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END OF LIFE CARE:

1.INTRODUCTION:
Life and death is the two main stages In human beings life, where we
come across many challenges,diseases,and other problems .Olden days
persons with chronic diseases, terminal illness and dying is viewed as
taboo topics , due to which few new concepts developed for care of
person who is at their end stage, one those topics is end of life care. The
time at the end of life is different for each person. Each individual has
unique need for information and support. Knowledge about end of life
decision and principles of care is essential to support patient during
decision making and in end of life closure in ways that recognize their
unique response to illness to support their values and goals.
2.DEFINITION;
It’s the concluding phase of lifespan although life can end at
any stage.
3.GOALS;
 Provide comfort and supportive care.
 Improve the quality of remaining life.
 Help to ensure dignity of life.
4.TERMINOLOGY:
 Advance directives; Advanced care directives are specific
instructions, prepared in advance , intended to direct a persons
medical care in the event that he/ she is unable to do so in the
future.
 Bereavement ; Its an individuals response to the loss of a
significant person.
 Cheyne-stoke respiration; A striking form of breathing in
which there is a cyclical variation in the rate. This becomes slower
until breathing stops for several seconds before speeding up to a
peak and than slowing again.
 Death; Legal definition of death ,in most states, requires
‘irreversible cessation of all functions of the entire brain, including
the brain stem’’.
 Death rattle; Inability to cough or clear secretions results in
grunting .
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 Hospice; A special concept of care diagnosed to provide comfort

and support to patients and their families when a life- limiting
illness no longer to cure -oriented treatments.
 Palliative ; A medicine that gives temporary relief from the
symptoms of diseases but actually does not cure the disease.
 Durable power of attorney : A legal document that allows an
individual to appoint someone else ( proxy )to make medical or
health care decisions , in the event the individual becomes unable
to make and / or communicate such decisions personally.
 Medical power of attorney : it’s a term which describes a
document used for listening the person to make health care
decisions when the patient is unable to make decision for self.
 Directive to physician : A written document specifying the
patients wish to be allowed to die without heroic or extraordinary
measures .
Physical changes at end of life:
Sensory changes: its mainly due to decrease oxygenation and
circulatory changes
 Hearing & touch: decreased perception of pain, touch & sensation
 Taste & smell: Decreases with disease progression, blurring of
vision, blinking reflex absent.
 Integumentary system: cold, clammy skin. Wax like skin due to
loss of muscle tone, cyanosis on nose, nail beds, knees due to
decrease oxygenation and circulatory changes.
 Cardiovascular system: pulse rate increases and slows down
later& becomes weak, blood- pressure decreases, elevation in the
body temperature due to changes in hypothalamic function. And
delayed absorption of drugs.
 Respiratory system: increased respiratory rate, Cheyne stroke
respiration, death rattle irregular breathing.
 Urinary system: urinary output decreases due to loss of ability to
form urine, incontinence of urine & unable to urinate.
 Gastrointestinal system: slowing of digestive tract, accumulation
of gas due to decrease gastric motility and peristalsis which lead to
constipation,
 Musculoskeletal system: gradual loss of ability to move, difficulty
in speaking & swallowing, maintaining body posture, due to
weakening of muscular system because of metabolic changes.
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Psychological changes at the end of life:

 A variety of feelings and emotions affect the dying patient and
family at the end of life, most patients and family struggle with a
terminal diagnosis and the realization that there is no cure
 Grief: it is a emotional and behavioral changes to loss, it is a
positive coping mechanism which also helps in individual
wellbeing
Stages of grief “ DABDA’’
 Denial ‘D’
Denial is usually only a temporary defense for the individual. This feeling
is generally replaced with heightened awareness of situations and
individuals that will be left behind after death. Example “I feel fine.”;
“This can’t be happening, not to me.”
 Anger ‘A’
Once in the second stage, the individual recognizes that denial cannot
continue. Because of anger, the person is very difficult to care for due to
misplaced feelings of rage and envy. Any individual that symbolizes life
or energy is subject to projected resentment and jealousy.
Example “Why me? It’s not fair!”; “How can this happen to me?”; “Who
is to blame?”
 Bargaining ‘B’
The third stage involves the hope that the individual can somehow
postpone or delay death. Usually, the negotiation for an extended life is
made with a higher power In exchange for a reformed lifestyle.
Psychologically, the person is saying, “I understand I will die, but if I
could just have more time…” Example – “Just let me live to see my
children graduate.”; “I’ll do anything for a few more years.”; “I will give
my life savings if.

 Depression ‘D’
During the fourth stage, the dying person begins to understand the
certainty of death. Because of this, the individual may become silent,
refuse visitors and spend much of the time crying and grieving. This
process allows the dying person to disconnect themselves 460.from
things of love and affection. It is not recommended to attempt to cheer
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an individual up that is in this stage. It is an important time for grieving

that must be processed. Example “I’m so sad, why bother with
anything?”; “I’m going to die… What’s the point?”; “I miss my loved one,
why go on?”
 Acceptance ‘A’
This final stage comes with peace and understanding of the death that is
approaching. Generally, the person in the fifth stage will want to be left
alone. Additionally, feelings and physical pain may be non-existent. This
stage has also been described as the end of the dying struggle. Example –
“It’s going to be okay.”; “I can’t fight it, I may as well prepare for it.”
 Ethical legal and communication issues at End Of Life :
Assessing decision making capacity: the physician must assess the
patient’s decision making capacity before concluding that a given
individual cannot speak for himself or herself. An assessment of decision
making capacity can and should be performed by the primary physician:
determining decision capacity for a specific medical intervention
requires neither legal intervention nor psychiatric expertise. On the
other hand. Decisions about competence are judicial determinations that
involve ruling on the patient’s global decision making ability.
Competency determinations are necessary when evaluating the capacity
of a person to make non-medical decisions, such as financial matters.
Patients and families struggle with many decisions during the terminal
illness and dying experience. Many people decide that the outcomes
related to their care should be based on their own wishes. The decisions
may involve the choice for:
Legal documents used in End of Life Care :
 Advance directives: Advanced care directives are specific
instructions, prepared in advance, intended to direct a person’s
medical care in the event that he/she is unable to do so in the
future.
 Durable power of attorney: A legal document that allows an
individual to appoint someone else (proxy) to make medical or
health care decisions, in the event the individual becomes unable
to make and/or communicate such decisions personally.
 Medical power of attorney: it’s a term which describes a
document used for listing the person to make health care decisions
when the patient is unable to make decisions for self.
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 Directive to physicians: A written document specifying the

patients wish to be allowed to die without heroic or extraordinary
measures, Under this acts patient can tell the physician that what
treatment is or is not desired. Verbal directives are given to
physicians with specific instructions in the presence of two
witnesses in case if person is not able to communicate his wishes,
the family and physician will decide what to be and what not to be
done and the decision taken by the family should be recorded by
physician.
 Organ and tissue donation: persons who are legally competent
may choose organ donation. Any body part or the entire body may
be donated. The decisions to donate organs or to provide anatomic
gifts may be made by a person before death and family permission
must be obtained at time of donation. These peoples will have the
ID card given by agencies given by the agencies. The physicians
must be notified immediately when organ donation is intended
because some tissues must be used within hours after death.
Euthanasia:
Refers to the practice of ending a life in a painless manner. Many
different forms of euthanasia can be distinguished, including animal
euthanasia and human euthanasia, and within the latter, voluntary and
involuntary euthanasia. Voluntary cuthanasia and physician-assisted
suicide have been the focus of great controversy in recent years.
Euthanasia by consent: Euthanasia may be conducted with consent
(voluntary euthanasia) or without consent (involuntary euthanasia).
Involuntary euthanasia is conducted where an individual makes a
decision for another person incapable of doing so. The decision can be
made. Based on what the incapacitated individual would have wanted, or
it could be made on substituted judgment of what the decision maker
would want were he or she in the incapacitated person’s place, or finally,
the decision could be made by assessing objectively whether euthanasia.
Is the most beneficial course of treatment. In any case, euthanasia by
proxy consent is highly controversial, especially because multiple proxies
may claim the authority to decide for the patient and may or may not
have explicit consent from the patient to make that decision.
Euthanasia by means: Euthanasia may be conducted passively, non-
actively, and actively. Passive euthanasia entails the withholding of
common treatments (such as antibiotics, chemotherapy in cancer, or
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surgery) or the distribution of a medication (such as morphine) to relieve

pain, knowing that it may also result in death (principle of double effect).
Passive euthanasia is the most accepted form, and it is a common
practice in most hospitals. Non-active euthanasia entails the
withdrawing of life support and is more controversial. Active euthanasia
entails the use of lethal substances or forces to kill and is the most
controversial means. An individual may use a cuthanasia machine to
perform euthanasia on him/her.
Assisted suicide: Assisted suicide is a form of euthanasia where the
patient actively takes the last step in their death. The term “assisted
suicide” is contrasted with “active euthanasia” when. The difference
between providing the means and actively administering lethal medicine
is considered important. For example, Swiss law on assisted suicide
allows assisted suicide, while all forms of active euthanasia (like lethal
injection) remain prohibited.
Resuscitation: in recent days it’s the right of the patient and the family
to Decide whether resuscitation to be done. For every patient physician
order is compulsory for the use of CPR
Types of CPR decisions:
 Full code: which allows CPR drugs and mechanical ventilation?
 Chemical code: allows use of chemical drugs but no CPR.
 No code or DNR( Do Not Resuscitate): which allows the
person to die comfortably without interference of the technology.
Advanced directives, organ donor information and Dr. Orders should be
recorded in both medical and nursing record.
ASPECTS OF END OF LIFE CARE
I. HOSPICE
DEFINITION:
Hospice is a concept of care that provides compassion,
concern, and support for the dying.
It exists to provide support and care for the persons in last
phase of incurable disease so that they may lead their life
comfortably.
Hospice care can be given by trained professionals .
As a nurse it’s our responsibility to co-ordinate the team. Hospice nurse
work with hospice physicians, pharmacists, dietitians, social workers,
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and volunteers to provide care and support to patient and family

members,
Hospice is a philosophy of care. The hospice philosophy or
viewpoint accepts death as the final stage of life. The goal of hospice is to
enable patients to continue an alert, pain-free life and to manage other
symptoms so that their last days may be spent with dignity and quality,
surrounded by their loved ones. Hospice affirms life and does not hasten
or postpone death. Hospice care treats the person rather than the
disease; it focuses on quality rather than length of life. Hospice care is
family-centered care it involves the patient and the family in making
decisions. Care is provided for the patient and family 24 hours a day, 7
days a week. Hospice care can be given in the patient’s home, a hospital,
nursing home, or private hospice facility. Most hospice care in the
United States is given in the home, with a family member or members
serving as the main hands- on caregiver. Hospice care is meant for the
time when cancer treatment can no longer help you, and you are
expected to live 6 months or less. Hospice gives you palliative care,
which is treatment to help relieve disease-related symptoms, but not
cure the disease: its main purpose is to improve your quality of life. You,
your family, and your doctor decide together when hospice cares should
begin. One of the problems with hospice is that it is often not started
soon enough. Sometimes “the doctor, patient, or family member will
resist hospice because he or she thinks it “means you’re giving up, or that
there’s no hope. This is not true. If you get better or the “cancer goes into
remission, you can be taken out of the hospice program and go into
active cancer treatment. You can go back to hospice care at a later time,
if needed. The hope that hospice brings is the hope of a quality life,
making the best of each day during the last stages of advanced Illness.
Goals of Hospice care :
 To enable the patient to continue an alert.
 To provide pain free life .
 To provide symptomatic treatment .
 To give social emotional and spiritual support to the patients .
 To improve quality of life during the last stages of advanced illness.

Hospice care services:

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There are many things about hospice care that set it apart from other
types of health care. A team of professionals In most cases, an
interdisciplinary health care team manages hospice care. This means
that many interacting disciplines work together to care for the patient.
Doctors, nurses, social workers, counselors, home health aides, clergy,
therapists, and trained volunteers care for you. Each of these people
offers support based on their special areas. Of expertise. Together, they
then give you and your loved ones complete palliative care aimed at
relieving symptoms and giving social, emotional, and spiritual support.
 Pain and symptom control: The goal of pain and symptom
control is to help you be comfortable while allowing you to stay in
control of and enjoy your life. This means that side effects are
managed to make sure that you are as free of pain and symptoms
as possible, yet still alert enough to enjoy the people around you
and make important decisions. To learn more on this topic, please
see our document, Spiritual care
 Hospice care also tends to your spiritual needs. Since people differ
in their spiritual needs and religious beliefs, spiritual care is set up
to meet your specific needs. It may include helping you to look at
what death means to you, helping you say good-bye, or helping
with a certain religious ceremony.
 People may think that they are not forgiven by god for their
mistakes, as a nurse it’s our responsibility to assess their spiritual
needs and help them to meet their spiritual needs to improve the
harmony of the patient and family.
 Home care and inpatient care : Although hospice care can be
centered in the home, you may need to be admitted to a hospital,
extended-care facility, or a hospice inpatient facility. The hospice
can arrange for inpatient care and will stay involved in your care
and with your family. You can go back to in-home care when you
and your family are ready.
 Respite care: While you are in hospice, your family and
caregivers may need some time away.. Hospice service may offer
them a break through respite care, which is often offered in up to
5-day periods. During this time you will be cared for either in the
hospice facility or in beds that are set aside for this in nursing
homes or hospitals. Families can plan a mini-vacation, go to
special events, or simply get much- needed rest at home while you
are cared for in an inpatient setting.
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 Family conferences: Through regularly scheduled family

conferences, often led by the hospice nurse or social worker, family
members can stay informed about your condition and what to
expect. Family conferences also give you all a chance to share
feelings, talk about expectations, and learn about death and the
process of dying. Family members can find great support and
stress relief through family conferences. Conferences may also be
done informally on a daily basis as the nurse or nursing assistant
talks with you and your caregivers during their routine visits.
 Bereavement care: Bereavement is the time of mourning after a
loss. The hospice care team works with surviving loved ones to help
them through the grieving process. A trained volunteer, clergy
member, or Professional counsellor provides support to survivors
through visits, phone calls, and/or letter contact, as well as
through support groups. The hospice team can refer family
members and care- giving friends to other medical or professional
care if needed. Bereavement services are often provided for about a
year after the patient's death.
 Volunteers: Hospice volunteers play an important role in
planning and giving hospice care in the United States. Volunteers
may be health professionals or lay people who provide services that
range from hands-on care to working in the hospice office or
fundraising.
 Staffs support: Hospice care staff members are kind and caring.
They communicate well, are good listeners, and are interested in
working with families who are coping with a life-threatening
illness. They are usually specially trained in the unique issues
surrounding death and dying. Yet, because the work can be
emotionally draining, it is very important that support is available
to help the staff with their own grief and stress. Ongoing education
about the dying process is also an important part of staff support.
 Coordination of care: The interdisciplinary team coordinates
and supervises all care 7 days a week, 24 hours a day. This team is
responsible for making sure that all involved services share
information. This may include the inpatient facility, the home care
agency, the doctor, and other community professionals, such as
pharmacists, clergy, and funeral directors. You and your caregivers
are encouraged to contact your hospice team if you are having a
problem, any time of the day or night. There is always someone on
call to help you with whatever may arise. Hospice care assures you
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and your family that you are not alone and help can be reached at
any time.
Hospice care settings:
Hospice care is defined not only by the services and care provided, but
also by the setting in which these services are delivered. Hospice care
may be provided in your home or in a special facility. Most cancer
patients choose to get hospice care at home. In fact, more than 90% of
the hospice services provided in this country is based in patients’ homes.
Before making a decision about the type of program that is best for you
and your family, it is important to know all your options and what each
requires. Your doctor, hospital social worker, or discharge planner can
be very helpful in deciding which program is best for you and your
family.
Hospice care may be provided in home in a special facility . They are:
 Home hospice care.
 Hospital based hospices .
 Independently owned hospices.
Home hospice care: Many, if not all, of the home health agencies in
your community, as well as independently owned hospice programs, will
offer home hospice services. Although a nurse, doctor, and other
professionals staff the home hospice program, the primary caregiver is
the key team member. The primary caregiver is usually a family member
or friend who is responsible for around-the-clock supervision of the
patient. This person is with the patient most of the time and is trained by
the nurse to provide much of the hands-on care. It is important to know
that home hospice may require that someone be home with you at all
times. This may be a problem if you live alone, or if your partner or adult
children have full-time jobs. But creative scheduling and good team work
among your friends and loved ones can overcome this problem.
Members of the hospice staff will visit regularly to check on you and your
family and give needed care and services. Care begins when you are
admitted to the program, which generally means that a hospice team
member visits the home to learn about your situation and needs. Return
visits are. Set up so that your needs can be re-evaluated regularly. To
handle around-the-clock patient needs or crises, home hospice programs
have an on-call nurse who answers phone calls day and night, makes
home visits, or sends the team member you may need between scheduled
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visits. Medicare-certified hospices must provide nursing, pharmacy, and

doctor services around the clock.
Hospital-based hospices: Hospitals that treat seriously ill patients
often have a hospice program. This arrangement allows patients and
their families’ easy access to support services and health care
professionals. Some hospitals have a special hospice unit, while others
use a hospice team of caregivers who visit patients with advanced disease
on any nursing unit. IN other hospitals ,the staff on the patients unit will
act as the hospice team.
Independently owned hospices: Many communities have free-
standing, independently owned hospices that feature inpatient care
buildings as well as home care hospice services. As with long-term care
facility hospice programs, the free-standing hospice can benefit patients
who do not have primary caregivers available at home.

II. Palliative:

Definition :
by WHOM Palliative care is an approach that improves the quality of
patients and their families facing the problem associated with life
threatening illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment
of pain and other problems, physical, psychological, and spiritual.
Goals of palliative care :
To prevent or treat as early as possible the symptoms of the disease, side
effects caused by treatment of the disease.
1. To prevent or treat psychological, social, and spiritual problems
related to the disease or its treatment.
2. To help people with life-threatening disease to live more
comfortably.
3. Palliative care emphasizes management of psychological, social,
and spiritual problems in addition to control of pain and other
physical symptoms. As the definition suggests, palliative. Care is
not care that begins when cure-focused treatment ends.
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4. The goal of palliative care is to improve the patient’s and families.

Quality of life and many aspects of this type of comprehensive,
comfort-focused approach to care are applicable earlier in the
process of life-threatening disease in conjunction with cure focused
treatment.
5. In addition to a focus on the multiple dimensions of the illness
experience for Both patients and their families, palliative care
emphasizes the interdisciplinary collaboration that is necessary to
bring about the desired outcomes for patients and their families.
6. Interdisciplinary collaboration: it is distinguished from
multidisciplinary practice in that the former is based on
communication and cooperation among the various disciplines;
each member of the team contributes to a single care plan that
addresses the needs of the patient and family.
7. Palliative philosophy identified from the last acts palliative care
task force and the national hospice and palliative care organization
includes the following.
8. Palliative care provides support and care for persons facing life
limited illness across all care settings.
9. Palliative care identifies death as normal and natural.
10. The dying process is profoundly individualized and occurs
within the dynamics of family.
11. Palliative care enhances the quality of life and integrates the
physical, psychological, social, and spiritual aspects of care.
12.The interdisciplinary team addresses the multidimensional needs
of the dying clients and his or her family.
13.Palliative interventions affirm life and neither hastens nor
postpones death.
14.Appropriate palliative care and a supportive environment promote
of life and health closure for the client and family.
Palliative care team
Several health care professionals may participate as part of a team to
give palliative care.
1. Doctor: The doctor serves as the health care team leader and
makes treatment plans and decides on medication and dosing and
may consult with other doctors such as a pain specialist or a
radiation oncologist.
2. Nurses: The nurse gives direct care to the patient and helps with
managing pain and other Side effects of cancer and its treatment.
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3. Social worker: They may help with financial issues, arrange

family meetings and helps with the discharge from the hospital to
home or hospice care,
3. Hospital chaplain or other spiritual advisor: They counsels
the patient and family members on religious and spiritual matters.
4. Dietitian: A dietitian helps the patient and family members plan
healthy meals and addresses nutritional concerns.
5. Physical therapist: A physical therapist helps the patient to
maintain movement and helps when the patient has difficulty
moving around. They also addresses safety concerns in the home.
6. Grief and bereavement co-ordinator: This professional
counsels the patient and family members and helps with planning
memorial services.
PALLIATIVE CARE SERVICES:
Some organizations that provide information and referrals to hospice
and palliative care are:
1) National Hospice and Palliative Care Organization.
2) Canter To Advance Palliative Care
3) Hospice Education Institute.
PREPARATION AT THE END OF LIFE:
Despite a doctor’s best efforts and hard work, diseases treatment
sometimes stops working and a cure for long-term remission is no
longer possible. This stage of illness is called advanced, terminal or
end stage.
Grieving your losses:
 Learning that persons illness has become terminal can bring
about intense feelings of Anger, fear, grief, regret and other
strong emotions It is normal to grieve and mourn the loss of
your abilities, the loved ones you will leave behind and the
days you will not have
 Talking about your feelings and concerns with family, friends
and care givers can help bring you comfort
 Getting your affairs in order, completing unfinished business
and reviewing your life are important steps in accepting
death and finding peace.
Getting your affairs in order:
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 For many people, worrying about what will happen to their

surviving family members is one of the most difficult aspects of
dying.
 Planning ahead to settle legal, financial ,and business affairs can
also free you and your family to concentrate on the emotional
aspects of completing your life.
 As you approach the end of your life ,there may b certain things
you wish to accomplish in the time you have left.These tasks can
help bring a sense of meaning and completion of your life.
Reviewing your life.
 Take time to reflect on and celebrate the event’s in your life,the
things you have accomplished.
 As you review your Life, you may want to record your memories.
Religion and Spirituality :
For some, organised religion is a central part of life and the support of
faith and clergy members are an important source of comfort at the end
of life.
Spirituality at the end of life
The spiritual assessment is a key component of comprehensive nursing
assessment for terminally ill patients and their families. The nurse
should explore:
 The harmony between the patients and family beliefs.
 Other sources of meaning, hope and comfort
 The presence or absence of a sense of peace of mind and purpose of
life
ADVANCED DIRECTIVES:
Advanced directives are legal documents that explain the kind of medical
treatment you would want and would not want if you become unable to
make these decisions for yourself.
 Advance directives protect your rights and preferences for
medical treatment and diminish the burden of family
members and other caregivers making decisions for you.
 It’s important to talk with your family and doctor about your
wishes ahead of time,so they can be aware of your choices .
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Making an Advance directive:

Any adult who is mentally and physically able to understand his or
her medical condition and express his or her preferences can make
an advance directive.
1. In most states, an advanced directive can be oral,
although it is less likely to be Challenged if it is in
writing.
2. . Most, but not all, states honor an advance directive
made in other states.
3. If you move to another state, it is a good idea to
complete a new advance directive. It is important that
you and other people involved in decisions about your
health care have accessible copies of your advance
directive.
4. Copies should also be given to any institution where
you are treated and where you live. At this time, there
is no advance directive form that is valid in all 50
states.
5. Check your state’s requirements and guidelines about
advance directive documents.
Types of Advance directive
a) Living will: This is a written set of instructions
outlining your wishes about types of medical care
you may or may not want in order to sustain life.
b) Durable power of attorney for health care:
This type of advance directive designates a person
that will make medical decisions for you if you
become unable to make them yourself. Any
competent adult age 18 or older can be a health care
agent.
UNDERSTANDING CPR AND DNR:
CPR (cardiopulmonary resuscitation ) is a combination of chest
compressions and rescue breathing that is given to a person in cardiac
arrest (when the heart has stopped beating ) .when a person goes into
cardiac arrest , the heart stopes pumping blood through the body .CPR
can temporarily help a small amount of blood flow to the heart and brain
until the hear begins beating again. CPR may include the following:
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 Manual chest compressions.

 Defibrillation .
 Giving drugs to stimulate the heart.
 Mouth – to –mouth breathing.
 Bag – valve mask ventilation
 Insertion of and artificial airway ,including :
 Nasopharyngeal airway.
 Oropharyngeal airway .
 Endotracheal(ET) tube .
Do Not Resuscitate (DNR) orders:
A DNR order is a type of advance directive, a document that instructs
medical personnel that you do not wish to receive CPR if your heart and
or breathing stops. Once completed your DNR order is added to your
medical record.
CARE DURING THE FINAL DAYS:
Treatment for end stage focuses on keeping the person comfortable and
free of pain as he or she approaches the end of life. It is important to
know that care will continue until the end of life and that everything
possible will be done to ensure that death will be peaceful and dignified.
Physical manifestations as death approaches and the nursing
management:
Certain signs and symptoms can help a caregiver anticipate when death
is near.
THE SIGNS OF APPROACHING DEATH
1. Loss of appetite
2. Excessive fatigue and sleep
3. Increased physical weakness
4. Mental confusion or disorientation
5. Labored breathing
6. Social withdrawal
7. Changes in urination
8. Swelling in the feet and ankles
9. Coolness in the tips of the fingers and toes
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10. Mottled veins

It’s important to remember that not every patient experiences each of
the signs and symptoms. In addition , the presence of one or more of
these symptoms doesn’t necessarily indicate that the patient is close to
death .
 Drowsiness ,increased sleep ,and / or unresponsiveness (caused by
changes in patients metabolism).the caregivers and family
members can plan visits and activities for times when the patient is
alert. Patients should not be shaken if they do not respond.
 Decreased socialization and withdrawal (caused by decreased
oxygen to the brain ,decreased blood flow, and mental
preparations for dying ).Speak to the patient directly .Let the
patient know you are there for them.
 Decreased need of food and fluids ,and loss of appetite(caused by
the body’s need to conserve energy) . Allow the patient if and when
to eat or drink. Keep the patients mouth and lips moist with
products such as glycerine swabs and lip balm.
 Loss of bladder or bowl control ( caused by the relaxing of muslces
in the pelvic area.).Keep the patient as clean ,dry ,& comfortable as
possible. Place disposable pads on the bed beneath the patient
and remove them when they become soiled.
 Skin becomes cool to the touch ,particularly the hand and feet ;skin
may become bluish in colour ,(caused by decreased circulation tp
the extremities ).blankets can be used to warm the patient.
 Increased difficulty controlling pain (caused by progression of the
disease). Its important to provide pain medications as the patients
doctor has prescribed.
CARE OF CARE GIVERS:
Being present during a family members dying process can be
highly stressful, our main goal is to :
 Recognize signs and behaviours among family members who may
be at risk of abnormal grief reaction.
 Family caregivers & other family members need encouragement to
continue their usual activities as much as possible .
 Family caregivers need to be encouraged to take care of themselves
CONCLUSION:
In the recent years end of life care concept is increasing in the society
because of various reasons. And it is necessary that someone nearby
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death should spent his life peacefully with the help of all medical and
nursing group and the family End-of-life often touches upon rationing
and the allocation of resources in hospitals and national medical
systems. Such decisions are informed. Both by technical, medical
considerations, economic factors as well as bioethics. In addition, end-
of-life treatments are subject to considerations of patient autonomy.
“Ultimately, it is still up to patients and their families to determine when
to pursue aggressive treatment or withdraw life support.”
Bibliography:
Books :
1. Basheer P Shabeer et al: A Concise Text Book Of Advanced Nursing
Practice: EMMEES Publications: Page-305
2. Timber BK. (2001). Fundamental skills and concepts in Patient
Care, 7 Edition, L. W 3. Potter &Perry: Fundamentals of Nursing,
6th Edition; Mosby Publication: Page-570
3. Lillian Sholtis Brunner et al: Brunner & Suddarth’s Textbook Of
Medical-Surgical Nursing: 12th Edition: Lippincott Williams &
Wilkins Publishers
4. Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014).
Medical-Surgical Nursing: Assessment and Management of
Clinical Problems:9 Edition;, St. Louis: Mosby Publications
5. Black, J.M. & Hawks, J.H. (2009). Medical-Surgical Nursing.
Clinical Management for Positive Outcomes:8 th Edition:
Philadelphia: Elsevier Saunders Publications.
Journals
1. Henderson, V.(1986). Some observations on health care by health
services or health Industries. Journal of Advanced Nursing, 54(1),
1-2.
2. Rolfe, G. (1993). Closing the theory practice gap: A model of
nursing praxis. Journal of Clinical Nursing, 2, 173-177.
Internet
1. https://en.wikipedia.org/wiki/End-of-life care
2. www.ncbi.nlm.nih.gov/pubmed/22990423
3 . hospicefoundation.ie/hospice/hospice-palliative-and-end-of-life-
care/.
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