Many deaths occur in hospitals. Most deaths are expected; ~75% of deaths in the hospital setting are expected or foreseeable. The remaining are sudden, unexpected deaths. During this period, patients require on-going care which may include end-of-life care. End-of-life is the final stage where death is imminent. It can be unpredictable, lasting minutes or weeks. Care during this period handles physical, psychosocial, and spiritual care addressing issues related to death and dying. The main goals of care during this period are:
- Relieve suffering
- Provide comfort and support
- Maintain human dignity
- Respect patient wishes and desires
- Improve quality of life
- Provide emotional support
In the broader scope, end-of-life care is a subset of palliative care, and contains hospice care. Palliative care focuses on improving quality of life for the patients and their families. It is provided during any stage of life-limiting illness, regardless of duration. It includes relief of suffering, care of emotional needs, bereavement support, curative treatments, and life-prolonging treatments provided by interdisciplinary teams. Hospice care is reserved for the terminally ill who have a remaining life expectancy of six month or less. Curative or life-prolonging treatments are no longer used. The primary focus is comfort care at the end of life.
| Palliative Care Programs | Hospice Care |
|---|---|
| Comfort Care | Comfort Care |
| Curative/Life-Prolonging | Non-curative/non-life-prolonging care |
| No time restrictions | Life-limiting with a prognosis of ≤6 months |
| Administered in hospitals, extended care facilities, and nursing homes | Reliance on family and visiting nurses and care is usually provided in the home |
| Bereavement support | Bereavement support |
Pathophysiology of Death and Dying
With dying, the body begins the final process of shutting down, which will end when all the physical systems cease to function. This manifests in changes in all body systems:
- Sensory: decreased sensation and perception, loss of blink reflex, eyes appearing “glazed over”. Among the senses, hearing is the last to disappear.
- Cardiovascular: increased heart rate followed by decreased HR, BP, and arrhythmia.
- Respiratory: increased rate followed by decreased rate and depth. Cheyne-Stokes respirations may be observed, where audible congestion is heard.
- Renal: oliguria, then anuria. Urine is dark amber, brown, or reddish in color. Incontinence may occur.
- Gastrointestinal: abdominal distention, gas, anorexia, and nausea
- Musculoskeletal: decreased movement, tone, difficulty speaking and swallowing, and the loss of gag reflex
- Integumentary: mottling of extremities, cyanosis of nose, fingertips, nailbeds, and toes. The skin becomes cold and clammy, with a “waxy” appearance.
Assessment During Death
The nurse obtains subjective assessment cues depending on presenting symptoms, underlying illness, and nearness to death. The medical records are reviewed and advance directives, cultural issues, personal desires, wishes and choices are noted. Objective assessment cues (vital signs, if appropriate; general appearance; level of consciousness; affect; level of comfort) are also obtained. Evaluate the patient’s pain control, comfort, psychosocial support, and state of peace.
Comfort Care
There are four main domains of comfort care:
| Discomfort | Intervention |
|---|---|
| Pain | Analgesics (narcotics may be used without diminished for addiction due to limited lifespan), anxiolytics, position of comfort, eye lubricants, light but warm blanket |
| Impaired Comfort | Position of comfort, elevation of head (esp. for labored breathing) |
| Social Withdrawal | The use of a soft voice and gentle touch |
| Social Isolation | Allowing the patient to sleep when fatigued/drowsy. Avoid quick movements and loud, startling noises. The patient is aided towards acceptance. |
Anorexia
Follow patient cues. Offer ice chips and sips of water, and dab a moistened warm cloth around the mouth and apply lip balm when appropriate.
Psychosocial Interventions
The patient’s sacred space is respected. Allow them as they are, and permit them to sleep when desired. If culturally acceptable, utilize therapeutic touch. The family should also be present if culturally acceptable. Any questions should be answered honestly, empathically, and compassionately. Absolutely no false reassurance should be used.