Palliative Care Fatigue Symptom Management End-of-Life Care Ethical/Legal Issues
Palliative Care
 



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Care of the Dying

The dying patient has to cope with a declining physical condition, as well as relevant issues about existence, spirituality, and separation. The patient may need help to make up for loss of function and maintain quality of life for the time he/she has remaining.

The goals of care for the dying patient now change from curative to palliative, helping patients live comfortably, as well as supporting them and their families emotionally and spiritually.

Comfort
Daily Care
Emotional and Spiritual Support
Palliative Care Guidelines and End-of-Life Care

Comfort
Comfort is the primary goal of therapy for dying patients.

Medication for pain can be given around-the- clock so that it does not wear off between doses. The medication schedule is tailored to each patient's perception of pain to ensure relief.

Drugs can also be helpful to relieve shortness of breath: Morphine is the most commonly used for this problem. Oxygen therapy may also help breathing problems. Often other simple measures can make breathing more comfortable: a familiar voice to reduce anxiety, a change in position, relaxation techniques, or an open window or fan. If the patient is unable to cough and secretions collect in the airway, the doctor may recommend suctioning (using a tube to remove fluids) through the nose or mouth.

Restlessness can be treated by managing other symptoms, such as pain. Familiar faces and objects also can have a calming effect. Medication may be used when necessary.

Problems with incontinence (lack of normal control) of urine or stool can be managed using drugs, catheters, or disposable products.

Dry mouth is a common complication relieved by simple means, such as drinking fluids, breathing humidified air, sucking on ice or Vitamin C tablets, or chewing sugarless gum. Medication is also available.

Fatigue (tiredness) is a common symptom as death approaches. A patient may need to sleep and rest a large part of the day and rely on a caregiver for day-to-day needs.

At the end of life, weight loss is common. There may be some concern about loss of appetite or difficulty swallowing as the patient's death approaches, but these conditions are not necessarily a cause of suffering for the patient. Despite concerns about weight loss and dehydration, a dying patient is usually most comfortable when allowed to eat and drink as much -- or as little -- as he or she would like. This helps the patient avoid digestive discomfort and fluid retention.

Daily Care
Grooming: Bathing a bed-bound patient every day can provide comfort and refreshment. Hair combing, as well as shaving, can also be done around bath time. Waterproof bed pads or lift sheets can be changed daily -- or more often if soiled. Bed sheets can be changed weekly.
Skin Care: Bedsores often occur in patients confined to bed for long periods. Check the patient's skin for reddened areas every day during bath time. Turning the patient frequently, keeping the skin clean and dry, gently massaging bony areas of the body and applying lotion once or twice daily, as well as supporting the patient lying on his/her side with pillows, can help to prevent bedsores. Ask the doctor or nurse about other ways to treat bedsores.
Mouth Care: Cleaning the mouth of the patient helps to prevent sores and may help to improve the patient's desire to eat. Cleaning can be done twice daily with a soft toothbrush or a cloth. Loose dentures can also cause mouth sores and should be taken out if refitting is not possible. If mouth sores develop, ask the doctor for medicine to treat them. Moisturizing the lips and corners of the mouth as needed prevents cracking.
Exercises: Check with the patient's doctor before exercising the patient. If moving the patient does not cause pain, exercising his/her arms and legs can be done during or after bath time.

Emotional and Spiritual Support
Dying patients also need psychological, social, and spiritual support. This support can be given by family, friends, the community, and health care professionals.

Honest, compassionate communication between the patient/family unit and caregivers is essential at the end of life. Frank, open communication about resuscitation orders, artificial nutrition, hydration (giving fluids), and life support, as well as arranging personal affairs, help the patient prepare psychologically for dying.

The patient should participate actively in treatment decisions as long as possible to maintain control over how and where he/she dies.

Reflection about the meaning of the patient's life helps to establish a legacy of his/her contribution to family, friends, and society. Regrets about the past, guilt for risky behaviors, and sadness about the future are also normal feelings for the dying patient. Working to resolve these issues gives the patient a sense of completion and fulfillment necessary to deal with the impending sense of loss and separation.

For some patients, religious beliefs or a close relationship with God can be a source of support. If the dying person finds meaning and comfort in his/her faith, members of the clergy are available to address the patient's spiritual needs.

Depression is a common symptom in the dying patient, arising from physical deterioration, loss of function, and a sense of impending loss and separation. Depression can be alleviated by counseling and medication.

Psychological, social, and legal support are available to deal with difficult questions that may arise near the end of life. A patient may need help expressing his/her wishes about death and addressing final tasks, such as making a will and getting documents in order.

VIDEO: Culture and End-of-Life

Palliative Care Guidelines and End-of-Life Care
Palliative care provides supportive interventions and management of physical, emotional and spiritual symptoms. The following are some palliative care guidelines that can assist caregivers and physicians to enhance the comfort and quality of life for dying patients and their families.

Health care procedures that optimize the patient's physical functioning, e.g., range of motion exercises and evaluation for use of assisting equipment in the home are done to encourage independent activities.
Diagnostic tests and other consultations can be ordered when necessary to effectively treat symptoms.
Every patient has the right to decide to authorize a Do Not Resuscitate (DNR) order.
Factors such as the patient's choice, diagnosis, disease process, life expectancy, influence nutrition/hydration options. Fluids are usually given by mouth if the patient is able.
Depending on the patient's wishes, diagnosis, and the disease process, antibiotics are used to treat acute infection.
Medications, including chemotherapy, are used to control pain or other symptoms and to maximize the patient's quality of life. Drugs with severe side effects or adverse reactions are not generally used.
Radiation therapy may be used for short-term treatment of specific symptoms of the disease in order to make the patient more comfortable.
Transfusions may be offered to enhance the patient's quality of life, but not recommended if the patient ceases to benefit.

VIDEO: Quality Indicators in End-of-Life Care

   
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