nursing related

1. INTRODUCTION
In medicine, nursing and the allied health professions, End of life care refers to health care,
not only of patients in the final hours or days of their live, but more broadly care of all those
with a terminal illness or terminal illness or terminal condition that has become advanced,
progressively and incurable
End of life care requires a range of decision,including questions of palliative
care,patients’ right to self- determination of (treatment,life), medical experimentation, the
ethics and efficacy of extraordinary or hazardous medical interventions and the ethic and
efficacy even of continued routine medical interventions.in addition, end of life often
touches upon rational and the allocation of resources in hospitals and national medical
system. such decision is informed both by family members may also be coping with unrelated
problems, such as physical or mental illness, emotional and relationship issues, or legal
difficulties. These problems can limit their ability to be involved, civil, helpful, or present.
DEFINITION:
“End of life care” in medicine nursing and the allied health profession end of life care refers
not only of patients in the final hours or day of their live but more broadly care of all those
with a terminal illness or terminal conditions that has becomes advance progressive and
incurable.
“End of life care” is the provision of care to the patients whose disease condition is not
responsive to curative treatment, and his /her life expectancy is estimated to be within days or
month.
palliative care- according to WHO. palliative care is an approach that improves the quality of
life of patients and their families facing the problem associated with life- threatening illness,
through the prevention and relief of suffering by means of early identifications and
impeccable assessment and treatment of pain and other problems, physical, psychosocial and
spiritual.
“End of life care” refers to health care, not only of a person in the final hour or days of their
lives, but care of all those patient with a terminal condition that has become advanced ,
progressive ,and incurable
“End of life care’’ it is a patient centered ,personalised and family oriented and perception of
good death

2. SETTING FOR END-OF-LIFE CARE
There are two types: - Palliative care and hospice
Palliative care: is an approach to care for the seriously ill that has been a part of cancer care.
Recently it has been expanded to express the comprehensive symptoms management,
psychosocial care, and spiritual support needed to enhance the quality of life for patients with
noncancers diagnoses. Although hospice care is considered by many to e the gold standard
for palliative care, the term hospice is generally associated with palliative care that is
delivered at home or in special facilities to patients who are approaching the end of life. Both
palliative care and hospice care have been recognised as important bridge between cure
oriented treatment and the need of the terminally ill patients and their families for
comprehensive care in their final years, months, or weeks of life.
Palliative care, which is conceptually broader than hospice care, is both an
approach to care and a structured system for care delivery that aim to “prevent and relieve
suffering and to support the best possible quality of life for patients and their families,
regardless the stage of the disease or the need for other therapies. Palliative care emphasizes
management of psychological, social and spiritual problem in additions to control of pain and
other physical symptoms.the goal of palliative care is to improve the patients and family
quality of life. In palliative care, interdisciplinary collaborations is necessary to bring about
the desired outcomes of patients and their families. Multidisciplinary which is differ from
interdisciplinary in which all the various team member contributing their care that addressed
the need of the patients and their families.
Palliative care at the end of life: - palliative care in a broaden conceptsactually followed the
hospice service. All hospice care is palliative care not all palliative care. The difference is
that hospice care is delivered at the end of life care where as palliative care focussed in
psycho social spiritual and financial preparations of death. Many chronic diseases do not have
a predictable “end stage” that fits hospice eligibility criteria, and many patients die after a
long, slow, and often decline, without the benefit of the coordinated palliative care that is
unique to hospice programs. Palliative care programme could be benefit many more patients
if it were available across in care settings
Palliative care in the Hospital setting: – it is clear that many patients will continue to
options for hospital care or will by default themselves in hospitals setting at the ends of life.
Increasingly hospital is conducting system wide assessments of end-of-life care practices and
outcomes and are developing innovative models for delivering high-quality, person centered

3. care to patients approaching the end of life. hospital cite considerable financial barriers to
providing high quality palliative care in acute care settings
Palliative care in long term care facilities: -the total number of nursing home residents
declined between 1985 and 2000. However, experts estimate that 69% people who reach the
age of 65 years will need some form of long -term care in their life time weather in the
community or in residential care facility yet residents of long term care facilities typically
have poor access to high quality palliative care. Regulations that govern how to care in these
facilities is organized and reimbursed tend to emphasize restorative measures and serve as a
disincentive to palliative care mean while long term care facilities are under increasing public
public pressure to improve care units or services, to contact with home hospice programs to
provide care in the facilities, and to educate staff, residents, and their families about pain and
symptoms management and end-life-care.
Hospice care: - hospice is a coordinated program of interdisciplinary services provided by
professional care givers and trained volunteers to patients with serious, progressive illness
that are not responsive to cure
GOAL SETTING IN PALLIATIVE CARE AT THE END OF LIFE
As treatment goals begin to shift in the directions of comfort care over aggressive disease -
focused treatment, symptoms relief and patient’s family defined quality of life assume greater
prominence in treatment decision making. Throughout the course of illness and especially as
the patient’s functional status indicate approaching death. Specifically, the nurse should
collaborate with other members of the interdisciplinary team to share assessment finding and
develop a coordinated plan of care, in additions the nurse should help the patient and family
to clarify their goals, expected outcomes and values their consider treatment options. And the
nurse should ensure that the patients and family are referred for continuing psychosocial
support symptoms and management.
SPIRITUAL CARE: - attention to the spiritual component of the illness experienced by the
patients is not new, yet many nurses lack the skill of comfort to assess and intervene.
Spiritual assessment is a key components of comprehensive nursing assessment for
terminally ill patients and their families. The following steps in which the nurse should
explore to assess spiritual care are: -
 The harmony between the patients and families’ beliefs
 Other source of meaning hope and comfort
 The presence or absence of sense of peace of mind
 Spiritual or religious belief about illness, medical treatment, and care of sick
HOPE: - Hope generally persists in some form across every stage of illness. In terminal
illness, hope represents the patient’s imagined future, forming the basic of a positive,
accepting attitudes and providing the patients life with meaning, direction and optimism.

4. Terminally ill patients can be extremely resilient as they approach the end of life. As a nurse
becomes more skilled in working with seriously ill patients he or she becomes less
determined to fix and more willing to listened, more comfortable with silence, grief, anger,
and sadness: and more fully presents with patients and families
Nursing interventions for enabling and supporting hope include the following:
 Listening attentively
 Encouraging sharing feelings
 Providing information’s
 Facilitating effective communication
 Making referral for psychosocial and spiritual counselling
 Supporting the patients control over his or her circumstances
PALLIATIVE SEDATION AT THE END OF LIFE
Effective control of symptoms can be achieved under most conditions, but sometimes
patients may experience distressing, in tractable symptoms. Although palliative sedations
remain controversial, it is offered in some setting to patients who are close to death or who
have symptoms who do not respond to conventional pharmacology and non-pharmacology
approaches, resulting in unrelieved suffering. Palliative sedations aredistinguished from
euthanasia and physician assisted suicide in that intent of palliative sedation is to relieve
symptoms not to hasten death. It is mostly used in intractable pain dyspnoea, seizure, or
delirium. Before implementing palliative sedation, health care team should assess for the
underlying and treatable causes of suffering such as depression or spiritual distress. Finally,
the patient’s family should be fully informed about the use of this treatment and alternatives
once sedations induce the nurse should continue to comfort the patients, monitor the
physiology effects of sedations, support the family during the final hour or days of their loved
one’s life.
PRINCIPLES OF END OF LIFE CARE
1. Affirm life and regards death and dying as an integral part of life continuumClient
include patient or family
2. Provide measure for relief from pain and other distressing symptoms.
3. Attend to physical, psychological social spiritual and culture aspect of care
4. Offer support to help client maintain optimal quality of life
5. Prepared the best possible supportive environment for client to end life with dignity
and comfort
6. Offers support to help the bereaved family to cope with the loss of family member or
love one
SIGNS THAT DEATH MAY BE NEAR

5.  Drowsiness increased sleep
 Confusion about time place and identity of loved one’s restlessness
 Decreased socialization and withdrawal
 Decreased need for food and fluids
 Loss of bladder or bowel control darkened urine or decreased amount of urine
 Skin becoming cool to touch
 Rattling or gurgling sounds while breathing
NURSING CARE OF TERMINALLY ILL PATIENTS
Many patients suffer unnecessarily when they do not receive adequate attention for the
symptoms accompanying serious illness. Carefully evaluation of the patients should include
not only the physical problems but also psychosocial and spiritual dimensions of patients as
well families. This approach includes:
 Psychosocial issues
 Communications
 Providing culturally sensitive care at the end of life
PSYCHOSOCIAL ISSUES: it is the responsibility of the nurse to educate the patients
about the ill ness and supporting the patients and family with life review, values
clarifications, treatment decision making and end of life closure. nurses should be both
cultural sensitive in their approaches to communication with patients and families about
death.
COMMUNICATIONS: to develop a level of comfort and expertise in communicating
with seriously and terminally ill patients and their families, nurses must consider their
own experiences with and values concerning illness and death. To develop a good
communication the nurse should have the habit of talking with people from different
cultural and beliefs through different lens and increase their sensitivity to death related
beliefs and practice in other culture.
Skills for communicating with the seriously ill: - nurse need to develop skill and
comfort in assessing patients and family’s response to serious illness and planning
interventions that support their value and choice. Though they have to undergo a hard
time however being a nurse an art of therapeutic communications should be practiced in a
“safe” setting. Communication with patients and family should be tailored to their
particular level of understanding and values concerning disclosure.
Nursing interventions when patients and families receive bad news: - communicating
about life threatening diagnosis or about disease progression is best accomplished by the
interdisciplinary team in any setting: a physician a nurse social worker should be present
whenever possible to provide information. The most important interventions the nurse can
provide is listening. The nurse who is able to listen without judging and with out trying to
solve the patients and family problems provide an invaluable intervention.

6. Responding with sensitivity to difficult questions: -patients often directs questions or
concerns to nurses before they have been able to fully discuss the details of their
diagnosis with their physicians or the entire health care team. Using open- ended
questions allows the nurse to elicit the patients and family’s concern, for example, a
seriously ill patient may ask the nurse, “am I dying?” the nurse should avoid making
unhelpful responses that dismiss the patient’s real concerns. Nursing assessment and
intervention are always possible, even a need for further discussion with a physician is
clearly indicated.
PROVIDING CULTURALLY SENSITIVE CARE AT THE END OF LIFE: - Although
death, grief, and mourning are universally accepted aspects of living, values expectations, and
practices during serious illness, as death approaches and after death are culturally bound to
expressed. Health care providers may share similar values concerning ends of life care. In
addition, lack of educations or knowledge about end of life care treatment options and
language barriers influence decisions among many socioeconomically disadvantages. The
nurse role is to assess the values belief socioeconomic status, or background. The nurse can
share knowledge about a patients and family’s culture belief and practice with other health
care team and facilitate the adaptations of the care plan to accommodate these practices.
DISEASES SYMPTOMSMANAGEMENT
 Pain- suffering from uncontrolled pain is significant fear of those at end of life.
Typically controlled using by morphine.
 Agitation-Delirium, terminal aguish, restlessness (e.g. trashing, plucking, or
twitching). Typically controlled using midazolam’.
 Respiratory tract secretions- saliva and other fluids can accumulate in the
oropharynx and upper airways when patients become too weak to clear their
throats leading to a characteristic gurgling or rattle-like sound (death rattle)
while apparently not painful for the patients, the associations of the diseases
symptoms with impending death can create fear and uncertainty for those at the
bedside the secretions may be controlled using drug like scopolamine,
glycopyrronium.
 Nausea and vomiting- typically control using haloperidol
 Dyspnoea (breathlessness)- typically using morphine
NURSING CARE OF PATIENTS WHO ARE CLOSE TO DEATH
Providing care to patients close to death and being present at the time of death can be one of
the most rewarding experiences a nurse can have. Patients and family are understandable

7. fearful of the unknown, and the approach of death may prompt new concerns or cause fears
or issues to resurface.
Expected physiologic changes: - as death approaches and organ systems begin to fail,
nursing care measures aimed at patient’s comfort, such as pain medications. mouth care, eye
care positioning to facilitate draining of secretions and measures to protects the skin from
urine or from faeces. The nurse should inform physicians about discontinuing measure
comfort such as drawing blood, administer tube feeding, suctioning and the nurse should
prepare the family for the normal expected changes that accompany the period immediately
preceding death. although the exact time of death cannot be predicting, it is possible to
identify when the patients is very closed to death. Family members may have difficulty
believing that the patients are not in pain. Patients and family reassurance are the most
helpful responses to these symptoms
Death vigil: - although each death is unique, it is often possible for experienced clinical to
assess that the patients is actively or imminently dying and to prepare the family in the final
days of hours leading to death. As death nears the patients may withdraw, sleep for longer
interval. Family should be encouraged to be with the patients, to speak and to reassure the
patients their presence. Nurse can reassure family members throughout the death vigil by
being presents intermittently or continuously, modelling behaviours such as touching and
speaking to the patients, providing encouragement in relations to family care giving,
providing reassurance about normal physiological changes.
Care after death: - for patients who have received adequate management of symptoms and
for families who have received adequate preparations and support, the actual time of death is
commonly peaceful and occurs without struggle. Nurses may or may not presents at the time
of a patient’s death. In many cases nurse is authorised to make the pronouncement of death
and sign the death certificate. The determinations of death are made through a physical
examination that includes auscultations. physiological changes immediately on cessations of
vital functions. immediately after death family should be allow and encouraged to spent time
with the deceased. Family members may wish to independently manage or assists with care
of the body after death. In home, after death care of the body include cultural specific rituals
such as bathing the body, home care agency and hospice is varying from the hospital policy.
GRIEF, MOURNING AND BEREAVEMENT
Grief refers to the person feelings that accompany an anticipated or actual loss. Mourning
refers to the individual, family group, and cultural expression of grief and associated
behaviours. Bereavement refers to the period of time during which mourning takes place.
Both grief reactions and mourning behaviours change over time as people learn to live with
the loss. Although the pain of loss may be tampered by passage of time bereavement do not
get over a loss entirely, rather they developed a new sense of who they are and where they fit
in a world that has changed dramatically and permanently.
COMPLICATED GRIEF AND MOURNING

8. Complicated grief and mourning are characterized:
Prolonged feelings of sadness and feelings of general worthless or hopelessnessthat persist
long after death.
Prolonged symptoms that interfere with activities of daily living (anorexia, insomnia, fatigue,
panic) or self-destructions behaviours such as alcohol or substance abuse and suicidal
attempts. Complicated grief and mourning require professional assessment and can be treated
with psychological interventions an in some cases with medications.
COPING WITH DEATH AND DYING PROFESSIONAL CAREGIVER ISSUES
Nurse are the closely person who involved with complex and emotionally laden issues
surrounding loss of life. Weather in icu or other acute care setting, home care, hospice, long
term or many locations.to be most effective and satisfied with care the nurse should attend to
her own responses to the losses witnessed every day. Before the nurse exhibit symptoms of
stress or burn out, she should acknowledge the difficult of coping with others pain on a daily
basis and put healthy practices in place that guard against emotional exhaustions.
RESPONSIBILITIESOF THE NURSE
 The nurse assesses and takes appropriate actions to alleviate the clients pain and
discomfort
 The nurse respects the client right to know and to obtain information about his/her
illness and prognosis. The nurse adopt an empathetic attitude when discussing the
illness condition and prognosis with the client
 The nurse acknowledges that making decision to forgo life-sustaining treatment is a
process built on trust and requires time, information’s, honesty, and empathy. The
nurse ensures that the client is involved in the evaluation of burdens, risks, efficacy
and benefits of the life-sustaining treatment in questions.
 The nurse conveys the client’s choice and wishes to the health care team. The client’s
right of self-determinations and choices are respected and accommodated as far as
possible
 The nurse maintains good relationship and effective communication with the client in
order to understand their needs and choices in treatment and care options
 The nurse also has a role to be the clients advocate in communicating to and from the
health care team
 Last office is a sacred and family affair. When performing last offices, the nurse
respects the values held by the client taking into consideration the cultural and
spiritual diversities in beliefs and customs
 The nurse appreciates that experiencing end stage of life is emotionally taxing for the
client. The nurse assists the family to cope with the suffering, grief and loss. The
nurse refers the family members for professional bereavement support if deemed
necessary.

9.  After the provision of care to the dying, the nurse conducts debriefing and provides
support to colleagues and co-workers.
 The nurse maintains his/her competency through continuous learning and updating.
BIBLIOGRAPHY
BOOKS:
 Stephanie’s principles and practice of nursing volume one Nursing Arts procedures by
sr. Nancy M.S.J sixth edition
 LeMone Lynn. T Fundamentals of nursing: the art and science of nursing care, 7th
editions
 Perry’s.P Fundamentals of nursing second south Asia Editions
Website
 https://en.m.wikipedia.org
 https:/ Goggles. Org