This is more complicated by the prevalence of other mental disorders like dementia and drug induced mood swings. Nurses need to be well trained in pattern recognition and logical assessment of the condition and take suitable action to solve these problems. [Steve Lliffe, 107] The failure to manage these symptoms would result in increased suffering and poor quality of life in the end stage. In a 1993 study conducted on 295 patients admitted for palliative care it was found that 99% of the patients had asthenia (fatigue) while more than 76% reported pain. Another study by Coyle et al. In 1990 revealed that in 75% of patients in palliative care there is usually a combination of symptoms. (Fatigue, pain, anorexia) etc. [Kim Kubler] Asides DNR, there are other morally distressing issues for the nurses to handle. For example, food intake would stop during the final hours of the patient as he is overcome by fatigue. End stage fatigue is also marked by the total cessation of fluid intake creating a panic among relatives and caregivers. However, research indicates that rapid dehydration and consequent endorphin release helps a lot in relieving pain and discomfiture during the dying moments. In some cases introducing parenteral fluids by intravenous method may also result in adverse effects such as breathlessness and prolong the dying process. It is not good to forcibly thrust fluid in such cases as it would result increase the discomfort for the already suffering patient. [EPEC Team]

Effective palliative nursing rests in understanding the symptoms and communicating both with the dying patient and his relatives. Sound knowledge of the end of life symptoms would help in providing the best possible care during the final phase of life. By making themselves more available and regularly apprising the relatives of the patient's condition they can develop a better supportive relationship between the care provider and the family. Since death of a loved one is an emotional experience for the relatives it would be reassuring for them to know that best possible care is provided for the patient. [Jean Lugton, 207] Nurses in palliative care have a crucial role as guides, liaisons and supporters whose service...

The successful management of palliative care would sometimes involve a sense of moral detachment. A good nurse advocate would be less affected by moral distress while discharging his/her duties to the terminally ill patient. DNR order can be emotionally, morally and professionally challenging for a nurse. If the directive and its implications are not properly understood it may even lead to a compromise on the quality of healthcare delivered to the concerned patient. Good palliative care is all about reducing the distress of the patient as much as possible and helping him attain a peaceful end. Since there is no way to reverse the causes for the condition, management of symptoms constitutes the key to palliative care.
Bibliography

1) EPEC Team, "Last Hours of Living," Accessed on March 16th, 2007, http://www.ama-assn.org/ethic/epec/download/module_12.pdf

2) Field D, James N. 1993 "Where and How People Die: The Future of Palliative

Care," Open University press

3) Steve Lliffe, Linda Patterson & Mairi M. Gould, 1998, "Health Care for Older

People," BMJ Books.

4) Ariana G. Gross, 'End of Life Care: Obstacles and Facilitators in the Critical Care

Units of a Community Hospital', Journal of Hospice and Palliative Nursing, Vol

8, no 2 Mar Apr 2006

5) Hanna Mari Hilden, Pekka Louhiala, Marja Lisa Honkasalo and Jorma Palo,

Finnish Nurses Views on End of Life Discussions and a Comparision with Physicians Views," Nursing Ethics, 2004

6) Kim Kubler, "The Difficulties Surrounding Clinical Decision Making in Advanced

Illness," Accessed on Mar 16th, 2007, www.minurses.org/apn/Palliative%20Care%201_03/PC_Mod2.pdf

7) Jean Lugton & Margaret Kindlen, 1999, "Palliative Care: The Nursing role," Churchill Livingstone Publishers.