2. • Ethics is the attempt to identify norms
or standards of right or good
behaviour. The ethical practices that
govern modern oncology nursing are
non-malfeasance, beneficence,
respect each person as a person and
respect individual autonomy, treat
people as they have a right to be
treated and treated people fairly (i.e.
principles of distributive justice).

3. • INTRODUCTION
Providing excellent care for a dying
patient is something all patients deserve.
It is important to remember that most
patients want to prepare for death, if at
all possible. Everyone does this his or
her own way, but oftentimes concern
about pain and symptom management
interferes with this very involved and
valuable process.

4. • End-of-life (EOL) care is defined as
an active, compassionate approach
that treats, comforts, and supports
persons who are living with, or dying
from progressive or chronic life
threatening conditions (Ross, 2000).

5. • The need for improvement in communication
with patients and family, and the need of more
education and support in nursing are
important issues in providing EOL care.
Nursing practice, education, and research
must embrace and respond to these changing
demographics, and nurses must focus on
spiritual-psychosocial health as well as the
physical health of the population (Heller,
2001).

6. • Undergraduate education provides the
foundation for nursing care, including EOL
care. Educational programs should focus on
addressing the problem of stable
misinformation.
• In addition, education should offer didactic
information and role modelling to skilfully
incorporate EOL care planning into clinical
practice.
• Health care providers are much better at
saving lives than helping patients know
when life is at its end.

7. • Research results indicate that nurses most
often selected discussion of the dying
process with patients and their families as
the number one core competency about
which they would like to have had more
education (White, 2001).
• Satisfaction at the end of life has been
positively correlated with EOL care, where
emphasis is placed on palliation.

8. • Stable misinformation is another inadequacy
identified which can be particularly resilient
to educational strategies because people
are unaware of their knowledge deficit and
therefore do not seek accurate information.
Continued efforts should be made to define
and improve communication techniques in
professional and continuing educational
programs.

9. • Oncology is the stream which deals with
care of the cancer clients. As medical
knowledge and technology increase, so
do options for healthcare. When
decisions arise concerning the treatment
of dying patients, these options present
complex ethical dilemmas. Oncology
nursing practitioners should be aware of
the present scenario of oncology
patients.

10. • Lack of access to Hospice Care
• Lack of palliative care facilities
• Advance Directives
• Medical power of attorney or
durable power of attorney

11. • Resuscitation
• Mechanical ventilation use
• Nutrition and Hydration

12. Medical Futility
• Medically futile treatments are those
that are highly unlikely to benefit a
patient. Ethical decisions to forgo or
withdraw life-sustaining treatments
are accompanied by an assessment
that such treatments would be
medically futile.

13. Terminal Sedation
• For some dying patients, profound
pain that occur when dying may not
be relievable by any means other
than terminal sedation. This uses
sedatives to make a patient
unconscious until death occurs from
the underlying illness.

14. Euthanasia
• Euthanasia is an act where a third party,
usually implied to be a physician,
terminates the life of a person—either
passively or actively. The modern concept
of euthanasia is based on the fact that
patients alive who are living in a situation
that they consider to be worse than death,
are in a coma or are in a persistent
vegetative state (PVS) can be relieved
from their pain and misery.

15. Physician Assisted Suicide
• With physician assisted suicide, a doctor
provides a patient with a prescription for
drugs that a patient could use to end his or
her life. The main distinction between
physician assisted suicide and active
euthanasia is that the doctor is not the
person physically administering the drugs.

16. • Good communication at the end of life is vital
to good healthcare. If communication breaks
down, mistrust and conflict can arise,
resulting in inappropriate or unwanted
treatment.

17. • Nurse needs look at both the ethical
and moral issues; to weigh the
burdens and benefits of particular
treatments and take into
consideration the clients values and
preferences

18. • Extra ordinary versus ordinary
• Withholding versus withdrawing
Forgoing life sustaining therapies
include withholding and withdrawing
• Foreseen versus intended
It is known as the principle of double
effect. Treatments have multiple
possible consequences (some good
and some bad) may still be justified.

19. Active versus passive
• It is used to distinguish between
actions that are not justified in leading
to a client’s death (boluses of
potassium) and omissions
(sometimes reffered to as ―allowing to
die‖) that are justified.

20. • Spiritual-Psychosocial Health
Areas of spiritual-psychosocial health of
dying patients have been identified as
weaknesses among nurses in their
fundamental education.

21. • Examination of focus areas identified
for improvement in spiritual-
psychosocial includes: anxiety,
delirium, depression, and
communication.

22. • Anxiety is common in the dying, as patients
face their fears and concerns about their
impending death. However, anxiety is not a
normal, inevitable consequence of dying and
should be managed aggressively. Risk
factors for anxiety include organic mental
disorders, concurrent life events or social
difficulties, lack of support and
understanding from one's family and friends,
and apprehension and worry.

23. • Delirium is a state of decreased cognitive
abilities. It usually has a quick onset and is
considered to be a potentially reversible
process. Changes in patients sleep and
wake cycle occur with fluctuating levels of
consciousness.

24. • Sadness is common in patients with life-
threatening disease. It is a myth that
feeling helpless, hopeless, and depressed
is inevitable. Sadness usually responds to
supportive interventions.

25. • There is evidence that communication with
the dying and their families is less than
optimal, and that few nurses receive
adequate training in appropriate
communication skills. It has been
concluded that nurses may neglect their
communication with patients who are very
ill, tending to rely instead on families to
communicate with the dying. (Ross, 2000).

26. • Healthcare professionals’ inadequate
knowledge of physical health including:
pain management, symptom control, and
other dimensions of terminal-illness care
have been cited as a key barrier to good
EOL care.

28. • Educate client and family
• Refer client to an appropriate resource
for imitating a living will or medical
power of attorney
• Ensure that the health care team is
aware of the existence and content of
the living will or medical power of
attorney

29. • Respect the cultural values of the dying
client and family members
• Promote independent decision making
through treatment by encouraging clients
and family members to communicate
openly with the health care team
• Ensure a clear understanding between
family members, client and physician
regarding DNR orders
• Refer client and family members to resort
to spiritual care

30. • Many healthcare professionals can be
involved in providing end of life care,
depending on the needs.
• Hospital doctors and nurses, general
practitioners, community nurses, hospice
staff and counsellors might all be involved,
as well as social services, religious
ministers, physiotherapists or
complementary therapists.

31. • When end of life care begins depends on
the client’s needs.
• The General Medical Council considers
that patients are approaching the end of
life when they are likely to die within the
next 12 months. This includes patients who
are expected to die within the next few
hours or days, and those with advanced
incurable conditions.

32. According to National Cancer Institute end of
life care is :
• When a patient's health care team
determines that the cancer can no longer
be controlled, medical testing and cancer
treatment often stop. But the patient's care
continues. The care focuses on making the
patient comfortable.

33. • Either way, services are available to help
patients and their families with the medical,
psychological, and spiritual issues
surrounding dying. A hospice often
provides such services. The time at the end
of life is different for each person.
• Each individual has unique needs for
information and support. The patient's and
family's questions and concerns about the
end of life should be discussed with the
health care team as they arise.

34. Definition
• Grief: Deep mental and emotional
anguish that is the response to the
subjective experience of loss of
something significant. Or Grief is a
multi-faceted response to loss,
particularly to the loss of someone or
something to which a bond was formed.

35. • Disease related and treatment related: It
includes poor diagnosis of cancer, poor
prognosis, uncertain outcome, likelihood of
reoccurrence. It arises due to changed body
structures and functions
• Situational and social: e.g. loss of the dear
one, breach of the relationship
• Developmental: loss of desires, dreams,
autonomy etc

36. Anticipatory Grief
• Anticipatory grief occurs when a death
is expected, but before it happens. It
may be felt by the families of people
who are dying and by the person
dying. Anticipatory grief helps family
members get ready emotionally for
the loss.

37. –Normal or common grief begins
soon after a loss and symptoms go
away over time.
• During normal grief, the bereaved
person moves toward accepting the
loss and is able to continue normal
day-to-day life even though it is hard
to do.

38. • There is no right or wrong way to grieve,
but studies have shown that there are
patterns of grief that are different from the
most common. This has been called
complicated grief.

39. • New grief stages. These are the three
phases of the New Grief Stages:
• SHOCK
• SUFFERING
• RECOVERY

40. • Individual or family psychotherapy
• Spirtiual counselling
• Pharmacological management of symptoms-
anoxiolytics, antidepressant, sedatives
• Complementary therapy- homeopathic
therapy
• Behavioural and cognitive interventions-
support groupa and relaxion techniques
• Occupational and recreational therapy

41. • After a person dies, the family, loved
ones, and friends will experience grief
and bereavement. For some people,
viewing the body helps grieving and
acceptance.

42. • Medical professionals can facilitate this
by arranging a private and pleasant
environment. Some believe that the
medical profession has a duty to
acknowledge the surviving family
members after a patient’s death and
that this obligation has a potential to be
rewarding.

43. • This respect for people’s individuality in
grieving and in their decision making
reflects the fundamental ethical principle of
autonomy.
• Living will and durable power of attorney
• Euthanasia
• The Price of Life-Sustaining Care

44. Definition
• Bereavement is the period after a loss
during which grief is experienced and
mourning occurs. The time spent in a
period of bereavement depends on
how attached the person was to the
person who died, and how much time
was spent anticipating the loss

45. – Bereavement is the period of sadness after
losing a loved one through death.
– Grief and mourning occur during the period of
bereavement. Grief and mourning are closely
related. Mourning is the way we show grief in
public. The way people mourn is affected by
beliefs, religious practices, and cultural
customs. People who are grieving are
sometimes described as bereaved.

46. • Shock and numbness
• Yearning and searching
• Disorganization and despair
• Reorganization

47. • Bereavement care is part of a
comprehensive palliative / hospice care
programme.
• Bereavement is a human experience
occurring with the death of a loved

48. Nursing Diagnosis
Dysfunctional grieving.
Goal:
• Family completes the tasks of
bereavement.

49. Nursing Assessment
• Assess family for risk factors associated
with unresolved grief.
• Evaluate family members for
manifestations of grief.
• Assess social support available to family

50. • The care of the dying client and his family is
a process in which the nurse provides
supportive care to the patient and family. The
main goals that affect the care of the dying
are:
– Relieve the dying person's pain
– Keep the patient comfortable
– help the patient to a peaceful death

51. • Care after death
• Comfort the family and let them
grieve.

52. • When cure is no longer possible, dying
people primarily need good nursing care.
Nurses witness firsthand the plight of
patients throughout the dying process and
are able to recognize and appreciate their
complex needs.

53. Specifically, nurses can contribute to
fundamental reform of systems to provide
end-of-life care by:
• Developing creative partnerships with
patients, health care professionals, policy
makers, and others to make care of the
dying a priority.
• Documenting the comprehensive needs of
dying patients and families and identifying
individual, professional, organizational, and
societal barriers to quality end-of-life care.

54. • Participating as members of
interdisciplinary groups within specialty
areas, institutions, or communities to
devise specific solutions to address
barriers and develop standards for quality
end-of-life care
• Advocating for systems of accountability
for comprehensive and holistic end-of-life
care that includes professional guidelines,
protocols, and standards to meet the
needs of the dying

55. • Participating in the development of
interdisciplinary pre-service and inservice
curriculums that provide students and
practitioners with the tools and skills
necessary to provide optimal end-of-life
care.
• Collaborating with patients and potential
patients to promote public and professional
understanding of the realities that surround
end-of-life care.

56. ASSESSMENT - WHERE AM I
(NURSE) ON THE JOURNEY:
• In order to be an effective Care giver to the
dying patient and the significant others,
nurses must come to terms and their own
mortality and views on dying and death.
Death is inevitable.

57. • Nurses are encouraged to maintain
composure when caring for patients.
However professionalism for the nurses
with this context does not require that the
nurse deny emotional engagement with the
patient and significant are the others
during the dying process and bereavement
period.

58. • Physical
• Psychological
• Shortness of breath
• Depression
• Insomnia
• loneliness
• Loss of appetite
• Anger and hastines
• Fear of God

59. • Personal Experiences with death and dying
influences how nurses give care to those
who are dying and their significant others.
E.g. examining nurses personal
experiences can help nurses understand
their own fears and anxieties related to
dying and death. Understanding the
meaning and significance of relationship
helps put the loss in perspective.

60. • The nurse’s ability to articulate feelings
regarding a good or a bad death is
important while working with individuals
who are dying. Exploring individuals
valued and biases can enhance the
nurse’s competence; this helps the nurse
to better understand the individual’s health
care attitudes and behaviour. (Warren
1999)