Palliative Care; A Nursing
Response
E. Veronica Cheney, RN, BSNS
American Nurses Association –
Palliative Care Scope of Practice
“Purpose: Nurses have always been at the bedside of dying patients. Their role in
providing the highest quality of remaining life and support at the end of life for both patients
and their loved ones is traditional, accepted, and expected. The nurse’s fidelity to the
patient requires the provision of comfort and includes expertise in the relief of suffering,
whether physical, emotional, spiritual, or existential. Increasingly, this means the nurse’s
role includes discussions of end-of-life choices before a patient’s death is imminent.
The purpose of this ANA Position Statement is to articulate the roles and responsibilities of
registered nurses in providing expert end-of-life care and guidance to patients and families
concerning treatment preferences and end-of-life decision making. It is meant to provide
information to guide the nurse in vigilant advocacy for patients throughout their lifespan as
they consider end-of-life choices, and includes discussion of personal ethical dilemmas that
can occur when caring for the dying.”
(ANA, 2014)), http://www.nursingworld.org/
The Goal of Palliative Nursing
“The goal of hospice and palliative care nursing “is to
promote and improve the patient’s quality of life
through the relief of suffering along the course of
illness, through the death of the patient, and into the
bereavement period of the family”
(ANA & HPNA, 2007, p.1).
WHO Definition of Palliative Care
Palliative care is an approach that improves the
quality of life of patients and their families facing
the problem associated with life-threatening illness,
through the prevention and relief of suffering by
means of early identification and impeccable
assessment and treatment of pain and other
problems, physical, psychosocial and spiritual.
World Health Organization. (2014). WHO definition of palliative care. Retrieved from World Health Organization:
http://www.who.int/cancer/palliative/definition/en/
WHO Definition of Palliative Care
Palliative care:
 provides relief from pain and other distressing symptoms;
 affirms life and regards dying as a normal process;
 intends neither to hasten or postpone death;
 integrates the psychological and spiritual aspects of patient
care;
 offers a support system to help patients live as actively as
possible until death;
World Health Organization. (2014). WHO definition of palliative care. Retrieved from World Health Organization:
http://www.who.int/cancer/palliative/definition/en/
WHO Definition of Palliative Care
Palliative care:
 offers a support system to help the family cope during the patients illness
and in their own bereavement;
 uses a team approach to address the needs of patients and their families,
including bereavement counselling, if indicated;
 will enhance quality of life, and may also positively influence the course of
illness;
 is applicable early in the course of illness, in conjunction with other
therapies that are intended to prolong life, such as chemotherapy or
radiation therapy, and includes those investigations needed to better
understand and manage distressing clinical complications.
World Health Organization. (2014). WHO definition of palliative care. Retrieved from World Health Organization:
http://www.who.int/cancer/palliative/definition/en/
The Beginning Manifestations
For all patients entering the end stages of disease and those with
chronic comorbidities
Failure to Thrive
Malnutrition is the key pathophysiological finding
Institute of Medicine – weight loss of more
than 5%, decreased appetite, poor nutrition,
physical inactivity
Malnutrition manifests as: weight loss, loss of
functional skills and psychological decline
Ali, MD, N. (2012). Failure to thrive in elderly adults. Medscape Reference.
Common Medical Conditions
Associated with Failure to Thrive
 Cancer: metastases
 Chronic lung disease; respiratory failure
 Chronic renal failure; insufficiency
 Depression; psychosis, other psychiatric disorders
 Hip or large bone fractures; functional impairment
 Inflammatory bowel disease; malnutrition, malabsorption
 MI, CHF, heart failure
 Recurrent & chronic infections; UTI, pneumonia
 Stroke: dysphagia, cognitive loss
Ali, MD, N. (2012). Failure to thrive in elderly adults. Medscape Reference.
Failure to Thrive Etiology “The Dwindles”
 Diseases (medical illness)
 Delirium
 Dementia
 Drinking alcohol; substance abuse
 Drugs - medications
 Deafness, blindness, other sensory deficits
 Dysphagia
 Depression
 Desertion
 Destitution
 Despair
Ali, MD, N. (2012). Failure to thrive in elderly adults. Medscape Reference.
The Six Phases of Dying
Dying is a process (3-6 months)
 All patients behave the same way
 Eating -- tasting -- looking at food
 Sleep wake cycle reverses
 Decreased functional ability
 Increased assistance with ADL’s
www.hospiceofmarion.com
Terminal Stage Signs (last 2-3 months)
 Beyond cure or rehab
 Progressive illness
 Anorexia/Cachexia (wasting) Syndrome
 Progressive weakness
 Increasing debility/dependence
 Declining condition
 Psychosocial & spiritual needs
 Family in crisis
www.hospiceofmarion.com
Pre-active Stage Signs (lasts 2-3 weeks)
 Little oral intake
 Increasing breathlessness
 Rising heart rate
 Reversal of sleep-wake cycle
 Delirium
 Restlessness
 Fluctuating level of consciousness
 Spiritual events – “visits” from those already
passed/angels
www.hospiceofmarion.com
Imminent Death Syndrome (days-hours)
 Decreased responsiveness/consciousness
 Decreased intake of food/water
 Decreased urine output
 Skin color and temperature decrease
 Mottling
 Decreased heart rate and blood pressure fluctuations
 Swallowing dysfunction
 Breathing changes/apnea
 Restlessness
 Gaze as if through you
www.hospiceofmarion.com
Agonal Stage Signs (last 2-3 hours)
 Stupor or coma
 Tachypnea
 Cheyne-Stokes/agonal pattern
 Imperceptible radial pulses (last 4-6 hours)
 Tachycardia or bradycardia
 Pupils dilated, fixed (last 15-30 minutes)
www.hospiceofmarion.com
Death Event (last 2-3 moments)
 Spiritual experiences (moment of death)
 Bolt upright as if seeing; smiling
 Epiphora (final tear)
 Bright reflection
 Sense of calm (end of suffering/reunion)
www.hospiceofmarion.com
Symptom Management
Symptoms associated with end-of-life and their management
Medication Dosing Rule of Thumb
 Most medications start on the PRN bases
 Assess pain and anxiety frequently using the numeric
pain scale (you can adapt the pain scale for anxiety
when the patient is alert)
 If you have to dose a patient four consecutive times with
PRN medications notify the MD/NP as soon as possible
for medication adjustment (either increasing the dose,
initiating routine, or increasing the frequency of
administration)
 The above applies to respiratory distress and excess
secretion control medications such as Robinol
Medication Dosing Rule of Thumb
 Initial end-of-life medications will start out PO/SL. When
the patient is no longer able to swallow switch
medications to the subcutaneous route
 Subcutaneous (SQ) medications are more effective,
ensures all medication is administered (not draining out
of the mouth) and absorbs within ten minutes ensuring
fast metabolism for effective symptom management
 When using the SQ route ensure flushing with 0.3 ml NS
after medication administration and no more than 2ml
(flush included) to each SQ port (might require more
than 1 site)
Pain Management
Pain Management
 Top priority
 Initially assess pain with numeric pain intensity scale
 As patient progresses use the behavioral pain scale
 Most common medications morphine and
hydromorphone
 Manage acute breakthrough pain
 Initiate bowel regimine for side effect management of
constipation
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.
Pain Medication Recommendations
Medication
Dose (Starting doses age >70)
Route
Morphine-Roxanol
Tabs: 15mg or 30mg
Oral Solution: 10mg/5ml, 20mg/5ml, and
100mg/5ml
PO/SL
Morphine Sulfate Injection
0.5mg (5mg/ml) 1 hour dose limit 4-6mg
SQ
Hydromorphone-Dilaudid
Tabs: 2, 4, 8mg
Oral Solution: 5mg/5ml
PO/SL
Hydromorphone-Dilaudid
Injection
0.1mg (1mg/ml) 1 hour dose limit 0.4 – 0.6mg
SQ
Oxycodone-OxyFAST
20mg/ml
PO/SL
University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:
https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf
Pain Scales: Wong-Baker
Google Images (2014)
Behavioral Pain Scale (BPS)
Google Images (2014)
Anxiety
Anxiety
 An expected finding
 Etiology:
 Chronic mental health disorders – Generalized anxiety disorder
 Chronic use of antianxiety medications
 Fear of the unknown
 Spiritual distress
 Fear of dying, dying alone
 Dyspnea
 Worry over family and unresolved life issues
 Adapt the pain scales (see previous slides) for level of anxiety
Anxiety Medication Recommendations
Medications
Dose
Route
Diazepam – Valium
Tab: 5 and 10 mg
Oral Solution: 2mg/5ml
Injection: 5mg/ml
Rectal Solution: 2.5, 5 and 10 mg
PO/SL/SQ/PR
Lorazepam – Ativan
Tabs: 0.25, 0.5, 1 and 2.5 mg
Injection: 2mg/ml
PO/SL/SQ
(IAHPC), I. A. (2013, January). WHO-Essential Medicines in Palliative Care. Retrieved from World Health
Organization:
http://www.who.int/selection_medicines/committees/expert/19/applications/PalliativeCare_8_A_R.pdf
Terminal
Restlessness/Agitation
Definition: Terminal restlessness is a syndrome observed in patients in
their last days of life. It is a variant of delirium and refers to a spectrum
of signs of central nervous system irritability that may include
restlessness, agitation, distressed vocalizing, twitching, myoclonic
jerking or recurrent fitting (Binns, 2014)
Patients that are too week to stand but insist on getting up
Uncomfortable even with adequate pain management
Yelling and calling out
Extremely agitated
Hallucinations
Psychotic episodes
Paranoia
Hospice Patients Alliance. (2014). Terminal restlessness or agitation. Hospice patients
alliance.
Determining the Cause
 Oliguria – bladder distention (end-of-life catheter placement might
be required)
 Assess pain
 Oxygenation
 Repositioning
 Constipation
 Infection
 Metabolic changes
 Emotional distress; spiritual assessment of needs
 New medications
 Pre-active phase of death
Hospice Patients Alliance. (2014). Terminal restlessness or agitation. Hospice patients alliance.
Terminal Restlessness and agitation
Medication Recommendations
Medication
Dose
Route
Haloperidol – Haldol®
Tabs: 0.5, 1, 2, 5, 10 mg. Available in
oral and injectable solutions
PO/SL/SQ
Risperidone - Resperdal®
Tabs: 0.25, 0.5, 1, 2, 3, or 4 mg
PO
Olanzapine - Zyprexa®
Tabs: 2.5, 5, 7.5, 10, 15 & 20 mg
PO/IM
Quetiapine - Seroquel®
Tabs: 25, 50, 100-400 mg
PO
University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:
https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf
Dyspnea
Shortness of air
Dyspnea Recommendations
Dyspnea is managed with opioid medications.
Start with a loading dose
Repeat loading dose bolus hourly until well
controlled
Adjust medications as needed
Reposition
Initiate O2 if required
Treat cause of dyspnea, i.e. anxiety, and or
pain.
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.
Weakness & Fatigue
Weakness and fatigue
A common occurrence with palliative
patients
Sometimes diet can assist in converting fat
to energy
Let the patient decide on activity level
Encourage frequent rest periods
Can assist patient in cope with suffering
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.
Constipation
Constipation
Most distressing symptom
Expected with use of opioids
Bowel regimen should always be in place with
opioid use
Signs and symptoms: abdominal cramps,
nausea and vomiting, continued urge to
defecate
Poor oral intake increases risk for dehydration
and constipation
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.
Constipation Medication Recommendations
Medication
Dose
Route
Senna
1-2 tabs daily or BID
PO
Docusate
100mg daily or BID
PO
Bisacodyl
Tabs: 5-15 mg daily or BID
10 mg suppository PR
PO/PR
Milk of Magnesium
30 ml daily or BID
PO
Miralax
17 g in 8 oz water daily
PO
Lactulos
15-30 ml daily or BID
PO
University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:
https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf
Secretion Control
Recovery position
Poor Secretion Control
 A result of type 1 or type 2 excessive secretions
 Type 1: Oral secretions of the mouth
 Type 2: Bronchial secretions
 Death Rattle – air moving over secretions in the airway
 Suctioning is not recommended:
 Causes discomfort and distress
 Leads to agitation
 Increases secretion production
 Positioning (see recovery position)
 Robinul does not cross blood brain barrier which reduces
occurrence of CNS stimulus
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.
Secretion Control Medication
Recommendations
Medication
Dose
Route
Robinul
Tabs: 1mg
Injection: 0.2 mg/ml
PO/SL/SQ
Atropine
Sublingual: 1 gtt
Injection: 0.1 mg
SL/SQ
Scopolamine
1mg
Transdermal
Levsin
Tabs/Drops: 0.125mg
PO
University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:
https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf
The Recovery Position
Google Images, (2014)
The Recovery Position
 Placing a patient in the recovery position will help to relieve dyspnea
 Uses gravity to facilitate drainage of excessive secretions built up in the
lungs and esophagus
 Relieves pressure on bony prominences
 Reduces the need to turn the patient frequently which disrupts comfort
in the later phases of death and can cause severe pain
 Caution: Some patients with certain medical conditions such as COPD
may not tolerate this position
 Place a pillow under the accessible arm, between legs, and under feet
 Remove all pillows from under the head and place a towel with a
pillow case on it under the cheek touching the mattress
 Teach family what to expect (excessive odorous secretions requiring
frequent oral care)
 Do not use Yonkers with bedside suction
Nausea & Vomiting
Nausea and vomiting
May develop early
Etiology of pharmacological therapy –
chemotherapy
May lead to dehydration
Leads to anorexia
Causes discomfort
Increases anxiety
Nausea & Vomiting Medication
Recommendations
Medication
Dose
Route
Haloperidol – Haldol
0.5 – 4 mg
PO/SL/SQ
Ondansetron – Zofran
4-8 mg
PO
Scopolamine
1.5 mg
Transdermal
Metoclopramide –
Reglan
5-20 mg
PO/SQ
University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:
https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf
Nutritional Problems
Nutritional Problems
 Little oral intake – reduction of caloric intake to support
physiological needs
 Nutritional needs decrease with progression of dying
phases
 Traumatic to family members – does not bother the
patient
 Offer soft foods and/or favorite foods – patient may
request favorite foods
 Hunger is suppressed due to the body no longer
requiring nutrition
 Provide support and education to the family
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today, 7(7), 22-27.
Vital Signs
Vital Signs
 Blood pressure and oxygenation decrease in imminent stage of
dying
 Unreliable in the indication of impending death
 Research does not support obtaining vital signs
 Febrile conditions are a natural process of the dying phase
 Can treat with Tylenol PO/PR – only if fever is causing distress to the
patient
 Administering antipyretics for elevated temperatures can cause
distress, discomfort, and increased agitation in patients that do not
appear to be effected by the febrile state
 Obtaining respirations and heart rate can help to determine
increased pain, anxiety, and dyspnea to guide PRN medication
administration
Bruera, S., Chisholm, G., Santos, R., Crovador, C., Bruera, E., & Hui, D. (2014, April 14). Variations in vital signs in the last days of life in
patients with advanced cancer. Journal of pain syptom management(14), S0885-3924. doi: doi: 10.1016/j.jpainsymman.2013.10.019
Family Support &
Education
Therapeutic Self
Family Support and Education
 Ensure the patients right to make informed decisions about their end of life care
 Cultural assessment and provision of needed cultural requirements
 Ensure appropriate referrals, social services, pastoral, Hosparus etc.
 Providing education at the beginning and throughout the process can reduce
stress and increase comfort for the patient and family
 Continued education to support the family establishes trust
 Empower the family through education to foster feelings of control – teaching
oral care, cool cloths, feeding (when the patient is still able to swallow)
 Nutritional education – oral intake of foods and fluids
 Encourage family and patients to ask questions
 Educate family on signs and symptoms of pain, dyspnea, and anxiety
 Educate that at times visitor restriction may be necessary to reduce patient
anxiety, agitation, and restlessness
 Educate on safety – during terminal restlessness phases
References
(IAHPC), I. A. (2013, January). WHO-Essential Medicines in Palliative Care. Retrieved from
World Health Organization:
http://www.who.int/selection_medicines/committees/expert/19/applications/PalliativeCar
e_8_A_R.pdf
Ali, MD, N. (2012). Failure to thrive in elderly adults. Medscape Reference.
American Nurses Association. (2010, June 14). Registered Nurses Roles and Responsibilities in
Providing Expert Care and Counseling at the End of Life. Retrieved from Position
Statement: http://www.nursingworld.org/mainmenucategories/ethicsstandards/ethicsposition-statements/etpain14426.pdf
Bruera, S., Chisholm, G., Santos, R., Crovador, C., Bruera, E., & Hui, D. (2014, April 14).
Variations in vital signs in the last days of life in patients with advanced cancer. Journal
of pain syptom management(14), S0885-3924. doi: doi:
10.1016/j.jpainsymman.2013.10.019
D'Arcy, MS, CRNP, CNS, Y. (2012). Managing end-of-life symptoms. American Nurse Today,
7(7), 22-27.
Hospice Patients Alliance. (2014). Terminal restlessness or agitation. Hospice patients alliance.
University of Pittsburg. (2013, July). Palliative care symptom guide. Retrieved from Pain Card:
https://www.dom.pitt.edu/dgim/spc/downloads/paincard2013.pdf
World Health Organization. (2014). WHO definition of palliative care. Retrieved from World
Health Organization: http://www.who.int/cancer/palliative/definition/en/