17.6 Applying the Nursing Process at End of Life

This section will summarize the steps of the nursing process when caring for a client who is actively dying as well as their family members.

Assessment

Assessments are generally limited for clients at the end of life with the overall treatment goal being comfort. The goal in any performed assessment is to help ease the client’s discomfort as the body begins to fail and facilitate a peaceful transition. If end-of-life care is occurring within the hospital setting, the nurse may need to remind members of the care team that “normal” care routines are not required. This may include collection of vital signs, intake and outputs, laboratory blood draws, and full physical assessment. It can feel challenging to switch modes of care in the inpatient setting where so many of our actions are focused on intervention and restoring a client to health. However, it is important to remember that our interventions take a different, but no less important, form. Providing comfort care at the end of life is one of the most important interventions a nurse can do to help ease client and family suffering.

Subjective Assessment

Many individuals at the end of life may be nonverbal. Some may experience times of reminiscence as they progress toward death. It is important for the nurse to inform the family that communication can be quite variable as the client progresses toward death, but the sense of hearing may still be intact. Family members and friends should be encouraged to share their thoughts and feelings with the client, taking time to relate stories of comfort and feelings to the client. This can be a therapeutic exchange for both the client and the family.

Objective Assessment

Physical assessments should be limited and focused on providing client comfort and creating a supportive environment for a therapeutic transition. Signs of pain such as grimacing, moaning, furrowing brow, and physical guarding should be noted and addressed. Many clients may experience increased respirations, labored breathing, and increased secretions that produce an audible respiratory “rattle.” The client typically has a significant decline in circulation as they progress towards death, evidenced by cool and clammy skin, mottled extremities, and diminished pulses. The nurse should continue to monitor for signs of skin breakdown and urinary retention.

Notify the provider of unexpected findings on assessment, such as severe pain not relieved by pain management protocol, acute labored breathing, terminal secretions, or urinary retention resulting in bladder distention.

Diagnosis

As the client progresses toward death, diagnosis statements are focused on provision of comfort for the client. Identification of acute pain and ineffective breathing are areas that typically become priority as clients near their final transition. Additionally, attention to family coping and caregiver role strain remain areas of focus as the nurse assists family members in coping with the dying process.

When planning care, review a nursing care planning source for current NANDA-I approved nursing diagnoses and evidence-based nursing interventions. See Table 17.6 for the definition and defining characteristics regarding the NANDA-I diagnosis Death Anxiety.

Table 17.6 NANDA-I Nursing Diagnoses Death Anxiety^[1]

Outcomes

An overall goal for a client who is actively dying is, “The client will experience dignified life closure as evidenced by:

• Expression of readiness for death
• Resolution of important issues
• Sharing of feelings about dying
• Discussion regarding spiritual concerns”^[2]

An example of a SMART outcome for a client actively dying is, “The client will express their fears associated with dying by the end of the shift.”^[3]

Nursing goals focus on the provision of comfort. For example, a common nursing goal is, “The client will experience adequate pain management based on their expressed goals for pain relief and alertness.”

Planning and Implementing Interventions

Many clients require pain medications to assist with a therapeutic transition as they near death. These medications often include morphine and lorazepam to help ease pain, dyspnea, and anxiety. It is important for the nurse to be conscientious of the appropriateness of the medication’s route of administration, recognizing that client condition can change rapidly. Concentrated oral solutions are absorbed through the buccal membranes, but if pain management needs are high, it may be necessary to contact the provider regarding a subcutaneous pump. Many clients in the imminent phase have terminal secretions so anticholinergic medications such as atropine or scopolamine may be administered. When anticholinergic medications are administered, good oral care is crucial because oral secretions are decreased. Oral swabs and lip moisturizer can be used to promote comfort. See the following box for a summary of other nursing interventions in the last days and hours of a client’s life.

Evaluation

It is always important to evaluate the effectiveness of interventions based on the outcome criteria established for each client. The nurse should closely monitor for escalating signs of client discomfort that is not managed by the current treatment plan. It is helpful to educate the family regarding whom to contact if additional concerns arise.