. Out of hospital “Do Not Resuscitate” (DNR) orders must be completed and in the home if this is consistent with patient’s wishes. |
Nursing diagnosis:
Deficient knowledge
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs. | This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate. |
Assess which advance care planning documents (will, trusts, Durable Power of Attorney for Health Care [DPOA-HC]) have been completed. Discuss role/limitations of DPOA-HC. | This ensures that patient, family, and staff are aware of advance care planning and promotes understanding of patient’s ability to make choices and maintain control over end-of-life decisions. |
| Discuss and document patient’s wishes. Ensure that patient’s preferences for hydration and nutrition are addressed specifically in DPOA-HC or living will documents as required by state law. | This documentation makes patient’s wishes regarding autopsy, organ donation/transplantation, hydration and feeding tubes, use of antibiotics, chemotherapy, radiation therapy, diagnostic procedures, blood transfusions, and intravenous IV) lines known to family members and health care providers and ensures that those wishes are clear. |
| Assist patient in completion of advance directives documents, including “Five Wishes” if available. | “Five Wishes,” a program currently available in most states, is a style of advance directives that outlines the type of care a patient wishes to receive, not just what should be withheld. |
| Assess understanding of DNR order and other limitations of therapy and clarify as needed. | This ensures that patient and family/significant others understand what will occur during this phase of care. |
| Explain what is meant by “comfort measures only” and how care continues even when withholding and/or withdrawing medically provided nutrition/hydration. | This information will help patients make decisions regarding care and nutrition as outlined in their advance directives. |
| Encourage professional counseling if any of the previous cause discord within the family. | Patients should select a DPOA-HC that is capable of carrying out their wishes. The patient’s wishes may not be the wishes of the person who is the closest relative. |
Nursing diagnoses related to symptom management
Nursing diagnosis:
Ineffective breathing pattern
related to dyspnea as disease process progresses
Desired Outcome: Within 1 hr of this nursing diagnosis, patient states that he or she does not perceive difficulty with breathing.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s perception of dyspnea, recognizing that objective parameters may not coincide with patient’s perception of dyspnea. Consider use of a 0-10 scale. | Patient’s perception should guide treatment interventions. Patient may have low O2 saturation as measured by pulse oximetry but not feel dyspneic, and vice versa. |
Assess for treatable causes of dyspnea. Consider least invasive interventions first (e.g., antibiotics, steroids, diuretics) to relieve underlying pathology causing dyspnea. | Anemia, heart failure, pleural effusion, ascites, and pneumonia, for example, are causes of ineffective breathing pattern (other than simply end of life) that can be treated. |
| Advise family that although breathing changes are common and distressing, they are manageable. | Breathing changes in the patient can be upsetting to the family. |
| Maintain room at cool temperature. | A cooler temperature minimizes feelings of suffocation. |
| Place a cool cloth on patient’s face or forehead as indicated. | This intervention is likely to promote comfort. |
Administer oxygen by nasal cannula only if this offers subjective relief of dyspnea. Use lowest flow rate possible and offer humidification if technically possible. | |
| Administer morphine or other opioid regularly by least invasive available route to relieve dyspnea. | Opioids are the drug of choice for relieving dyspnea. The oral route is preferred, but if not possible, rectal, sublingual, subcutaneous, or IV route can be used. |
| Place fan close to patient’s face. | The face contains baroreceptors that respond to air movement and can effectively relieve perception of dyspnea. |
| Position patient with head/upper body elevated. Suggest sleeping in chair, if needed. | Elevation of the head may make breathing easier and provide comfort. |
| Administer nebulized bronchodilators, steroids, and/or opioids. | These medications relieve dyspnea. |
| Teach relaxation breathing techniques to patient and family. Encourage physical touch/massage as a calming technique. | These actions relieve anxiety, which may improve breathing pattern. |
| Consider need for pharmacologic management of anxiety (e.g., use of anxiolytics). | These medications help alleviate fear and concomitant breathlessness. |
| Elicit patient preferences and values about alertness vs. sedation or discomfort if both goals cannot be achieved. Honor patient’s choices for symptom management. | Some medicines that relieve symptoms may have the unintended side effect of sedation or hastened death. This is known as the principle of “double effect.” |
Nursing diagnosis:
Ineffective airway clearance
| ASSESSMENTS/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for and explain etiology of noisy breathing. | Noisy breathing is a result of secretions in the upper airway in patients who are too weak to cough effectively. |
| Reassure family and significant others that patient’s breathing, though noisy, is not causing discomfort. | Noisy breathing can be distressing to family and friends of the patient. |
| Attempt to position patient laterally and recumbent, rather than supine. | This position helps maintain as patent an airway as possible. |
| Use oxygen only if it enables patient to have unlabored respirations. | Oxygen can cause further discomfort the patient if it is not minimizing labored respirations. |
| Avoid suctioning, other than in the oral cavity. | Aggressive, deep suctioning will increase, not decrease, secretions and cause trauma. |
| Maintain patient in a relatively dehydrated state. | This will minimize accumulation of pulmonary secretions and increase comfort. |
| If death rattle persists despite dehydration, administer prescribed anticholinergics via least invasive route. | Anticholinergics decrease secretions and are much more effective when administered early in the onset of this symptom. Effective agents include scopolamine patch, glycopyrrolate (IV, subcutaneous, per os [PO]), atropine, and hyoscine butylbromide. |
| Reassure family that patients are often unaware of discomfort at this point. | This information will help relieve anxiety of family and significant others about possible discomfort resulting from dehydration to manage pulmonary secretions. |
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