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 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
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
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
||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
|| 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
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
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
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.
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
||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.
Quality Indicators in End-of-Life Care