Care of the dying person
This article outlines some of the processes nurses might need to consider when providing holistic and person-centred care to an individual who is at the end of their life, as well as support that can be offered to family, friends and others.
Article by Peter Ellis
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Purpose
This article outlines some of the processes nurses might need to consider when providing holistic and person-centred care to an individual who is at the end of their life, as well as support that can be offered to family, friends and others.
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Assessment
The care which a person needs at the end of their life will depend on various factors, including:
- their diagnosis
- concomitant illness
- the severity of signs and symptoms
- their wishes, which may have been previously stated
- their level of consciousness
Holistic care of the dying patient needs to account for their wellbeing and needs, which can be:
- physical
- psychological/emotional
- social
- spiritual
The National Institute for Health and Care Excellence (NICE, 2021a) identify that any assessment informing end-of-life care for adults should consider their needs and preferences and might include a holistic needs assessment which, as well as the above, might take into account practical issues (eg support with shopping and financial needs).
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Equipment
Nurses assessing a person’s wishes at the end-of-life should take into account any existing records of their wishes, which may include a:
- Do Not Attempt Cardiopulmonary Resuscitation order (DNACPR)
- Treatment Escalation Plan (TEP)
- Advance Decision to Refuse Treatment plan (ADRT)
- Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form
- Advance Care Plan
- Lasting Power of Attorney or Court Appointed Deputy (Ellis, 2018)
Recorded wishes often state a preferred place of care, a preferred place of death and may include other choices such as music to be played and people who could be present when they are dying. Some people will be clear about ceilings of treatment, which identify what medical intervention might be acceptable for their comfort. Such plans are important, as they enable patients to die in as much comfort as possible (Broadhurst et al, 2019).
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Procedure
While end-of-life care is a holistic undertaking, it can sometimes be helpful to breakdown required care according to the symptoms being experienced:
Pain
Pain is often the most prevalent symptom at the end of life. Managing pain requires the nurse to:
- Objectively measure the pain and the effects of pain relief strategies (eg using a numeric rating scale) (Karcioglu, 2018)
- Consider non-medicinal management of pain, including:
- positioning
- relaxation
- distraction
- complementary therapies
- Administer and monitor pain relief medication, including its effects and side effects
Medicinal management of pain may be delivered in a variety of ways, and must reflect the needs of the patient and their ability to take medication. Common means of medication delivery include:
- oral, including liquids and syrups
- injections (subcutaneous, intramuscular and intravenous)
- patches
- per rectum
- syringe driver (continuous subcutaneous infusion)
- sprays, creams and gels
- inhalation
Pain relief needs to be matched not only to the severity
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Risks and complications
End of life is unpredictable, so early planning for end-of-life care and understanding individual preferences is important. Delivering inappropriate end-of-life care risks the individual dying in physical, emotional or spiritual distress and can leave an emotional burden on family and friends as well as care staff.
Nurses and others involved in the care of the dying person are often placed under a significant emotional burden and need to ensure they have strategies for self-care as well as engaging in supervision and support sessions (Bapat and Bojarski, 2019).
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Next steps
Much of the care of the dying takes place away from specialist centres, such as hospices, in hospitals and care homes. This means nurses and care staff who work in these settings need to be informed and prepared in the provision of high-quality end-of-life care.
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Resources
Bapat AC, Bojarski EF. Transference and Countertransference in Palliative Care. J Pall Med. 2019;22(4):452-453. http://doi.org/10.1089/jpm.2019.0042
Broadhurst HL, Droney J, Callender T et al. Advance care planning: the impact of Ceiling of Treatment plans in patients with Coordinate My Care. BMJ Supportive & Pall Care, 2019;9:267-270. http://dx.doi.org/10.1136/bmjspcare-2017-001414
Ellis P. Advance care planning for patients with chronic kidney disease. J K Care. 2018;3(4):238-241.
Hosker CMG, Bennett MI. Delirium and agitation at the end of life. BMJ. 2016;353:i3085. https://doi.org/10.1136/bmj.i3085
Karcioglu O, Topacoglu H, Dikme O, Dikme O. A systematic review of the pain scales in adults: which to use? A J Emergency Med. 2018;36(4):707-714. https://doi.org/10.1016/j.ajem.2018.01.008
Lynch M. Nausea and vomiting. In: Dahlin C, Coyne P, Ferrell B (eds). Advanced practice palliative nursing. New York, NY: Oxford University Press; 2016: 289-298
Marshall K. Breathlessness: causes, assessment and non-pharmacological management. Nursing Times [online]. 2020;116(9):24-26
National Institute for Health and Care Excellence (NICE). Pressure ulcers: prevention and management. 2014.
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