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Advance Directives

Legal documents stating the wishes of an individual regarding future medical care treatments and/or who should make those medical decisions in the event that the individual is no longer capable of giving personal informed consent.


Living Will

  • Provides information of preferences regarding end of life issues: types of care to provide and whether to use various resuscitation measures
  • Basis is "if-then" plan and the condition stated as "if" must be dianosed by a physician


Durable Power of Attorney (POA) for Health Care AKA Health Care Proxy

  • Legally designates a substitutionary decision maker for medical decisions should a patient be unable to make informed decisions for self
  • May be family member or trusted friend
  • May diminish family conflict and facilitate the provision of the care that the patient wishes


Physician Orders for Life-Sustaining Treatment (POLST)


Known as MOLST (Medical Orders for Life-Sustaining Treatment) In NY state

  • Includes limitations on resuscitation in the event of cardiac or R. arrest, including DNR
  • Moves from one care setting to another
  • DNR order does not limit other types of care setting to another
  • DNR order does not limit other types of care that can be provided (wound care, pain management, antibiotics, O2)
  • Based on effective communication of patient wishes, documentation of medical orders on a brightly colored form, and a promise by health care professionals to honor patient wishes
  • Must be signed by a physician and reviewed periodically
  • Can be revoked or modified at any time


What is the American Nuses' Association's stance on the RN role in advance directives?

  • Understanding and implementing the laws of advance directives
  • Ask and inform each patient about advance directives
  • Serve as a patient advocate for patient wishes


Palliative Care VS Hospice/Comfort Care

Palliative care is defined as the active total care of patients whose disease in not responsive to curative treatment. Palliative care focuses on controlling pain and other symptoms, as well as reducing psychological, social, and spiritual distress for the patient and family. Palliative care is the framework for hospice/comfort care because it can start much earlier in the disease process.

Hospice, a concept of care that is traditionally limited to the projected last 6 months of life, if often used interchangeably with comfort care. It provides support, care, and compassion for the dying so that they might live as fully and and as comfortable as possible.


Tips for working dying children

  1. Be flexible. Straightforward approaches don't always work with children
  2. Recognize that many children communicate best through nonverbal means such as artwork or music. They also may be more willing to talk things over with puppets or stuffed animals than with real people.
  3. Respect both children's need to be alone and thier desire to share. Allow communication, don't force it.
  4. Be receptive when children initiate a conversation. Opportunities to teach may be fleeting, and to capitalize on them, you n eed to respond immediately.
  5. Be specific and literal in explanations of death. Euphemistic expressions that equate death with sleep or going on a long trip can be very confusing for children.
  6. Acknowledge that child's life can be complete, even if it's breif. Let dying children know that they'll always be loved and remembered, and help them find a sense of accomplishement and purpose in the lives they've led.
  7. Empower children as much as possible in circumstances concerning their own deaths. Reassure them of continued love and physical closeness, provide adequate symptom relief, and involve them in decisions regarding care as much as possible



While IV hydration has been provided routinely to many dying patients, research has called this practice into question.

  1. Many patients refuse fluids and food when they are dying
  2. An increase in endorphins, which result from dehydration and decreased nutrition can produce analgesia and anesthesia
  3. No decrease in comfort has been reported due to dehydration
  4. IV infusion of D5W contains enough carbohydrate to block the anesthetic effect of ketosis
  5. Nature restricts fluid intake and accelerates fluid loss; anoerexia, vomiting, dirrhea, wound drainage and bleeding
  6. Artificial hydration in a paitent with end-stage organ failure worsens peripheral and pulmonary edema, dypnea, acites, edema around tumors, and pleural effusions


Anxiety and Depression

  1. Encouragement, support, education
  2. Pharmcological and non-pharmacological interventions


Fear of Pain

  1. Assure prompt administration of pain medications/side effect managemnt
  2. Encourage patient participation in discussing pain relief measures


Fear of shortness of breath

  1. Determine cause of dyspnea
  2. Opiods, brocnhodilators, O2, anxiety-reducing agents to provide relief


Fear of lonliness and abandonment

  1. Provide companionshio
  2. Hold hands, listen, touch


Fear of meaninglessness

  1. Help patients review their lives
  2. Remain nonjudemental with patient's life review



  1. Demonstrate empathy and understanding
  2. Listen and interact in a sensitive way



  1. Acknowledge and encourage the expression of feelings
  2. Do not react on a personal level


Hopelessness and powerlessness

  1. Encourage realistic hope within limits of the situation
  2. Promote patient identified goals to reolve some sense of power


Death Anxiety

Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one's existence

Defining characteristics:

  1. Reports concerns of overworking the caregiver
  2. Reports deep sadness
  3. Reports fear of  developing a terminal illness, loss of mental abilities when dying, pain, premature death, process of dying, prolonged dying, or suffering
  4. Reports feeling powerless over dying
  5. Reports worry about the impact of one's own death on significant others

Related Factors:

  1. Antcipating pain/suffering
  2. Discussions and observations regarding death
  3. Uncertainity about an encounter with or the existence of a higher power
  4. Nonacceptance of own mortality
  5. uncertainity of prognosis

Nursing Interventions:

  1. Assess: psychosocial maturity of the individual, pain/provide pain relief measures, fears r/t death
  2. Assist: patients with life planning, with life review and reminiscence; help to create a momento book reflecting life achievements
  3. Identify times/places when anxiety is greatest and provide psychosocial support at those times
  4. Support religious beliefs
  5. Refer to support groups as appropriate; provide social support for families
  6. Identify patient's preference for end of life care, provide assistance in honoring preferences as much as practiable
  7. Teach patients and families about advanced directives
  8. Promote effective communication to caregivers
  9. Allow family members to be physically close to their dying loved one
  10. Keep family members informed


Pallative Care

  • Goal is to make the patient and family comfortable physically, emotionally, and spiritually
  • Palliative care team can consist of phjysician, nurse, physical thearpy, occupational therapy, social work, chaplain, and nutritionist
  • Consultation should begin at first diagnosis to enhance relationships, build trust, and design a better plan of care
  • Families need accurate information on which to make decisions


Concerns of the dying

  • Pain and symptom management
  • Avoid prolongation of dying
  • Sense of control
  • Relieve burdens
  • Strengthen relationships


The Conversation

  • Listening is key
  • Use open-ended questions
  • Ask patients to clarify their thoughts
  • Do not give advice unless asked for
  • Be sensitive to timing, cultural differences, and educational levels
  • Be present physically, emotionally, and mentally


The Palliative Care Assessment


  • Pain: assess regularly and respond to immediately
  • Oral Complications: provide good, frequent oral care
  • Dyspnea: increase HOB, opioids, breathing techniques
  • Constipation: assess causes, laxatives
  • Confusion: many causes
  • Pressure Sores: ROM, massage, turn and reposition
  • If the patient is not able to take food or fluid by mouth and it is pumped in mechanically, it is not of any benefit to the patient. In most cases, harm is being inflicted


  • Ask patient to discuss feelings
  • Listen attentively and anticipate needs
  • Grief is a "journey" depression is "stuck"
  • Including family members and spiritual assessment


  • Practical questions
  • Who are caregivers, community resources, financial impact


  • Address special arrangements and beliefs
  • After death rituals

Advanced Care:

  • Does the patient have advanced care directives?
  • Determine capacity
  • Facilitate completion of forms if patient requests assistance


The Last Hours

Maximize physical care and symptom control

  • Peaceful death includes a progression from sleepiness to lethargy to coma to death
  • Difficult death can include restlessness, confusion, hallucinations, delirium, moaning, spasms, seizures, and eventual coma and death
  • Acknowledge the life of the patient

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