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When People Are Dying:
Palliative Care
Originally by:
Pamela Parrish, RN, CHPN
Clinical Consultant
School of Nursing, University of Pennsylvania
Diane Stillman, MSN, RN, CS
School of Nursing, University of Pennsylvania
Neville Strumpf, PhD, RN, C, FAAN
Edith Clemmer Steinbright Professor in Gerontology
Director, Center for Gerontologic Nursing Science and
Hartford Center of Geriatric Nursing Excellence
Rewritten in 2012 by:
Rebecca Trotta, PhD, RN
Hospital of the University of Pennsylvania
Geriatric Education Center of Greater Philadelphia
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Introduction
• The U.S. population is rapidly aging
• Many people who live in a long-term
care setting will die there
• The long-term care setting is an
excellent one for palliative care
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Objectives
• Understand the principles of palliative care
• Understand importance of establishing goals
of care
• Describe common physical and psychological
symptoms at end-of-life and ways to address
them using a palliative care approach
• Describe ways to recognize the final hours
and how best to support resident, family and
staff, including spiritual and cultural
considerations
Geriatric Education Center of Greater Philadelphia
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What is Palliative Care?
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WHO definition
Different from traditional care
Different from hospice
A philosophy of care….
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Who Benefits from
Palliative Care?
• Residents
• Family
• Staff
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Who Provides Palliative Care?
• A team approach is best
• Anyone involved in the resident’s
care can provide some aspect of
palliative care
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Who Provides Palliative Care?
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Nurse
Nursing Assistant
Physician
Social Worker
Dietitian
Chaplain
Physical/Occupational Therapist
Recreation Therapist
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Developing a Palliative
Plan of Care
• Agreed to by all members of
interdisciplinary team
• Propelled by nursing
• Addresses the following:
– Goals of Care
– Physical Symptoms
– Psychological Symptoms
– Spiritual Needs
– Family Needs and Concerns
– Liberalized Restrictions
Geriatric Education Center of Greater Philadelphia
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Goals of Care
• Hold family meeting with
interdisciplinary care team
– Clarify that palliative care does not mean
withdrawing care
– Focus on what will be done, not what will be
removed
• Complete advance directives
– Know various types
– Understand that family may be overwhelmed
• Frame plan to meet goals of care
• Revisit plan frequently with team,
including family
Geriatric Education Center of Greater Philadelphia
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Symptoms at End-of-Life
• Pain
– Common, complex
• Respiratory Symptoms
– Shortness of breath, coughing,
wheezing
• Gastrointestinal Symptoms
– Nausea, constipation
• Psychological Symptoms
– Depression, delirium, anxiety
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Interventions
• Around the clock vs. PRN medications,
especially for pain
• Oxygen, nebulizers, diuretics,
antitussive w. codeine, prednisone
• Anti-nausea medications, gentle bowel
stimulants
• Anti-depressants, anxiolytics
• Non-pharmacological therapies
Geriatric Education Center of Greater Philadelphia
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Addressing Spiritual Needs
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Don’t wait until the last minute!
Offer religious music and/or icons
Arrange visit from religious leader
Facilitate rituals
Assist with funeral arrangements
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Cultural Considerations
• Everyone has one or more cultures
• Race, ethnicity, religion, lifestyle
contribute to culture
• Culture
– Is manifested through values,
customs, behaviors & beliefs
– Affects decision-making and views re:
death and dying and palliative care
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Preserving Personhood and
Dignity
• Cleanliness and odor control
• Bathing and grooming
– Face, hands, and feet
• Mouth care, nail care
• Clothing and bedding
• Promote home-like environment
– Pictures, bedding, personal items
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Final Hours
• Common symptoms are distressing
– Pain, noisy breathing
• Attend to symptoms and hygiene
• Limit/withhold food and fluid intake
• Maintain personhood
– Talk to resident
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Supporting the Family
• Address questions
• Provide information
• Give suggestions on how to support
resident
• Offer comforting items
– Chairs, tissues, drinks
• Offer interdisciplinary support
– Social work, chaplain
Geriatric Education Center of Greater Philadelphia
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Can You Now…
• Understand the principles of palliative care
• Understand importance of establishing goals
of care
• Describe common physical and psychological
symptoms at end-of-life and ways to address
them using a palliative care approach
• Describe ways to recognize the final hours
and how best to support resident, family and
staff, including spiritual and cultural
considerations
Geriatric Education Center of Greater Philadelphia