End of Life Care

¶ … Life Care

End-of-life care may be one of the most difficult aspects of healthcare services. After all, the goal of most healthcare providers is to heal, and providing end-of-life requires a shift in perspective. One of the challenges in planning end-of-life care is that many healthcare providers are simply not comfortable discussing end-of-life (Detering et al. 2014). Fortunately, when providers take targeted classes with the goal of improving their ability to engage in end-of-life discussions, they self-report feeling more comfortable having these conversations (Detering et al. 2014). As a result, prior to ever working with a patient to help plan end of life care, any professional should make sure and take the classes necessary to help them with those decisions, including classes that are specific to racial, cultural, or social issues that might be linked to a specific group. This is important because different cultures approach death and dying in very different ways, which may necessitate a different approach based on the individual client.

Advanced Care Directives

Perhaps the most important thing to know when working with a patient at the end-of-life is whether or not the patient has prepared any advanced care directives aimed at transitioning from life to death. If the patient has provided a written documentation of the patient's wishes, then it is the duty of the healthcare provider to respect those wishes insofar as it is possible within the confines of the patient's physical circumstances as well as any legal or ethical rules that might prohibit carrying out any of the patient's wishes. If there is a conflict between what is possible and what the patient has requested in an advanced care directive, it is important to discuss that conflict with the patient, if possible, as close in time to the beginning of hospice care as possible, to attempt to elicit input from the patient about potential changes. Moreover, if the patient has not prepared an advanced care directive, if the patient is still lucid, competent, and capable of decision-making, then the patient should be encouraged to prepare detailed instructions about end-of-life arrangements. This is true even if the patient and his or her family members have made assumptions that they know how they want to face the end-of-life challenges. Different diseases rob patients of different things at different rates. Therefore, it is critical to discuss specific end-of-life decisions with patients with reference to their condition. This is because, in many instances specific treatment decisions do not align with general treatment goals, particularly if the patient is facing a disease including a component of cognitive decline (Evans et al., 2014).

Physical

Perhaps the most basic goal of palliative end-of-life care is to eliminate or reduce pain for the patient. Furthermore, pain reduction goals are different with patients who are dying than with patients who are expected to recover, because the prescriber does not need to worry about addiction arising secondary to pain treatment. Physical care and comfort goes beyond medication. Patients may need to be moved at regular intervals to avoid the build-up of pressure sores. Moreover, many patients find that they are unable to provide basic self-care for hygiene, but may have concerns about cleanliness. The nurses need to work with patients to help them with waste elimination in a manner that helps preserve patient dignity, which can prevent physical challenges for the nursing staff.

Psychosocial

Most end-of-life patients will have family and friends present during the dying process. However, it can take several days, or even weeks, for a person to transition from life to death. The patient may experience moments of clarity with a generally declining mental state or may maintain significant mental function up until the very end of life. The interaction between the patient and loved ones can provide great comfort to the patient, but can also be source of significant distress, as some loved ones may look at this time as the last chance to make amends or to air grievances and hope for a resolution. The medical care team must make it clear to family members that the care is patient-centered and that loved ones causing distress to the patient will be removed.

However, it is also important to consider the goals and needs of loved ones; unlike the patient, the loved ones will have to live with the outcome of the hospice environment for years. Family members should be educated about the dying process as much as possible, so that they are prepared for the changes that the patient will undergo. Some natural aspects of dying can seem painful to family members, and having knowledge about them can better-prepare loved ones for aspects of the tradition. If the patient has an advanced care directive and allows it to be shared with family members, doing so can ease tensions dramatically. In fact, advance care planning can be of critical importance, not only to the patient, but also the patient's family. Where wishes are written out, relatives experience lower levels of emotional distress when a patient is dying (Vandervoot et al., 2014). While caring for relatives may not be the primary concern of a healthcare professional working with patients in end-of-life settings, it is a serious and important concern for those workers.