ARELLANO UNIVERSITY

GRADUATE SCHOOL OF NURSING

END-OF-LIFE CARE

In partial fulfillment of the requirement of the course:

Medical-Surgical Nursing III

Submitted by:

ARIF RAKHMAN

MANILA
2014
END-OF-LIFE CARE
INTRODUCTION

Nurses can have a significant and lasting effect on the way in which patients
live until they die, the manner in which the death occurs, and the enduring
memories of that death for the families. Nursing has a long history of holistic,
person-centered and family-centered care. Indeed, the definition of nursing
highlights nursings commitment to the diagnosis and treatment of human
responses to illness (American Nurses Association [ANA], 2003). There may be no
setting or circumstance in which nursing carethat is, attention to human
responsesis more important than in caring for dying patients.
Knowledge about end-of-life principles of care and patients and families
unique responses to illness are essential to supporting their unique values and
goals. There is an opportunity to bring research, education, and practice together
to change the culture of dying, bringing much-needed improvement to care that
is relevant across practice settings, age groups, cultural backgrounds, and
illnesses.
Education about death helps healthcare professionals to be better informed
about dying and death and to incorporate this knowledge into the care they give
clients. Nurses who care for dying clients share emotional pain with them and
their families. Denying death creates a barrier to becoming involved with clients
and families and interferes with personal growth.
Death can occur in any healthcare setting; therefore, facing the death of
clients is necessary for nurses. It is not partial to a particular age group or
population. Death can be slow and tortuous or very sudden and unexpected.
Preparing clients and their families for an expected death is usually very different
from caring for grieving family members after an unexpected death. Recognizing
that nursing care always requires sensitivity and compassion for clients, families,
and significant others is an essential component of quality care.
HOSPICE CARE
Hospice is a coordinated program of interdisciplinary services provided by
professional caregivers and trained volunteers to patients with serious,
progressive illnesses that are not responsive to cure. Hospice in the United
States is not a place but a concept of care in which the end of life is viewed as a
developmental stage. The root of the word hospice is hospes, meaning host.
According to Cicely Saunders, who founded the world-renowned St. Christophers
Hospice in London, the principles underlying hospice are as follows:
1. Death must be accepted.
End-of-Life Care | 1

2. The patients total care is best managed by an interdisciplinary team whose

3.
4.
5.
6.
7.

members communicate regularly with one another.

Pain and other symptoms of terminal illness must be managed.
The patient and family should be viewed as a single unit of care.
Home care of the dying is necessary.
Bereavement care must be provided to family members.
Research and education should be ongoing.
A hospice is a facility for the care of terminally ill clients, who can live out their

final days with comfort, dignity, and meaningfulness. Hospice care emphasizes
helping clients live however the wish until they die. Clients receive services that
relieve their physical symptoms and emotional distress and promote spiritual
support. Pain is liberally controlled (Timby & Smith, 2010).
The goal of hospice is to enable the patient to remain at home, surrounded by
the people and objects that have been important to him or her throughout life.
The patient and family make up the unit of care. Hospice care does not seek to
hasten death or encourage the prolongation of life through artificial means.
Hospice care hinges on the competent patients full or open awareness of
dying; it embraces realism about death and helps patients and families
understand the dying process so that they can live each moment as fully as
possible.
Since 1983, the Medicare Hospice Benefit has covered costs of hospice care
for Medicare beneficiaries. State Medical Assistance (Medicaid) also provides
coverage for hospice care, as do most commercial insurers. To receive Medicare
payment for hospice services, programs are required to comply with rules known
as conditions of participation, which are enforced by the Centers for Medicare
and Medicaid Services. In many aspects, Medicare standards have come to
largely define hospice philosophy and services.
Eligibility criteria for hospice vary depending on the hospice program, but
generally patients must have a progressive, irreversible illness and limited life
expectancy and must opt for palliative care rather than cure-focused treatment.
According to Medicare, the patient who wishes to use his or her
Medicare Hospice Benefit must be certified by a physician as terminally ill,
with a life expectancy of 6 months or less if the disease follows its natural
course. Thus, hospice has come to be defined as care provided to terminally ill
persons and their families in the last 6 months of the patients life. Because of
additional Medicare rules concerning completion of cure-focused medical
treatment before the Medicare Hospice Benefit may be accessed, many patients
delay enrollment in hospice programs until very close to the end of life.
End-of-Life Care | 2

Federal rules for hospices require that patients eligibility be reviewed

periodically. Patients who live longer than 6 months under hospice care are not
discharged if their physician and the hospice medical director continue to certify
that the patient is terminally ill with a life expectancy of 6 months or less
(assuming that the disease continues its expected course). Once a patient meets
eligibility criteria and elects to use the benefit, the Medicare-certified hospice
program assumes responsibility for providing and paying for the care and
treatment related to the terminal illness for which hospice care was elected. The
Medicare-certified hospice is paid a predetermined dollar amount for each day of
hospice care that each patient receives. Four levels of hospice care are covered
under Medicare and Medicaid hospice benefits:
1. Routine home care: All services provided are included in the daily rate to the
hospice.
2. Inpatient respite care: A 5-day inpatient stay, provided on an occasional basis
to relieve the family caregivers.
3. Continuous care: Continuous nursing care provided in the home for
management of a medical crisis. Care reverts to the routine home care level
after the crisis is resolved. (For example, seizure activity develops and a nurse
is placed in the home continuously to monitor the patient and administer
medications. After 72 hours, the seizure activity is under control, the family
has been instructed how to care for the patient, and the continuous nursing
care is discontinued.)
4. General inpatient care: Inpatient stay for symptom management that cannot
be provided in the home. This is not subject to the guidelines for a standard
hospital inpatient stay.
Most hospice care is provided at the routine home care level and includes
the services as follow:
1. Nursing care provided by or under the supervision of a
2. registered nurse, available 24 hours a day
3. Medical social services
4. Physicians services
5. Counseling services, including dietary counseling
6. Home health aide/homemaker
7. Physical/occupational/speech therapists
8. Volunteers
9. Bereavement follow-up (for up to 13 months after the death of the patient)
10.Medical supplies for the palliation of the terminal illness
11.Medical equipment for the palliation of the terminal illness
12.Medications for the palliation of the terminal illness
Hospice programs are reaching out to patients with very advanced illness and
seeking ways to provide them with hospice services while they are completing
End-of-Life Care | 3

courses of treatment that many programs previously defined as lifeprolonging,

such as disease-modifying therapies for dementia, enteral or parenteral
nutritional support, and certain types of chemotherapy.
PALLIATIVE CARE
Palliative care is whole-person care provided by an interdisciplinary team of
physicians, nurses, social workers, chaplains, and other health care
professionals. The interdisciplinary care model aims to relieve suffering and
improve quality of life for patients with chronic, serious, and advanced disease
and their families. Palliative treatment can consist of many different
interventions, including aggressive interventions to control pain and other
distressing symptoms. Palliative care is offered along with all other appropriate
medical treatments.
According to World Health Organization (as cited in Monahan, et al., 2007),
palliative care is a model of care that improves the quality of life of patients and
their families facing problems associated with life-threatening illness, through
the prevention and belief of suffering by means of early identification and
treatment of pain and other distressing symptoms (physical, psychological, and
spiritual). The purpose of palliative care as follow:
1.

Provide relief from pain and other distressing symptoms

2.

Affirms life and regards dying as a normal process

3.

Intends to neither hasten nor postpone death

4.

Integrates the psychologic and spiritual aspects of patient care

5.

Offers a support systems to help patients live as actively as possible until

death

6.

Offers a support system to help the family cope during the patients illness
and their own bereavement

7.

Uses a team approach to address the need of patients and their families,
including bereavement counseling

8.

Enhances quality of life, positively influences the course of illness, and

support death with dignity

9.

Is applicable early in the course of illness, offered simultaneously with

other therapies that are intended to prolong life, such as chemotherapy or
radiation therapy

PALLIATIVE CARE PLAN

End-of-Life Care | 4

Care provided by all team members is holistic and directed by the patient and
family. Best practice in palliative care uses the strengths of the interdisciplinary
team. The leader of the team is the person, regardless of discipline, who knows
the most about issue at hand. This strategic, since not all symptoms arise from a
physical need. Dyspnea may occur due to anxiety, pain can be exacerbated by
depression and restlessness may be a result of spiritual conflict.
Palliative care nurses act as patient advocates, case managers, and symptoms
assessment and management experts. The nurses primary role in palliative care
is to establish a trusting relationship with the patient and family and to
coordinate care across all disciplines and health care settings. Quality of life and
death with dignity can be achieved with a treatment plan that fosters the
patients physical, psychosocial, spiritual and family well-being. Patients perceive
high quality end of life care as including adequate pain and symptom
management, avoiding inappropriate prolongation of dying, achieving a sense of
control, relieving the burden of loved ones, and strengthening relationship with
loved ones and a higher power. Other factors important to high quality end of life
care vary by role, developmental stage and personal preferences.
Developmental Vies of Death:
AGE
Birth to 2
yr
2-5 yr
6-12 yr

DEVELOPMENTAL
STAGES
Infancy
Early childhood
Late childhood

13-25 yr

Adolescence
Young adulthood

26-65 yr

Middle age
Other auldthood

TASK AREA OF RESOLUTION

Sense of separation with no concept of
death
Death perceived as temporary
Beginning awareness of the reality of
death
Realization of mortality and eventual
death
Death anxiety more prevalent
Death perceived as a future event
More awareness and accepting death

The palliative care plan includes care goals, advance care planning, financial
planning, symptom management, family support, spiritual care, functional
support status and rehabilitation, and comorbid disease management.
1. Palliative care goal
The nurse ascertains the patients understanding and desire to know about
the diagnosis and prognosis so that the palliative care interdisciplinary team
can construct the most effective plan to manage the disease and its
symptoms. Family meeting are an effective forum to discuss the patient and
familys goals, hopes, and expectations of treatment. Acting as facilitator, the
End-of-Life Care | 5

nurse provides information on benefits versus burdens of treatments and

allows everyone to express concerns.
Communication is essential for achieving consensus on a course of action.
To the extent possible, communication includes all who are emotionally
invested in the outcome and who provide information about the patients
wishes and best interest regarding quality of life.
2. Advance care planning
Advance care planning is important part of palliative care medicine and end
of life care. Exploration of a patients life and treatment goals are the
foundation for future health care decision making. Advance care planning
discussions should occur with healthy, competent, adult patients in the
primary care setting. Such discussions include living wills, durable power of
attorney for health care, an advance medical care directive and a patientcompleted values history, which serves as a foundation for advance care
decisions.
An advance medical care directive combines the living will and durable
power of attorney for health care, providing specific instructions for various
medical situations. Like the durable power of attorney, an advance medical
care directive may appoint a health care proxy to aid in the treatment decision
making when the patient is no longer able to communicate medical wishes.
A values history reveals the patients values and beliefs and directs health
care clinicians, proxies, and family members through difficult treatment
decisions. When the clinicians and health care proxy are aware of the patients
treatment choices and the values that support those decisions, medical
treatment efficacy increases. This, in turn, enhances the patients and familys
quality of life by preserving autonomy. Nurses in all setting provide
opportunities for the patient to discuss medical wishes. Advance directives can
be in verbal or written form. Any verbal statements made by the patients
regarding treatment choices should be documented in the patients medical
file brought to the attention of other interdisciplinary team members. Advance
directives are not recognized for dying children; however, allowing a child to
share in his or her own medical care decision is critical.
3. Financial Planning
When considering the patients ability to adhere in a treatment plan, the
nurse must assess the resources available. For example, if the patient is
unable to pay for pain medication, then it is likely that pain will not be
managed at home and hospitalization will be routinely required. The nurse can
work with the social worker on the interdisciplinary team to obtain assistance
for the patient and family with estate planning, long-term care, other
End-of-Life Care | 6

insurance options, and community medication reimbursement programs. The

care providers assess the patients understanding of health care coverage
(medical, home care, prescription, long term care, and family support needs)
and make referrals as needed.
4. Comorbid disease
The nurse must monitor for coexisting illness coordinate with other health
care specialist. This is necessary to provide high quality, coordinated care and
achieve the goal of maintaining health and function. The nurse reviews
medications on an ongoing basis to identify potential drug interactions and
make changes as needed. The nurses also review treatment options offered by
specialist and help patient understand the benefit versus burden of treatment
in terms of quality and length of life. When the patient can no longer benefit
from treatment, the nurse recommends that it be discontinued. At that point
all the members of palliative care team are involved in providing emotional
support.
5. Symptom management
Symptom management is the cornerstone to ensuring a high quality of life
and death with dignity. Nurses caring for individuals with chronic, serious, and
terminal illness must monitor symptoms such as pain, nausea and vomiting,
anorexia, constipation, and changes in level of consciousness. A whole patient
assessment is a spiritual aspect of the patient, family members, and
caregiver, examining a range of issues that may cause suffering.
Nurses should be aware also with the perideath period. Perideath period
encompasses the symptoms and experiences right before death, the actual
death, and the care of the body after death. At this time inpatients live they
rely on the nurses skills to help them and their families, through uncharted
waters. Perideath period includes:
a. Phase 1: Preparation for death
The sign and symptoms before death occur are indicative of the first
phase of the perideath period as the body prepares for death. Sign and
symptoms such as coolness, sleeping, fluid and food decrease,
incontinence, congestion, breathing pattern change, disorientation, and
restlessness might be occur. Furthermore patient may experience of
withdrawal, visionlike experience, letting go and the final is saying goodbye.
b. Phase 2: Death
The sign of death include no heartbeat, release of bowel and bladder, no
response, eyelids slightly open, pupils enlarged, eyes fixed on a certain
spot, no blinking, jaw relaxed, and mouth slightly open.
End-of-Life Care | 7

Throughout the dying process, and particularly at the very end of life, the
nurse must be aware of cultural and religious values, practices, and
traditions of the patient and the family. Religious and ethnic group practices
regarding postmoterm care vary in the worldwide. Although it is possible to
generalize about the practices of various group or religious, the nurse must
avoid stereotyping.
c. Phase 3: After death
Once he patient has died, the family has many decisions to make or
plans to carry out, depending on whether the patient has already arranged
to funeral. Choices include organ donation, cremation, traditional burial or
internment the body. For same family, the wake, or visitation, is the first
component of postdeath ritual. It is a time for family and friends to view the
death body emphasize that the person is dead; declining to see the body
may delay grieving.
The second component of postdeath ritual is the funeral. It is a
ceremonial service that typically includes music, prayers, poetry, and
eulogies. Some people plan their funeral before they die, which can be
comforting to both the dying person and family. The last ritual is the
committal service, the concluding funeral rite. It is the final act of caring for
the deceased and is celebrated at the grave, tomb, or crematorium.
6. Family support
In palliative care the family is whomever the patient calls family; another
term is family of choice. The nurse asks the patient and family about practical
support needs such as transportation, prescription drug coverage, respite care
and personal care. Counseling can help patient and family reconnect and build
relationships. The nurse should establish relationships with all significant
family and friends so that he or she can provide follow-up bereavement
support after patients death. The nurse encourages family and friends to
assist in care if they desire. The patient and the family together are
considered the unit of care. Care givers are prone to negative physical, social,
and emotional effect of caring for individuals with chronic and serious
conditions. By including the care givers in the unit of care, the nurse can
ensure all benefit from the positive outcomes of palliative care.
7. Cultural care
It is assumed in Western culture that the patient is the best person to make
health care decisions. In non-Western cultures the family or community has a
vital role in receiving, organizing, and disclosing information needed to make a
decision regarding care. Establishing rapport with the patient and family

End-of-Life Care | 8

allows the nurse to foster an individualized care plan addressing personal

beliefs, wishes, and needs.
There are some cultural diversity and death according to Mazanec and Tyler
(2003):

8. Spiritual care
Nurses are not expected to be experts in spiritual assessment and care
giving, yet they may assist the patient in acknowledging the meaning and last
effects of a life lived. Nurses are pivotal in the process of spiritual assessment
because of their frontline health care position, role as coordinator, intimacy
with the patient and holistic perspective on care. Individuals who life with an
irreversible disease often consider aspects of spirituality a major contributing
factor to quality of life and death with dignity.
Spirituality is an important component of many patients physical well-being
and mental health. The nurse addresses it at each visit, since spirituality is an
ongoing issue. The nurse portrays an attitude of acceptance by respecting the
patients right to privacy regarding spiritual beliefs, not imposing personal
beliefs on others, and referring the patient to the clergy of choice or palliative
care clergy for additional spiritual support as needed. Personal spiritual beliefs
overflow in encounters with patients. When health care providers understand
their own values and beliefs, it allows the nurse-patient encounter to become
more humanistic and effective.

End-of-Life Care | 9

The following overview of religious and cultural beliefs and views on death
and dying in many religions according to Firth (2005), Dorff (2005),Keown
(2005), Sachedina (2005), Engelhardt & Smith (2005).:

GRIEF, MOURNING, AND BEREAVEMENT

End-of-Life Care | 10

A wide range of feelings and behaviors are normal, adaptive, and healthy
reactions to the loss of a loved one. Grief refers to the personal feelings that
accompany an anticipated or actual loss. Mourning refers to individual, family,
group, and cultural expressions of grief and associated behaviors. Bereavement
refers to the period of time during which mourning takes place. Both grief
reactions and mourning behaviors change over time as people learn to live with
the loss. Although the pain of the loss may be tempered by the passage of time,
loss is an ongoing developmental process, and time does not heal the bereaved
individual completely. That is, the bereaved do not get over a loss entirely, nor
do they return to who they were before the loss. Rather, they develop a new
sense of who they are and where they fit in a world that has changed
dramatically and permanently.
Denial, sadness, anger, fear, and anxiety are normal grief reactions in people
with life-threatening illness and those close to them. Kbler-Ross (1969)
described five common emotional reactions to dying that are applicable to the
experience of any loss.
Stage
Denial: This cannot be true.
Feelings of isolation. May
search for another health
care professional who will
give a more favorable
opinion. May seek unproven
therapies.

Anger: Why me? Feelings

of rage, resentment or envy
directed at God, health care
professionals, family, others.
Bargaining: I just want to
see my grandchilds birth,
then Ill be ready. . . . Patient
and/or family
plead for more time to reach
an important goal. Promises
are sometimes made with
God.

Nursing Implications
Denial can be an adaptive response, providing a buffer after
bad news. It allows time to mobilize defenses but can be
maladaptive when it prevents the patient or family from
seeking help or when denial behaviors cause more pain or
distress than the illness or interfere with everyday
functions. Nurses should assess the patients and familys
coping style, information needs, and understanding of the
illness and treatment to establish a basis for empathetic
listening, education, and emotional support. Rather than
confronting the patient with information he or she is not
ready to hear, the nurse can encourage him or her to share
fears and concerns. Open-ended questions or statements
such as Tell me more about how you are coping with this
new information about your illness can provide a
springboard for expression of concerns.
Anger can be very isolating, and loved ones or clinicians
may withdraw. Nurses should allow the patient and family
to express anger, treating them with understanding,
respect, and knowledge that the root of the anger is grief
over impending loss.
Terminally ill patients are sometimes able to outlive
prognoses and achieve some future goal. Nurses should be
patient, allow expression of feelings, and support realistic
and positive hope.

End-of-Life Care | 11

Depression: I just dont

know how my kids are going
to get along after Im gone.
Sadness, grief, mourning for
impending losses.
Acceptance: Ive lived a
good life, and I have no
regrets. Patient and/or
family are neither angry nor
depressed.

Normal and adaptive response. Clinical depression should

be assessed and treated when present. Nurses should
encourage the patient and family to fully express their
sadness. Insincere reassurance or encouragement of
unrealistic hopes should be avoided.
The patient may withdraw as his or her circle of interest
diminishes. The family may feel rejected by the patient.
Nurses need to support the familys expression of emotions
and encourage them to continue to be present for the
patient.

Not every patient or family member experiences every stage; many patients
never reach a stage of acceptance, and patients and families fluctuate on a
sometimes daily basis in their emotional responses. Furthermore, although
impending loss stresses the patient, people who are close to him or her, and the
functioning of the family unit, awareness of dying also provides a unique
opportunity for family members to reminisce, resolve relationships, plan for the
future, and say goodbye.
The nurse should assess the characteristics of the family system and
intervene in a manner that supports and enhances the cohesion of the family
unit. The nurse can suggest that family
members talk about their feelings and understand them in the broader context of
anticipatory grief and mourning. Acknowledging and expressing feelings,
continuing to interact with the patient in meaningful ways, and planning for the
time of death and bereavement are adaptive family behaviors. Professional
support provided by grief counselors, whether in the community, at a local
hospital, in the long-term care facility, or associated with a hospice program, can
help both the patient and the family sort out and acknowledge feelings and make
the end of life as meaningful as possible.
When a loved one dies, the family members enter a new phase of grief and
mourning as they begin to accept the loss, feel the pain of permanent
separation, and prepare to live a life without the deceased. Even if the loved one
died after a long illness, preparatory grief experienced during the terminal illness
does not preclude the grief and mourning that follow the death. With a death
after a long or difficult illness, family members may experience conflicting
feelings of relief that the loved ones suffering has ended, compounded by guilt
and grief related to unresolved issues or the circumstances of death. Grief work
may be especially difficult if a patients death was painful, prolonged,
accompanied by unwanted interventions, or unattended. Families who had no
End-of-Life Care | 12

preparation or support during the period of imminence and death may have a
more difficult time finding a place for the painful memories.
After-death rituals, including preparation of the body, funeral practices, and
burial rituals, are socially and culturally significant ways in which family
members begin to accept the reality and finality of death. Preplanning of funerals
is becoming increasingly common, and hospice professionals in particular help
the family make plans for death, often involving the patient, who may wish to
play an active role. Preplanning of the funeral relieves the family of the burden of
making decisions in the intensely emotional period after a death.
In general, the period of mourning is an adaptive response to loss during
which mourners come to accept the loss as real and permanent, acknowledge
and experience the painful emotions that accompany the loss, experience life
without the deceased, overcome impediments to adjustment,
and find a new way of living in a world without the loved one. Particularly
immediately after the death, mourners begin to recognize the reality and
permanence of the loss by talking about the deceased and telling and retelling
the story of the illness and death. Societal norms in the United States are
frequently at odds with the normal grieving processes of people; time excused
from work obligations is typically measured in days, and mourners are often
expected to get over the loss quickly and get on with life.
In reality, the work of grief and mourning takes time, and avoiding grief work
after the death often leads to long-term adjustment difficulties. According to
Rando (2000), mourning for a loss involves the undoing of psychosocial ties
that bind mourners to the deceased, personal adaptation to the loss, and
learning to live in the world without the deceased. Six key processes of mourning
allow people to accommodate to the loss in a healthy way:
1. Recognition of the loss
2. Reaction to the separation, and experiencing and expressing the pain of the
loss
3. Recollection and reexperiencing the deceased, the relationship, and the
associated feelings
4. Relinquishing old attachments to the deceased
5. Readjustment to adapt to the new world without forgetting the old
6. Reinvestment
Although many people complete the work of mourning with the informal
support of families and friends, many find that talking with others who have had
End-of-Life Care | 13

a similar experience, such as in formal support groups, normalizes the feelings

and experiences and provides a framework for learning new
skills to cope with the loss and create a new life. Hospitals, hospices, religious
organizations, and other community organizations often sponsor bereavement
support groups. Groups for parents who have lost a child, children who have lost
a parent, widows, widowers, and gay men and lesbians
who have lost a life partner are some examples of specialized support groups
available in many communities.
WITHHOLDING OR WITHDRAWING TREATMENT
It is appropriate to consider withholding or withdrawing specific therapy when
the therapy offers no reasonable expectation of helping the patient attain any
human awareness; the therapy is proving medically ineffective and useless after
sufficient trial; or patient (or decision-making representative) has expressed that
the therapy is cumulatively a greater burden than a benefit.
When decision are made to withhold or withdraw life sustaining treatment, the
goal of medical and nursing care focuses on keeping the patient comfortable;
preventing suffering and pain; and providing support, comfort, and care on
physical, emotional, and spiritual levels. Indentifying those procedures not
directed to supportive care becomes more difficult once medical procedures
designed to prolong life are withheld of withdrawn. Perhaps the most
controversial area is that of determining the proportionate benefit and burden of
medical (artificial) nutrition and any hydration. The issue of withdrawing
treatment, once it is started, is also difficult.
1. Do not resuscitate (DNR)
Do not resuscitate (DNR), or no code, is a legal order written either in the
hospital or on a legal form to withhold cardiopulmonary resuscitation (CPR)
or advanced cardiac life support (ACLS), in respect of the wishes of a patient in
case their heart were to stop or they were to stop breathing. "No code" is a
reference to the use of "code" as jargon for "calling in a Code Blue" to alert a
hospital's resuscitation team. The DNR request is usually made by the patient
or health care power of attorney and allows the medical teams taking care of
them to respect their wishes. In the health care community, allow natural
death (AND), is a term that is quickly gaining favor as it focuses on what is
being done, not what is being avoided.[citation needed] Some criticize the
term "do not resuscitate" because it sounds as if something important is being
End-of-Life Care | 14

withheld, while research shows that only about 5% of patients who require
CPR outside the hospital and only 15% of patients who require CPR while in
the hospital survive. Patients who are elderly, are living in nursing homes,
have multiple medical problems, or who have advanced cancer are much less
likely to survive.
A DNR does not affect any treatment other than that which would
require intubation or CPR. Patients who are DNR can continue to get
chemotherapy, antibiotics, dialysis, or any other appropriate treatments. In
1991 Congress passed into law the Patient Self-Determination Act that
mandated hospitals honor an individual's decision in their healthcare.
2. Assisted suicide
Assisted suicide refers to providing another person the means to end his or
her own life. Physician-assisted suicide involves the prescription by a physician
of a lethal dose of medication for the purpose of ending someones life.
Assisted suicide is suicide committed with the aid of another person,
sometimes a physician. The term is often used interchangeably with physicianassisted suicide (PAS), which involves a doctor "knowingly and intentionally
providing a person with the knowledge or means or both required to commit
suicide, including counselling about lethal doses of drugs, prescribing such
lethal doses or supplying the drugs. Assisted suicide and euthanasia are
sometimes combined under the umbrella term "assisted dying", an example of
a trend by advocates to replace the word "suicide" with "death" or ideally,
"dying". Other euphemisms in common use are "physician-assisted dying",
"physician-assisted death", "aid in dying", "death with dignity", "dying with
dignity", "right to die" "compassionate death", "compassionate dying", "endof-life choice", and "medical assistance at the end of life".
Physician-assisted suicide is often confused with euthanasia (sometimes
called "mercy killing"). In cases of euthanasia the physician administers the
means of death, usually a lethal drug. Physician-assisted suicide (PAS) is
always at the request and with the consent of the patient, since he or she selfadministers the means of death.
In 1994-1997, Oregon voters approved the Oregon Death With Dignity Act 341 persons who have died. In November 2008, voters approved The
Washington Death with Dignity Act. ANA: nursing participation in assisted
suicide is a violation of the Code for Nurses.
3. Euthanasia
End-of-Life Care | 15

Greek words meaning good or pleasant death. Euthanasia is the act of

deliberately ending a person's life to relieve suffering.
Euthanasia can be classified in different ways, including:
a. Active euthanasia where a person deliberately intervenes to end
someones life for example, by injecting them with a large dose of
sedatives
b. Passive euthanasia where a person causes death by withholding or
withdrawing treatment that is necessary to maintain life, such as
withholding antibiotics from someone withpneumonia
The 2002 statement from the American Medical Association Council on
Ethical and Judicial Affairs holds that the patient or immediate family can
decide to discontinue all means of life-prolonging medical treatment.
Euthanasia can also be classified as:
a. Voluntary euthanasia where a person makes a conscious decision to die
and asks for help to do this
b. Non-voluntary euthanasia where a person is unable to give
their consent (for example, because they are in a coma or are severely
brain damaged) and another person takes the decision on their behalf,
often because the ill person previously expressed a wish for their life to be
ended in such circumstances
c. Involuntary euthanasia where a person is killed against their expressed
wishes
Depending on the circumstances, voluntary and non-voluntary euthanasia
could be regarded as either voluntary manslaughter (where someone kills
another person, but circumstances can partly justify their actions) or
murder. Involuntary euthanasia is almost always regarded as murder.

REFERENCES:
American Nurses Association (ANA). (2003). Nursings social policy statement
(2nd ed.). Washington, DC: Author.
Dorff, E. N. (2005). End of life: Jewish perspectives. Lancet, 366(9488),862865.
Engelhardt, H. T. & Smith Iltis, A. (2005). End of life: The traditional Christian
view. Lancet, 366(9490), 10451049.
End-of-Life Care | 16

Firth, S. (2005). End of life: A Hindu view. Lancet, 366(9486), 682686.

Keown, D. (2005). End of life: the Buddhist view. Lancet, 366(9489), 952955.
Kuebler, K. K., Davis, M. P. & Moore, C. (2005). Palliative practices: An
interdisciplinary approach. St. Louis, MO: Elsevier Mosby.
Mazanec, P., & Tyler, M. K. (2003). Cultural considerations in end-of-life care.
American Journal of Nursing, 134(3), 53.
McCready, T., MacDonald, J. & McSherry, W. (2008). Introduction to palliative
care. Hoboken, NJ: Wiley.
Rando, T. A. (2000). Promoting healthy anticipatory mourning in intimates of the
life-threatened or dying person. In Rando, T. A. (Ed.). Clinical dimensions
of anticipatory mourning. Champaign, IL: Research Press.
Sachedina, A. (2005). End of life: The Islamic view. Lancet, 366(9487), 774779.
Timby, B.K. & Smith, N.E. (2010).Introductory medical surgical nursing. China:
Wolters Kluwer Health|Lippincott Williams & Wilkins.
Williams, L.S., & Hopper, P.D. (2007).Understanding medical surgical nursing.
Philadelphia: FA Davis Company.

End-of-Life Care | 17