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C H A P T E R 29
Caring for Older Adults
at the End of Life
LEARNING OBJECTIVES
After reading this chapter, you will be able to:
1. Identify factors that influence attitudes toward
death.
2. Describe cultural and historical approaches to end-
of-life care.
3. Explain the nurse’s role in end-of-life care.
4. Identify the common characteristics of “quality of
life” and a “good death.”
5. Describe palliative care and hospice nursing.
6. Assess physical, psychological, social, and spiritual
care needs for older adults at the end of life.
7. Identify appropriate nursing interventions to ad-
dress symptoms commonly experienced by older
adults at the end of life.
K E Y P O I N T S
death medicalization
death with dignity palliation
dying rehumanizing
end of life spiritual well-being
hospice
B
ecause of the dramatic increases in life expectancy and
the trend toward living longer with chronic conditions,
there has been increasing interest in and emphasis on
end-of-life care. Advances in medical knowledge and tech-
nology have shifted the focus of care to prolonging and sus-
taining life because many illnesses that once were fatal (e.g.,
cancer, cardiovascular disease) are now chronic conditions.
Because of these changes, health care providers focus not
only on preventing and curing disease but also on managing
chronic illness and promoting quality of life. For people in
the terminal stages of an illness, the focus of health care is
on optimal comfort and quality of life for people who are
dying and for their families. In older adults, death is usually
associated with the cumulative effects of chronic illness and
many interacting conditions, rather than a single cause.
THE DYING PROCESS AND DEATH
Although life and death appear to be clear concepts, the lack
of an exact definition of the terms life, dying, and death can
at times cloud the goals of care. According to the American
Geriatrics Society’s (AGS’s) position statement on The Care
of Dying Patients (AGS, 2002), birth and death give defini-
tion to life as the period of time in between. Death is an irre-
versible lifeless state in which the physiologic functions of
life are absent. Dying is regarded as a less specific, individ-
ualized process in which an organism’s life comes to an end
(i.e., the final portion of the life cycle). When does the dying
process begin? People are considered to be dying when they
are ill with a progressive condition that is expected to end in
death and for which there is no treatment that can substan-
tially alter the outcome (AGS, 2002). The length of the dying
process varies and depends on the individual’s holistic situa-
tion. Its duration may be a matter of minutes, hours, weeks,
or months.
The end of life is the period for patients when “there is
little likelihood of cure for their disease(s); further aggressive
therapy is judged to be futile; and comfort is the primary goal”
(Wilke & TNEEL Investigators, 2003, p. 9). This period can
last from hours to months, and it encompasses the time during
which a person is actively dying. Palliation is defined as “the
relief of suffering when cure is impossible” (Wilke & TNEEL
Investigators, 2003, p. 41). Palliative care is an evolving pro-
fessional specialization, defined by the Robert Wood Johnson
Foundation Last Acts Task Force (2002) as the “comprehen-
sive management of the physical, psychological, social, spir-
itual, and existential needs of patients, particularly those with
incurable, progressive illness. The goal of palliative care is to
help patients achieve the best possible quality of life through
minimizing suffering, controlling symptoms, and restoring
functional capacity, while remaining sensitive to personal, cul-
tural, and religious values, beliefs, and practices.”
575
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576 PA RT 5 Promoting Wellness in All Stages of Health and Illness
NURSING SKILLS FOR PALLIATIVE CARE
Regardless of the setting, nurses take on a primary role in the
delivery of palliative care at a time in which aggressive, cur-
ative medical care is no longer feasible or appropriate. Ac-
cording to the Hospice and Palliative Nurses Association
(HPNA) position statement on the Value of Professional
Nurse in Palliative Care, nurses have long advocated for at-
tention to quality of life throughout the lifespan, including
end of life, and they are the healthcare professionals who pro-
vide consistent presence to patients and families who are
facing terminal illness (HPNA, 2008). The position statement
describes nursing skills for effective end-of-life care as
follows:
Advanced terminal or chronic illness usually presents with
not one, but multiple and often complex symptoms that affect
the body, mind, and spirit of the patient. These symptoms re-
quire the professional nurse to employ highly trained skills
and provide holistic care that is consistent with the goals of
the patient and family . . . . Competent, patient-centered nurs-
ing practice for palliative care includes expert assessment
skills, critical thinking, comprehensive pain and symptom
management of the whole patient, effective communication
skills, and a professional knowledge base to support ethical
decision making. These are the skills that patients and fami-
lies value highly as death approaches. HPNA (2008, p.1)
PERSPECTIVES ON DEATH AND DYING
During the last hundred years, society witnessed significant
change in the perception and management of death. Before
the 20th century, death was more readily accepted as an in-
evitable and normal part of life. Illness and death were family
centered, with care provided by family members in their
homes. As health care became more sophisticated, a shift oc-
curred. Hospital-based care provided by physicians, nurses,
and other professionals replaced the family caregiving model.
This medicalization of end-of-life care has had a major im-
pact on the dying experience in the last three to four decades:
end-of-life experiences in formal health care facilities are
often technologically driven and dehumanized (Saunderson
& Brener, 2007).
Nursing is a leading force in the palliative care movement—
a natural fit given the holistic tradition of the profession. In
the past two to three decades, as hospice has grown, so has a
realization that the end of life can be positively affected by
returning to basics. Goals are slowly refocusing on comfort,
companionship, and caring, with nurses in a pivotal role. This
rehumanizing of death and dying recognizes and respects
the process as an important and meaningful stage of the con-
tinuum of human life. Box 29-1 presents strategies for rehu-
manizing death.
Sites of Death and Dying
Since the beginning of the 20th century, when most people
died in their homes, the place of death gradually shifted, so
Box 29-1 Strategies for Rehumanizing Death
● Reintroduce a peaceful sense of harmony between dying peo-
ple and the process of dying.
● Provide the support of community participation in dying rituals.
● Support the harmonious acceptance of death as ordinary and
natural, not a social evil.
● Emphasize the comforting roles of fellowship, ritual, and
ceremony.
● Facilitate, even mandate, the notion that dying should be a
culturally shared community experience.
● Culturally legitimize the pain and suffering that often accompa-
nies dying.
● Provide a common base of participation and sense of belong-
ing; attach the dying person to the community of living.
Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to
compassionate care (p. 281). Philadelphia, PA: Lippincott Williams & Wilkins.
that by the 1990s, only 20% of people died at home or in non-
institutional settings. However, that trend is reversing, and in
1999, 25% of deaths occurred in private homes (Wilke &
TNEEL Investigators, 2003). According to the report by the
Robert Wood Johnson Foundation Last Acts Task Force
(2002), a national coalition to improve care and caring near
the end of life, 50% of Americans aged 65 years and older
die in hospitals, although more than 70% state their desire to
die at home. The deaths are often preceded by multiple physi-
cian visits and expensive life-prolonging treatments.
Studies indicate that between 24% and 30% of deaths
among older Americans occur in long-term care facilities
(Munn et al., 2008; Menec, Nowicki, Blandford, & Veselyuk,
2009). A national nursing home survey found that the number
of hospice patients receiving care in nursing homes has been
increasing significantly in recent years (Bercovitz, Decker,
Jones, & Remsburg, 2008). Concerns have been raised about
end-of-life care in nursing facilities. For example, Menec et al.
(2009) found that unnecessary and inappropriate hospitaliza-
tions of long-term care residents close to the end of life are
common and have a particularly negative impact.
Views of Death and Dying in Western Culture
As a result of many interacting factors, Western culture has
tended to deny or ignore the universality of death. During the
last several decades, responsibility for the dying experience has
been informally and more exclusively delegated to clinicians,
with a majority of deaths occurring in hospitals. In health care
settings, physicians are usually the major decision makers be-
cause of their medical expertise. Many older adults revere
physician suggestions and recommendations for treatment,
even though they do not always fully understand the issues, op-
tions, or potential consequences. Older adults are often reluc-
tant to question physicians, and they may set aside their
personal values, ideas, and wishes to follow the advice of their
doctor. Consequently, they may not explore their options of
dying in places other than hospitals or institutional settings.
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Caring for Older Adults at the End of Life
In studies of social gerontology, Markson (2003) identi-
fied the following four contemporary societal values or be-
liefs that shape the general outlook on aging and death:
1. Work and activity are intertwined with self-worth, and
chronic illness or disability is associated with the end of
productivity and loss of purpose. Consequently, people
may not acknowledge illness and aging because they are
viewed as predecessors to death.
2. Through self-determination and individual responsibility,
anyone can do anything if he or she tries hard enough. Be-
cause human life has inherent limitations, this false men-
tality is a major underpinning to the denial of aging and
death in the 21st century.
3. Medical advances of the last several decades foster the be-
lief that aging, illness, and even death can be manipulated,
managed, and controlled.
4. Authority over and responsibility for death has subtly
transferred from religious leaders to physicians. Conse-
quently, the ability to cure illness and prolong life has im-
bued life and death with qualities that are more humanistic
and less spiritual.
In some ways, society is more accepting of an older adult’s
death compared with that of a younger person. The rationale
for this attitude is that older people have had an opportunity
to “live their lives.” Sometimes, death is viewed as a blessing,
taking an older adult out of a situation of suffering and reduced
capacity. Caregivers often express relief when death occurs,
stating that “he wouldn’t have wanted to live like this.”
Despite these prevalent attitudes and beliefs, in the past 20
to 30 years, society in general has begun to culturally acknowl-
edge and integrate an increasing acceptance of life’s end. This
change has been largely provoked by the baby boom generation
facing its own aging process while simultaneously dealing with
their parents’ aging and health issues. Ethical questions and
challenges have surfaced as a result of problems in care and ris-
ing associated costs. For example, in the midst of the assisted
suicide debate, society has begun asking a second layer of ques-
tions: “What value is there in the last phase of life? Can there
be any meaning and value in the process of dying? Can there
be value in grieving? Can there be value in caring for people as
they die?” (Byock, 2006). The changing demographics and in-
crease in the numbers of older adults dying will be an impetus
for continued discussion and changes in social policies.
Older Adults’ Perspective on Death and Dying
How do older adults view death when mortality becomes im-
minent? Common stereotypes about old age contribute to the
myth that older adults are ready to die because their lives have
lost their value. These beliefs have been proven to be ageist.
On the contrary, although studies have suggested that death
anxiety decreases with advancing age, older adults’ feelings
about death vary according to individual social circumstances
and life experiences (Markson, 2003). In spite of their
chronologic years, many older adults have life goals they ex-
pect to fulfill; consequently, they are not ready to die.
CHAPTER 29 577
A Student’s Perspec tive
This week, I learned that it is okay to accept that an elderly
patient is ready to die and that is his/her wish. I had a patient
who requested that we not perform any measures—just give
him his beer with lunch, wine with dinner, and some pain
medicine to make him comfortable. He stated that he has led
a good life and is ready to go see God. That is really hard for
me because it’s my job to help people and save lives. The
other aspect of that is helping people die a dignified death—
it’s just a really TOUGH aspect!!!
Sarah E.
Although younger generations may feel a sense of entitle-
ment to a long life, many older adults hold the opposite view.
They may be more accepting of the possibility of imminent
death, viewing long life as a privilege. Young people tend to
place life and death on opposite ends of the spectrum, and
feel threatened and cheated by death because of the opportu-
nity for living that is lost. From their vantage point, older
adults more frequently view death as a natural part of life’s
continuum, and the process of dying as a period of self-
actualization. Even though physical decline is a main theme
of aging and dying, for many older adults, this time of life is
one of growth and fulfillment. From this holistic perspective
on death and dying, old age can be turned into an opportunity
for development and death into an ultimate accomplishment.
Health Care Professionals’ Perspective
on Death and Dying
Health care facilities have been institutionally designed to be
centers for disease care and disease cure. Given this orienta-
tion, practitioners and health care professionals often view
death as something to be avoided because it symbolizes pro-
fessional and personal incompetence or failure. Prolonging
life, even at the expense of quality, was thought to be the ul-
timate accomplishment: a symbol of success for patients,
families, and the health care teams involved.
In recent decades, palliative and end-of-life care have be-
come part of the medical mainstream, and health care profes-
sionals realize they can find meaning and satisfaction in caring
for people who are dying and their loved ones. As experts, pro-
fessionals in the disciplines of hospice and palliative care play
a key role in promoting awareness and understanding in this
process of social, cultural, and professional maturation. Stan-
dards of care define and guide health professionals’ practice
to include clear communication, ethical decision making,
technical competence, and intensive management of symp-
toms, respecting the dying individual’s autonomy. The issue
of quality of life versus quantity of life at all costs has rede-
fined the professional perspective.
To provide effective end-of-life care, nurses need to ex-
amine their own feelings and attitudes, which may affect the
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578 PA RT 5 Promoting Wellness in All Stages of Health and Illness
care they provide. Personal beliefs about death are shaped by
experiences from the time of birth, with the family as the pri-
mary influence. Religious affiliations, popular media and cul-
ture, and ethnic background contribute to one’s reactions to
death and dying. Whether death is discussed as part of normal
life or whether it is seen as “the enemy” influences care.
Nurses need to learn about clinical aspects of end-of-life care,
and they must also take time to process their own feelings
and concerns. Some questions to ponder for self-awareness
and insight include the following (Ohio State University
Health Sciences Center, 2003):
● When you hear the word “death,” what comes to your
mind? What do you personally fear the most? What are
you most curious about?
● How old were you the first time someone close to you
died? How was grief handled in your family? What do you
believe happens to you when you die?
● Have you ever seen anyone die? What was that like for
you?
● How do your own attitudes and previous experiences af-
fect the way you work with dying patients now?
Because of the nature of their work as care providers, nurses
are in an ideal position to serve primary roles in achieving
quality end-of-life experiences for older adults.
Culturally Diverse Perspectives
on Death and Dying
Nurses providing holistic care to older adults at the end of
life need to recognize the effects of culture on the dying ex-
perience because cultural beliefs and practices are particularly
influential with regard to end-of-life care (Hampton et al.,
2010; Salman & Zoucha, 2010). Cultural factors can affect
all the following aspects of end-of-life nursing care:
● Perceptions of a good death
● Acceptance of hospice and palliative care services
● Lines of communication about pending death and end-of-
life decisions
● Expectations about medical interventions (e.g., decisions
about resuscitation)
● Place where death occurs
● Practices and rituals near the end of death and immediately
following death
● Decisions about autopsy or organ donations.
Because the experience of death and dying is very personal,
nurses should incorporate cultural considerations into indi-
vidualized assessments and be aware of diverse beliefs and
attitudes associated with the experience of death and dying.
Cultural Considerations Box 29-1 provides information about
death rituals that are commonly associated with specific
groups. It also suggests interventions that nurses can apply
in different situations. As with other aspects of culturally ap-
propriate care, nurses need to be aware of different practices
that may be associated with particular groups; at the same
time, they need to avoid stereotypes.
A Student’s Perspec tive
I found myself in a situation today in which I quickly recognized
the importance of the lesson on cultural sensitivity in nursing.
My aging client unfortunately had a significant change over the
weekend, and her husband requested for her to be transported
to the hospice inpatient unit. As she and I sat on her bed, she
verbalized her acceptance that her disease is terminal. She wept
as she voiced her heartache in telling her family of her “disap-
pointment.” Even though she is Catholic, because of her Chi-
nese heritage and her family’s Buddhist belief in “saving face,”
she worries that she has let her family down. While she ex-
pressed her thoughts, I listened and provided emotional sup-
port, which seemed to ease some of her grief. We transported
her to the hospice unit, and I assisted in making her comfort-
able with the new environment. When I went out to the nurses’
station to give my report, the receiving nurse’s first comment to
me was, “I see she is Asian and you have her religious prefer-
ence documented as Catholic. Are you sure that is correct?”
Because of our recent discussions and reading on cultural sen-
sitivity, I quickly realized how we as nurses can make incorrect
assumptions in categorizing individuals based on their ethnicity.
I reported about my client’s childhood history, her parents’ be-
lief in Buddhism, the Catholicism she was taught in school, and
her long and strong Catholic faith. I found myself really under-
standing the importance of educating ourselves as nurses about
different cultures and the effect of cultural belief systems on in-
dividualized health care. As difficult as it was for me to leave
my client in a strange environment, I felt that the information I
had learned and shared would enable the staff to be respectful
of her beliefs, which in turn would be a positive experience for
my client during her stay.
Deborah L.
QUALITY OF CARE AT THE END OF LIFE
During the 1990s and early 2000s, reports from several major
institutions—including the Institute of Medicine and the
Robert Woods Johnson Foundation—identified serious prob-
lems with end-of-life care in the United States. These reports
found that many people experienced discomfort and suffering
from end-of-life symptoms because health care professionals
did not possess the skills and knowledge required to meet the
needs of a dying person. To address some of the problems,
the Nathan Cummings Foundation and the Robert Wood
Johnson Foundation developed the Toolkit of Instruments for
Measuring End-of-life Care (TIME) to help health care pro-
fessionals identify opportunities for improving care. The End
of Life Nursing Education Consortium (ELNEC) is a major
initiative to improve nursing care for people who are near the
end of life. A recent study concluded that the ELNEC project
has been tremendously successful in improving nursing
knowledge at end of life during the past decade (Whitehead,
Anderson, Redican, & Stratton, 2010). Information about
these and other educational programs is listed in the
Resources at the end of this chapter.
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Caring for Older Adults at the End of Life CHAPTER 29 579

CULTURAL CONSIDERATIONS 29 - 1
Death Rituals Commonly Associated With Specific Groups
Group Death Ritual Intervention

African Americans May respond to news of death of a loved one by falling
out (i.e., sudden collapse, paralysis, and inability to see
or speak).
Amish Appalachians Provide a wake-like “sitting up” during the night for seri-
ously ill and dying family members.
Cubans, Filipinos, Mexicans A large gathering of relatives and friends may attend the
dying person and place religious artifacts around the
person; candles are lit after death to illuminate the path
of the spirit to the afterlife.
Europeans Believe that the dying person should not be left alone.
Haitians Family members gather and pray when death is immi-
nent and may cry uncontrollably; all family members
try to be at the person’s bedside at the time of death.
Hindus, Indians Priest and eldest son may perform death rites, with all male
relatives assisting; women may respond with loud wailing.
Japanese Family members gather at the bedside at the time of
death, with the eldest son having particular responsi-
bilities at the time.
Jews Dying person should not be left alone; death rituals vary and
some are not performed on the Sabbath or holy days.
Koreans Family members are expected to stay with the person
who is dying and assist with care.
Mexicans Some, especially women, may have an ataque de nervios
(i.e., the person exhibits hyperkinetic and seizure-like
activity to release strong emotions) on hearing of the
death of a loved one.
Muslim groups The bed should be turned to face the holy city of Mecca,
family recites prayers from the Qur’an.
Navajo Indians It is taboo to talk about a fatal disease or dying; the issue
needs to be discussed in the third person, as if it is
occurring in someone else.
Puerto Ricans Death is perceived as a time of crisis; the head of the
family (i.e., usually the oldest daughter or son) is re-
sponsible for receiving the news of death.
Vietnamese Flowers are avoided during illness because they are usu-
ally reserved for rites of the dead.
Recognize that this is a culturally based response and not
an emergency medical condition; provide support.
Arrange for privacy and accommodate family members
staying overnight.
Arrange for a gathering place close to the dying person;
find electric candles if open flames are not allowed;
summon clergy for religious rituals; do not move reli-
gious items.
Make accommodations for family members to be present
at all times.
Make accommodations for privacy, encourage family to
bring in religious objects, allow families to participate in
postmortem care if they desire to do so.
Provide a supportive and private environment; offer un-
derstanding of death rituals and grief behaviors.
Notify eldest son of pending death, identify lines of com-
munication if eldest son is not available.
Ask the closest relative specifically about postmortem
practices.
Support family in caring for the person.
Recognize that this is a culture-bound syndrome and treat-
ment is usually not necessary; remain with the person, pro-
vide support, and involve family with assistance if possible.
Facilitate positioning of the bed whenever possible, pro-
vide privacy for prayers.
Avoid suggesting that someone is dying because this
may be interpreted as a wish that the person be dead.
Allow time for family to view, touch, and stay with the
body before it is removed; ask if the family wants a
clergy member called.
Ask permission from the patient or family before placing
flowers in a room.

Source: Purnell, L. D. ( 2009). Culturally competent health care. Philadelphia, PA: F. A. Davis.

Promoting Wellness at the End of Life ● The patient is psychologically comfortable.

Wellness at the end of life is closely connected to the concept
of a “good death,” which has been described by Western so-
cieties as a death with dignity. A death with dignity is
specifically characterized by a dying experience in which
(Wilke & TNEEL Investigators, 2003):
● The patient’s and family’s wishes are respected.
● The patient and family feel a sense of control over the
situation.
● The patient is physically comfortable.
● The patient has spiritual support available according to her
or his wishes.
These characteristics are in accord with the “Dying Patient’s
Bill of Rights,” a document created at a workshop on “The
Terminally Ill Patient and the Helping Person” by Linda
Austin (1975) to identify concretely the dignified care that
dying people deserve (Box 29-2). This document continues
to be helpful as a fundamental guide for defining goals and
interventions for individualized end-of-life care.
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580 PA RT 5 Promoting Wellness in All Stages of Health and Illness
Box 29-2 The Dying Person’s Bill of Rights
I have the right to be treated as a living human being until I die.
I have the right to maintain a sense of hopefulness, however, changing
its focus may be.
I have the right to express my feelings and emotions about my
approaching death in my own way.
I have the right to participate in decisions concerning my care.
I have the right to expect continuing medical and nursing attention
even though cure goals must be changed to comfort goals.
I have the right not to die alone.
I have the right to be free from pain.
I have the right to have my questions answered honestly.
I have the right not to be deceived.
I have the right to have help from and for my family in accepting
my death.
I have the right to die in peace and with dignity.
I have the right to retain my individuality and not be judged for my
decisions, which may be contrary to the beliefs of others.
I have the right to be cared for by caring, sensitive, knowledgeable
people who will attempt to understand my needs and will be
able to gain some satisfaction in helping me face my death.
I have the right to be cared for by those who can maintain a sense
of hopefulness, however, changing this might be.
I have the right to expect that the sanctity of the human body will
be respected after death.
I have the right to discuss and enlarge my religious and/or spiritual
experiences, whatever these may mean to others.
Source: Austin, L. (1975). Dying patient’s bill of rights. Created at The Terminally Ill Pa-
tient and the Helping Person Workshops. Sponsored by the Southwest
Michigan Inservice Education Council in Lansing, MI.
For many older adults, a “good death” is part of the process
of “aging well,” but both processes are very individualized and
strongly influenced by cultural and spiritual factors. In the con-
tinuum of life, the experiences of aging, the end of life, and
death are opportunities for self-actualization. Defining a “good
death” for older adults is extremely personal and often depend-
ent on the effects of aging and illness on the person’s level of
function and independence. The goal of nursing is to support
this stage of life and help patients maintain optimal personal
dignity.
Patient comfort, which has always been a core nursing re-
sponsibility, is an essential component of death with dignity.
The word “patient” is derived from the Latin word patiens,
which means “one who endures” or “one who suffers.” The
word “comfort” comes from the Latin confortare, which
means “to strengthen.” Literally, then, nurses who provide
comfort to patients are strengthening those who suffer. This
definition is particularly appropriate for nurses who provide
care for patients at the end of life that is built on the following
beliefs (Wilke & TNEEL Investigators, 2003):
● The dying are not people for whom “nothing can be done.”
● Patients deserve to be assured that everything will be done
to prevent them from dying in pain, without dignity.
● Patients will not die alone, isolated from those they love
and who love them.
DIVERSITY NOTE
A study of 284 Muslims of 14 nationalities identified the following pri-
orities as important components of a “good death”: dignity, privacy,
spiritual and emotional support, access to hospice care, ability to
issue advance directives, and time to say goodbye (Tayeb, Al-Zamel,
Fareed, & Aboueillail, 2010).
Hospice Care
Hospice refers to a philosophy of care that seeks to support
dignified dying or a good death experience for those with ter-
minal illnesses. Hospice care involves a core interdisciplinary
team of professionals and volunteers who provide medical,
psychological, and spiritual support as well as support for the
patient’s family. These services are provided by public and
private agencies in home- or facility-based care settings, or
in freestanding, short-term residential facilities.
The term hospice (from the same linguistic root as “hospi-
tality”) was first applied to specialized care for dying patients
in the 1960s by physician and nurse Dame Cicely Saunders,
who founded the first modern hospice—St. Christopher’s—
in a residential suburb of London. During a guest lecture for
medical students, nurses, social workers, and chaplains at Yale
University, Saunders introduced the idea of hospice care and
emphasized holistic services and symptom control. This lec-
ture sparked interest, which led to the development of hospice
care as it is known today.
In 1969, psychiatrist Elisabeth Kübler-Ross published On
Death and Dying. This book, based on interviews with dying
patients, identified five stages through which many termi-
nally ill patients progress: denial, anger, bargaining, depres-
sion, and acceptance (Kübler-Ross, 1969). The book was well
received by all disciplines and drew attention to the needs of
dying people. In 1972, Kübler-Ross testified at the first na-
tional hearings conducted by the U.S. Senate Special Com-
mittee on Aging, on the subject of death with dignity. In her
testimony she stated,
A Student’s Perspec tive
When I left the nursing home today I felt better about working
with people facing the certain end of their lives. Mr. F. had a
really positive attitude about his inoperable brain tumor and it
made me understand that I am the one who feels uncomfortable
with death. He expressed that his life has meaning and that he is
here for a reason. He told me about some of his goals in life: he
plans to get out of the nursing home so that he can travel around
the country in an RV with his wife. He seemed to imply that even
if that goal never occurred, it was OK, that it was mostly some-
thing to look forward to. All of the communication with Mr. F.
had a huge impact on me. It gave me a whole new perspective on
how people view their lives. This man is suffering from this
terrible disease, yet he still finds hope and has goals in life.
Erin H.
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Caring for Older Adults at the End of Life
We live in a very particular death-denying society. We isolate
both the dying and the old, and it serves a purpose. They are
reminders of our own mortality. We should not institutionalize
people. We can give families more help with home care and
visiting nurses, giving the families and the patients the spir-
itual, emotional, and financial help in order to facilitate the
final care at home. National Hospice and Palliative Care
Organization (NHPCO) (n.d.)
In 1982, Congress created a Medicare hospice benefit,
which provided federal financial support to people dying of
a terminal illness. Hospice benefits have become increasingly
available and are now supported by many health insurance
plans. Advantages of these services include the following:
● Hospice treats the person, not the disease; focuses on the
family, not the individual; and emphasizes the quality of
life, not the duration.
● Hospice care relies on the combined knowledge and skill
of an interdisciplinary team of professionals, including
physicians, nurses, home care aides, social workers, coun-
selors, and volunteers.
● Hospice care is a cost-effective alternative to the high costs
associated with hospitals and traditional institutional care.
Hospice eligibility criteria, which are defined by
Medicare, require a physician referral, including a statement
that a patient is terminally ill and has a life expectancy of 6
months or less. This requirement is problematic because it is
difficult to predict the length of time before death. As a result,
many patients have missed opportunities for services and had
their benefits delayed until the last few weeks of life. Despite
the substantial increase in the use of hospice services in re-
cent years, the mean length of service has decreased from 25
days in 1998 to 20 days in 2007 (Connor, 2009).
An important role of nurses is to advocate for referrals to
engage hospice support earlier for the benefit of older adult
patients and their families. Hospice programs offer the fol-
lowing services:
● Physician and nursing care
● Home health aide
● Therapies such as music, art, and other supportive services
● Social work and counseling services
● Spiritual care
● Volunteer support
● Bereavement counseling, including support programs for
1 year after death
● Medical equipment and supplies
● Drugs related to the disease
● Inpatient care for symptom management, caregiver respite,
or both.
NURSING INTERVENTIONS
IN END-OF-LIFE CARE
To assist patients and their families in attaining death with dig-
nity in a caring manner, the nurse must possess the following
skills: interpersonal communication abilities; expertise in the
CHAPTER 29 581
assessment and treatment of the physical, psychosocial, and
spiritual dimensions of dying; the ability to relate prognoses
to patients and families; and knowledge of resources. Nurses
assist patients and families with end-of-life tasks, such as
identifying sources of support (e.g., hospice), managing
symptoms, supporting life-closure processes, and planning
for rites and rituals at the time of death and after. Nurses have
primary roles not only in assisting with these tasks but also
in teaching families about the signs of imminent death and
management of the dying processes.
McSteen and Peden-McAlpine (2006) discuss the primary
role of nurses as advocates serving as guides, liaisons, and
supporters during the dying experience. Guiding activities in-
clude providing and clarifying information and options in a
manner that supports the decision making of the dying indi-
vidual and his or her family. In addition, the nurse advocate
serves as a liaison between the family and members of the
health care team. Including family members in their loved
ones’ dying process ultimately has a positive impact on the
experience. Finally, the nurse advocate acts to support the
choices and decision making of patients and families, setting
aside his or her own perspective as a health care professional.
Nurses will gain personal and professional satisfaction
from serving as care providers, coordinators, and advocates
for older adults at the end of life. Fulfillment can be obtained
from knowing that patients die in comfort, with their dignity
intact and their wishes and values respected.
Promoting Communication
The National Institutes of Health consensus statement on im-
proving end-of-life care (National Institutes of Health Con-
sensus Development Program, 2004) identified numerous
transitions that people face at the end of life, including phys-
ical, emotional, spiritual, and financial. Nurses have many
opportunities to intervene in each of these realms by using
communication strategies and interpersonal skills. These in-
terventions include presence, compassion, touch, recognition
of an individual’s autonomy, and honesty (Box 29-3).
Communication is the cornerstone of interpersonal rela-
tionship building. When caring for people who are dying,
communication is critically important to all involved, and its
importance is magnified by the unpredictability of the situa-
tion. Nurses can help dying patients express their needs by
using open, honest, direct, and empathetic communication,
even when they may be uncertain about what to say. (See
Box 29-4 for examples of what to say as well as what not to
say.) Dying patients value the ability to express themselves;
in particular, older adults value the opportunity to achieve
closure and say good-bye.
Offering Spiritual Support
Spiritual support provided by nurses is widely recognized as
an important component of end-of-life care because it con-
tributes to the dying person’s quality of life (Murray, 2010;
Wallace & O’Shea, 2007). Spiritual well-being at the end of
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582 PA RT 5 Promoting Wellness in All Stages of Health and Illness

Box 29-3 Supportive Interventions for Relationship Building

Presence A core nursing intervention, presence can be described as a “gift of self” in which the nurse is available and
open to the situation.
Presence can be demonstrated through verbal communication, valuing what the patient says, accepting
the patient’s meaning for things, and remembering or reflecting.
Compassion The nurse strives to be totally and compassionately with the patient and family, allowing the most positive
experience.
Touch A powerful therapeutic intervention, touch communicates an offer of unconditional acceptance. It can be
both healing and life affirming, a means of communicating genuine care and compassion.
Recognition of autonomy The nurse realizes and respects the individual’s right to make all end-of-life decisions.
Honesty The nurse is often in a front-line position to communicate/explain what can be expected. Compassionate
honesty builds trust with the older adult facing death and his or her family.
Expert communication At any given moment, nurses need to be able to assess the patient and family, implement a plan to
comfort them, and communicate clearly and supportively throughout.
Assisting in transcendence At the highest level of care, nurses provide emotional support that facilitates the experience of self-
transcendence and a sense of triumph over death.

Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to compassionate care (p. 6). Philadelphia, PA: Lippincott Williams & Wilkins.

life includes meaningful existence, the ability to find meaning
in daily experience, and the ability to transcend physical dis-
comfort and prepare for death (Ferrell & Coyle, 2006).
Nurses assess spiritual needs both initially and on an ongoing
basis because these needs are likely to change during the end-
of-life process. Nurses can apply information from Chapter 13
to assess spirituality in older adults.
Nursing diagnoses pertinent to spiritual care during the end
of life are Risk for Spiritual Distress, Spiritual Distress, and
Readiness for Enhanced Spiritual Well-being. The following
nursing interventions relevant to spiritual care at the end of
life are as follows: Active Listening, Coping Enhancement,
Emotional Support, Guilt Work Facilitation, Hope Instillation,
Presence, Religious Ritual Enhancement, Spiritual Support,
and Touch. Nurses also make referrals for pastoral care, hos-
pital chaplains, parish nurses, or other spiritual support re-
sources when appropriate. Hospice programs provide spiritual
support and can provide resources to assist nurses in address-
ing spiritual needs of patients and families.
Managing Symptoms
Although the end-of-life period and dying are very individu-
alized and unpredictable processes, some symptoms occur
commonly and require expert and timely nursing care, par-
ticularly for older adults who may experience more symptoms

Box 29-4 Communicating With Dying Patients

and Their Families A Student’s Perspec tive
I had a special experience with a man at the nursing and rehab
What to Say center. “Mort” and I had great conversations, and he quickly
● What do you need me to do for you? became a friend. Mort was suffering from cardiovascular fail-
● Is there anyone I can call for you? ure, and I knew he did not have long to live. I interviewed Mort
● I’m here to listen. and then wrote a paper about his life. I wrote the paper early
● No need to rush. Take your time. so that I could read it to Mort before his health declined any
● It’s okay to cry. Let me get you a tissue.
more. I read my paper to Mort one morning, and he listened
● Would you like to be left alone?
● Would you like to share some memories? with a seeming sense of sacredness about the words being
read. This was his life, and I could tell that it meant a lot to
What Not to Say him that I wrote it all down. When I finished, Mort simply said,
● She’s in a better place now. “I thank you . . . I thank you.” He asked me to put the paper
● He lived a full life. in a safe place so it would not get ruined. Mort and I had a
● She’s out of her pain. special connection; he was a hero to me. The following week,
● It’ll be all right. I went to the clinic and found out that Mort had passed away.
● Don’t cry. I am grateful that I had the opportunity to know Mort and to
● Be strong. grow and learn from his good life. I am glad that I could serve
● He’d want you to get on with your life. him at this final time and help him reflect on his life.
Amy C.
Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to
compassionate care (p. 18). Philadelphia, PA: Lippincott Williams & Wilkins.
LWBK783_c29_p575-588:Layout 1 11/9/10 1:54 PM Page 583
Caring for Older Adults at the End of Life
(Ogle & Hopper, 2005). Symptoms, which can occur at any
time, include fatigue and weakness, constipation, dyspnea,
nausea and vomiting, dehydration, decreased appetite, and
pain. Because these symptoms usually occur in combination,
management is challenging and it is not always possible to
control every symptom completely. Although not every pa-
tient will have a peaceful passing, nurses and other health
care professionals must make every effort to manage symp-
toms and alleviate distress to the extent possible.
Nurses can use information in Table 29-1 and the follow-
ing sections as a guide to nursing assessment and interven-
tions for some of the commonly occurring symptoms. In
addition, nurses can use information in Chapter 28 to address
pain, which is a symptom that occurs frequently at the end of
life and is one of the most feared symptoms associated with
death. This chapter addresses the symptoms only in relation
to the end of life; other pertinent topics are discussed more
comprehensively in other chapters: confusion or delirium
(Chapter 14), depression (Chapter 15), constipation (Chapter
18), and sleep problems (Chapter 24).
Fatigue (Asthenia)
Fatigue is one of the most commonly reported symptoms at
the end of life. Fatigue is often described as tiredness, or lack
of physical strength and endurance, or decreased mental con-
centration. Older adults may have reduced energy or activity
tolerance caused by usual aging changes, so it is important
for the nurse to establish a baseline for comparison and mean-
ingful interpretation. Fatigue is generally a symptom with un-
derlying causes related to disease processes or conditions,
such as anemia, malnutrition, infection, drug therapy, or de-
pression. Other concurrent end-of-life symptoms, such as
pain and dyspnea, may exacerbate fatigue.
Constipation
Constipation, a reduced frequency of bowel movements, can
include passing hard stools, straining to pass a stool, or im-
paction (hard stool that is blocked). Constipation may be ac-
companied by pain, abdominal fullness, and reduced bowel
sounds. In general, older adults are at increased risk for con-
stipation because of medications, dietary patterns, and de-
creased physical activity. Factors that increase the risk for
constipation at the end of life include pain medications
(discussed in Chapter 28), dehydration, kidney failure, ele-
vated calcium levels, and disease effects (e.g., ascites, spinal
cord damage, colon or pelvic cancers). One study found that
constipation was the most common and frustrating adverse
effect of opioids in patients near the end of life (Lentz &
McMillan, 2010).
Dyspnea
Dyspnea is a sensation of shortness of breath or breathless-
ness. It has been described as a sensation of suffocation or
being smothered that can generate fear that death is occur-
ring. A study of almost 6000 patients receiving hospice care
CHAPTER 29 583
found a high prevalence of breathlessness during the 3
months leading to death, with increasing prevalence and
severity closer to the time of death (Currow et al., 2010). Dys-
pnea may result from abnormalities or imbalanced states in
the pulmonary, cardiac, neuromuscular, or metabolic systems,
as well as arising from psychological causes.
Nausea and Vomiting
Nausea and vomiting are common symptoms associated with
terminal illness. Causes of nausea and vomiting at the end of
life include the following:
● Irritation/obstruction of gastrointestinal tract (bowel ob-
struction, constipation, cancer tumor, delayed emptying of
stomach from ascites, tumor pressure [often called squashed
stomach syndrome])
● Medication side effect (particularly opioids such as
morphine)
● Ear infection or labyrinthitis
● Electrolyte imbalance, sepsis
● Kidney failure, liver failure
● Increased intracranial pressure (brain tumor, cerebral
edema, intracranial bleeding, metastasis)
● Foul odors
● Anxiety, fear.
Dehydration
Because older adults normally have an age-related decrease
in body water, they become dehydrated more easily. Causes
of dehydration at the end of life include reduced or inadequate
oral intake, medications such as diuretics, vomiting, diarrhea,
and fever. Symptoms of dehydration can interfere with com-
fort by causing dry mouth, constipation, confusion, and skin
impairment.
Anorexia and Cachexia
Additional symptoms include anorexia, a lack of appetite that
progresses to the inability to eat, and cachexia, which is a
general state of malnutrition in which there is loss of fat, mus-
cle, and bone mineral content. People with cachexia usually
do not respond to increased intake or nutritional supplements
(Ferrell & Coyle, 2006). Even before the terminal illness,
older adults often have less lean tissue, so there is less reserve
and malnutrition can progress quickly. Factors that contribute
to anorexia and cachexia include nausea and vomiting, con-
stipation, dehydration, weakness, depression, pain, oral can-
didiasis or dry mouth, gastritis, and medication side effects.
Symptoms During the Active Dying Process
When it becomes apparent that a dying person has only a few
days to live, it is especially important that the nurse work
closely with the individual and his or her family to help them
understand the dying process and anticipate changes. Guid-
ance about what to expect helps reduce fear and anxiety (Ogle
& Hopper, 2005). Characteristic physical signs indicate the
“active dying” process. In most situations, the individual has
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TABLE 29- 1 Guide to Nursing Assessment and Interventions for Common Symptoms at the End of Life
Symptom Nursing Assessment
Fatigue (asthenia) Assess for associated conditions, in-
cluding infection, fever, pain, depres-
sion, insomnia, anxiety, dehydration,
hypoxia, medication effects.
Constipation Identify risks (e.g., chronic laxative
users, medications).
Perform abdominal assessment, in-
cluding palpation for distention,
tenderness, or masses and ausculta-
tion of bowel sounds and pitch.
Assess patients taking pain medica-
tions daily.
Monitor the character of the bowel
movements.
Check the rectum if the older adult has
not had a bowel movement in more
than 3 days or is leaking liquid stool
(which can occur with an impaction).
Dyspnea Respiratory: Assess vital signs, includ-
ing oxygen saturation, breathing pat-
tern, and use of accessory muscles.
Auscultate breath sounds.
Assess cough (type, if present).
Check for tachypnea and cyanosis.
General: Assess for restlessness, anxi-
ety, and activity tolerance.
Nausea and Assess for potential cause (e.g., con-
vomiting stipation, bowel obstruction).
Palpate abdomen and check for
distention.
Assess vomitus for fecal odor.
Assess heartburn and nausea, which
may occur after meals in squashed
stomach syndrome.
Assess pain (e.g., pain on swallowing
may indicate oral thrush; pain on
standing may be caused by mesen-
teric traction).
Hiccups occur with uremia.
Dehydration Assess for clinical signs of hydration
(e.g., skin turgor over the upper
chest or forehead).
Assess buccal membranes for moist-
ness.
Assess vital signs: pulse, orthostatic
blood pressure.
Anorexia and Assess for weight loss.
cachexia Assess for levels of weakness and
fatigue.
Conduct physical examination for
decreased fat, muscle wasting,
decreased strength.
Assess mental status, including
depression.
COPD, chronic obstructive pulmonary disease.
Nursing Interventions
Inform older adult and family of the normality of
fatigue at end of life.
Pace activities and care according to tolerance.
Exercise if tolerated.
Promote optimal sleep, with regular times of
rest, sleep, and waking.
Anticipate and prevent constipation with em-
phasis on fiber, fluid intake, and activity, but
recognize that patients may have difficulty tol-
erating the optimal interventions. Promote reg-
ular routine.
Strongest propulsive contractions occur after
breakfast; provide patient privacy at this time.
Pace activities and rest.
Provide oxygen, usually at 2–4 L per cannula
(avoid using face mask because of discomfort
and sensation of smothering).
Provide calm reassurance.
Use a fan to circulate air and help reduce the
feeling of breathlessness.
Position for optimal respiratory function (e.g.,
leaning forward over a table with a pillow on
top is helpful for COPD; on the side with head
slightly elevated for unresponsive patient).
Teach patient to use pursed-lip breathing, and
encourage relaxation techniques to reduce
muscle tightness and associated sensation of
breathlessness.
Offer frequent, small meals; serve foods cold or
at room temperature.
Apply damp, cool cloth to face when nauseated.
Provide oral care after vomiting.
Encourage fluids as tolerated; offer ice chips and
popsicles if swallowing.
Provide frequent oral care; use swabs or mois-
tened toothettes.
Remove unpleasant odors.
Provide frequent oral care.
Treat pain optimally.
Provide frequent, small meals.
Provide companionship.
Serve meals in a place that is separate from the
bed area.
Involve patient with meal planning.
Collaborate with dietician for nutritional analysis
and meal planning.
Encourage culturally appropriate foods.
Consider using an alcoholic beverage before meals.
Pharmacologic Interventions
Corticosteroids, although generally
contraindicated in older adults, may
decrease fatigue in patients with
cancer.
Treat associated conditions (e.g., with
antibiotics, antidepressants).
Individualize laxative regimen based on
the cause(s) of constipation, history,
and preferences. Use bulk-forming
and stool-softening agents for pa-
tients with normal peristalsis.
A laxative regimen (with stimulant
laxative) may be ordered for patients
taking a pain medication known to
cause constipation.
Stimulant laxatives are the most appro-
priate for opioid-induced constipation.
Treat causes.
Treat symptoms with morphine or
hydromorphone, which relieves the
breathless sensation in almost all
cases.
Use antianxiety agents or antidepres-
sants if appropriate (and if perception
of breathlessness is exaggerated
because of anxiety or depression).
Corticosteroids can be used for their
anti-inflammatory effects in certain
conditions (e.g., COPD, radiation
pneumonitis).
Medications need to be specific to the
cause:
● Squashed stomach syndrome, gastri-
tis, and functional bowel obstruction:
metoclopramide (contraindicated in
full bowel obstruction)
● Chemical causes, such as morphine,
hypercalcemia, or renal failure:
haloperidol
● If caused by dysfunction of vomit-
ing center (e.g., associated with
mechanical bowel obstruction,
increased intracranial pressure,
motion sickness): meclizine or
diphenhydramine
Give intravenous fluids or administer
clysis per advance directives.
Discuss continued diuretic use with
physician.
Medications that are used to stimulate
appetite, promote weight gain, and
provide a sense of well-being: mege-
strol acetate, corticosteroids, and
mirtazapine.
Metoclopramide is used to improve
gastric motility and appetite.
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Caring for Older Adults at the End of Life CHAPTER 29 585

become totally dependent on others for all aspects of care, with friends are also difficult for those being left behind. Nurses
less wakeful or alert time. Levels of consciousness may change can offer and coordinate grief support through the hospice or
or fluctuate. The person has little or no interest in the oral intake palliative care team, or through chaplains or other meaningful
of food or fluids. Physiologic changes occur in breathing pat- religious and spiritual resources.
terns, circulation slows down, sensory awareness decreases,
and muscle weakness occurs as a result of decreased tone. In
addition to these physiologic manifestations, up to 85% of pa-
tients experience delirium during the last weeks of life, with
agitation being a common manifestation (Clary & Lawson,
P art I: Mr. Bauer is a 91-year-old man with medical
diagnoses including hypertension, type 2 diabetes mellitus,
2009). Table 29-2 summarizes some signs and symptoms that
occur within days of death. Nurses should describe plans for history of cerebrovascular accident, and benign prostatic hy-
care to give reassurance that comfort needs will be met. The perplasia. He was taking the following medications, lisinopril
overall focus of nursing care at this point is to continue to pro- (Prinivil), 20 mg daily; aspirin, 81 mg daily; furosemide (Lasix),
mote physiologic and psychological comfort, while assisting 40 mg daily; potassium, 20 mEq daily; and acetaminophen
the older adult in achieving a peaceful, dignified death. The (Tylenol) as needed for arthritis pain. He has lived at home
Dying Person’s Bill of Rights (Box 29-2) continues to provide by himself for the last 15 years since the death of his wife.
guidance for care in the final hours of life. He has three adult children, all living out of state, who visit
When death does not occur suddenly, the older adult may on average once monthly. He is very well known in his
have opportunities for final closure. Reminiscence and life neighborhood as the older man who helps everyone. He
review can promote self-actualization during this time. Par- loves his home and spends his days “keeping house.” His fa-
ticipation in decisions concerning the person’s death, as well
vorite chores include mowing the grass in the summer and
as those concerning the continuation of life for loved ones,
blowing the snow in the winter. He owns and drives a car
can assist in bringing inner peace. Older adults often reach a
point of readiness and anticipation of death, and they may to the local supermarket and barber and to the cemetery to
communicate that they are ready to make the transition from visit his wife’s grave. In late summer, he had an accident with
life to death. Nurses can use therapeutic communication tech- his lawn mower that drew his family’s attention to the fact
niques to acknowledge their expressions in a genuine and that he was losing his strength. While mowing his grass, he
supportive manner. Final good-byes to family members and fell over the lawn mower, scraping his face on the cement.
He required emergency department (ED) evaluation and
treatment, including stitches for facial lacerations. He later
TABLE 29- 2 Signs and Symptoms of Death Within Days admitted that, before his fall, he had been experiencing
Physiologic Change Signs and Symptoms dizziness, especially when getting out of his easy chair.
Three weeks after his ED evaluation, Mr. Bauer’s daughter
Altered breathing patterns ● Breathing initially becomes more
shallow
came to visit. She was shocked to see her father looking so
● Cheyne-Stokes respirations “thin and gaunt.” Mr. Bauer admitted that he had lost a few
● Noisy breathing (death rattle) pounds over the summer and still didn’t have much energy.
Changing circulation ● Limbs, ears, and nose become cold to He stated that he wasn’t sleeping well at night, with his sleep
touch or mottled in appearance
disrupted every 30 to 45 minutes because of the need to uri-
● Decreased blood pressure
● Pulse may weaken and become irregular nate. To control his urination, he had decided to limit his
● Diaphoresis drinking fluids to less than 8 oz daily. Mr. Bauer’s daughter
● Possible increase in dependent edema
● No urine output or small amount of
noticed that in spite of his weight loss, his abdomen was very
very dark urine (anuria or oliguria) large and distended. “Do you have any aches?” she asked her
Decreased muscle tone ● Relaxed facial muscles, lower jaw father. He nodded yes and grabbed his lower abdomen.
drops, mouth open
● Decreased/loss of gag reflex
● Difficulty swallowing
T H I N K I N G P O I N T S
● Abdominal distention due to ● Based on symptoms and history, what points would you
decreased gastrointestinal activity
● Possible urinary and fecal incontinence address in your nursing assessment?
due to relaxation of sphincter muscles ● What nursing problems would you address in
Decreased senses ● Reduced level of consciousness Mr. Bauer’s nursing care plan?
● Blurred or distorted vision ● What are some probable causes of Mr. Bauer’s abdom-
● Decreased taste and smell (probable inal discomfort?
continued sense of hearing) ● What would the appropriate nursing interventions be?
Source: Saunderson, C. A., & Brener, T. H. (Eds.). (2007). End of life: A nurse’s guide to
● What health teaching would you provide?
compassionate care. Philadelphia, PA: Lippincott Williams & Wilkins.
LWBK783_c29_p575-588:Layout 1 11/9/10 1:54 PM Page 586
586 PA RT 5 Promoting Wellness in All Stages of Health and Illness
P art II: Mr. Bauer and his daughter have a follow-up
office visit with his primary care physician. On arrival, his
vital signs are as follows: temperature, 98⬚ PO; apical pulse,
82 beats per minute and irregularly irregular; respirations,
24 per minute; and blood pressure sitting, 98/50. When
standing to walk to the scale for his weight measurement,
he swayed a bit, grabbed the wall, and then steadied him-
self. “I just got a little dizzy,” he admitted. As the office nurse,
you immediately grabbed the blood pressure cuff and
took his blood pressure in the standing position. It was
70/40. Mr. Bauer’s pulse at that time was 90 and irregular.
Noting the vital sign changes, the physician ordered some
laboratory tests. Blood samples for testing were drawn in
the office. With results pending, no changes were made in
his medical care at that time.
T H I N K I N G P O I N T S
● What are your immediate nursing concerns for
Mr. Bauer based on information about his decline dur-
ing the past 6 months?
● What risk factors are likely to be contributing to
Mr. Bauer’s dizziness?
● What patient teaching is indicated at this time?
P art III: Mr. Bauer’s blood test results come back the
next day, confirming dehydration and malnutrition:
● Sodium: 150
● Potassium: 3.7
● Serum albumin: 3.0
● Prealbumin: 14
● Blood urea nitrogen: 35
● Serum creatinine: 1.7
The physician discontinued Mr. Bauer’s furosemide and
lisinopril and suggested a follow-up visit in 2 weeks. Two
days before his next appointment, Mr. Bauer’s daughter
called the office to relay that her father had fallen and was
taken to the hospital for evaluation. A workup revealed that
he had a transient ischemic attack and was now too weak
to eat and he was experiencing difficulty swallowing. The
family declined a feeding tube and a hospice referral was
made.
T H I N K I N G P O I N T S
● Identify two priority nursing diagnoses appropriate for
Mr. Bauer at this time.
● For each diagnosis, list two to three nursing interven-
tions.
Mr. Bauer died in the hospital 1 week after his fall, on the
day he was scheduled for discharge.
Chapter Highlights
End-of-Life Transitions
• The end of life is the period in which there is little likeli-
hood of cure, and comfort is the primary goal.
Cultural and Historical Perspectives on Death and Dying
• There is a gradual trend toward dying at home, which is
where most people say they want to die, and where most
people did die during the early part of the 20th century.
• American society is moving beyond the culture of denial
of death and finding ways to address death as an integral
part of life (Box 29-1).
• Cultural factors significantly affect attitudes toward death
and dying (Cultural Considerations Box 29-1).
Quality of Care at the End of Life
• Nurses and other health care professionals have strong
roles in supporting death with dignity (Box 29-2).
• Hospice is a philosophy of care whose goal is to support
dignified dying and a good death experience for people
who are terminally ill.
Nursing Interventions in End-of-Life Care
• Nurses use many interventions, including verbal and non-
verbal communication (Boxes 29-3 and 29-4), to address
the complex needs of patients who are dying and their
families.
• Nurses assess and address common symptoms that occur
during the end of life, including fatigue, constipation, dys-
pnea, nausea and vomiting, dehydration, and anorexia
(Table 29-1).
• Nurses holistically address needs of patients and families
during the immediate end-of-life process (Table 29-2).
Critical Thinking Exercises
1. Review the section on Health Care Professionals’ Perspec-
tive on Death and Dying and spend a few minutes answer-
ing the questions for self-reflection.
2. Review Cultural Considerations 29-1 and think about how
each of the points listed applies to your personal perspec-
tives on death and dying.
3. From a nursing perspective, identify the ways in which
caring for patients at the end of life differs from caring for
patients with acute care needs.
4. From a nursing perspective, identify the ways in which
caring for patients at the end of life differs from caring for
patients who have chronic illnesses.
LWBK783_c29_p575-588:Layout 1 11/9/10 1:54 PM Page 587
Caring for Older Adults at the End of Life
Resources
For links to these resources and additional helpful Internet
resources related to this chapter, visit at http://thePoint.
lww.com/Miller6e.
Clinical Tools
Center to Advance Palliative Care
Promoting Excellence in End-of-Life Care
TIME: Toolkit of Instruments for Measuring End-of-life Care
Evidence-Based Practice
National Guideline Clearinghouse
• End-of-life care
• Quality palliative care
• Interventions to improve palliative care of pain, dyspnea, and
depression at the end of life
• Family preparedness and end-of-life support before death of
a nursing home resident
Health Education
American Association of Colleges of Nursing, End-of-Life Care
(ELNEC)
Dying Well
Growth House: Guide to Death, Dying, Grief, Bereavement, and
End of Life Resources
Hospice and Palliative Nurses Association
National Association for Home Care & Hospice
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