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C H A P T E R 29
Caring for Older Adults
at the End of Life

LEARNING OBJECTIVES on optimal comfort and quality of life for people who are
dying and for their families. In older adults, death is usually
After reading this chapter, you will be able to:
associated with the cumulative effects of chronic illness and
1. Identify factors that influence attitudes toward many interacting conditions, rather than a single cause.
death.
2. Describe cultural and historical approaches to end-
THE DYING PROCESS AND DEATH
of-life care.
3. Explain the nurse’s role in end-of-life care. Although life and death appear to be clear concepts, the lack
of an exact definition of the terms life, dying, and death can
4. Identify the common characteristics of “quality of
at times cloud the goals of care. According to the American
life” and a “good death.”
Geriatrics Society’s (AGS’s) position statement on The Care
5. Describe palliative care and hospice nursing. of Dying Patients (AGS, 2002), birth and death give defini-
6. Assess physical, psychological, social, and spiritual tion to life as the period of time in between. Death is an irre-
care needs for older adults at the end of life. versible lifeless state in which the physiologic functions of
7. Identify appropriate nursing interventions to ad- life are absent. Dying is regarded as a less specific, individ-
dress symptoms commonly experienced by older ualized process in which an organism’s life comes to an end
adults at the end of life. (i.e., the final portion of the life cycle). When does the dying
process begin? People are considered to be dying when they
are ill with a progressive condition that is expected to end in
death and for which there is no treatment that can substan-
K E Y P O I N T S tially alter the outcome (AGS, 2002). The length of the dying
process varies and depends on the individual’s holistic situa-
death medicalization tion. Its duration may be a matter of minutes, hours, weeks,
death with dignity palliation or months.
The end of life is the period for patients when “there is
dying rehumanizing
little likelihood of cure for their disease(s); further aggressive
end of life spiritual well-being therapy is judged to be futile; and comfort is the primary goal”
hospice (Wilke & TNEEL Investigators, 2003, p. 9). This period can
last from hours to months, and it encompasses the time during

B
which a person is actively dying. Palliation is defined as “the
ecause of the dramatic increases in life expectancy and relief of suffering when cure is impossible” (Wilke & TNEEL
the trend toward living longer with chronic conditions, Investigators, 2003, p. 41). Palliative care is an evolving pro-
there has been increasing interest in and emphasis on fessional specialization, defined by the Robert Wood Johnson
end-of-life care. Advances in medical knowledge and tech- Foundation Last Acts Task Force (2002) as the “comprehen-
nology have shifted the focus of care to prolonging and sus- sive management of the physical, psychological, social, spir-
taining life because many illnesses that once were fatal (e.g., itual, and existential needs of patients, particularly those with
cancer, cardiovascular disease) are now chronic conditions. incurable, progressive illness. The goal of palliative care is to
Because of these changes, health care providers focus not help patients achieve the best possible quality of life through
only on preventing and curing disease but also on managing minimizing suffering, controlling symptoms, and restoring
chronic illness and promoting quality of life. For people in functional capacity, while remaining sensitive to personal, cul-
the terminal stages of an illness, the focus of health care is tural, and religious values, beliefs, and practices.”

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576 PA RT 5 Promoting Wellness in All Stages of Health and Illness

NURSING SKILLS FOR PALLIATIVE CARE Box 29-1 Strategies for Rehumanizing Death
Regardless of the setting, nurses take on a primary role in the
delivery of palliative care at a time in which aggressive, cur- ● Reintroduce a peaceful sense of harmony between dying peo-
ple and the process of dying.
ative medical care is no longer feasible or appropriate. Ac- ● Provide the support of community participation in dying rituals.
cording to the Hospice and Palliative Nurses Association ● Support the harmonious acceptance of death as ordinary and
(HPNA) position statement on the Value of Professional natural, not a social evil.
Nurse in Palliative Care, nurses have long advocated for at- ● Emphasize the comforting roles of fellowship, ritual, and
tention to quality of life throughout the lifespan, including ceremony.
● Facilitate, even mandate, the notion that dying should be a
end of life, and they are the healthcare professionals who pro- culturally shared community experience.
vide consistent presence to patients and families who are ● Culturally legitimize the pain and suffering that often accompa-
facing terminal illness (HPNA, 2008). The position statement nies dying.
describes nursing skills for effective end-of-life care as ● Provide a common base of participation and sense of belong-
follows: ing; attach the dying person to the community of living.

Advanced terminal or chronic illness usually presents with Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to
not one, but multiple and often complex symptoms that affect compassionate care (p. 281). Philadelphia, PA: Lippincott Williams & Wilkins.
the body, mind, and spirit of the patient. These symptoms re-
quire the professional nurse to employ highly trained skills
and provide holistic care that is consistent with the goals of
the patient and family . . . . Competent, patient-centered nurs- that by the 1990s, only 20% of people died at home or in non-
ing practice for palliative care includes expert assessment institutional settings. However, that trend is reversing, and in
skills, critical thinking, comprehensive pain and symptom 1999, 25% of deaths occurred in private homes (Wilke &
management of the whole patient, effective communication TNEEL Investigators, 2003). According to the report by the
skills, and a professional knowledge base to support ethical Robert Wood Johnson Foundation Last Acts Task Force
decision making. These are the skills that patients and fami- (2002), a national coalition to improve care and caring near
lies value highly as death approaches. HPNA (2008, p.1)
the end of life, 50% of Americans aged 65 years and older
die in hospitals, although more than 70% state their desire to
die at home. The deaths are often preceded by multiple physi-
PERSPECTIVES ON DEATH AND DYING
cian visits and expensive life-prolonging treatments.
During the last hundred years, society witnessed significant Studies indicate that between 24% and 30% of deaths
change in the perception and management of death. Before among older Americans occur in long-term care facilities
the 20th century, death was more readily accepted as an in- (Munn et al., 2008; Menec, Nowicki, Blandford, & Veselyuk,
evitable and normal part of life. Illness and death were family 2009). A national nursing home survey found that the number
centered, with care provided by family members in their of hospice patients receiving care in nursing homes has been
homes. As health care became more sophisticated, a shift oc- increasing significantly in recent years (Bercovitz, Decker,
curred. Hospital-based care provided by physicians, nurses, Jones, & Remsburg, 2008). Concerns have been raised about
and other professionals replaced the family caregiving model. end-of-life care in nursing facilities. For example, Menec et al.
This medicalization of end-of-life care has had a major im- (2009) found that unnecessary and inappropriate hospitaliza-
pact on the dying experience in the last three to four decades: tions of long-term care residents close to the end of life are
end-of-life experiences in formal health care facilities are common and have a particularly negative impact.
often technologically driven and dehumanized (Saunderson
& Brener, 2007). Views of Death and Dying in Western Culture
Nursing is a leading force in the palliative care movement—
As a result of many interacting factors, Western culture has
a natural fit given the holistic tradition of the profession. In
tended to deny or ignore the universality of death. During the
the past two to three decades, as hospice has grown, so has a
last several decades, responsibility for the dying experience has
realization that the end of life can be positively affected by
been informally and more exclusively delegated to clinicians,
returning to basics. Goals are slowly refocusing on comfort,
with a majority of deaths occurring in hospitals. In health care
companionship, and caring, with nurses in a pivotal role. This
settings, physicians are usually the major decision makers be-
rehumanizing of death and dying recognizes and respects
cause of their medical expertise. Many older adults revere
the process as an important and meaningful stage of the con-
physician suggestions and recommendations for treatment,
tinuum of human life. Box 29-1 presents strategies for rehu-
even though they do not always fully understand the issues, op-
manizing death.
tions, or potential consequences. Older adults are often reluc-
tant to question physicians, and they may set aside their
Sites of Death and Dying personal values, ideas, and wishes to follow the advice of their
Since the beginning of the 20th century, when most people doctor. Consequently, they may not explore their options of
died in their homes, the place of death gradually shifted, so dying in places other than hospitals or institutional settings.
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Caring for Older Adults at the End of Life CHAPTER 29 577

In studies of social gerontology, Markson (2003) identi-

fied the following four contemporary societal values or be- A Student’s Perspec tive
liefs that shape the general outlook on aging and death: This week, I learned that it is okay to accept that an elderly
1. Work and activity are intertwined with self-worth, and patient is ready to die and that is his/her wish. I had a patient
chronic illness or disability is associated with the end of who requested that we not perform any measures—just give
productivity and loss of purpose. Consequently, people him his beer with lunch, wine with dinner, and some pain
may not acknowledge illness and aging because they are medicine to make him comfortable. He stated that he has led
viewed as predecessors to death. a good life and is ready to go see God. That is really hard for
2. Through self-determination and individual responsibility, me because it’s my job to help people and save lives. The
anyone can do anything if he or she tries hard enough. Be- other aspect of that is helping people die a dignified death—
it’s just a really TOUGH aspect!!!
cause human life has inherent limitations, this false men-
Sarah E.
tality is a major underpinning to the denial of aging and
death in the 21st century.
3. Medical advances of the last several decades foster the be-
lief that aging, illness, and even death can be manipulated,
managed, and controlled.
Although younger generations may feel a sense of entitle-
4. Authority over and responsibility for death has subtly
ment to a long life, many older adults hold the opposite view.
transferred from religious leaders to physicians. Conse-
They may be more accepting of the possibility of imminent
quently, the ability to cure illness and prolong life has im-
death, viewing long life as a privilege. Young people tend to
bued life and death with qualities that are more humanistic
place life and death on opposite ends of the spectrum, and
and less spiritual.
feel threatened and cheated by death because of the opportu-
In some ways, society is more accepting of an older adult’s nity for living that is lost. From their vantage point, older
death compared with that of a younger person. The rationale adults more frequently view death as a natural part of life’s
for this attitude is that older people have had an opportunity continuum, and the process of dying as a period of self-
to “live their lives.” Sometimes, death is viewed as a blessing, actualization. Even though physical decline is a main theme
taking an older adult out of a situation of suffering and reduced of aging and dying, for many older adults, this time of life is
capacity. Caregivers often express relief when death occurs, one of growth and fulfillment. From this holistic perspective
stating that “he wouldn’t have wanted to live like this.” on death and dying, old age can be turned into an opportunity
Despite these prevalent attitudes and beliefs, in the past 20 for development and death into an ultimate accomplishment.
to 30 years, society in general has begun to culturally acknowl-
edge and integrate an increasing acceptance of life’s end. This
Health Care Professionals’ Perspective
change has been largely provoked by the baby boom generation
facing its own aging process while simultaneously dealing with on Death and Dying
their parents’ aging and health issues. Ethical questions and Health care facilities have been institutionally designed to be
challenges have surfaced as a result of problems in care and ris- centers for disease care and disease cure. Given this orienta-
ing associated costs. For example, in the midst of the assisted tion, practitioners and health care professionals often view
suicide debate, society has begun asking a second layer of ques- death as something to be avoided because it symbolizes pro-
tions: “What value is there in the last phase of life? Can there fessional and personal incompetence or failure. Prolonging
be any meaning and value in the process of dying? Can there life, even at the expense of quality, was thought to be the ul-
be value in grieving? Can there be value in caring for people as timate accomplishment: a symbol of success for patients,
they die?” (Byock, 2006). The changing demographics and in- families, and the health care teams involved.
crease in the numbers of older adults dying will be an impetus In recent decades, palliative and end-of-life care have be-
for continued discussion and changes in social policies. come part of the medical mainstream, and health care profes-
sionals realize they can find meaning and satisfaction in caring
for people who are dying and their loved ones. As experts, pro-
Older Adults’ Perspective on Death and Dying fessionals in the disciplines of hospice and palliative care play
How do older adults view death when mortality becomes im- a key role in promoting awareness and understanding in this
minent? Common stereotypes about old age contribute to the process of social, cultural, and professional maturation. Stan-
myth that older adults are ready to die because their lives have dards of care define and guide health professionals’ practice
lost their value. These beliefs have been proven to be ageist. to include clear communication, ethical decision making,
On the contrary, although studies have suggested that death technical competence, and intensive management of symp-
anxiety decreases with advancing age, older adults’ feelings toms, respecting the dying individual’s autonomy. The issue
about death vary according to individual social circumstances of quality of life versus quantity of life at all costs has rede-
and life experiences (Markson, 2003). In spite of their fined the professional perspective.
chronologic years, many older adults have life goals they ex- To provide effective end-of-life care, nurses need to ex-
pect to fulfill; consequently, they are not ready to die. amine their own feelings and attitudes, which may affect the
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578 PA RT 5 Promoting Wellness in All Stages of Health and Illness

care they provide. Personal beliefs about death are shaped by

experiences from the time of birth, with the family as the pri- A Student’s Perspec tive
mary influence. Religious affiliations, popular media and cul- I found myself in a situation today in which I quickly recognized
ture, and ethnic background contribute to one’s reactions to the importance of the lesson on cultural sensitivity in nursing.
death and dying. Whether death is discussed as part of normal My aging client unfortunately had a significant change over the
life or whether it is seen as “the enemy” influences care. weekend, and her husband requested for her to be transported
Nurses need to learn about clinical aspects of end-of-life care, to the hospice inpatient unit. As she and I sat on her bed, she
and they must also take time to process their own feelings verbalized her acceptance that her disease is terminal. She wept
and concerns. Some questions to ponder for self-awareness as she voiced her heartache in telling her family of her “disap-
and insight include the following (Ohio State University pointment.” Even though she is Catholic, because of her Chi-
nese heritage and her family’s Buddhist belief in “saving face,”
Health Sciences Center, 2003):
she worries that she has let her family down. While she ex-
● When you hear the word “death,” what comes to your
pressed her thoughts, I listened and provided emotional sup-
mind? What do you personally fear the most? What are port, which seemed to ease some of her grief. We transported
you most curious about? her to the hospice unit, and I assisted in making her comfort-
● How old were you the first time someone close to you
able with the new environment. When I went out to the nurses’
died? How was grief handled in your family? What do you station to give my report, the receiving nurse’s first comment to
believe happens to you when you die? me was, “I see she is Asian and you have her religious prefer-
● Have you ever seen anyone die? What was that like for ence documented as Catholic. Are you sure that is correct?”
you? Because of our recent discussions and reading on cultural sen-
● How do your own attitudes and previous experiences af- sitivity, I quickly realized how we as nurses can make incorrect
fect the way you work with dying patients now? assumptions in categorizing individuals based on their ethnicity.
I reported about my client’s childhood history, her parents’ be-
Because of the nature of their work as care providers, nurses lief in Buddhism, the Catholicism she was taught in school, and
are in an ideal position to serve primary roles in achieving her long and strong Catholic faith. I found myself really under-
quality end-of-life experiences for older adults. standing the importance of educating ourselves as nurses about
different cultures and the effect of cultural belief systems on in-
dividualized health care. As difficult as it was for me to leave
Culturally Diverse Perspectives my client in a strange environment, I felt that the information I
had learned and shared would enable the staff to be respectful
on Death and Dying
of her beliefs, which in turn would be a positive experience for
Nurses providing holistic care to older adults at the end of my client during her stay.
life need to recognize the effects of culture on the dying ex- Deborah L.
perience because cultural beliefs and practices are particularly
influential with regard to end-of-life care (Hampton et al.,
2010; Salman & Zoucha, 2010). Cultural factors can affect
all the following aspects of end-of-life nursing care:
● Perceptions of a good death QUALITY OF CARE AT THE END OF LIFE
● Acceptance of hospice and palliative care services
During the 1990s and early 2000s, reports from several major
● Lines of communication about pending death and end-of-
institutions—including the Institute of Medicine and the
life decisions Robert Woods Johnson Foundation—identified serious prob-
● Expectations about medical interventions (e.g., decisions
lems with end-of-life care in the United States. These reports
about resuscitation) found that many people experienced discomfort and suffering
● Place where death occurs
from end-of-life symptoms because health care professionals
● Practices and rituals near the end of death and immediately
did not possess the skills and knowledge required to meet the
following death needs of a dying person. To address some of the problems,
● Decisions about autopsy or organ donations.
the Nathan Cummings Foundation and the Robert Wood
Because the experience of death and dying is very personal, Johnson Foundation developed the Toolkit of Instruments for
nurses should incorporate cultural considerations into indi- Measuring End-of-life Care (TIME) to help health care pro-
vidualized assessments and be aware of diverse beliefs and fessionals identify opportunities for improving care. The End
attitudes associated with the experience of death and dying. of Life Nursing Education Consortium (ELNEC) is a major
Cultural Considerations Box 29-1 provides information about initiative to improve nursing care for people who are near the
death rituals that are commonly associated with specific end of life. A recent study concluded that the ELNEC project
groups. It also suggests interventions that nurses can apply has been tremendously successful in improving nursing
in different situations. As with other aspects of culturally ap- knowledge at end of life during the past decade (Whitehead,
propriate care, nurses need to be aware of different practices Anderson, Redican, & Stratton, 2010). Information about
that may be associated with particular groups; at the same these and other educational programs is listed in the
time, they need to avoid stereotypes. Resources at the end of this chapter.
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Caring for Older Adults at the End of Life CHAPTER 29 579

CULTURAL CONSIDERATIONS 29 - 1
Death Rituals Commonly Associated With Specific Groups
Group Death Ritual Intervention

African Americans May respond to news of death of a loved one by falling Recognize that this is a culturally based response and not
out (i.e., sudden collapse, paralysis, and inability to see an emergency medical condition; provide support.
or speak).
Amish Appalachians Provide a wake-like “sitting up” during the night for seri- Arrange for privacy and accommodate family members
ously ill and dying family members. staying overnight.
Cubans, Filipinos, Mexicans A large gathering of relatives and friends may attend the Arrange for a gathering place close to the dying person;
dying person and place religious artifacts around the find electric candles if open flames are not allowed;
person; candles are lit after death to illuminate the path summon clergy for religious rituals; do not move reli-
of the spirit to the afterlife. gious items.
Europeans Believe that the dying person should not be left alone. Make accommodations for family members to be present
at all times.
Haitians Family members gather and pray when death is immi- Make accommodations for privacy, encourage family to
nent and may cry uncontrollably; all family members bring in religious objects, allow families to participate in
try to be at the person’s bedside at the time of death. postmortem care if they desire to do so.
Hindus, Indians Priest and eldest son may perform death rites, with all male Provide a supportive and private environment; offer un-
relatives assisting; women may respond with loud wailing. derstanding of death rituals and grief behaviors.
Japanese Family members gather at the bedside at the time of Notify eldest son of pending death, identify lines of com-
death, with the eldest son having particular responsi- munication if eldest son is not available.
bilities at the time.
Jews Dying person should not be left alone; death rituals vary and Ask the closest relative specifically about postmortem
some are not performed on the Sabbath or holy days. practices.
Koreans Family members are expected to stay with the person Support family in caring for the person.
who is dying and assist with care.
Mexicans Some, especially women, may have an ataque de nervios Recognize that this is a culture-bound syndrome and treat-
(i.e., the person exhibits hyperkinetic and seizure-like ment is usually not necessary; remain with the person, pro-
activity to release strong emotions) on hearing of the vide support, and involve family with assistance if possible.
death of a loved one.
Muslim groups The bed should be turned to face the holy city of Mecca, Facilitate positioning of the bed whenever possible, pro-
family recites prayers from the Qur’an. vide privacy for prayers.
Navajo Indians It is taboo to talk about a fatal disease or dying; the issue Avoid suggesting that someone is dying because this
needs to be discussed in the third person, as if it is may be interpreted as a wish that the person be dead.
occurring in someone else.
Puerto Ricans Death is perceived as a time of crisis; the head of the Allow time for family to view, touch, and stay with the
family (i.e., usually the oldest daughter or son) is re- body before it is removed; ask if the family wants a
sponsible for receiving the news of death. clergy member called.
Vietnamese Flowers are avoided during illness because they are usu- Ask permission from the patient or family before placing
ally reserved for rites of the dead. flowers in a room.

Source: Purnell, L. D. ( 2009). Culturally competent health care. Philadelphia, PA: F. A. Davis.

Promoting Wellness at the End of Life ● The patient is psychologically comfortable.

Wellness at the end of life is closely connected to the concept ● The patient has spiritual support available according to her
of a “good death,” which has been described by Western so- or his wishes.
cieties as a death with dignity. A death with dignity is These characteristics are in accord with the “Dying Patient’s
specifically characterized by a dying experience in which Bill of Rights,” a document created at a workshop on “The
(Wilke & TNEEL Investigators, 2003): Terminally Ill Patient and the Helping Person” by Linda
● The patient’s and family’s wishes are respected. Austin (1975) to identify concretely the dignified care that
● The patient and family feel a sense of control over the dying people deserve (Box 29-2). This document continues
situation. to be helpful as a fundamental guide for defining goals and
● The patient is physically comfortable. interventions for individualized end-of-life care.
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580 PA RT 5 Promoting Wellness in All Stages of Health and Illness

Box 29-2 The Dying Person’s Bill of Rights DIVERSITY NOTE

A study of 284 Muslims of 14 nationalities identified the following pri-
I have the right to be treated as a living human being until I die. orities as important components of a “good death”: dignity, privacy,
I have the right to maintain a sense of hopefulness, however, changing spiritual and emotional support, access to hospice care, ability to
its focus may be. issue advance directives, and time to say goodbye (Tayeb, Al-Zamel,
I have the right to express my feelings and emotions about my Fareed, & Aboueillail, 2010).
approaching death in my own way.
I have the right to participate in decisions concerning my care.
I have the right to expect continuing medical and nursing attention
even though cure goals must be changed to comfort goals.
I have the right not to die alone. Hospice Care
I have the right to be free from pain. Hospice refers to a philosophy of care that seeks to support
I have the right to have my questions answered honestly. dignified dying or a good death experience for those with ter-
I have the right not to be deceived.
I have the right to have help from and for my family in accepting
minal illnesses. Hospice care involves a core interdisciplinary
my death. team of professionals and volunteers who provide medical,
I have the right to die in peace and with dignity. psychological, and spiritual support as well as support for the
I have the right to retain my individuality and not be judged for my patient’s family. These services are provided by public and
decisions, which may be contrary to the beliefs of others. private agencies in home- or facility-based care settings, or
I have the right to be cared for by caring, sensitive, knowledgeable
people who will attempt to understand my needs and will be
in freestanding, short-term residential facilities.
able to gain some satisfaction in helping me face my death. The term hospice (from the same linguistic root as “hospi-
I have the right to be cared for by those who can maintain a sense tality”) was first applied to specialized care for dying patients
of hopefulness, however, changing this might be. in the 1960s by physician and nurse Dame Cicely Saunders,
I have the right to expect that the sanctity of the human body will who founded the first modern hospice—St. Christopher’s—
be respected after death.
I have the right to discuss and enlarge my religious and/or spiritual
in a residential suburb of London. During a guest lecture for
experiences, whatever these may mean to others. medical students, nurses, social workers, and chaplains at Yale
University, Saunders introduced the idea of hospice care and
Source: Austin, L. (1975). Dying patient’s bill of rights. Created at The Terminally Ill Pa- emphasized holistic services and symptom control. This lec-
tient and the Helping Person Workshops. Sponsored by the Southwest ture sparked interest, which led to the development of hospice
Michigan Inservice Education Council in Lansing, MI.
care as it is known today.
In 1969, psychiatrist Elisabeth Kübler-Ross published On
Death and Dying. This book, based on interviews with dying
patients, identified five stages through which many termi-
For many older adults, a “good death” is part of the process nally ill patients progress: denial, anger, bargaining, depres-
of “aging well,” but both processes are very individualized and sion, and acceptance (Kübler-Ross, 1969). The book was well
strongly influenced by cultural and spiritual factors. In the con- received by all disciplines and drew attention to the needs of
tinuum of life, the experiences of aging, the end of life, and dying people. In 1972, Kübler-Ross testified at the first na-
death are opportunities for self-actualization. Defining a “good tional hearings conducted by the U.S. Senate Special Com-
death” for older adults is extremely personal and often depend- mittee on Aging, on the subject of death with dignity. In her
ent on the effects of aging and illness on the person’s level of testimony she stated,
function and independence. The goal of nursing is to support
this stage of life and help patients maintain optimal personal
dignity.
Patient comfort, which has always been a core nursing re- A Student’s Perspec tive
sponsibility, is an essential component of death with dignity. When I left the nursing home today I felt better about working
The word “patient” is derived from the Latin word patiens, with people facing the certain end of their lives. Mr. F. had a
which means “one who endures” or “one who suffers.” The really positive attitude about his inoperable brain tumor and it
word “comfort” comes from the Latin confortare, which made me understand that I am the one who feels uncomfortable
means “to strengthen.” Literally, then, nurses who provide with death. He expressed that his life has meaning and that he is
comfort to patients are strengthening those who suffer. This here for a reason. He told me about some of his goals in life: he
definition is particularly appropriate for nurses who provide plans to get out of the nursing home so that he can travel around
the country in an RV with his wife. He seemed to imply that even
care for patients at the end of life that is built on the following
if that goal never occurred, it was OK, that it was mostly some-
beliefs (Wilke & TNEEL Investigators, 2003):
thing to look forward to. All of the communication with Mr. F.
● The dying are not people for whom “nothing can be done.”
had a huge impact on me. It gave me a whole new perspective on
● Patients deserve to be assured that everything will be done
how people view their lives. This man is suffering from this
to prevent them from dying in pain, without dignity. terrible disease, yet he still finds hope and has goals in life.
● Patients will not die alone, isolated from those they love Erin H.
and who love them.
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We live in a very particular death-denying society. We isolate assessment and treatment of the physical, psychosocial, and
both the dying and the old, and it serves a purpose. They are spiritual dimensions of dying; the ability to relate prognoses
reminders of our own mortality. We should not institutionalize to patients and families; and knowledge of resources. Nurses
people. We can give families more help with home care and assist patients and families with end-of-life tasks, such as
visiting nurses, giving the families and the patients the spir-
identifying sources of support (e.g., hospice), managing
itual, emotional, and financial help in order to facilitate the
symptoms, supporting life-closure processes, and planning
final care at home. National Hospice and Palliative Care
Organization (NHPCO) (n.d.) for rites and rituals at the time of death and after. Nurses have
primary roles not only in assisting with these tasks but also
In 1982, Congress created a Medicare hospice benefit, in teaching families about the signs of imminent death and
which provided federal financial support to people dying of management of the dying processes.
a terminal illness. Hospice benefits have become increasingly McSteen and Peden-McAlpine (2006) discuss the primary
available and are now supported by many health insurance role of nurses as advocates serving as guides, liaisons, and
plans. Advantages of these services include the following: supporters during the dying experience. Guiding activities in-
● Hospice treats the person, not the disease; focuses on the clude providing and clarifying information and options in a
family, not the individual; and emphasizes the quality of manner that supports the decision making of the dying indi-
life, not the duration. vidual and his or her family. In addition, the nurse advocate
● Hospice care relies on the combined knowledge and skill serves as a liaison between the family and members of the
of an interdisciplinary team of professionals, including health care team. Including family members in their loved
physicians, nurses, home care aides, social workers, coun- ones’ dying process ultimately has a positive impact on the
selors, and volunteers. experience. Finally, the nurse advocate acts to support the
● Hospice care is a cost-effective alternative to the high costs choices and decision making of patients and families, setting
associated with hospitals and traditional institutional care. aside his or her own perspective as a health care professional.
Hospice eligibility criteria, which are defined by Nurses will gain personal and professional satisfaction
Medicare, require a physician referral, including a statement from serving as care providers, coordinators, and advocates
that a patient is terminally ill and has a life expectancy of 6 for older adults at the end of life. Fulfillment can be obtained
months or less. This requirement is problematic because it is from knowing that patients die in comfort, with their dignity
difficult to predict the length of time before death. As a result, intact and their wishes and values respected.
many patients have missed opportunities for services and had
their benefits delayed until the last few weeks of life. Despite Promoting Communication
the substantial increase in the use of hospice services in re- The National Institutes of Health consensus statement on im-
cent years, the mean length of service has decreased from 25 proving end-of-life care (National Institutes of Health Con-
days in 1998 to 20 days in 2007 (Connor, 2009). sensus Development Program, 2004) identified numerous
An important role of nurses is to advocate for referrals to transitions that people face at the end of life, including phys-
engage hospice support earlier for the benefit of older adult ical, emotional, spiritual, and financial. Nurses have many
patients and their families. Hospice programs offer the fol- opportunities to intervene in each of these realms by using
lowing services: communication strategies and interpersonal skills. These in-
● Physician and nursing care
terventions include presence, compassion, touch, recognition
● Home health aide
of an individual’s autonomy, and honesty (Box 29-3).
● Therapies such as music, art, and other supportive services
Communication is the cornerstone of interpersonal rela-
● Social work and counseling services
tionship building. When caring for people who are dying,
● Spiritual care
communication is critically important to all involved, and its
● Volunteer support
importance is magnified by the unpredictability of the situa-
● Bereavement counseling, including support programs for
tion. Nurses can help dying patients express their needs by
1 year after death using open, honest, direct, and empathetic communication,
● Medical equipment and supplies
even when they may be uncertain about what to say. (See
● Drugs related to the disease
Box 29-4 for examples of what to say as well as what not to
● Inpatient care for symptom management, caregiver respite,
say.) Dying patients value the ability to express themselves;
or both. in particular, older adults value the opportunity to achieve
closure and say good-bye.

NURSING INTERVENTIONS Offering Spiritual Support

IN END-OF-LIFE CARE
Spiritual support provided by nurses is widely recognized as
To assist patients and their families in attaining death with dig- an important component of end-of-life care because it con-
nity in a caring manner, the nurse must possess the following tributes to the dying person’s quality of life (Murray, 2010;
skills: interpersonal communication abilities; expertise in the Wallace & O’Shea, 2007). Spiritual well-being at the end of
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582 PA RT 5 Promoting Wellness in All Stages of Health and Illness

Box 29-3 Supportive Interventions for Relationship Building

Presence A core nursing intervention, presence can be described as a “gift of self” in which the nurse is available and
open to the situation.
Presence can be demonstrated through verbal communication, valuing what the patient says, accepting
the patient’s meaning for things, and remembering or reflecting.
Compassion The nurse strives to be totally and compassionately with the patient and family, allowing the most positive
experience.
Touch A powerful therapeutic intervention, touch communicates an offer of unconditional acceptance. It can be
both healing and life affirming, a means of communicating genuine care and compassion.
Recognition of autonomy The nurse realizes and respects the individual’s right to make all end-of-life decisions.
Honesty The nurse is often in a front-line position to communicate/explain what can be expected. Compassionate
honesty builds trust with the older adult facing death and his or her family.
Expert communication At any given moment, nurses need to be able to assess the patient and family, implement a plan to
comfort them, and communicate clearly and supportively throughout.
Assisting in transcendence At the highest level of care, nurses provide emotional support that facilitates the experience of self-
transcendence and a sense of triumph over death.

Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to compassionate care (p. 6). Philadelphia, PA: Lippincott Williams & Wilkins.

life includes meaningful existence, the ability to find meaning Presence, Religious Ritual Enhancement, Spiritual Support,
in daily experience, and the ability to transcend physical dis- and Touch. Nurses also make referrals for pastoral care, hos-
comfort and prepare for death (Ferrell & Coyle, 2006). pital chaplains, parish nurses, or other spiritual support re-
Nurses assess spiritual needs both initially and on an ongoing sources when appropriate. Hospice programs provide spiritual
basis because these needs are likely to change during the end- support and can provide resources to assist nurses in address-
of-life process. Nurses can apply information from Chapter 13 ing spiritual needs of patients and families.
to assess spirituality in older adults.
Nursing diagnoses pertinent to spiritual care during the end
of life are Risk for Spiritual Distress, Spiritual Distress, and Managing Symptoms
Readiness for Enhanced Spiritual Well-being. The following Although the end-of-life period and dying are very individu-
nursing interventions relevant to spiritual care at the end of alized and unpredictable processes, some symptoms occur
life are as follows: Active Listening, Coping Enhancement, commonly and require expert and timely nursing care, par-
Emotional Support, Guilt Work Facilitation, Hope Instillation, ticularly for older adults who may experience more symptoms

Box 29-4 Communicating With Dying Patients

and Their Families A Student’s Perspec tive
I had a special experience with a man at the nursing and rehab
What to Say center. “Mort” and I had great conversations, and he quickly
● What do you need me to do for you? became a friend. Mort was suffering from cardiovascular fail-
● Is there anyone I can call for you? ure, and I knew he did not have long to live. I interviewed Mort
● I’m here to listen. and then wrote a paper about his life. I wrote the paper early
● No need to rush. Take your time. so that I could read it to Mort before his health declined any
● It’s okay to cry. Let me get you a tissue.
more. I read my paper to Mort one morning, and he listened
● Would you like to be left alone?
● Would you like to share some memories? with a seeming sense of sacredness about the words being
read. This was his life, and I could tell that it meant a lot to
What Not to Say him that I wrote it all down. When I finished, Mort simply said,
● She’s in a better place now. “I thank you . . . I thank you.” He asked me to put the paper
● He lived a full life. in a safe place so it would not get ruined. Mort and I had a
● She’s out of her pain. special connection; he was a hero to me. The following week,
● It’ll be all right. I went to the clinic and found out that Mort had passed away.
● Don’t cry. I am grateful that I had the opportunity to know Mort and to
● Be strong. grow and learn from his good life. I am glad that I could serve
● He’d want you to get on with your life. him at this final time and help him reflect on his life.
Amy C.
Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to
compassionate care (p. 18). Philadelphia, PA: Lippincott Williams & Wilkins.
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Caring for Older Adults at the End of Life CHAPTER 29 583

(Ogle & Hopper, 2005). Symptoms, which can occur at any found a high prevalence of breathlessness during the 3
time, include fatigue and weakness, constipation, dyspnea, months leading to death, with increasing prevalence and
nausea and vomiting, dehydration, decreased appetite, and severity closer to the time of death (Currow et al., 2010). Dys-
pain. Because these symptoms usually occur in combination, pnea may result from abnormalities or imbalanced states in
management is challenging and it is not always possible to the pulmonary, cardiac, neuromuscular, or metabolic systems,
control every symptom completely. Although not every pa- as well as arising from psychological causes.
tient will have a peaceful passing, nurses and other health
care professionals must make every effort to manage symp- Nausea and Vomiting
toms and alleviate distress to the extent possible. Nausea and vomiting are common symptoms associated with
Nurses can use information in Table 29-1 and the follow- terminal illness. Causes of nausea and vomiting at the end of
ing sections as a guide to nursing assessment and interven- life include the following:
tions for some of the commonly occurring symptoms. In ● Irritation/obstruction of gastrointestinal tract (bowel ob-
addition, nurses can use information in Chapter 28 to address struction, constipation, cancer tumor, delayed emptying of
pain, which is a symptom that occurs frequently at the end of stomach from ascites, tumor pressure [often called squashed
life and is one of the most feared symptoms associated with stomach syndrome])
death. This chapter addresses the symptoms only in relation ● Medication side effect (particularly opioids such as
to the end of life; other pertinent topics are discussed more morphine)
comprehensively in other chapters: confusion or delirium ● Ear infection or labyrinthitis
(Chapter 14), depression (Chapter 15), constipation (Chapter ● Electrolyte imbalance, sepsis
18), and sleep problems (Chapter 24). ● Kidney failure, liver failure
● Increased intracranial pressure (brain tumor, cerebral

Fatigue (Asthenia) edema, intracranial bleeding, metastasis)

Fatigue is one of the most commonly reported symptoms at ● Foul odors

the end of life. Fatigue is often described as tiredness, or lack ● Anxiety, fear.

of physical strength and endurance, or decreased mental con-

centration. Older adults may have reduced energy or activity Dehydration
tolerance caused by usual aging changes, so it is important Because older adults normally have an age-related decrease
for the nurse to establish a baseline for comparison and mean- in body water, they become dehydrated more easily. Causes
ingful interpretation. Fatigue is generally a symptom with un- of dehydration at the end of life include reduced or inadequate
derlying causes related to disease processes or conditions, oral intake, medications such as diuretics, vomiting, diarrhea,
such as anemia, malnutrition, infection, drug therapy, or de- and fever. Symptoms of dehydration can interfere with com-
pression. Other concurrent end-of-life symptoms, such as fort by causing dry mouth, constipation, confusion, and skin
pain and dyspnea, may exacerbate fatigue. impairment.

Constipation Anorexia and Cachexia

Constipation, a reduced frequency of bowel movements, can Additional symptoms include anorexia, a lack of appetite that
include passing hard stools, straining to pass a stool, or im- progresses to the inability to eat, and cachexia, which is a
paction (hard stool that is blocked). Constipation may be ac- general state of malnutrition in which there is loss of fat, mus-
companied by pain, abdominal fullness, and reduced bowel cle, and bone mineral content. People with cachexia usually
sounds. In general, older adults are at increased risk for con- do not respond to increased intake or nutritional supplements
stipation because of medications, dietary patterns, and de- (Ferrell & Coyle, 2006). Even before the terminal illness,
creased physical activity. Factors that increase the risk for older adults often have less lean tissue, so there is less reserve
constipation at the end of life include pain medications and malnutrition can progress quickly. Factors that contribute
(discussed in Chapter 28), dehydration, kidney failure, ele- to anorexia and cachexia include nausea and vomiting, con-
vated calcium levels, and disease effects (e.g., ascites, spinal stipation, dehydration, weakness, depression, pain, oral can-
cord damage, colon or pelvic cancers). One study found that didiasis or dry mouth, gastritis, and medication side effects.
constipation was the most common and frustrating adverse
effect of opioids in patients near the end of life (Lentz & Symptoms During the Active Dying Process
McMillan, 2010). When it becomes apparent that a dying person has only a few
days to live, it is especially important that the nurse work
Dyspnea closely with the individual and his or her family to help them
Dyspnea is a sensation of shortness of breath or breathless- understand the dying process and anticipate changes. Guid-
ness. It has been described as a sensation of suffocation or ance about what to expect helps reduce fear and anxiety (Ogle
being smothered that can generate fear that death is occur- & Hopper, 2005). Characteristic physical signs indicate the
ring. A study of almost 6000 patients receiving hospice care “active dying” process. In most situations, the individual has
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TABLE 29- 1 Guide to Nursing Assessment and Interventions for Common Symptoms at the End of Life
Symptom Nursing Assessment Nursing Interventions Pharmacologic Interventions
Fatigue (asthenia) Assess for associated conditions, in- Inform older adult and family of the normality of Corticosteroids, although generally
cluding infection, fever, pain, depres- fatigue at end of life. contraindicated in older adults, may
sion, insomnia, anxiety, dehydration, Pace activities and care according to tolerance. decrease fatigue in patients with
hypoxia, medication effects. Exercise if tolerated. cancer.
Promote optimal sleep, with regular times of Treat associated conditions (e.g., with
rest, sleep, and waking. antibiotics, antidepressants).
Constipation Identify risks (e.g., chronic laxative Anticipate and prevent constipation with em- Individualize laxative regimen based on
users, medications). phasis on fiber, fluid intake, and activity, but the cause(s) of constipation, history,
Perform abdominal assessment, in- recognize that patients may have difficulty tol- and preferences. Use bulk-forming
cluding palpation for distention, erating the optimal interventions. Promote reg- and stool-softening agents for pa-
tenderness, or masses and ausculta- ular routine. tients with normal peristalsis.
tion of bowel sounds and pitch. Strongest propulsive contractions occur after A laxative regimen (with stimulant
Assess patients taking pain medica- breakfast; provide patient privacy at this time. laxative) may be ordered for patients
tions daily. taking a pain medication known to
Monitor the character of the bowel cause constipation.
movements. Stimulant laxatives are the most appro-
Check the rectum if the older adult has priate for opioid-induced constipation.
not had a bowel movement in more
than 3 days or is leaking liquid stool
(which can occur with an impaction).
Dyspnea Respiratory: Assess vital signs, includ- Pace activities and rest. Treat causes.
ing oxygen saturation, breathing pat- Provide oxygen, usually at 2–4 L per cannula Treat symptoms with morphine or
tern, and use of accessory muscles. (avoid using face mask because of discomfort hydromorphone, which relieves the
Auscultate breath sounds. and sensation of smothering). breathless sensation in almost all
Assess cough (type, if present). Provide calm reassurance. cases.
Check for tachypnea and cyanosis. Use a fan to circulate air and help reduce the Use antianxiety agents or antidepres-
General: Assess for restlessness, anxi- feeling of breathlessness. sants if appropriate (and if perception
ety, and activity tolerance. Position for optimal respiratory function (e.g., of breathlessness is exaggerated
leaning forward over a table with a pillow on because of anxiety or depression).
top is helpful for COPD; on the side with head Corticosteroids can be used for their
slightly elevated for unresponsive patient). anti-inflammatory effects in certain
Teach patient to use pursed-lip breathing, and conditions (e.g., COPD, radiation
encourage relaxation techniques to reduce pneumonitis).
muscle tightness and associated sensation of
breathlessness.
Nausea and Assess for potential cause (e.g., con- Offer frequent, small meals; serve foods cold or Medications need to be specific to the
vomiting stipation, bowel obstruction). at room temperature. cause:
Palpate abdomen and check for Apply damp, cool cloth to face when nauseated. ● Squashed stomach syndrome, gastri-

distention. Provide oral care after vomiting. tis, and functional bowel obstruction:
Assess vomitus for fecal odor. metoclopramide (contraindicated in
Assess heartburn and nausea, which full bowel obstruction)
may occur after meals in squashed ● Chemical causes, such as morphine,

stomach syndrome. hypercalcemia, or renal failure:

Assess pain (e.g., pain on swallowing haloperidol
may indicate oral thrush; pain on ● If caused by dysfunction of vomit-

standing may be caused by mesen- ing center (e.g., associated with

teric traction). mechanical bowel obstruction,
Hiccups occur with uremia. increased intracranial pressure,
motion sickness): meclizine or
diphenhydramine
Dehydration Assess for clinical signs of hydration Encourage fluids as tolerated; offer ice chips and Give intravenous fluids or administer
(e.g., skin turgor over the upper popsicles if swallowing. clysis per advance directives.
chest or forehead). Provide frequent oral care; use swabs or mois- Discuss continued diuretic use with
Assess buccal membranes for moist- tened toothettes. physician.
ness.
Assess vital signs: pulse, orthostatic
blood pressure.
Anorexia and Assess for weight loss. Remove unpleasant odors. Medications that are used to stimulate
cachexia Assess for levels of weakness and Provide frequent oral care. appetite, promote weight gain, and
fatigue. Treat pain optimally. provide a sense of well-being: mege-
Conduct physical examination for Provide frequent, small meals. strol acetate, corticosteroids, and
decreased fat, muscle wasting, Provide companionship. mirtazapine.
decreased strength. Serve meals in a place that is separate from the Metoclopramide is used to improve
Assess mental status, including bed area. gastric motility and appetite.
depression. Involve patient with meal planning.
Collaborate with dietician for nutritional analysis
and meal planning.
Encourage culturally appropriate foods.
Consider using an alcoholic beverage before meals.

COPD, chronic obstructive pulmonary disease.

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Caring for Older Adults at the End of Life CHAPTER 29 585

become totally dependent on others for all aspects of care, with friends are also difficult for those being left behind. Nurses
less wakeful or alert time. Levels of consciousness may change can offer and coordinate grief support through the hospice or
or fluctuate. The person has little or no interest in the oral intake palliative care team, or through chaplains or other meaningful
of food or fluids. Physiologic changes occur in breathing pat- religious and spiritual resources.
terns, circulation slows down, sensory awareness decreases,
and muscle weakness occurs as a result of decreased tone. In
addition to these physiologic manifestations, up to 85% of pa-
tients experience delirium during the last weeks of life, with
agitation being a common manifestation (Clary & Lawson,
P art I: Mr. Bauer is a 91-year-old man with medical
diagnoses including hypertension, type 2 diabetes mellitus,
2009). Table 29-2 summarizes some signs and symptoms that
occur within days of death. Nurses should describe plans for history of cerebrovascular accident, and benign prostatic hy-
care to give reassurance that comfort needs will be met. The perplasia. He was taking the following medications, lisinopril
overall focus of nursing care at this point is to continue to pro- (Prinivil), 20 mg daily; aspirin, 81 mg daily; furosemide (Lasix),
mote physiologic and psychological comfort, while assisting 40 mg daily; potassium, 20 mEq daily; and acetaminophen
the older adult in achieving a peaceful, dignified death. The (Tylenol) as needed for arthritis pain. He has lived at home
Dying Person’s Bill of Rights (Box 29-2) continues to provide by himself for the last 15 years since the death of his wife.
guidance for care in the final hours of life. He has three adult children, all living out of state, who visit
When death does not occur suddenly, the older adult may on average once monthly. He is very well known in his
have opportunities for final closure. Reminiscence and life neighborhood as the older man who helps everyone. He
review can promote self-actualization during this time. Par- loves his home and spends his days “keeping house.” His fa-
ticipation in decisions concerning the person’s death, as well
vorite chores include mowing the grass in the summer and
as those concerning the continuation of life for loved ones,
blowing the snow in the winter. He owns and drives a car
can assist in bringing inner peace. Older adults often reach a
point of readiness and anticipation of death, and they may to the local supermarket and barber and to the cemetery to
communicate that they are ready to make the transition from visit his wife’s grave. In late summer, he had an accident with
life to death. Nurses can use therapeutic communication tech- his lawn mower that drew his family’s attention to the fact
niques to acknowledge their expressions in a genuine and that he was losing his strength. While mowing his grass, he
supportive manner. Final good-byes to family members and fell over the lawn mower, scraping his face on the cement.
He required emergency department (ED) evaluation and
treatment, including stitches for facial lacerations. He later
TABLE 29- 2 Signs and Symptoms of Death Within Days admitted that, before his fall, he had been experiencing
Physiologic Change Signs and Symptoms dizziness, especially when getting out of his easy chair.
Three weeks after his ED evaluation, Mr. Bauer’s daughter
Altered breathing patterns ● Breathing initially becomes more
shallow
came to visit. She was shocked to see her father looking so
● Cheyne-Stokes respirations “thin and gaunt.” Mr. Bauer admitted that he had lost a few
● Noisy breathing (death rattle) pounds over the summer and still didn’t have much energy.
Changing circulation ● Limbs, ears, and nose become cold to He stated that he wasn’t sleeping well at night, with his sleep
touch or mottled in appearance
disrupted every 30 to 45 minutes because of the need to uri-
● Decreased blood pressure
● Pulse may weaken and become irregular nate. To control his urination, he had decided to limit his
● Diaphoresis drinking fluids to less than 8 oz daily. Mr. Bauer’s daughter
● Possible increase in dependent edema
● No urine output or small amount of
noticed that in spite of his weight loss, his abdomen was very
very dark urine (anuria or oliguria) large and distended. “Do you have any aches?” she asked her
Decreased muscle tone ● Relaxed facial muscles, lower jaw father. He nodded yes and grabbed his lower abdomen.
drops, mouth open
● Decreased/loss of gag reflex
● Difficulty swallowing
T H I N K I N G P O I N T S
● Abdominal distention due to ● Based on symptoms and history, what points would you
decreased gastrointestinal activity
● Possible urinary and fecal incontinence address in your nursing assessment?
due to relaxation of sphincter muscles ● What nursing problems would you address in
Decreased senses ● Reduced level of consciousness Mr. Bauer’s nursing care plan?
● Blurred or distorted vision ● What are some probable causes of Mr. Bauer’s abdom-
● Decreased taste and smell (probable inal discomfort?
continued sense of hearing) ● What would the appropriate nursing interventions be?
Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to
● What health teaching would you provide?
compassionate care. Philadelphia, PA: Lippincott Williams & Wilkins.
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586 PA RT 5 Promoting Wellness in All Stages of Health and Illness

● For each diagnosis, list two to three nursing interven-

P art II: Mr. Bauer and his daughter have a follow-up tions.
office visit with his primary care physician. On arrival, his Mr. Bauer died in the hospital 1 week after his fall, on the
vital signs are as follows: temperature, 98⬚ PO; apical pulse, day he was scheduled for discharge.
82 beats per minute and irregularly irregular; respirations,
24 per minute; and blood pressure sitting, 98/50. When
standing to walk to the scale for his weight measurement,
he swayed a bit, grabbed the wall, and then steadied him-
self. “I just got a little dizzy,” he admitted. As the office nurse, Chapter Highlights
you immediately grabbed the blood pressure cuff and
End-of-Life Transitions
took his blood pressure in the standing position. It was
• The end of life is the period in which there is little likeli-
70/40. Mr. Bauer’s pulse at that time was 90 and irregular. hood of cure, and comfort is the primary goal.
Noting the vital sign changes, the physician ordered some
laboratory tests. Blood samples for testing were drawn in Cultural and Historical Perspectives on Death and Dying
the office. With results pending, no changes were made in • There is a gradual trend toward dying at home, which is
where most people say they want to die, and where most
his medical care at that time.
people did die during the early part of the 20th century.
• American society is moving beyond the culture of denial
of death and finding ways to address death as an integral
T H I N K I N G P O I N T S
part of life (Box 29-1).
● What are your immediate nursing concerns for • Cultural factors significantly affect attitudes toward death
Mr. Bauer based on information about his decline dur- and dying (Cultural Considerations Box 29-1).
ing the past 6 months?
Quality of Care at the End of Life
● What risk factors are likely to be contributing to
• Nurses and other health care professionals have strong
Mr. Bauer’s dizziness?
roles in supporting death with dignity (Box 29-2).
● What patient teaching is indicated at this time?
• Hospice is a philosophy of care whose goal is to support
dignified dying and a good death experience for people
who are terminally ill.

P art III: Mr. Bauer’s blood test results come back the
Nursing Interventions in End-of-Life Care
• Nurses use many interventions, including verbal and non-
next day, confirming dehydration and malnutrition: verbal communication (Boxes 29-3 and 29-4), to address
● Sodium: 150
the complex needs of patients who are dying and their
● Potassium: 3.7
families.
● Serum albumin: 3.0
• Nurses assess and address common symptoms that occur
● Prealbumin: 14 during the end of life, including fatigue, constipation, dys-
● Blood urea nitrogen: 35 pnea, nausea and vomiting, dehydration, and anorexia
● Serum creatinine: 1.7 (Table 29-1).
• Nurses holistically address needs of patients and families
The physician discontinued Mr. Bauer’s furosemide and
during the immediate end-of-life process (Table 29-2).
lisinopril and suggested a follow-up visit in 2 weeks. Two
days before his next appointment, Mr. Bauer’s daughter Critical Thinking Exercises
called the office to relay that her father had fallen and was
taken to the hospital for evaluation. A workup revealed that 1. Review the section on Health Care Professionals’ Perspec-
he had a transient ischemic attack and was now too weak tive on Death and Dying and spend a few minutes answer-
ing the questions for self-reflection.
to eat and he was experiencing difficulty swallowing. The
2. Review Cultural Considerations 29-1 and think about how
family declined a feeding tube and a hospice referral was
each of the points listed applies to your personal perspec-
made. tives on death and dying.
3. From a nursing perspective, identify the ways in which
caring for patients at the end of life differs from caring for
T H I N K I N G P O I N T S
patients with acute care needs.
● Identify two priority nursing diagnoses appropriate for 4. From a nursing perspective, identify the ways in which
Mr. Bauer at this time. caring for patients at the end of life differs from caring for
patients who have chronic illnesses.
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Caring for Older Adults at the End of Life CHAPTER 29 587

Resources Hospice and Palliative Nurses Association (HPNA). (2008, October). Posi-
tion statement: Value of the professional nurse in palliative care.
For links to these resources and additional helpful Internet Retrieved from www.hpna.org.
resources related to this chapter, visit at http://thePoint. Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.
lww.com/Miller6e. Lentz, J., & McMillan, S. C. (2010). The impact of opioid-induced consti-
pation on patients near the end of life. Journal of Hospice and Pallia-
Clinical Tools tive Nursing, 12(1), 29–38.
Center to Advance Palliative Care Markson, E. (2003). Social gerontology today. Los Angeles, CA:
Promoting Excellence in End-of-Life Care Roxbury.
TIME: Toolkit of Instruments for Measuring End-of-life Care McSteen, K., & Peden-McAlpine, C. (2006). The role of the nurse as ad-
vocate in ethically difficult care situations with dying patients. Journal
Evidence-Based Practice of Hospice and Palliative Nursing, 8, 259–269.
Menec, V. H., Nowicki, S., Blandford, A., & Veselyuk, D. (2009). Hospi-
National Guideline Clearinghouse
talizations at the end of life among long-term care residents. Journal of
• End-of-life care Gerontology: Medical Sciences, 64A, 395–402.
• Quality palliative care Munn, J. C., Dobbs, D., Meier, A., Williamsn, C. S., Biola, H., & Zimmer-
• Interventions to improve palliative care of pain, dyspnea, and man, S. (2008). The end-of-life experience in long-term care: Five
depression at the end of life
themes identified from focus groups with residents, family members,
• Family preparedness and end-of-life support before death of and staff. The Gerontologist, 48, 485–494.
a nursing home resident
Murray, R. P. (2010). Spiritual care beliefs and practices of special care
and oncology RNs at patients’ end of life. Journal of Hospice and Pal-
Health Education
liative Care, 12, 51–58.
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