Elective

HOW TO DEVELOP A LEVEL OF COMFORT AND EXPERTISE IN COMMUNICATING
WITH SERIOUSLY AND TERMINALLY ILL PATIENTS AND THEIR FAMILIES
NURSING CARE OF TERMINALLY ILL PATIENTS
Terminall Illness is a progressive, irreversible illness that despite

cure-focused medical treatment will result in the patient’s death.
Many patients suffer unnecessarily when they do not receive adequate

attention for the symptoms accompanying serious illness. Careful evaluation
of the patient should include not only the physical problems but also the
psychosocial and spiritual dimensions of the patient’s and family’s
experience of serious illness.
This approach contributes to a more comprehensive understanding of

how the patient’s and family’s life has been affected by illness and leads to
nursing care that address the needs in every dimension.
COMMUNICATION
Remarkable strides have been made in the ability to prolong life, but
attention to care for the dying lags behind each of us will eventually face
death, and most would agree that one’s own demise is a subject he or she
would prefer not to contemplate. Indeed, Glaser and Strauss (1965) noted
that unwillingness in our culture to talk about the process of dying is tied to
our discomfort with the notion of particular deaths-those of our patients and
our own-rather than death in the abstract. Finucane (2002) observed that our
struggle to stay alive is a prerequisite to being human. Confronting death in
our patients uncovers our own deeply rooted fears.
To develop a level of comfort and expertise in communication with
seriously and terminally ill patients and their families:
 Nurses and other clinicians should first consider their own experiences
with and values concerning illness and death.
 Reflection, reading, and talking with family members, friends, and
colleagues can help nurses examine beliefs about death and dying.
 Talking with people from different cultural backgrounds can help nurses
view personally held beliefs through a different lens and can help
nurses become sensitive to death-related beliefs and practices in other
cultures. Discussion with nursing and non-nursing colleagues can also
be useful; it may reveal the values shared by many health care
N AVA R R E T E , G E O O F R I E Y S A N D L E R | BS N 3 | E L E C T I V E 1
professionals and identify diversity in the values of patients in their
care.
 Values clarification and personal death awareness exercise can provide
a starting point for self-discovery and discussion.
Skills for Communicating With the Seriously Ill
Nurses need to develop skill and comfort in assessing patients’ and

families’ responses to serious illness and planning interventions that will
support their values and choices throughout the continuum of care. Patients
and families need ongoing assistance. Throughout the course of a serious
illness, patients and their families encounter complicated treatment
decisions, bad news about disease progression, and recurring emotional
responses.
In addition to the time of initial diagnosis, lack of response to the

treatment course, decisions to continue or withdraw particular interventions,
and decisions about hospice care are examples of critical points on the
treatment continuum that demand patience, empathy, and honesty from
nurses.
Discussing sensitive issues such as serious illness, hopes for survival,

and fears associated with death is never easy. However, the art of
therapeutic communication can be learned and, like other skills, must be
practiced to gain expertise. Similar to the other skills, communication should
be practiced in a safe setting.
Although communication with each patient and family should be tailored

to their particular level of understanding and values concerning disclosure,
general guidelines for nurses include the following (Addington, 1991):
 Deliver and interpret the technical information necessary for making

decisions without hiding behind medical terminology.
 Realize that the best time for the patient to talk may be when it is least
convenient for you.
 Being fully present during any opportunity for communication is often

the most helpful form of communication
 Allow the patient and family to set the agenda regarding the depth of
the conversation.
Nursing Interventions When Patients and Families Receive Bad News
 Communicating about life-threatening diagnosis or about disease

progression is best accomplished by the interdisciplinary team in any
setting: a physician, nurse, and social worker should be present whenever
possible to provide information, facilitate discussion, and address
concerns.
 Most importantly, the presence of the team conveys caring and respect
for the patient and family.
 Creating the right setting is particularly important. A quiet area with a
minimum of disturbances should be used.
 Coping with news about a serious diagnosis or poor prognosis is an
ongoing process. The nurse should be sensitive to these ongoing needs
and may need to repeat previously provided information or simply be
present while the patient and family react emotionally.
 The most important intervention the nurse can provide is listening
empathetically.
 Keys to effective listening include:
o Resist the impulse to fill the “empty space” in communication with
talk.
o Allow patient and family sufficient time to reflect and respond after
asking a question.
o Prompt gently: “Do you need more time to think about this?”
o Avoid distractions (noise, interruptions)
o Avoid the impulse to give advice.
o Avoid canned responses: “I know just how you feel.”
o Ask questions.
o Assess understanding-your own and the patient’s –by restating,
summarizing, and reviewing.
Responding With Sensitivity to Difficult Questions
Patients often direct questions or concerns to nurses before they have

been able to fully discuss the details of their diagnosis and prognosis with
their physicians or the entire health care team.
Using open ended questions allows the nurse to elicit the patient’s and
family’s concerns, explore misconception and needs for information, and
form the basis for collaboration with physicians and other team members.
In one case, a seriously ill patient may ask the nurse, “Am I dying?”
o The nurse should avoid making unhelpful responses that dismiss the
patient’s real concerns or defer the issue to another car provider.
o The nurse could establish eye contact and follow with a statement
acknowledging the patient’s fears and an open-ended statement or
question.
As a member of the interdisciplinary team caring for the patient at the

end of life, the nurse plays an important role in facilitating the team’s
understanding of the patient’s values and preferences, family dynamics
concerning decision making, and the family’s response to treatment and
changing health status. The nurses can help the patient and family clarify
their values and preferences concerning end-of-life care by using structured
approach. Nurses may need to plan several meetings to accomplish the four
steps described the table below.
Discussing End-of-Life Care

Steps Actions
1. Initiate  Establish a supportive relationship with patient and family

discussion
o State the purposes of the patient/ family-health care team
conference:
 To ensure that the plan of care is consistent with

patient an family values and preferences
 To find out how best to support this patient and family
o Inquire if the patient or family have questions or concerns

that they want to express.
 Elicit values and preferences concerning
o Patient and family decision-making roles
 How many major decisions been made in the past?
 How have treatment/care decisions been made during

the course of the illness?
 Has the patient appointed a surrogate?
o Formal (Durable Power of Attorney)
o Informal
 How does the patient/ family want decisions to be
structured from this point on?
o Setting for receiving care at the end of life
 Home
 Home with hospice care
 Assisted living or long-term with/without hospice
 Disposition when unable to care for self-independently
o Family involvement in care provision
2. Clarify  Identify what the patient and family understand

understanding of
the medical  Identify gaps in knowledge, need for consultation with other
treatment plan members of the health care team
and prognosis
 Use simple, everyday language
3. Identify end-of-  Facilitate open discussion about priorities

life priorities
o State the purposes of the patient/ family-health care team
conference:
 “What is most important to you now?”
 “How can (I/we) best help you to meet your goals?”
 Allow sufficient time for emotional response
4. Contribute to  Provide guidance and/or referral for understanding medical

the options
interdisciplinary
care plan  Make recommendations for referrals to other disciplines or
services
 Identify need for patient/family teaching
 Develop a plan for follow-up:
o Schedule
o Participants
o Tasks/ assignments
o Communication that needs to occur before the next

meeting
o Family member responsible for coordination
REFERENCE: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11 th
Edition Volume 1
HOW TO DEVELOP A LEVEL OF COMFORT AND EXPERTISE IN
COMMUNICATING WITH SERIOUSLY AND TERMINALLY ILL PATIENTS
AND THEIR FAMILIES
Ingredients of Therapeutic Communication
1. Empathy
o Is the ability to enter into another person’s experience to

perceive it accurately and to understand how situation is viewed
from the client’s perspective.
o Empathy is a complex process, The nurse should:
 Have enough knowledge and experience to perceive the

client’s perspective accurately.
 Feel secure enough not to be intimated if client

experiences a situation differently.
 Feel comfortable enough to be able to imagine what a

situation might be like someone else, while remaining
outside that situation to maintain objectivity.
 Convey to the client that the nurse perceives that client’s

feelings, thoughts and experiences accurately.
o Simple action such as touch, kindness, attentiveness and

information sharing also signify empathy.
2. Positive Regard
o Refers to warmth, caring, interest and respect for the person,

seeing the person unconditionally or non-judgmentally.
o Respect or the person does not mean that the nurse accepts all
aspects of a person’s behavior.
3. Comfortable Sense of Self
o Before a nurse can communicate therapeutically, a comfortable

sense of self, such as being aware of one’s own personality,
values, cultural background and style of communication, is
necessary.
 The nurse with comfortable sense of self can evaluate

his/her work strength and weaknesses.
 Self-evaluation also means taking responsibility for one’s
actions as a professional.
 A person with a comfortable sense of self is open to

experiences and is aware of his/her feelings and attitudes.
 The professional with comfortable sense of self feels

separate from others, an important aspect of being
therapeutic.
 Being therapeutic with one’s self is necessary before one

can be therapeutic with others.
Nursing Intervention for the Terminally Ill/ Dying Client
1. Assist client achieve a dignified and peaceful death
a. Provide relief from loneliness, fear and depression
b. Maintain the client’s sense of security, self-confidence, dignity and

self-worth
c. Maintain hope
d. Help the client accept his or her losses
e. Provide Physical Comfort
2. Maintain Physiologic and Psychologic comfort
a. Personal hygiene measures
b. Pain Control
c. Relief of Respiratory Difficulties
d. Assistance with movement, nutrition, hydration and elimination
e. Measures related to sensory changes
3. Provide Spiritual Support
a. Search for meaning
b. Sense of forgiveness
c. Need for love
d. Need for hope
ILLNESS AND DISEASE
Illness is a highly personal state in which the person’s physical,

emotional. Intellectual, social, developmental, or spiritual functioning is
thought to be diminished.
Terminal Illness is a progressive, irreversible illness that despite cure-
focused medical treatment will result in the patient’s death.
Effects of Illness
Illness brings about change in both the involved individual and in the
family. The changes vary depending on the nature, severity, and duration of
the illness, attitudes associated with the illness by the client and others, the
financial demands, lifestyle changes incurred, adjustments to usual roles,
and so on.
A. Impact on Client
o Ill clients may experience behavioral and emotional changes, changes

in self-concept and body image.
o All individuals are also vulnerable to loss of autonomy (state of being

independent without outside control)
Nurses Role:
 Nurses need to help clients express their thoughts and feelings, and
to provide care that helps the client effectively cope with change.
 Nurses need to support client’s right to self-determination and

autonomy as much as possible.
 Nurses need to help patient adjust their lifestyle.
B. Impact on the family
 A person’s illness affects not only the person who is ill but also the
family or significant others.
 Illness of a family member is a crisis that affects the entire family

system.
 The family experiences anxiety because members are concerned about

the sick person and the resolution of the illness.
 During health crisis, families need to realize that it is a strength, not a

sign of weakness, to turn to others for support. Nurses can be a part of
the support system in the community.
Intervening in Families Experiencing Illness
 Nurses committed to family-centered care involved both the ailing

individual and the family in the nursing process.
 Nurses make sure that not only the individual but also each family
member understands the disease, its management, and the effect
of these factors on family functioning.
 Nurses help families cope with the realities of the illness and the
changes it may have brought about, which may include new roles
and functions of family members or the need to provide continued
medical care to the ill or recovering person.
CARING, COMFORTING, AND COMMUNICATING
It is a critical skill for nursing. It is the process by which humans meet

their survival needs, build relationships and experience joy. In nursing,
communication is used to gather information, to teach and persuade, and to
express caring and Comfort. Comforting is the process by which nurses assist
clients and significant other to face the distress and discomforts they may
encounter. In nursing, Communication is an integral part of the helping
relationship.
CARING
Caring is considered by many nurses to be an essential aspect of

Nursing. Madeleine Leininger states that care is the essence of nursing and
the dominant, distinctive, and unifying feature of nursing. She says that
there can be no cure without caring, but that there may be caring without
curing.
COMFORTING
Comforting is a characteristic unique to nursing and an essential

aspect of caring. “Making the patient as comfortable as possible” has been a
frequent nursing action since the days of Nightingale.
Comforting Process
Comforting is a complex process that “includes discrete, transitory

actions, such as touching, or broad, longer lasting interventions such as
listening.”
Comfort
The desired outcome or product of comforting is comfort. Comfort

implies a renewal, an amplification of power or sense of control, an
invigorating influence, a positive mind-set, and a readiness for action. It
enables the client to perform the usual activities of daily life.
A. Comfort Needs
Kolcaba identifies comfort needs within four contexts:
o Physical comfort needs to relate to bodily sensations and the
physiologic problems associated with the medical diagnosis.
o Psychospiritual comfort needs relate to the internal awareness

of self, esteem, concept, sexuality and meaning in one’s life.
o Social comfort needs relate to interpersonal, family, and social

relationships.
o Environmental comfort needs relate to the external background

of human experience and can include light, noise, ambience, color,
temperature and natural versus synthetic elements.
B. Intensity (Type) of Comfort
o Relief from discomfort is the experience of having specific need met.
o Ease refers to a state of calm or peaceful contentment. This state of

comfort enables the client to perform activities efficiently.
o Transcendence refers to the state in which the client rises above

problems or pain.
Comfort Measures
Comfort measures may be provided both directly to the client and

indirectly through other personnel, family, or environment. Comfort
measures are initiated when the nurse perceives client distress or discomfort
or the client indicates a specific need for comforting.
Communication Strategies for Providing Comfort

Characteristic Description
Pity An expression of regret or sorrow for a client who is
suffering, distressed, or unhappy; confirms the
sufferer’s state; facilitates acceptance of reality.
Sympathy An expression of the nurse’s own sorrow for the
client’s condition or situation; has an “I am sorry”
focus; shows acceptance of the client’s state,
thereby providing comfort
Compassion Expresses a strong emotional response to the
client’s distress; leads to sharing of the suffering;
shows acceptance of the client’s problem;
strengthens and comforts; nurse experiences the
client’s pain
Consolation Involves soothing and encouraging to ease
discomfort and pain; may offer support and hope;
express feelings of concern in nurse; can alter focus
to the positive without negating crisis
Commiseration Used commonly in support groups or when the
nurse has experienced the client’s problem in some
form; nurse and client have mutual response to a
common experience; the nurse sincerely
communicates agreement and understanding
Reflexive Spontaneous reaction by the nurse to try to calm
reassurance the client who feels anxiety and distress over some
circumstance; the nurse’s response is intended to
balance the client’s feelings.
PALLIATIVE CARE
-Philosophy of and system for delivering care that expands on traditional

medical care for serious, progressive illness to include a focus on quality of
life, function, decision making, and opportunities for personal growth.
-an approach to care and a structured system for care delivery that aims to
“prevent and relieve suffering” and to support the best possible quality of life
for patients and their families, regardless of the stage of the disease or the
need for other therapies.
-in palliative care, interdisciplinary collaboration is necessary to bring out the

desired outcomes for patients and their families. Interdisciplinary
collaboration is based on communication and cooperation among the various
disciplines, with each member of the team contributing to a single integrated
care plan that addresses the needs of the patient and family.
Palliative Care at the End of Life
All hospice care is palliative care; however, not all palliative care is hospice
care. The difference is that the hospice care is an application of palliative
care delivered at the end of life. Hospice care focus on quality of life, and by
necessity, it usually includes realistic emotional, social, spiritual, and
financial preparation for death. The palliative approach to care could benefit
many more patients if it were available across care settings and earlier in the
disease process.
Characteristics of Palliative Care
The following characteristics are those traditionally used to refer to a

community hospice setting, however, many may be applicable for care in
other settings.
1. Patient-centered
The comfort of the patient is the primary concern. Diagnosis and
pathology are important but primarily for understanding the basis of
symptoms and how to relieve them, and for assessing prognosis.
2. Family/friend-centered
The patient is seen as an integral part of a larger unit, which is the
network of family and friends. In crisis situations, family dynamics are
often strained. One of the tasks of hospice team members is to
distinguish between problems which are clearly those for the patient,
and others which may stem from discomforts being experienced by
other members of the family. Family conferences are often very
valuable in clarifying such tensions.
3. Comprehensive
Care attends to the physical, emotional and spiritual needs of the
patient and family. It addresses fear and anger as well as pain,
recognizing the emotional associations of physical distress. It
recognizes the importance of the meaning and significance which the
individual attaches to serious illness and death. The personalities of
care providers and simple measures which enhance comfort are
potentially as therapeutic as powerful medications.
4. Continuous
Palliative care aims to attend to patient and family needs throughout
the experience of terminal illness, wherever the care is delivered and
right through into the bereavement period.
5. Coordinated
There are many individuals and agencies providing care for the
terminally ill, now as they always have done. They include specialists,
general practitioners, visiting nurses, domiciliary services, hospitals and
nursing homes, self-help groups, clergy, charitable organizations,
families and friends. A palliative care program aims to bring these
valuable services into a coordinated network of care, so that there are
minimal gaps and deficiencies in the care of the dying individual.
6. Teamwork
Because so many persons can be important in helping the resident who
is dying, it is important for each to recognize their role, and the
functions appropriate to the others. Effective communication among
team members and respect for each other’s skills is basic.
7. Regular Review
The situation of a person who is dying may change quickly: a regime
providing comfort today may be inadequate tomorrow. Assessment of
comfort and of therapy should be carried out often and regularly. For
example, as weight decreases or organ function deteriorates
medications may need to be reviewed.
8. No Right Answer
It follows that there is no universally correct response to resident and
family discomfort. Much depends on the expectations and hopes of
those affected. Appropriate intervention may take many forms.
Palliative care tries to control the symptoms that have made dying
unpleasant in the past. Dying is an inevitable part of being alive and is
therefore to be accepted as part of the natural pattern of life. The process of
dying, however, can be influenced by our care and our preparedness to
involve the resident and ‘family’ in decisions and in the care.
Source:
Brunner & Suddarth’s Textbook of Medical-surgical Nursing 13 th
edition, Hinkle J.L., Cheever K.H.
https://hopewell.org.au/your-family/what-palliative-care/characteristics-
palliative-care
THERAPEUTIC COMMUNICATION
Communication is the process of conveying information through various

complex verbal and nonverbal behaviors.
This process can be broken into several components:
1. Communicators are people who simultaneously send and receive

messages through words and nonverbal actions
Examples: nodding, eye contact, facial expressions, posture).
2. Encoding is the process by which a communicator put into words or

behaviors the ideas or feeling that he or she is trying to convey.
Examples: shouting, crying, looking away, and choosing particular
words.
3. Decoding is the process by which a communicator discerns or

interprets, what another is saying.
4. Channel is the router or method a communicator chooses to convey a

message. Channels include writing, talking, looking, e-mailing, and
phoning.
5. Feedback is the discernible responses that a receiver makes to a
sender’s message. All behaviors, including silence, ignoring, are forms
of feedback.
6. Environment refers to the personal experiences that each

communicator brings to the interaction.
Noise is another factor that can influence the effectiveness of

communication.
Therapeutic communication – occurs when the nurse demonstrate

empathy uses effective communication skills, and responds to the client’s
thoughts needs and concerns. This planned process allows nurse and client
to build a trusting relationship in which the client is free to express thoughts,
feelings, and options without fear or judgment.
Nontherapeutic communication - develop when nurses respond in ways

that cause clients feel defensive, misunderstood, controlled, minimized,
alienated, or discouraged from expressing thoughts and feelings. Although
most people use nontherapeutic responses in everyday communication, it is
important to be aware of how these responses deter open discussion and
increase the like hood of withdrawal by clients. Learning the labels for non-
therapeutic responses helps nurses to recognize and avoid them.
THERAPEUTIC COMMUNICATION TECHNIQUES
TECHNIQU PURPOSE EXAMPLE

E
Giving Communicates a desire to begin “What would you like to
broad a meaningful interaction discuss today?”
openings Allows the client to define the “Tell me about how you have
problem or issue been doing.”
Paraphras Reflects the meaning of the “So you’re saying that your
ing client’s message in the nurse’s husband is unwilling to work
words on the marriage anymore.”
Allows for clarification
Lets the client know that the
nurse has understood the
message
Offering Encourage the client to continue “I see.”
general elaborating “uh- huh.”
leads Communicates the nurse’s
interest in listening
Reflecting Reflects the emotion underlying “It sounds like you’re feeling
feelings the client’s message hopeless about the situation.”
Conveys empathy
Focusing Encourage the client to expand “Can you give me an example
upon one part of a statement of how that typically happens
Concentrates on a single issue for you?”
Useful techniques with clients “Let’s go back to______
who are confused or
because I’m not sure I follow
overwhelmed by many issues at you.”
the same time “What is about_____that
bothers you?”
Voicing Gentle way of challenging the “Really?”
Doubt client’s perceptions “Are you sure that your
Encourages reconsideration parents will never accept your
decision?”
Clarifying Makes clear that which is vague “I’m not sure what you mean
or not meaningful. May help by_____.”
clients clarify their own
understanding
Placing Allows the client to organize “So how did this start?”
events in thoughts “What happened next?”
time Provides clues to recurring
sequence patterns
Helps the nurse follow the
client’s train of thought and
understand what is happening.
Giving Allows for teaching and “Several halfway houses have
informatio clarification work program.”
n
Encouragi Encourages client to think about “What do you think you
ng solutions without the nurse should do about this
formulatio giving advice problem?”
n of a Helps the client problem solve “What are your options, as
plan you see them?
Testing Helps the client become aware “you say that you want to
discrepan of inconsistencies in statements participate in this group, but I
cies versus behaviors notice that you have missed
Allows for gentle confrontation the past three meetings.”
NONTHERAPEUTIC COMMUNICATION TECHNIQUES
TECHNIQU PURPOSE EXAMPLE

E
Social Engaging in superficial Client: “I’m glad I’m being
respondin conversation that is not client discharged today.”
g centered Nurse: “are you going to watch
the football game tonight”
Asking Questions that elicit a “yes” or Nurse: “Do you understand
closed- “no” answer instead of allowing everything I’ve told you about
ended for wider exploration of the electroconvulsive therapy?”
questions client’s thoughts and feeling
Changing Introducing an unrelated or Client: “I don’t think my
the peripherally related(usually to husband finds me attractive
subject avoid sensitive issues or reduce since I had the mastectomy.”
the nurse’s anxiety) Nurse: “I didn’t realize you had
breast cancer. Does it run in
your family?”
Belittling Discounting the client’s feelings Client: my home was totally
or making comparisons that imply destroyed in the fire”
the client’s problems are smaller Nurse: “At least you are alive.”
than he or she perceives
Making Offering platitudes or wise sayings Client: “I can’t get over the loss
stereotype that seem automatic or contrived of my mother”
d Nurse: “Time heals wound.
comments Everything happens for a
reason.”
Offering Attempting to cheer up the client Client: “I’m afraid my boss will
false by suggesting there is no real fire me if he finds out that I
assurance problem have substance abuse
problem”
Nurse: “Don’t worry. He
wouldn’t do that.”
Moralizing Passing judgment by imposing Client: “I want a divorce”
one’s own values on the client Nurse: “Don’t you think you
and implying that the client’s owe it to your children to give
thinking is wrong the marriage another try?”
Interpretin Making intrusive comments in an Client: I don’t want to take this
g attempt to overanalyze or medication.”
“psychoanalyze” client’s Nurse: I think you’re in denial
statement about your illness.”
Advising Making specific suggestions Client: “I feel depressed.”
instead of offering information Nurse: “ you should do some
and asking clients what they think volunteer work to take your
is most likely to work mind off things.”
Challengin Denying or diminishing the Client: “nobody cares about
g client’s perceptions, forcing the me.”
client to prove what he or she is Nurse: “What about your sister?
saying I saw her visiting yesterday.”
Defending Arguing or justifying your position Client: “I can’t get any help
rather that attempting to hear the with this problem.”
client’s concerns Nurse: “ we are doing our best
to help you but we are very
busy.”
Reference: Psychiatric-Mental Health Nursing: Evidenced-Based concepts,
Skills, and Practices 8th edition by Wanda K. Mohr
RECOGNIZE AND FOLLOW HIS FAMILY
COPING NEEDS AND UNDERSTANDING
OF THE ILLNESS AND TREATMENT TO
ESTABLISH THE BASIS OF EMPATHETIC
LISTENING EDUCATION AND
EMOTIONAL SUPPORT
MACATANGAY, ARLENE
BSN 3
TECHNIQUES TO ALLOW EXPRESSION
OF FEELING,SUPPORT,IDEALISTIC AND
POSITIVE HOPE
MAGO, IRENE JESSICA

BSN 3
PSYCHOLOGICAL, ETHICAL, SPIRITUAL
ASPECTS & BELIEFS IN THE CARE OF
PALLIATIVE PATIENT
BRAVO, ROSEDEL
BSN 3
PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya
School of Health Sciences
COLLEGE OF NURSING
ELECTIVE COURSE I
SUBMITTED TO:
CYNTHIA P. BAYSAC, RN, MAN

INSTRUCTOR
SUBMITTED BY:
ALONZO, JEVERLYN
BRAVO, ROSEDEL
BULLIONAN, LIZA
CALLANG, DAWN GELLINE
MACARUBBO, RESSIE CATHERINE
MACATANGAY, ARLENE
MANANGPA, LIGAYA
MAGO, IRENE JESSICA
NAVARRETE, GEOFFRIEY SANDLER
PAGGAD, HECY
SAGUN, MARC EROLL
SALAZAR, FROILAN
VALDEZ, ROSELYN
BSN - 3
A.Y 2018-2019
RECOGNIZE AND FOLLOW HIS FAMILY COPING NEEDS AND
UNDERSTANDING OF THE ILLNESS AND TREATMENT TO ESTABLISH
THE BASIS OF EMPATHETIC LISTENING EDUCATION AND
EMOTIONAL SUPPORT
ANTICIPATORY GRIEF AND MOURNING
Denial, sadness, anger, fear, and anxiety are normal grief reaction in
people with life threatening illness and those close to them. Kubler-Ross
(1969) described five common emotional to dying that are applicable to the
experience to loss. Not every patient or family member experiences every
stage; many patients never reach a stage of acceptance, and patients and
families fluctuate on sometimes daily basis in their emotional responses.
Furthermore, although impending loss stresses the patient, people who are
close to him or her, and the functioning of the family unit, awareness of
dying also provides a unique opportunity for family members to reminisce,
resolve relationships, plan for the future, and say goodbye
Individual and family coping with the anticipation of death is

complicated by the varied and conflicting trajectories that grief and
mourning may assume in families. For example, the patient may be
experiencing sadness while contemplating for changes that have been
brought about by the illness and the patient’s spouse or partner may be
expressing or suppressing feelings of anger about the current changes in role
and impending loss of the relationship. Others in the family may be engage
in denial (e.g. “dad will get better; he just needs to eat more”), fear (“ho will
take care of us.” Or “will I get sick too”), or profound sadness and
withdrawal. Although each of these behaviors is normal, tension may arise
when one or more family members perceive that others are less caring, too
emotional, or too detached.
The nurse should assess the characteristics of the family system and
intervene in a manner that supports and enhances the cohesion of the family
unit. Parameters for assessing the family facing life-threatening are identified
in Chart 17-12. The nurse can suggest that family members talk about their
feelings and understand them in the border context of anticipatory grief and
mourning. Acknowledging and expressing feelings, continuing to interact
with the patient in meaningful ways, and planning for the time of death and
bereavement are adaptive family behaviors. Professional support provided by
grief counselors, whether in the community, at a local hospital, in the long-
term care facility, or associated with a hospice program, can help both the
patient and the family sort out and acknowledge feelings and make the end
of life as meaningful as possible.
Coping with death and dying: professional caregiver issues
Whether practicing in the trauma Centre, intensive care unit or other
acute care setting, home care, hospice, long-term care, or the many
locations where patients and their families receive ambulatory services,
nurses are closely involved with complex and emotionally laden issues
surrounding loss of life. To be most effective and satisfied with the care they
provide, nurses need to attend their own emotional responses to the losses
they witness every day. Well before the nurse exhibits symptoms of stress or
burn out, he or she acknowledge the difficulty of coping with others’ pain on
a daily basis and put healthy practices in place that will guard against
emotional exhaustion. In hospice setting, where death grief and loss are
expected outcomes of patient care, interdisciplinary colleagues rely for each
other for support, using meeting time to express frustration, sadness, anger,
and other emotions; to learn coping skills from each other; and to speak
about how they were affected by life of those patient who have died since
the last meeting. In many setting, staff members organized or attend
memorial services to support families and other caregivers, who fine comfort
in joining each other to remember and celebrate the life of patients. Finally,
healthy personal habits, including diet, exercise, stress reduction activities
(such as dance, yoga, Tai chi, meditation), and sleep, will help to guard
against the detrimental effects of stress.
Reference: handbook for brunner and suddarth’s textbook of Canadian

medical-surgical nursing [https://books.google.com.ph]
LEGAL AND ETHICAL ASPECT AND BELIEF IN THE CARE OF
PALLIATIVE PATIENT
Providing good care for dying patients requires that physicians be

knowledgeable of ethical issues pertinent to end of-life care. Effective
advance care planning can assure patient autonomy at the end of life even
when the patient has lost decision-making capacity. Medical futility is difficult
to identify in the clinical setting but may be described as an intervention that
will not allow the intended goal of therapy to be achieved. Medical
interventions, including artificial nutrition and hydration, can be withheld or
withdrawn if this measure is consistent with the dying patient’s wishes.
Physicians caring for terminally ill patients receive requests for physician-
assisted suicide. The physician should establish the basis for the request and
work with the healthcare team to provide support and comfort for the
patient. Physician-assisted suicide could negate the traditional patient-
physician relationship and place vulnerable populations at risk. Physicians
need to incorporate spiritual issues into the management of patients at the
end of life. The integrity of the physician as a moral agent in the clinical
setting needs to be recognized and honored. The physician has a moral
imperative to assure good care for dying patients.
Physicians and other healthcare professionals providing care for dying

patients will confront many ethical dilemmas and challenges. Providing good
care to dying patients requires physicians to be knowledgeable of potential
ethical dilemmas and be aware of strategies and interventions aimed at
avoiding conflict. It is important for the physician to be proactive with regard
to decision making and have good communication skills. Keeping the patient
central in all decision making, that is, respecting patient autonomy, is
essential to ethical care for dying patients. Thus, the role of advance care
planning is important in caring for patients at the end of life. The physician
needs to have a good understanding of ethical principles and issues such as
medical futility and the withdrawing and withholding of medical interventions
as well as the legal ramifications of these ethical issues. With the growing
attention on physician-assisted suicide and euthanasia, physicians need not
only to be knowledgeable of the ethical, legal, and professional ramifications
of these issues, but also to have a clear understanding of their own beliefs on
this and other ethical issues at the end of life. Good care for dying patients
also encompasses attention to spiritual issues at the end of life. Therefore,
physicians need to be comfortable with their role regarding end-of-life care
and spirituality. It is important that physicians have an understanding of the
ethical principles that underlie biomedical ethics and how they relate to
providing care for dying patients.1 Providing good care to dying patients is
an ethical mandate inherent in the very nature of the physician’s role. As
indicated in the 18th Century by John Gregory, “It is as much the business of
a physician to alleviate pain as to smooth the avenues of death...as to cure
disease.
ETHICAL PRINCIPLES AND END-OF-LIFE CARE
An understanding of the principles that underlie biomedical ethics is

important in addressing the issues that confront physicians and their patients
at the end of life. The ethical principles include autonomy, beneficence, non-
maleficence, justice, and fidelity. If one of the ethical principles could be
viewed as central to ethical decision making, autonomy would meet that
description. Autonomy calls for the patient to be the decision maker,that is,
having the right to self-determination. This principle calls for physicians to
preserve a patient’s right to self-determination even when the patient has
lost decision-making capacity. This preservation can be achieved through the
appropriate use of advance directives. Because of the difficulty physicians
and patients have in discussing end-of-life issues, physicians frequently
resort to caregivers to make decisions in lieu of the patient. This action may
be a violation of the principle of autonomy if the patient still has decisional
capacity and has not authorized a surrogate decision maker, or if the patient
no longer has decisional capacity and the decision maker was not designated
by the patient or is unaware of the patient’s wishes. The ethical principle of
beneficence calls for the physician to advocate for what is good or beneficial
for the patient.
Frequently, patients’ choices regarding end-of-life decisions have not been

expressed through advance care planning and caregivers who are
knowledgeable of the patient’s wishes may be absent. In this case, the
physician’s role for the dying patient must always be to advocate for
approaches that promote good care for the patient at the end of life. The
physician needs to be careful that patient autonomy must not be violated in
an attempt to do what the physician views is in the patient’s
best interest. The patient’s desire to choose an option should be respected
even if the physician views the option as not in the patient’s best interest.
Thus, patient autonomy should prevail over paternalism.1 The principle of
nonmaleficence calls for the physician not to inflict harm intentionally. This
principle relates to a basic maxim in good medical care, Primum non
nocere(“above all, do no harm”. Many physicians view participation in
physician-assisted-suicide as a violation of this principle. This position is
reflected in the Osteopathic Oath required of all graduates of colleges of
osteopathic medicine, which states “I will give no drug for deadly purposes
to any person though it may be asked of me.” The ethical principle of justice
demands fairness in the delivery of healthcare. It may apply on a societal
level by assuring a just distribution of healthcare resources, or it may apply
to an individual patient by assuring fair treatment to that patient at the end
of life. In either case, physicians have an ethical obligation to advocate for
fair and appropriate treatment of patients at the end of life. The last ethical
principle, fidelity, requires the physician to be faithful and truthful to the
dying patient. The physician should provide ongoing information about the
patient’s condition when appropriate. Also, the physician needs to be truthful
in issues such as diagnosis and prognosis and be faithful in defending the
choices and decisions of the patient even when the patient can no longer
speak for himself or herself. This defense, of course assumes that the
patient’s request not violate the physician’s own moral code or values.
PRINCIPLE APPLICATION TO END-OF-LIFE CARE
AUTONOMY—The patient’s right to self-determination
Physicians should encourage dialogue about end-of life care and use of
advance directives so that autonomy can be preserved even if patient’s
decision-making capacity is lost.
Physicians should do what they believe is in the patient’s best interest, but
this action must not conflict with the patient’s right to self-determination
Many physicians view participation in physician assisted suicide as a

violation of this principle.
BENEFICENCE—Doing what is good or beneficial for the patient
NONMALEFICENCE—Avoidance of infliction of intentional harm
Physicians should advocate for treatment of their dying patients which is

just and without discrimination.
JUSTICE—Fairness in the delivery of healthcare
Physicians should be truthful to their dying patients regarding the diagnosis

and prognosis and advocate for their dying patients’ wishes even when those
patients’ decision-making capacity has been lost.
FIDELITY—Truthfulness and faithfulness in delivering healthcare.
The management of patients at the end-of-life will involve several issues that
can be challenging ethical dilemmas. These may include issues such as
withdrawing and withholding of interventions, medical futility, and physician-
assisted suicide.
Withdrawing and Withholding Interventions
The withdrawing and withholding of life-sustaining treatment in the

management of patients at the end of life may be appropriate both medically
and ethically. First, certain interventions may simply be medically futile, in
which case there are no ethical, legal, or medical requirements to administer
care that offers no benefit. Second, it is appropriate to withdraw and
withhold treatment that is not wanted by the patient or the patient’s proxy
decision maker. Physicians often have difficulty withdrawing interventions
that have already been initiated. However, if an intervention can no longer
achieve its intended goal or the patient no longer wants this specific
intervention, the intervention should be withdrawn. Thus, from an ethical
perspective, withholding and withdrawing treatment are moral equivalents.
Medical Futility
The issue of medical futility is a clinical situation in medical ethics that may
pose challenges in providing care at the end of life. Reference to an
intervention as being medically futile is a common description; however,
clear definitions of medical futility are still lacking and few clinical scenarios
exist in which there may be uniform agreement that a specific intervention is
medically futile. For example, most would agree that providing
cardiopulmonary resuscitation to a patient who is determined to have brain
death would be futile. In contrast, there would not be uniform agreement
that the provision of artificial nutrition and hydration to a patient in a
persistent vegetative state would be medically futile. Yet, either of these
interventions may be considered medically futile, depending on one’s
definition of medical futility. Thus, unequivocal cases of medical futility are
not commonplace.
Physician-Assisted Suicide
Most physicians involved in end-of-life care have received requests for

physician-assisted suicide. Physician-assisted suicide involves the physician’s
providing the means to end the patient’s life, usually by prescribing a lethal
dose of a sedative hypnotic. Patients may request physician-assisted suicide
because of intractable pain, depression, fear of being a burden on their
family, or fear of loss of their dignity. It is important that the physician
identify the underlying cause of the patient’s suffering. Depression should be
assessed and managed, and other professionals such as psychiatrists,
psychologists, and the clergy should be engaged when appropriate. Patients
should be reassured that physical symptoms such as pain can be effectively
managed. Spiritual symptoms of guilt, loss of purpose in life, and
abandonment often can be addressed by including the chaplain as part of
the healthcare team. The physician should address common fears that the
patient may exhibit which lead to the desire for physician-assisted suicide. It
is important that the physician work as part of a healthcare team in
addressing the varied etiologies that lead to a patient’s request for
physician-assisted suicide. Through a team approach, nearly all the reasons
for which patients may request physician-assisted suicide can be addressed
effectively. It is important for the physician to provide support and a
commitment to dying patients that they will not be abandoned and their
symptoms will be managed throughout the dying process. Physicians must
be cautious not to affirm the patient’s request for physician-assisted suicide
as the request frequently emanates from the patient’s feelings of self-
worthlessness. Therefore, the patient could interpret the physician’s
affirmation as supporting that perception of self-worthlessness.
Pain Management and the Principle of Double Effect
Traditionally, there has been reluctance on the part of physicians to use

higher doses of narcotic analgesics in terminally ill patients because of a fear
of causing death due to central nervous system depression. Some have
viewed this administration of such medication as euthanasia. Data have
indicated that this effect has largely been overstated. Nevertheless, even if
administration of a narcotic analgesic may hasten the dying process in
patients who are near death, as long as the prime intention of administering
the narcotic analgesic is for the purpose of pain management and not the
purposeful hastening of death, it is ethically acceptable to administer the
analgesic. In this case, the ethical principle of the double effect allows for the
unintended, secondary consequences—that is, the hastening of death—
because of the good primary intention of the principle intervention—that is,
pain management. One assumes that the patient or proxy decision maker is
aware of the unintended consequences of aggressive pain management.
The Ethical Integrity of the Physician
The physician’s role as a moral agent in medical ethics is frequently

overlooked. Although few argue about the centrality of patient autonomy as
it relates to ethical decision making, one cannot lose sight of the fact that
the physician is an integral agent in moral acts that take place in healthcare.
Therefore, physicians should not be compelled to violate ethical convictions
or religious beliefs at the request of a patient or the patient’s caregiver.
When a patient indicates requests or desires for interventions that may
violate the physician’s own conscience or ethical standards, the physician
should recognize and discuss these differences at the outset. When a patient
and physician are at odds regarding proceeding with care that the patient
requests, the patient should seek another healthcare provider and the
physician should assist and support the transition.
Spiritual Issues and End-of-Life Care
Physicians frequently hesitate to ask their patients questions about spiritual

issues, yet spirituality may become central to a patient near the end of life.
Spirituality may span affirmation of specific religious beliefs to simply making
sense or identifying meaning in life. It has been recognized that patients at
the end of life could experience significant spiritual growth. The physician
should explore the patient’s past and current spiritual life, whether the
patient would value a visit from a clergy person, and the importance of
religious rituals to the patient. Physicians should be aware of how important
religion may be to a specific patient, and physicians should facilitate
available resources to aid their patients in spiritual care.
TECHNIQUES TO ALLOW EXPRESSION OF

FEELING,SUPPORT,IDEALISTIC AND POSITIVE HOPE
 Enabling client to talk differently
-Focusing the here and now

Enable client to focusupon what is currently happening, as
opposed to focusing on the past and present.
-Avoiding “why’s”
Almost all “why” question of this type lead us to answer with
“because…..”so that dealing with feeling become intellectual and
prevents connection with feelings.
TWO THINGS TO AVOID

1. We focus upon the question “what and How” of behaviour
2. Encourage client to make statements rather than ask
questions.
-Owning feelings
Encourage client to connect their feelings in a compassionate
way and to take responsibility for those feeling and connection with
their bodies.
-Taking responsibility
Encourage client to accept full responsibility for their feeling.
-Saying “won’t, not, can’t”
Another language technique encourage client to stop saying
“can’t” and replace it with “wont”
 Enabling clients to behave differently
-Writing feeling down

We routinely recommend clients to keep a journal or diary to
record thei feeling and monitor which skills and techniques they find
useful.
-Using “empty chair”
This is a valuable and flexible techniques people to say what
they feel.it can help client recognize and accept their feeling to deal
with inappropriate feeling and to take responsibility for these feeling.
1. Expressing an emotion
2. Dealing with inner conflict
3. Making difficult choices
-Sculpting and other psychodrama techniques
Psychodrama is a powerful ways for client to understand
predicaments in relationships and explore new role and relationship.
Sculpting is one especially useful tool within psychodrama .All
sculpting process start non-verbally by creating or exploring.
-Amplification
Useful technique client thinks they recognize feeling, such as
anger, or guilt, excitement, but this is unable to assess how strong
feeling is ,or how it is influencing their thoughts and action.
-Reversals
Involve asking the client to act out the feelings they want to feel.
-Rehearsal
Rehearsal of feeling can be particularly useful in managing
overwhelming anxiety about.
 Working with images
-Using dreams and imagery

This technique can be utilize for people who need to access their
emotions.
-Working with imagery art work
By exploring and changing images, we can affect every aspect of
ourselves powerfully.
 Working with bodily sensation
-Focusing on the body

Work with the person bodily sensation or felt sense as a way of
connecting with their inner feeling and experience.
 Developing mindfulness
-Present moment awareness

Cultivating a present awareness is a way of enabling a person to
stand back from the situation that has triggered unpleasant feelings
and begin to take stock from a cantered meditative
-Befriending emotion
This is a meditative approach to feeling which we encourage the
client to allow their feeling to be “just they are”. By not getting caught
up I judging their feeling and just letting them be, they can begin to
experience their emotions directly.
DIFFERENT TECHNIQUES
 Congruence: this technique involves therapists being genuine and

authentic, and ensuring that their facial expressions and body language
match their words.
 Unconditional Positive Regard: unconditional positive regard (UPR) is
practice by accepting, respecting, and caring about one’s clients; the
therapist should operate from the perspective that clients are doing the
best they can in their circumstances and with the skills and knowledge
available to them.
 Empathy: it is vital for the therapist to show clients that s/he
understands their emotions rather than just feeling sympathy for them.
 Non directiveness: a cornerstone of client-centered therapy, non-
directiveness refers to the method of allowing the client to drive the
therapy session; therapists should refrain from giving advice or planning
activities for their sessions.
 Reflection of Feelings: repeating what the client has shared about his
or her feelings; this lets the client know the therapist is listening actively
and understanding what the client is saying, as well as giving them an
opportunity to further explore their feelings.
 Open Questions: this technique refers to the quintessential “therapist”
question – “How does that make you feel?” Of course, that is not the only
open question that can be used in client-centered therapy, but it is a good
open question that can encourage clients to share and be vulnerable.
 Paraphrasing: therapists can let clients know that they understand
what the clients have told them by repeating what they have said back to
them in the therapist’s own words; this can also help the client to clarify
their feelings or the nature of their problems.
 Encouragers: these words or phrases, like “uh-huh,” “go on,” and
“what else?” are excellent at encouraging the client to continue; these can
be especially useful for a client who is shy, introverted, or afraid of
opening up and being vulnerable (J & S Garrett, 2013)
SOURCE: Helping people with their feeling

https://www.slideshare.net
DISCUSS THE BOUNDARIES IN THERAPEUTIC COMMUNICATION

WITH RESPECT TO DISTANCE AND SENSE OF TOUCH
GUIDELINES FOR USE OF TOUCH
 Touch is one of the nurse’s most potent forms of communication.
 Many messages such as affection, compassion, empathy, emotional
support, encouragement, tenderness, and personal attention are
conveyed through touch.
 Touch should be as gentle or as firm as needed and delivered in a
comforting, non-threatening manner.
 There are times when touch should be withheld; for example, suspicious
or delusional or angry patients may respond negatively or even violently
to the nurse’s touch.
Zone for personal touch
A. Zones of Personal Space

a. Intimate Zone (0 to 18 inches)
 Holding a crying baby
 Performing physical assessment
 Bathing, grooming, dressing, feeding, and toileting a client
 Changing client’s dressing
b. Personal Zone (18 inches to 4 feet)

 Sitting at a client’s bedside
 Taking the client’s nursing history
 Teaching an individual client
 Exchanging information at change of shift
c. Social Zone (4 to 12 feet)

 Making rounds with a physician
 Sitting at the head of a conference table
 Conducting a family support group
d. Public Zone (12 feet and greater)

 Speaking at a community forum
 Testifying at a legislative hearing
 Lecturing to a class of student
B. Zones of Touch
a. Social Zone (permission not needed)
 Hands, arms, shoulders, back
b. Consent Zone (permission needed)
 Mouth, wrist, feet
c. Vulnerable Zone (special care needed)
 Face, neck, front of body
d. Intimate Zone (great sensitivity needed)
 Genitalia, rectum
THE IMPORTANCE OF HEALTH EDUCATION IN THE CARE OF

TERMINALLY ILL PATIENT
HOSPICE CARE
Many people consider hospice to be a place where people go to die.

However, hospice (or palliative care) is not a place, but a special type of care
for terminally ill patients and their families. Terminally ill means that the
patient's illness can't be cured and he or she is going to die from the illness.
Therefore, hospice care is not meant to cure the patient, but to provide
comfort for him or her. Hospice caregivers often provide this type of care in
the patient's home, but can also provide it in a hospital or nursing home.
The goal of hospice care is to help terminally ill patients and their families
cope with the end of life. Hospice is made up of a team of caregivers who
specialize in end-of-life care. This team usually includes doctors, nurses,
social workers, counselors, home health aides, and trained volunteers.
Usually a family member or close friend is the main caregiver, who helps the
patient make important decisions.
The hospice team tries to make the patient's death as peaceful and painless
as possible. The team may use medical treatments to help ease the patient's
pain and discomfort.
Palliative care approaches
The goal of palliative care is to provide treatment that eases the patient’s
pain and other symptoms, as opposed to trying to cure the disease causing
the symptoms. Palliative care specifically addresses quality of life issues and
symptom management.
Communication plays a very large role in palliative care. Good

communication between the patient, family, caregivers, and hospice team or
healthcare providers can provide comfort, relieve stress, and ease the fears
of everyone involved.
Addressing the patient's quality of life is the central focus of palliative care.
This may mean addressing psychological, spiritual, and social issues, as well
as the physical symptoms the patient may have. It is very important that the
patient feel as comfortable as possible.
Dying at home
Many people choose to receive hospice care in the comfort of their home,
which means that they choose to die in their home. There are advantages
and disadvantages of a home death, which people need to consider when
making their decision.
When diagnosed with a terminal illness, many people feel a loss of control. A
home death allows them to keep some sense of control over their lives. It
also provides a more comfortable setting in which to die. However, while
dying at home may be the right choice for some patients, family members
and caregivers have to decide if they can provide the intense care needed.
They must also decide if they can cope with the care and how having their
loved one die at home will affect them.
When a patient chooses to die at home, it is important for his or her family
members and caregivers to learn what to expect. The hospice team will
provide them with information and support. This will help them cope with the
issues and emotions involved in a home death. Family members and
caregivers need to be prepared for the symptoms and suffering that may
occur while the patient is dying. They also need to know how to manage the
symptoms and whom they should contact if the symptoms can't be
controlled, in an emergency, or when death occurs. With the right support
and education, some families find that a home death can be a peaceful and
natural experience.
Grief and bereavement
When a person is very close to dying, his or her family members may begin
to feel grief. Grieving is a natural response to loss. Bereavement (the state of
sorrow over the loss of a loved one) support is a very important part of
hospice care, and it should begin before the death occurs.
The hospice team helps the family grieve by guiding the family as they say
good-bye. Expressing love and other emotions is very important when
someone is near death. It can be helpful for family members to share stories
and look through photos with the patient. Sharing memories is a great way to
ease grief and recall the happy moments in the patient's life.
Family members should also try to settle any conflicts that may exist before
the patient dies. Family members should try to resolve any issues that they
fought over. This helps to relieve any guilt or regret they may feel after the
patient is gone.
Grief is a process that takes time; the amount of time depends on the
individual. The hospice team will generally tend to the survivor(s) for up to
one year, such as counseling, support groups, and educational classes.
Without the proper bereavement support, the survivor(s) are in danger of
developing a more severe grief response. The hospice team can check for
signs of this behavior (such as suicide attempts or drug abuse) and help
guide the survivor(s) in a safer direction.
Humor plays an important role in healthcare even when patients are terminally
ill
Humour can play an essential role in the most serious healthcare settings,
even when patients are receiving intensive or end of life care.
They concluded that humour played an essential role in promoting team

relationships and adding a human dimension to the care and support that
staff provided to seriously ill patients and their families.
The researchers found that staff used humour in a number of ways,

including:
 To cope with, and sometimes distance themselves, from difficult

situations. As one interviewee commented: "When you've had the most
stressful day and you're ready to cry, sometimes it's easier to bring out
humour and take it in the other direction instead of bawling on
somebody's shoulder.
 To connect with other healthcare professionals and provide mutual

support. Shared laughter energised and nurtured a sense of
community. "If you have those fun moments and that connectedness
even the worst hell can happen" said one healthcare professional who
worked with terminally ill patients. "You sail through it as opposed to
walking out really wounded"
 To reduce tension when things don't go as well as they could do. A

doctor who admitted he had been hasty suggesting that a terminally ill
man give up his apartment so soon was greeted with the quip: "Shall I
chart that you made a confession or that you made a mistake"
 To express frustration at life-prolonging measures that staff disagreed

with. Staff in the intensive care unit told researchers how they
paralleled what was happening to one patient by using an inflatable
dinosaur called Dino and putting him through the same interventions.
He became a symbol of their dissatisfaction with the situation.
 To connect with patients and make them feel cared for as individuals.
When a health care aide took a joke picture of a patient with a bubble
bath helmet on his head to put him at ease it became one of his prized
possessions. He showed it to everyone who visited as evidence of the
special treatment he was receiving. And when he died, it was displayed
alongside important family photos.
 To reduce patients' embarrassment with the indignity of needing help

with toileting and other highly personal functions. When a patient
suffered an episode of incontinence she reported that she found the
nurse's matter of fact humour - "what goes in must come out" - made
her feel less distressed.
THE IMPORTANCE OF PALLIATIVE CARE FOR TERMINALLY ILL CANCER

PATIENTS AND THEIR FAMILY MEMBERS
The present paper focuses on close family members’ report of satisfaction

with the care that terminally ill cancer patients and their close family
members receive at the end of the patients’ life. The situation today is that
the death has moved out of the home and into the institution. It seems that
the more developed a country's health care system is, the fewer patients
die at home.
The Aim of Palliative Care
Palliative care is active, holistic care and treatment for patients with
incurable diseases and short expected time left to live. Relieving physical
pain and other bothersome symptoms are central together with efforts
against psychological, social, spiritual and existential problems. The aim of
palliative care is to improve both the patients’ and the close family
members’ quality of life and well-being.
Do health care personnel have the courage and take the time it needs to
listen to the terminally ill who often have thoughts and wishes in their last
days to live? Talking about the death may create safety and
reduce anxiety for all the involved. Unpleasant symptoms occur frequently
among dying patients in hospitals the last days of their lives. In order to
provide dignity for the terminally ill’s last days and the death, improving
relief of symptoms of physical, psychological, spiritual and existential
character is needed. It may be challenging for the health care personnel to
open up for talks with palliative patients about short expected time left to
live and about the death. Dignity in death is related to having someone
together with them in the death moment. It is important that the dying one
receive good pain relief and support to cope with anxiety, worries, and
physical symptoms. To succeed in this, cooperation among the patients,
close family members and health personnel is provided.
Although dying patients may have different needs and wants, there are some
assumptions that characterize "good care” for the dying, such as relief from
emotional and physical problems, social support, continuity in care, and good
communication both with the physicians and the nurses. To evaluate
palliative care, satisfaction with care is an often used method.
In the last decades several kinds of palliative care have been developed,
such as home care and hospice. So far few randomized trials comparing
such program with traditional treatment have been executed. Based on
existing studies it is difficult to make any certain conclusions about what kind
of influences such interventions may have on the patients’ and the close
family members’ satisfaction with the palliative care they receive.
https://www.urmc.rochester.edu/encyclopedia/content.aspx?
contenttypeid=34&contentid=23505-1
https://www.eurekalert.org/pub_releases/2008-04/w-hpa040808.php
PHYSIOLOGIC FUNCTIONS THAT FREQUENTLY IMPAIRED IN

PEOPLE WITH TERMINAL ILLNESS
A. Loss of Muscle tone
1. Relaxation of the facial muscles (the jaw may sag)
2. Difficulty of speaking
3. Difficulty of swallowing and gradual loss of the gag reflex
4. Decreased activity of the gastrointestinal tract
5. Possible urinary and rectal incontinence
6. Diminishes body movement
B. Slowing of Circulation
1. Diminished sensation
2. Mottling and cyanosis of the extremities
3. Cold skin, first in the feet and later in the hands, ears and nose
C. Changes in Vital signs
1. Decelerated and weaker pulse
2. Decreased blood pressure
3. Rapid, shallow, irregular or abnormally slow respirations; Cheyne strokes
respirations; noisy breathing (death rattle); mouth breathing.
D. Sensory Impairment
1. Blurred vision
2. Impaired sense of taste and smell.
MEETING PHYSIOLOGIC NEEDS OF TERMINALLY ILL CLIENT
The physiologic needs of people who are terminally ill are related to a
slowing of body processes and to homeostatic imbalances. Interventions
include providing personal hygiene measures; controlling pain; relieving
respiratory difficulties; assisting with movement, nutrition, hydration and
elimination and providing measures related to sensory changes.
Pain control is essential to enable clients to maintain some quality in their life
and their daily activities including eating, moving and sleeping. Many drugs
have been used to control the pain associated with terminal illness:
Morphine, Heroin, Alcohol, Marijuana and LSD. Usually the physician
determines the dosage but the client’s opinion should be considered; the
client is the one ultimately aware of personal pain tolerance and fluctuations
of internal states. Because physicians usually prescribe dosage ranges for
pain medications, nurses use their own judgment as to the amount and
frequency of pain medication in providing client relief.
PROBLEM NURSING INTERVENTIONS
1. Ineffective Airway Clearance -Fowler’s position: conscious clients
-Throat suctioning: conscious clients
-Lateral position: unconscious clients
-Frequent baths and linen changes if
2. Self-Care Deficit: Bathing/ diaphoretic.
Hygiene -Mouth care as needed for dry
mouth.
-Assist client out of bed periodically.

3. Impaired Physical Mobility -Regularly change bedridden client’s
position.
-Support client’s position with
pillows, blanket rolls, or towels as
needed.
-Elevate client’s legs when sitting
up, to prevent pooling of blood.
4. Altered Nutrition: Less Than
Body Requirement -Antiemetics or small amount of
alcoholic beverage to stimulate
Constipation appetite.
-Encourage liquid foods as tolerated.
-Dietary fiber as tolerated.
5. Altered Urinary Elimination -Laxatives as needed to prevent
constipation.
-Skin care in response to

incontinence of urine or feces.
-Bedpan, urinal, or commode chair
within easy reach.
-Call light within reach for assistance
onto bedpan; linen changed as often
as ordered.
6. Sensory/ Perceptual -Catheterization, if necessary.
Alterations: Visual, Tactile -Keep room as clean and odor free
as possible.
-Clients prefer a light room.

-Hearing is not diminished; speak
clearly and do not whisper.
-Touch is diminished, but client will
feel pressure of touch.
INDICATORS OF IMMINENT DEATH OF TERMINALLY ILL CLIENT

Certain physical, cognitive and behavioral changes occur as a person the
active dying process. The following are common diagnosis:
1. Impaired urinary elimination: due to renal failure decreased perfusion
of the kidney.
2. Total urinary incontinence or lack of muscular control.
3. Ineffective tissue perfusion: peripheral resulting from shunting of
circulation to vital organ system leading to tachycardia, mottling and
peripheral cyanosis.
4. Urinary retention: due to medication or sensory changes causing
inability to relax urinary sphincter.
5. Impaired gas exchange: and ineffective breathing pattern due to
pulmonary compromise or compensation for metabolic alteration leading to
tachycardia, dyspnea, apnea or cheyne strokes respirations.
6. Ineffective airway clearance: resulting from weakness, leading to
congested breathing. (Sometimes as referred to a “death rattle”).
7. Impaired physical mobility: due to generalized weakness.
8. Impaired Swallowing: resulting from weakness and loss of gag reflex.
9. Disturbed sensory perception: due to altered perfusion to sensory
organs and the brain itself and metabolic alteration; may progress to coma.
Hearing is believed to remain intact throughout the dying process.
10. Acute confusion: from delirium or decreased circulation to the brain.
11. Disturbed thought process: resulting from biochemical alterations.
12. Anxiety, death anxiety or fear: due to physical discomfort (pain,
dyspnea) unfinished business or spiritual concerns.
COMMON OBJECTIVE BODY SYSTEM INDICATOR OF TERMINALLY ILL

CLIENT
1. Cognition/ Orientation -Not always responsive, may be
agitated or restless, cannot
subjectively respond to verbal
stimuli.
2. Cardiovascular
-Tachycardia, irregular heart rate,
lowered blood pressure or significant
widening between systolic and
diastolic pressures, DHN.
3. Pulmonary
-Tachypnea, dyspnea, use of
accessory muscle, acetone breath,
cheyne strokes breathing, pooling of
secretions or noisy respirations.
4. Gastrointestinal
-Diminished appetite, smaller
amounts of feces (despite not
5. Renal eating) incontinence.
-Diminished urine output,

incontinence, concentrated urine.

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HOW TO DEVELOP A LEVEL OF COMFORT AND EXPERTISE IN COMMUNICATING

WITH SERIOUSLY AND TERMINALLY ILL PATIENTS AND THEIR FAMILIES

NURSING CARE OF TERMINALLY ILL PATIENTS

Terminall Illness is a progressive, irreversible illness that despite

Many patients suffer unnecessarily when they do not receive adequate

This approach contributes to a more comprehensive understanding of

Skills for Communicating With the Seriously Ill

Nurses need to develop skill and comfort in assessing patients’ and

In addition to the time of initial diagnosis, lack of response to the

Discussing sensitive issues such as serious illness, hopes for survival,

Although communication with each patient and family should be tailored

 Deliver and interpret the technical information necessary for making

 Being fully present during any opportunity for communication is often

 Communicating about life-threatening diagnosis or about disease

Responding With Sensitivity to Difficult Questions

Patients often direct questions or concerns to nurses before they have

As a member of the interdisciplinary team caring for the patient at the

Discussing End-of-Life Care

1. Initiate  Establish a supportive relationship with patient and family

 To ensure that the plan of care is consistent with

 To find out how best to support this patient and family

o Inquire if the patient or family have questions or concerns

 Elicit values and preferences concerning

o Patient and family decision-making roles

 How many major decisions been made in the past?

 How have treatment/care decisions been made during

 Has the patient appointed a surrogate?

o Formal (Durable Power of Attorney)

o Setting for receiving care at the end of life

 Home with hospice care

 Assisted living or long-term with/without hospice

 Disposition when unable to care for self-independently

o Family involvement in care provision

2. Clarify  Identify what the patient and family understand

3. Identify end-of-  Facilitate open discussion about priorities

 “What is most important to you now?”

 “How can (I/we) best help you to meet your goals?”

 Allow sufficient time for emotional response

4. Contribute to  Provide guidance and/or referral for understanding medical

 Identify need for patient/family teaching

 Develop a plan for follow-up:

o Communication that needs to occur before the next

o Family member responsible for coordination

Ingredients of Therapeutic Communication

o Is the ability to enter into another person’s experience to

o Empathy is a complex process, The nurse should:

 Have enough knowledge and experience to perceive the

 Feel secure enough not to be intimated if client

 Feel comfortable enough to be able to imagine what a

 Convey to the client that the nurse perceives that client’s

o Simple action such as touch, kindness, attentiveness and

o Refers to warmth, caring, interest and respect for the person,

3. Comfortable Sense of Self

o Before a nurse can communicate therapeutically, a comfortable

 The nurse with comfortable sense of self can evaluate

 A person with a comfortable sense of self is open to

 The professional with comfortable sense of self feels

 Being therapeutic with one’s self is necessary before one

Nursing Intervention for the Terminally Ill/ Dying Client

1. Assist client achieve a dignified and peaceful death

a. Provide relief from loneliness, fear and depression

b. Maintain the client’s sense of security, self-confidence, dignity and

d. Help the client accept his or her losses