What is the focus of EOL care?
Nurses spend more time with patients near the EOL than any other health care professionals.
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Respect, dignity, and comfort are important for the patient and family.
Although there is no cure for the patient’s disease, the treatment plan still consists of
assessment, planning, implementation, and evaluation.
The main difference is that the focus of care is on the management of the symptoms.
What is the importance of the
assessment in EOL care?
Nurses should be concise when completing assessments on EOL patients.
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Utilize resources available such as the health history data in the medical record to avoid
tiring the patient with an interview.
Assess the patient’s functional status, intake, patterns of sleep and rest, and response to
the stress of the terminal illness.
Review their coping skills and the family’s ability to manage the needed care and cope
with the illness.
Physical Assessment
The physical assessment focuses on changes that accompany terminal illness and the specific
disease process.
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Depends on the patient’s stability:
o Done at least every 8 hours in the agency setting.
o For patients cared for in their homes by hospice programs, assessment may occur
weekly.
Pay attention to patients who are nonverbal for subtle changes in their condition.
As changes occur, documentation may be needed more often.
Social Assessment
Key elements of a social assessment include the relationships and patterns of
communication among the family.
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Actively listen to concerns and evaluate the goals of the patient and
family.
Differences in expectations and interpersonal conflict can produce
disruptions during the dying process and after the death of the loved
one.
Patient Monitoring
Monitor the patient for multiple systems failing with attention to subtle
physical changes.
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Neurologic assessment is especially important and includes level of
consciousness, presence of reflexes, and pupil responses.
Vital signs, skin color, and temperature show changes in circulation.
Monitor and describe respiratory status, character and pattern of
respirations, and characteristics of breath sounds.
Assess nutrition and fluid intake, urine output, and bowel function
since this gives data about renal and gastrointestinal functioning.
Assess skin condition on an ongoing basis since fragile skin may easily
break down.
Limiting Assessments
In the last hours of life, limit assessments to those that determine patient
comfort.
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Assessment of pain and respiratory status may be the most important
during this time.
May be more comforting to the patient and family if you refrain from
measuring blood pressure or checking for pupillary response.
As death approaches, provide emotional and psychosocial support to
the patient and family.
Limit tasks that will not impact the comfort or outcome for the patient
What are the clinical problems and the
overall goals for the dying patient and
their family?
Clinical problems for the patient who is dying and their family include:
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Grief
Dying process
The overall goals for the patient who is dying are that the patient will:
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Make decisions about EOL care
Experience a peaceful death
It is important for the nurse to:
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Involve the patient and family in planning and coordinating EOL care
Develop a comprehensive plan to support, teach, and evaluate patients and families
Care goals during the last stages of life:
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Involve comfort and safety measures and care of the patient’s emotional and physical
needs
May include determining where the patient would like to die and whether this is possible
o For example, the patient may want to die at home, but the family may object or be
unable to manage the care.
What is the role of the nurse as the
patient prepares for death?
Nurses should advocate for the patient’s wishes to be met.
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Patients and families need ongoing information on the disease, the dying process, the care the
nurse will be providing, and how to cope.
Denial and grieving may be barriers to learning for both the patient and family.
As death approaches, respond appropriately to the patient’s psychosocial manifestations at the
EOL (Table 10.7).
Table 10.7 Nursing Management: Psychosocial Care at End of
Life
Dimensions
Nursing Management
Preparing for Death
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Serious illness can create strain on
relationships.
It is important to facilitate
meaningful discussions for the
patient and family to prepare for
death.
They may reconcile the past to
find meaning in the present.
Spiritual Needs
 Religion, faith, and spirituality
may be sources of strength for
patients and families
 Patients and family members may
experience spiritual longing.
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Unusual Communication
 This may indicate altered coping
that may prevent the patient
from resolving issues and letting
go.
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Encourage the patient and family to
share their feelings of love,
sadness, loss, and forgiveness.
Saying goodbye can be therapeutic.
Encourage the use of physical touch
(e.g., hand holding, hugging) and
expressions such as crying.
Allow the patient and family privacy
to express their feelings and
comfort one another.
Assess spiritual needs, cultural
norms, hopes, values, and fears
Address the needs of the family and
caregivers
Allow patient to express concerns
about quality of life, fear of death
or dying, spiritual practices, and
significant relationships.
Recognize the presence of spiritual
or existential distress.
Promote visits by spiritual care
service provider, chaplain, family
member.
Assess for depression, anxiety,
and/or delirium.
Encourage the family to talk with
and reassure the patient.
Dimensions
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Comorbid psychiatric conditions
may worsen.
Patients may become restless and
agitated, which may be a
manifestation of terminal
delirium.
End-of-Life Dreams and Visions
 Patients may be seen talking to
persons who are not there or
seeing places and objects not
visible.
 They may report dreams of living
or deceased loved ones.
 These experiences may comfort
the patient in coming to terms
with meaning in life and
transition from it.
Withdrawal
 This may be an emotional
response or part of grieving.
 Patient near death may seem
withdrawn from the physical
environment, maintaining the
ability to hear but unable to
respond.
Nursing Management
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Coordinate with the IPT to assist
with counseling and
communication.
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Assess for the presence, distress, or
comfort from these visions.
Affirm the patient’s experience as a
part of transition from this life.
Teach families and caregivers about
the patient’s experiences.
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Allow the patient to sleep and rest.
Converse as though the patient
were alert, using a soft voice and
gentle touch.
Provide education to families and
caregivers.
Encourage meaningful tasks and
discussions during periods of
wakefulness.
How does the nurse manage
psychosocial elements near EOL?
Patients experience many different emotions near the end of life.
Anxiety and Depression
Causes may include:
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Uncontrolled pain and dyspnea
o Respiratory distress and dyspnea are common near the EOL.
o The sensation of air hunger results in anxiety for the patient and family.
o Current treatments include opioids, bronchodilators, and oxygen, depending on
the cause of the dyspnea.
Psychosocial factors related to the disease process or impending death
Altered physiologic states
Drugs used in high dosages
Anxiety often related to fear
Encouragement, support, and teaching may help alleviate anxiety. Management may include
both medications and nonpharmacologic interventions.
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Relaxation strategies, such as relaxation breathing, muscle relaxation, music, and
imagery, may be useful.
Anxiety-reducing agents (e.g., anxiolytics) may help produce relaxation.
How does the nurse manage
psychosocial elements near EOL?
Patients experience many different emotions near the end of life.
Anxiety and Depression
Anger
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Anger is a normal response to grief.
A grieving person cannot be forced to accept the loss.
The surviving family members may be angry with the dying loved one who is leaving
them.
Encourage the expression of feelings.
The nurse may be the target of the anger.
o Understand the anger response and avoid reacting on a personal level.
Hopelessness and Powerlessness
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Feelings of hopelessness and powerlessness are common.
Encourage realistic hope within the limits of the situation.
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Support the patient’s involvement in decision making to foster a sense
of control and autonomy.
Allow the patient and family to deal with what is within their control
and help them recognize what is beyond their control.
Fear
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Fear is a typical feeling associated with dying.
Specific fears include fear of pain, fear of shortness of breath, fear of
loneliness and abandonment, and fear of meaninglessness.
Some fear death is painful but do not want the medication side effects
of grogginess or sleepiness.
o Pain relief measures do not have to deprive the patient of the
ability to interact with others.
o Assure the patient and family that medication will be given
promptly when needed and that any side effects will be managed.
o As many EOL patients are unable to swallow, other routes, such
as patches, sublingual, and rectal, may be used.
o Consider alternative methods like massage, music, aromatherapy,
and mindfulness.
Most terminally ill and dying people do not want to be alone.
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Being present offers support and comfort (Fig. 10.8).
Holding hands, touching, and listening are important nursing
interventions.
Providing companionship allows the patient a sense of security.
Fear of meaninglessness leads people to review their lives.
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Assist patients with life review to help them recognize the value.
Practical ways of helping may include looking at photo albums or
collections of important mementos while sharing thoughts and feelings.
Fig. 10.8 Dying patients often want someone whom they know and trust to
stay with them. (© KatarzynaBialasiewicz/iStock.com)
Patients and family members may have difficulties expressing their feelings.
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Empathy and active listening are essential at EOL.
Recognize that silence is often an effective communication technique.
A family conference can create a good environment for communication
and help to prepare family members for changes in the patient’s
emotional and cognitive function as death nears.
What does physical care focus on at
EOL?
Physical care at the EOL focuses on symptom management and comfort (Table 10.8).
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Priority is meeting the patient’s physiologic and safety needs.
Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and
skin care.
People who are dying deserve and require the same physical care as people who are expected to
recover.
Discuss the goals of care with the patient and family before treatment begins.
Table 10.8 Nursing Management: Physical Care at End of Life
Manifestation
Nursing Management
Anorexia, Dehydration, Nausea, and Vomiting
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May be caused by complications of
disease process
Hunger and thirst decrease at EOL
Dehydration is common
Medications contribute to nausea
Constipation, impaction, and bowel
obstruction can cause anorexia,
nausea, vomiting
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Assess the patient for nausea or
vomiting, and possible
contributing causes
Provide antiemetics as needed
and before meals if ordered
Offer and provide frequent meals
with small portions of favorite
foods. Offer culturally
appropriate foods
Manifestation
Nursing Management
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Bowel Patterns
 Immobility, opioid use, depression,
lack of dietary fiber in the diet,
dehydration, obstructive cancer can
cause constipation
 Diarrhea may occur from laxative
use, obstruction, fecal impaction,
infection, medications,
chemotherapy
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Do not force the patient to eat or
drink
Provide frequent mouth care
Encourage consumption of ice
chips and sips of fluids or use
moist cloths to moisten the
mouth
Use moist cloths and swabs for
unconscious patients to avoid
aspiration
Apply lubricant to the lips and
oral mucous membranes as
needed
Ensure uninterrupted mealtimes
Teach family that hunger and
thirst naturally decreases at EOL.
Assess bowel function and
associated symptoms
Assess for and remove fecal
impactions
Encourage movement and
physical activities as tolerated
Encourage fiber in the diet if
appropriate. Discuss the role of
IV fluids in context of goals of
care
Use suppositories, stool
softeners, laxatives, and/or
enemas as ordered, especially if
on opioids
Assess for confusion, agitation,
restlessness, and pain, which
may indicate constipation.
Encourage the intake of simple
carbohydrates, if appropriate,
Manifestation
Nursing Management
and use of antidiarrheals as
needed.
Oral Conditions
 Candidiasis may be present due to
chemotherapy, immunosuppression
 Xerostomia or dry mouth is
common. This may be due to
comorbidities, medication,
radiation, dehydration
Delirium and Restlessness
 Develops over a short period of time
with severity fluctuating through
the day
 Characterized by confusion,
disorientation, restlessness,
clouding of consciousness,
incoherence, fear, anxiety,
excitement, hallucinations
 May be misidentified as depression,
psychosis, anger, anxiety
 Contributing factors include
medications, underlying disease,
environment, sensory impairment,
metabolic problems
 Associated with adverse outcomes
 Considered reversible
 Common in final days of life
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Assess oral cavity and cause of
problems
If ordered, give oral antifungal
Clean dentures and other dental
appliances to prevent reinfection
Provide oral hygiene and use soft
toothbrush or sponge
Perform a thorough assessment
for delirium using a validated
tool
Assess for risk factors for
delirium, including pain,
constipation, and urinary
retention and treat as needed.
Include nonpharmacologic
interventions as appropriate
Provide a room that is quiet, well
lit, and familiar to reduce the
effects of delirium
Reorient the patient to person,
place, and time with each
encounter
Give ordered antipsychotics,
benzodiazepines, and sedatives
as needed
Stay physically close to frightened
patient. Reassure in a calm, soft
voice with touch and slow
strokes of the skin
Avoid physical restraints
whenever possible
Manifestation
Difficulty Swallowing
 May occur due to cancer, neurologic
problems, weakness
 Common at EOL
 May lead to aspiration of liquids
and/or solids, pneumonia,
malnutrition, dehydration, death
 Drooling/inability to swallow
secretions may be present
Nursing Management
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Provide family with emotional
support and encouragement in
their efforts to cope with the
behaviors associated with
delirium
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Assess level of alertness and
safety of oral intake
Collaborate with IPT for
evaluation based on goals of
care. Referral for speechlanguage pathologist
If needed, use alternative routes
for (rectal, buccal, transdermal,
IV) drug administration for
symptom management
Modify diet to focus on comfort
or pleasure, as tolerable by
patient
Teach family on safety and risk
for aspiration
Review medications and stop
nonessential medications
Hand feed small meals
Elevate the head for meals and at
least 30 minutes after
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What is the nurse’s role in managing
physical care manifestations at EOL?
Table 10.8 concludes with further discussions about physical nursing care that should be
provided at end of life.
Table 10.8 Nursing Management: Physical Care at End of Life
– cont’d
Manifestation
Nursing Management
Dyspnea, Terminal Secretions, and Cough
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Can significantly impair
quality of life.
Dyspnea is often
accompanied by chest
tightness, fear of
suffocation, anxiety
Terminal secretions, or death
rattle, is noisy breathing
from secretion
accumulation. Very common
in the hours before death
Presence of terminal
secretions can be distressing
to family members
Cough is a reaction to an
irritation of the respiratory
tract, and can be debilitating
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Myoclonus
 Mild to severe abnormal
movements
 Can be caused by
medications, metabolic
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Assess respiratory status regularly
Assess for anxiety and other associated
symptoms including pain and fatigue
Elevate the head and/or position patient
on side to improve chest expansion
Use a fan or air conditioner to help
movement of cool air
Teach and encourage the use of pursedlip breathing
Teach relaxation and guided imagery
techniques for relaxation
Administer medications as needed:
o Opioids for dyspnea
o Benzodiazepines for associated
anxiety
o Anticholinergics for secretions
o Antitussives, mucolytics, and
expectorants
Oxygen use should be based on the
goals of care at the EOL
Avoid deep suctioning. Gentle oral
suctioning may be used
Teach the patient and family on these
symptoms and treatments. Provide
emotional support for caregivers
Assess for onset, duration, any
discomfort or distress
Review potential causes, including
medications
Treat symptoms with benzodiazepines
Manifestation
imbalances, central nervous
system damage
Nursing Management
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Provide education and emotional
support to patient and family
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Assess pain thoroughly and regularly to
determine the onset, duration, quality,
intensity, location, and aggravating and
alleviating factors
Pain
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Is a major symptom at EOL,
can contribute to suffering,
and the most feared
Often associated with other
symptoms and sources of
distress
Can be acute or chronic,
neuropathic, nociceptive,
inflammatory, and/or
mechanical
Often requires opioids for
management
Bone pain can be caused by
metastases, fractures,
arthritis, immobility
Physical and emotional
stressors can worsen pain
Assess for associated symptoms including
anxiety, social or spiritual distress
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Skin Breakdown
Give medications around the
clock, in a timely manner, and on
a regular basis to provide
constant relief rather than
waiting until the pain is
unbearable and then trying to
relieve it
Provide nonpharmacologic
interventions, such as guided imagery,
massage, and relaxation techniques as
needed
o
Frequently evaluate effectiveness of pain
relief measures
Ensure that the patient is on a correct,
adequate drug regimen
Monitor for side effects of opioids, such
and nausea and constipation, and treat
as appropriate
Teach the patient on all interventions
and medications
Do not delay or deny pain relief
measures to a terminally ill patient
Manifestation
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Skin integrity is hard to
maintain at end of life
Immobility, urinary and
bowel incontinence, dry
skin, malnutrition, anemia,
friction, and shearing forces
lead to a high risk for skin
breakdown
Disease and other processes
may impair skin integrity
In the last days of life,
circulation to the
extremities decreases and
they become cool, mottled,
cyanotic
Nursing Management
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Assess skin for signs of breakdown or
injury
Assess risk factors for skin breakdown
and implement protocols to prevent
Perform wound assessments as needed
Follow protocols for dressing wounds
Premedicate if turning, repositioning, or
wound care cause discomfort
Follow protocols to prevent skin
irritation and breakdown from urinary
and bowel incontinence
Use blankets to cover for warmth. Use
lotions to prevent dryness
Urinary and Bowel Incontinence
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May result from disease
progression or changes in
the level of consciousness,
medications, decreased
mobility
As death becomes imminent,
the perineal muscles relax,
causing incontinence of
bowel and bladder
Urine production is
decreased at EOL
Weakness and Fatigue
 Decline in mental status and
energy is expected
 Causes include metabolic
demands related to disease,
underlying chronic
condition, cancer,
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Assess urinary and bowel function
Use absorbent pads for incontinence
and barrier creams to prevent irritation
Follow protocols for the use and
management of indwelling or external
catheters
Follow protocols to prevent skin
irritation and breakdown from urinary
and bowel incontinence
Assess the patient’s tolerance for
physical and mental activities
Help the patient identify and complete
valued or desired activities
Modify and time nursing interventions
to conserve energy
Manifestation
malnutrition, insomnia,
infection
Nursing Management
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Refer to physical and occupational
therapy for safe movement
Review nutrition and hydration based on
goals of care
Give frequent rest periods and adjust
environment to allow for quiet
surroundings
What are the steps to providing
postmortem care?
After a patient is pronounced dead, the nurse will need to prepare or delegate preparing the
patient’s body for immediate viewing by the family.
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Consider cultural customs and follow agency policy for postmortem care (Table 10.9).
When the death is unexpected, preparing the patient’s body for viewing or release to a funeral
home depends on state law and agency policy.
Be respectful and allow the family privacy and as much time as they need with the deceased
patient.
Table 10.9 Nursing Management: Postmortem Care
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Provide privacy throughout the process. Teach family and caregivers on process if present.
Assess cultural and/or religious preferences or rituals about this process from family or
caregivers before starting.
Obtain supplies needed before starting. This may include a kit or individual items. Ask for help if
needed.
Wash hands, and use protective equipment as needed.
Close the patient’s eyes and jaw.
Replace dentures; if unable, place in labeled cup.
Remove jewelry, eyeglasses, and other personal belongings.
Remove tubes and dressings (per policy).
Wash the body as needed then apply clothes selected by the patient or family (home), or a clean
gown (agency). Comb and arrange the hair neatly.
Place a waterproof pad or incontinence brief to absorb urine and feces.
Straighten the body, placing the arms at their sides or across the abdomen with palms down.
Follow instructions per policy in home or agency setting.
What are the signs of abnormal grief
reactions with caregivers at EOL?
Family caregivers are important in meeting the patient’s physical and psychosocial needs.
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Role includes working and communicating with the patient and other family members,
supporting the patient’s concerns, and helping the patient resolve any unfinished
business.
Families often face emotional, physical, and economic consequences from caring for a
family member who is dying.
The caregiver’s responsibilities do not end when the patient is admitted to an acute care,
inpatient hospice, or long-term care agency.
Being present during a family member’s dying process can be highly stressful.
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Recognize signs and behaviors of abnormal grief reactions among family members.
Warning signs may include:
o Dependency and negative feelings about the dying patient
o Inability to express feelings
o Sleep problems
o A history of depression
o Difficult reactions to previous losses
o Perceived lack of social or family support
o Low self-esteem
o Multiple previous bereavements
o Alcohol or substance use
Caregivers with concurrent life crises (e.g., divorce) are especially at risk.
Encourage family caregivers and other family members to continue their usual activities
where possible to maintain some control over their lives.
Inform caregivers about resources for support, including respite care, community
counseling, and local support in working through grief.
Encourage caregivers to build a support system of extended family, friends, faith
community, and clergy to call on to express any feelings they are experiencing.
What are the special needs of nurses
who provide EOL care?
Caring for patients and their families at the EOL is rewarding but is also challenging, intense and
emotionally charged.
Nurses who care for the dying need to recognize their own needs when dealing with grief and
dying.
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Be aware of how grief personally affects you.
Express feelings of sorrow, guilt, and frustration.
Recognize own values, attitudes, and feelings about death.
o Realizing that it is okay to cry with the patient or family during the EOL may be
important for your well-being.
To meet personal needs, focus on interventions to decrease stress:
o Hobbies
o Adequate sleep
o Personal time
o Peer support system
o Support system beyond the workplace.
Many hospice agencies offer support groups and discussion sessions that can help nurses cope.