Nurses treat patients from birth all the way to death. And understanding how to care for your patients in each stage will make you a well-rounded nurse. So, let’s dive into nursing care specifically for the end-of-life.
Hospice Versus Palliative Care
During the end-of-life, it is important to place your patient into the right care. Palliative versus hospice care should be discussed with the patient in detail so the right choice can be made for them and their family.
Hospice
Hospice care is specifically for patients who are not expected to live past 6 months. The treatment plan is re-evaluated for comfort measures only. Examples of medications given to a patient receiving hospice care would be pain and anti-nausea medications, sleeping aids, and possibly appetite stimulating medications.
The purpose of hospice is to make the patient more comfortable with their transition into the afterlife. To provide them with peace and an enhanced quality of life before a dignified passing.
Palliative Care
The difference between hospice and palliative care is that with palliative care, the patient can still receive treatment measures to cure, prevent, or slow their disease process. Palliative care does not put an expected time frame on death like hospice care does. Meaning any patient at any end-of-life stage can go into palliative care.
Palliative care similarly focuses on improving the quality of life for the patient whilst providing death with dignity care. All while also addressing the patients’ families’ feelings. Palliative care addresses physical pain as well as mental, emotional, and spiritual care during the end-of-life.
More healthcare providers are typically involved in caring for a palliative care patient. Including not only nurses and doctors, but social workers, physical and occupational therapists, massage, music and art therapists, and pastors, priests, and chaplains just to name a few.
Mental and Physical Care
Whether your patient is in hospice or palliative care, or really at any stage of life, we should be caring for all our patients both mentally and physically.
Mental Care
Talk and listen to your patient. Observe their surroundings. Do they have spiritual symbols in their room? Have they been seen with a spiritual advisor yet? If not, ask if they would like a visit from one and what their religious beliefs are so that you can assign the right care.
Maybe the patient and their family are having a difficult time accepting the situation. Set aside time to speak with them about their concerns. Is there something you can do to provide comfort at this time? Provide the family with information about end-of-life care in the form of communication and handouts. Some patients and family members won’t be ready for the difficult conversations now but will be curious about it later. So leave a handout at their bedside for them to read in their own time.
Physical Care
Regardless of if the patient is on hospice or palliative care, the physical care is going to be about the same. You’re going to have PRN medications that can be given to alleviate pain and make the patient more comfortable. Explain to the patient not to wait until the pain becomes too severe to say anything, as it will be harder to treat. Devise a schedule with the patient for when the next PRN can be given and write it on their white board. Also be sure to ask them if they want to be woken up for pain medications or if they’d prefer to call when in pain.
Visit Nursing Fundamentals: A Guide to Pain and Patient Education: How to Effectively Manage Acute and Chronic Pain. Plus An Intro to Pharmacology and A Guide to the 10 Rights of Medication Administration for more information on treating pain.
Non-Pharmaceutical Care
On top of proving comfort care in the form of medications, be sure to use other non-pharmaceutical remedies as well. For example, you can provide them with warm blankets and even encourage a blanket from home. Does your hospital have aromatherapy towelettes? Great! Offer that to your patient. Is your patient intermittently nauseated? Leave some alcohol wipes on their bedside table for them to smell when the nausea comes on. Are they in pain? Offer heating packs. Are they unable to sleep? Offer earplugs or maybe earbuds and some calming music.
Whatever you do, make sure to include your patient in any decisions you possibly can. This time can feel scary and out of control, especially to a younger patient who was recently able to fully care for themselves. Giving them decisions and including them in their care is a great way to give back some autonomy to your patient. Even if it seems like a small ask, just ask. Do they want ice in their water? Would they like a heated blanket or just a regular one? Do they want one pillow or two? It’s the small things, but they really do make all the difference in end-of-life care.
The Kubler-Ross Model of Grief
In addition to providing good physical and emotional care, the patient and their family are going to need time and space for grieving. Let’s quickly go over the stages of grief as defined by Kubler-Ross. It is important to keep in mind that these stages can happen in any order and will take a varied amount of time for different people.
Denial
The diagnosis of a terminal illness will be incredibly difficult for the patient and their family. They are likely going to have a hard time accepting this diagnosis to be true.
Anger
The patient and family members are going to become upset with this diagnosis and may take it out on the nursing staff and other healthcare workers. You must understand that this is not a personal attack but rather an emotional roller coaster.
Be sure to visit How to Handle Aggressive Patients to help deescalate the situation if needed.
Bargaining
At this point the patient is going to try to bargain for more time. They’re going to want to know if there’s a treatment option to cure them or at least one to buy them some time.
Depression
After the patient accepts their terminal illness, they are going to feel extreme sadness. No one wants their life cut short, especially if they feel like there are things they still haven’t done in their life.
Acceptance
The patient comes to term with their diagnosis and plans for what this now means for them, their family, and the rest of their life.
Aid in Mourning – For the Patient
Use therapeutic communication along with active listening, clarification, and summarization. If you aren’t sure of something, ask your patient open-ended questions and repeat back their biggest concerns. Address the stages of grief as they come and let the patient know that these are normal. Practice silence with your patient as they move through their mourning process. Give them information about their disease through both communication and printed handouts including support groups.
Aid in Mourning – For the Family
Address the plan for the family. Are they able to be at bedside? Do they want or need breaks from their loved one? Provide them with education on grief and on their loved ones disease process, again in both communication and printed handouts. Give the patient and their family privacy but also let them know that you are right down the hall should they need absolutely anything. Practice silence with your patient and their family and answer any questions as they arise. Ask the family how much they want to be involved in the care of their loved one. Do they want to help turn or toilet the patient? Do they want to provide oral care or other personal hygiene tasks? If so, provide any supplies they may need at bedside and ask them to call you should they need help.
Take Care of Yourself
It takes a special nurse to provide end-of-life care and your care is going to resonate with the patients’ family for many years to come. Make sure to take care of yourself and allow time for you to grieve with the family when appropriate or by yourself in the break room. If you need a few minutes, ask your breaker to cover for you while you collect yourself and your thoughts.
For more information, visit How to Cope with the Death of a Patient.
Also be sure to check out the rest of the Nursing Fundamentals Series: