End of Life Nursing
Donnie Barnes
Oklahoma Wesleyan University

End of Life Nursing
Every life will end in death. It can happen anywhere or anytime along the human lifespan, but it will definitely happen. Death is never an event in life that is encouraged or hope for, however when faced with impending end of life circumstances, it can be faced with dignity and decency.
Many people associate end-of-life care with treating physical pain and discomfort. While that is an important part, complete end-of-life (EOL) care also includes helping the dying person manage mental and emotional distress. An elder who is nearing the end of life who is alert might understandably feel depressed or anxious. Encourage conversations, so the elder has an opportunity to talk about their feelings. You might want to contact a counselor, possibly one familiar with end-of-life issues. If the depression or anxiety is severe, medicine might provide relief.
A dying person might also have some specific fears and concerns. He or she may fear the unknown or worry about those left behind. Some people are afraid of being alone at the very end. This feeling can be made worse by the understandable reactions of family, friends, and even the medical team. For example, when family and friends do not know how to help or what to say, sometimes they stop visiting. Or, someone who is already beginning to grieve may withdraw. Doctors may become discouraged because they can't cure their patient and feel helpless. Some seem to avoid a dying patient. This can add to a dying person's sense of isolation. If this appears to be happening, the nurse should discuss their concerns with the family, friends, or the doctor.
People nearing the end of life may have spiritual needs as compelling as their physical and emotional concerns. Spiritual needs involve finding meaning in one's life and ending disagreements with others, if possible. The dying person might find peace by resolving unsettled issues with friends or family. Visits from a social worker or a counselor may also help. Many people find solace in their faith. Praying, talking with someone from one's religious community, such as a minister, priest, rabbi, or Muslim cleric, reading religious text, or listening to religious music may bring comfort. It is important to allow the patient and family to be completely comfortable and accepting of religious offerings. The nurse should be non-judgmental of those that refuse religious or spiritual guidance, and never push or pressure them in to a spiritual intervention process.
End-of-life (EOL) decisions and the accompanying legal ramifications related thereto are important matters to be considered and understood by nurse practitioners (NPs). The Journal of Medical Ethics (2000) explains the importance of focusing on three potential legal issues: creating advance directives with patients and their families, withholding or withdrawal of life-sustaining treatment, and do-not-resuscitate orders (438). The nurse is tasked with improving communication between the patient, family, and care team about end-of-life care, thereby avoiding any potential legal pitfalls. Other areas of legal importance when dealing with end-of-life matters is proper and accurate documentation in the patient's medical record, and knowledge of advance care planning.
Puntillo and McAdam (2006) explain that most EOL patients have families that are providing some level of care and support. In the case of older adults and people with chronic disabilities of all ages, this “informal care” can be substantial in scope, intensity, and duration. Family caregiving raises a few issues that should concern nurses in all settings. First, caregivers sometimes require as much attention as the patient facing the end-of-life circumstances. They become secondary patients to the nurse, who need and deserve protection and guidance. The nurse charged with care for the dying patient must support the family caregiver with ways to protect their health and safety, because their caregiving demands place them at high risk for injury and adverse events (p. 338). Also, it is important to remember that family caregivers are unpaid providers who often need help to learn how to become competent in their delivery of care, while at the same time exercise safety to protect themselves, other family members, as well as the patient. The experienced nurse must always be an available resource when needed. The family caregiver must also be responsible enough to know their boundaries and when it is appropriate to ask for assistance.
According to the Journal of Nurse Practitioners (2009), one common nursing diagnosis related to end of life care is ineffective family coping related to prolonged disease/disability progression that exhausts the supportive capacity of significant persons. Some nursing interventions that can be employed towards this diagnosis are 1. Determine the level of impairment of perceptual, cognitive, and/or physical abilities of the patient. 2. Evaluate illness and current behaviors that are interfering with the care of the patient. 3. Establish rapport and acknowledge difficulty of the situation for the family. 4. Involve significant other in information giving, problem solving, and care of patient as feasible. Instruct in medication administration techniques, needed treatments, and ascertain adeptness with required equipment, and 5. Include all family members as appropriate in discussions. Provide and/or reinforce information about terminal illness and/or death and future family needs (p. 668).
Nurses are at the bedside during the dying process; they spend entire shifts with patients and families, they develop trusting relationships, and they are competent to assess patient and family needs. Nurses gain a unique perspective that allows them to become aware when a patient is not responding to treatment. This perspective places nurses in a position to facilitate end-of-life decision making. A systematic understanding of what roles nurses enact and what strategies they use in end-of-life decision making is necessary to ensure that decisions made are consistent with the patient’s and family’s goals of care.
Nurses have a very big responsibility when it comes to end-of-life care. Nurses play an important role in facilitating communication between and among family members and between family members and the health care team. Nurses enact the supporter role in EOL care by building trusting relationships with family members as they navigate the EOL decision making process and by demonstrating empathy for patients, family members, and physicians. To make decisions, family members need to understand the condition of the patient and the options available; this necessitates receiving clear and truthful information. When family members develop a trusting relationship with nurses, they feel that they can ask nurses questions, trust that they will get the truth, have a better understanding of the prognosis, and fill more prepared. (Limerick, 2007, p. 335). As the population ages and technology permits prolongation of life, dealing with dying patients and their families is likely to become a more frequent experience for all nurses, especially those in acute care environments. Nurses must be prepared mentally, emotionally, and technically to face the challenges of end-of-life care.

References
Puntillo, K. A., & McAdam, J. L. (2006). Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Critical Care Medicine, 34(11), 332-340. doi:10.1097/01.CCM.0000237047.31376.28
Ravenscroft, A. J. (2000). 'End-of-life' decision making within intensive care - objective, consistent, and defensible? Journal of Medical Ethics, 26(6), 435-440. doi:10.1136/jme.26.6.435
Ward, R. L. (2009). End-of-Life Legal Considerations. The Journal for Nurse Practitioners, 5(9), 668-672. doi:10.1016/j.nurpra.2009.07.021
Limerick, M. H. (2007). The process used by surrogate decision makers to withhold and withdraw life-sustaining measures in an intensive care environment. Oncology Nursing Forum, 34(2), 331–339.