Caring for a dying patient is a complex role for a nurse. Some nurses are better prepared for this role, others are not. In order to effectively care for this type of patient, nurses need to shift from saving life to preparing for death.
Helping the Patient Transition
It is important for nurses to recognize the symptoms of the terminal phase of life so that they can alter their care. These symptoms include an increase in pulse just before death, withdrawal and increased secretions. These increased secretions along with relaxations of the tongue and tissues of the soft palate cause what is known as the death rattle. Increasing unresponsiveness and decreasing urinary output are also impending signs of death. Many of these symptoms may be ways in which the body conserves energy for the last moments of life.1
In order to help the patient transition, nurses might want to abandon routine practices and diagnoses. For example, forcing fluids or using nutritional supplements are interventions that may not be a priority in terminally ill patients. It may be more appropriate to provide the patients with a quiet atmosphere and less environmental stimuli.1 Turning the patient every one or two hours, taking vital signs regularly, and complete bed baths in the last days of life may only distress the patient and family in their last moments together.
When caring for dying patients, it is more important to have strong assessment skills in order to know what is more appropriate for the patient. Death is very individualistic and what is helpful for one patient may not be for another. Understanding the patient's disease, learning about the patient's coping abilities, and communicating effectively regarding their wishes are essential to proper treatment.1
Terminally ill dehydration is a complex issue. Many health professionals feel that IV and nasogastric tube feedings are unnecessary. Others feel that keeping a patient hydrated is a basic care intervention that is as vital as any other life-sustaining treatment, such as mechanical ventilation or CPR. Nursing plays a vital role in deciding whether or not to hydrate a terminally ill patient.2 Studies have shown that medical hydration does not provide any less discomfort to the patient than dehydration does.
At this point in time, the issue comes down to the patient's and family's personal beliefs and wishes. Nurses fulfill the role of the patient advocate by being knowledgeable with regard to hydration research. They need to be able to adequately inform the patient about benefits and burdens of therapy and promote discussion.2
Care of a dying patient is riddled with ethical concerns. This is probably due to the intense emotions that death brings about as well as the widely varied opinions and values that people have. Pain management and the right to information both require much consideration in regard to the patient's serenity.
The important part for nurses to remember is that they need to separate their own ethical standards from those of the patient's.
Pain management is an important but difficult intervention for a nurse to administer. Nurses in the critical care setting are torn between preserving life and providing comfort care.3 This comfort care can sometimes hasten death even when that is not the intention. This draws a fine line between euthanasia and pain relief that is difficult to establish. Many nurses have a difficult time dealing with the mixed roles of caring for dying patients and tend to treat them as patients who will eventually get better.
Pain management interventions may place a nurse's career at risk as well.3 Many patients die with unnecessary suffering because of this risk. To provide some clarification to nurses on what is acceptable in terms of pain management, the American Nurses Association put out this statement in 1996:
"The American Nurses Association believes that the promotion of comfort and aggressive efforts to relieve pain and other symptoms in dying patients are obligations of the nurse, Nurses should not hesitate to use full and effective doses of pain medication for the proper management of pain in the dying patient. The increasing titration of medication to achieve adequate symptom control, even at the expense of life, thus hastening death secondarily, is ethically justified."
Even with this statement, it is still difficult for people to distinguish the ethically correct approach that a critical care nurse should take.
The Patient's Right to Information
One ethical issue that nurses face with the dying patients is how much information should be given to them. Some health professionals feel that complete information is not always helpful to the patient's serenity. Some healthcare professionals feel that if the patient was not mentally competent or not prepared to cope with such information that it is not useful to inform them of a terminal illness. Many patients did feel though, that complete honesty was much more helpful. They also feel that this communication was conducive to the patient-professional relationship.4
After reviewing these articles, several themes emerge. One important issue is the need for increased training concerning physical interventions of the dying. Communication skills also need to be addressed so that nurses can better communicate with family and patients.5 Establishing support groups for nurses who work with dying patients is another good tool to prevent burnout.
Another theme that is apparent is the need for the nurse to be a true patient advocate. In the terminal stages of life, patients cannot always communicate their wishes effectively. It is the role of the nurse to assess the patient and learn what is important to that patient. The nurse also needs to be willing to stand up to other members of the healthcare team to make sure that those wishes are honored.
The third key theme is the importance of education. Nurses need to be up to date and well-informed on laws, interventions, and medical information. Therapies, practices, and legal standards are constantly evolving. Nurses need to understand the new information so that they can give the most current options to patients and their families. Addressing these themes will enable the nurse to be more prepared for this intense role.
- Lindley-Davis, B. (1991). Process of Dying: Defining characteristics. Cancer Nursing, 14, 328-333.
- Jackonen, S. (1997). Dehydration and hydration in the terminally ill: Care considerations. Nursing Forum, 32(3), 5-13.
- LaDuke, S. D. (1998). Pain management at the end of life: A critical care perspective. Journal of the New York State Nurses Association, 29(2), 9-12. Retrieved April 2, 2002, from the EBSCOhost database.
- Osuna, E., Perez-Carceles, M. D., Esteban, M. A., & Luna, A. (1998). The right to information for the terminally ill patient. Journal of Medical Ethics, 24(2), 106-110. Retrieved April 2, 2002, from the EBSCOhost database.
- Plante, A., & Bouchard, L. (1995-1996). Occupational stress, burnout, and professional support in nurses working with dying patients. Omega, 32, 93-109.
Kati Richards is a student nurse at The University of Maine.