The document discusses various aspects of end-of-life care including communicating bad news, managing symptoms, providing comfort, and ensuring a peaceful death. It notes that less than 10% of people die suddenly while 90% experience a prolonged illness. It provides steps for communicating bad news to patients and families, describes approaches to managing common physical and psychological symptoms experienced by dying patients, and emphasizes the nurse's role in coordinating care and advocating for a dignified death without unnecessary suffering.

1. By
Sheila Marie P. Oconer, RN,
MAN

3. REALITY TELLS US THAT
EVERY PERSON WILL DIE
LESS THAN 10% WILL DIE
SUDDENLY AND 90% WILL
DIE AFTER PROLONGED
ILLNESS

4. Experiences throughout lifetime defines the
way he or she wishes the end of own life
Family, culture, life events influences a
person choices facing life and death come
sooner rather than later
Anthropologist Margaret Mead says,
“When a person is born we rejoice, and
when they get married we jubilate, but
when they die we pretend nothing
happens”.

5. Talking about death and dying is often
difficult for nurses and patients, if
nurses does not want to talk about it
there is no discussion, and death
become the "elephant in the room”---
something unavoidable and taboo.
Communicating bad news is an
essential skills for the physician, nurses
and interdisciplinary team members
who interacts with the patient and
families

6. 6 Steps to communicating Bad News
1. Get started
-plan what to say based on medical facts, create
conducive environment, determine who are others
persons present, and allocate ample time.
2. Find out what the patient knows
-assess his or her ability to comprehend bad news
3. Find out what the patient wants to know
-recognize and support patient’s preference to
decline information and designate someone else to
communicate in his/her behalf, consider cultural,
religious, and socioeconomic influences

7. 4. Share information
-say it then stop. Pause frequently, check for
understanding and use silence and body
language, avoid vagueness, jargon and
euphemism
5. Respond to feelings
- expect affective, cognitive and fight-flight
responses., be prepared for strong emotions and
a broad range of reactions. Give time to react,
listen and encourage description of feelings. Use
nonverbal communication of touch and eye
contact

8. 6. Plan/follow up
-provide additional test, symptom treatment,
and referrals as needed, discuss potential
sources of support, assess safety of the
patient and home supports before he/she
leaves . Repeat the news at future visits.

9.  Advance directives Help individual identify their
personal wishes in a legal manner and to share
that information with the people around them,
including medical personnel.
 Durable power of attorney, living will declaration,
appointment of health care representative, DNR
and life prolonging procedures declaration are all
legally recognized documents for indicating one’s
health care wishes
 Five Wishes (towey,2005) and Allow Natural Death
(AND) are 2 more recent options for stating end-
of-life care wishes.

11. CURATIVE/ACUTE CURE
 Life-prolonging and acute care options focus on cure
HOSPICE CARE
 Nonlife prolonging care, provide comfort and dignity at
end of life.
PALLIATIVE CARE
 Refers to comprehensive management of physical,
psychological, social, spiritual and existential needs of
the patient.
 Care of people with incurable and progressive illnesses
 Achieve the best quality of life, control of pain, and other
symptoms

13. Nurse’s primary
responsibilities is to
coordinate patient’s
care and to assist
with Symptom
Management or
Focus on treating
Symptom

14. Physical Non pain
symptoms
Respiratory – difficulty of
breathing, excess secretions,
anxiety
Gastrointestinal –
constipation, nausea/vomiting

15.  Anxiety and Delirium
Anxiety at end of life – loss of control, loss of self
esteem, loss of independence
 treating physical symptoms of pain and SOB, anti-
anxiety meds
Delirium – fluctuating cognitive disturbance, changes in
mental status, occurs in the last hours to days of most
dying patients
 environmental comfort by reducing stimuli,
reorientation, familiar person at bedside, health team
members providing emotional, social and spiritual
support, music therapy, therapeutic/healing touch,
nonmedical nursing interventions, anti-anxiety meds
given cautiously

16.  NUTRITION AND HYDRATION
Declining appetite for Dying persons,
less active body requires less
nourishment
Hydration is detrimental to fluid
overload
 Give bites rather than regular portions,
foods in variety
 Provide small amounts of fluid like
popsicles or ice chips, meticulous
 mouth care for dry mouth

17.  PHYSICAL, PAIN SYMPTOMS
“We all must die. But if I can save him from
days of torture, that is what I feel is my great
and ever new privilege. Pain is more terrible
Lord of mankind than even death itself”
Albert Schweitzer

18. Unrelieved pain can contribute to unnecessary suffering,
evidenced by sleep disturbance, hopelessness, loss of
control and impaired social interactions
Pain may hasten death by increasing physiological stress,
decreasing mobility, contributing to pneumonia and
thromboemboli
 Nurse must be able to assess pain, assist patient in
describing their pain, use Wong-Baker Pain Rating scale
 Treatment of pain based on origins and systematic
approach (pain meds and adjuvant)
 Pain meds remain the 1st line of tx
 Opiods are used if nonopiods ineffective
 Understanding between addiction and tolerance,
physical dependence

19. Physiological Type of Pain
 Nociceptive
- Somatic
Tissue injury
Skeletal system, soft tissue, joints, skin or connective tissue
Localized pain can be point by finger
Describe as throbbing, dull, aching, gnawing in nature
Treated with NSAIDs, steroids partially responsive to opiod
therapy or combinations
- Visceral
Activation of nociceptors
Internal organs
Unable to localize, may use open hand to show affected
area,pain is diffuse
Deep, aching, cramping or sensation of pressure
Very responsive to opiod therapy
Example is shoulder pain secondary to lung or liver metatases

20.  Neuropathic
-injury to peripheral nerve or CNS
Shooting, stabbing, burning, shock-like
Constant or intermittent
Less responsive to opiods, responds best to
anticonvulsants, tricyclic antidepressants
Ex. Herpes zoster or diabetic neuropathy

21. LOSS AND GRIEF
 Primary Losses
Loss of people close to them –
spouses, children, parents, siblings
 Secondary Losses
Are those resulting from the primary Loss-
companionship, roles the deceased assume
in relationship and independence

22. Grief – is the natural and normal loss of any kind
and is experienced psychologically, behaviorally,
socially and physically. It involves changes over
time
Mourning- is the cultural and/or public display of
grief through one’s behaviors. These include
accepting the reality of loss, reacting to separation,
and finding ways to channel reactions, handling
the unfinished business, and transferring the
attachment to the deceased from physical
presence to symbolic interaction.

23. COMPONENTS OF PEACEFUL DYING
“The key to peaceful dying is achieving the components
of peaceful living during the time you have left”
(Preston, 2000)
 Instilling good memories
 Uniting with family and medical staff
 Avoiding suffering, with relief of pain and other
symptoms
 Maintaining alertness, control, privacy, dignity and
support
 Becoming spiritually ready
 Saying goodbye
 Dying quietly

24. GOOD DEATH
 Is possible and can be facilitated by
the nurse who advocates for and
works to ensure that the patients,
families, and caregivers are free from
avoidable distress and suffering, that
the process is in accord with the wishes
of the patient, family, and that is
consistent with clinical, cultural, and
ethical standards.

25. POSTMORTEM CARE
Pronouncing Death
 Pronouncing the death of the person varies from state to
state and institution to institution, nurses may pronounce the
death, in some may not be allowed
 Policies differ and individual institutional polices are
followed
In pronouncing death, it is customary to identify the patient
and note the following;
 General appearance of the body
 Lack of reaction to verbal or tactile stimulation
 Lack of pupillary light reflex (pupils fixed and dilated)
 Absent breathing and lung sounds
 Absent carotid and apical pulses (listening for apical pulse is
full minute)

26. PHYSICAL CARE OF THE BODY
 IS AN IMPORTANT NURSING FUNCTION
 Careful and gentle handling of the body communicates
care and concern on the part of the nurse
 Rituals and customs should have been identified before
the death, to be incorporated into the care, reflecting
the patient/family wishes
 Nursing care also includes removal of drains, tubes, IVs
and other devices

27. The Nurse’s gratification does not come from caring, but
rather from supporting the patient in a peaceful and
dignified “ good death”.