Hospice and

Palliative Nursing

Rainier C. Moreno-Lacalle
NLAC-SON Clinical Instructor
• Telling a patient that they are going
to die is probably the most difficult
situation any health professional will
face.
 Grading system
Quizzes - 50% (includes assignment and reflections on research
abstracts)
Exams- 25%
Research critique- 15% (format and grading system will be send
through e mail)
Attitude & Attendance- 10%
Hospice

“means give to hospitality”

A medieval term, refers to a resting place for

travelers along pilgrim routes, where the sick, the
poor, and those weary from travelling were taken
in and receive care

Means a system of specialized care that provides

shelter and comfort for the most difficult of
journeys- facing one’s won death
 Palliative care

(WHO 1990) is the active total care of patients

whose ease is not responsive to curative
treatment. Control of pain, of others symptoms,
and of psychological, social and spiritual problems,
is paramount. The goal is achievement of the BEST
QUALITY OF LIFE for patients and their family.
 Basic principles

When dying is accepted as normal

process, intensive caring instead of
intensive care is a more appropriate
approach. This does not mean
nothing more can be done. It does
mean compassionate expertise is
applied to relieve or palliative
physical, emotional, spiritual, or
But we cannot live the afternoon of life
according to the program of life’s
morning—for what was great in the
morning will be little at evening, and
what in the morning was true will at
the evening have become a lie.
Hospice affirms
life. Hospice
exists to
provide
support for
persons in the
last phases of
incurable
diseases so
that they may
live as fully and
 • Death never occurs within a vacuum but
within a social context. Consequently, the case
provided, within the hospice not only affects
the patients, also the family including close
relative and friends with an intellectual ability.
Focus of the plan of care:

1. Quality of life
2. alleviation of distressing symptoms’
3. bereavement support
 Priorities:

-To maintain control over

their environment
--to have enduring expert
physical care
-To be assured that they
and their families won’t be
abandoned
--top achieve peace of mind
-
 Acute Care Hospice Care

Objective Quantity of Life Quality of Life

Philosophy Curative Palliative

Goal Control of dse Control of symptoms

Focus Disease Person

Death seen as Failure Inevitable, natural

Tx depends on Lab values Patient symptoms & goals

Results measured by Cure rates, improve lab Freedom from pain,

values peaceful death
The dying have the right to a great
things that’s institutions cannot
provide. They need life around them,
spiritual and emotional comfort and
support of every sort. They need
“unsanitary” things like a favorite dog
ling on the foot of the bed. They need
their own clothes, their own pictures,
music, food, surroundings that are
familiar to them, people they know
and love, people they can trust to care
about them.
 DESIRABLE TRAITS OF HOSPICE & PALLIATIVE
NURSE
FLEXIBILITY- in handling complex situations with
patients, families and staff
AUTONOMY- to make independent decisions with
competence and confidence
SENSITIVITY- to the values and belief systems of
a wide variety of people and cultures
OPENNESS- to new ideas, new information, new
approaches and to differing opinions
SPIRITUALITY- results in a respect for self and
others, and recognition of the values of belief
systems and meaning
1. Confront the problem and take appropriate strategies
2. Deny as much as possible
3. Conform and comply with what is expected or advised
4. Seek out information and direction
5. Resign yourself to what cannot be changed
6. Forget about it and think of other things
7. Keep busy with interests or new pursuits unrelated to the
problem
8. Share concerns with interested or experienced persons

COMMON COPING STRATEGIES

9. Do something, anything: even futile, it shows effort
10. Redefine the problem and look for realistic possibilities
11. Release emotional tension by venting your feelings
12. Retreat from problem or postpone in dealing with it
13. Review alternatives, rationally reflecting on the
consequences
14. Laugh it off and change the subject
15. Blame or shame someone or something: that palces
responsibilitty outside yourself

COMMON COPING STRATEGIES

• DYING: A WHOLE-PERSON EXPERIENCE

As the time of death nears, the body

goes through a natural process of
shutting down.
Points to remember as the patient
is nearing death:
• Dying happens to all dimensions of the
person- physical, emotional, spiritual, mental
• Death is natural and normal process
• All body systems begin to shutdown; the
failure of one affects the others
• The spirit begins to release from the body
(catholic belief)
Points to remember as the patient
is nearing death:
• Near death experience may occur
• All dimensions of mind and body may not
progress simultaneously
• Interest in surroundings, events, and
socialization generally decreases
• Sleep increases
• Phenomena may occur abruptly or very slowly
 Comfort interventions when a
patient is dying:
• Continue to explain your actions
• Anticipate needs: don’t force talking
• Watch the nonverbal signs
• Remember the value of presence
• Maintain the calm atmosphere
• Encourage family members to communicate
their feelings
• Show deep respect for the person and the body
 PHYSICAL CHANGES
• Skin may be pale, blue or gray
• Lips and fingernail beds may be very blue
• Skin may feel cold unless if with fever
• Eyes may be half open
• Neck may be hyperextended
• Lower jaw may relax, and mouth will be open
• Skin may become more fragile
 PHYSICAL CHANGES
INTERVENTIONS
• If the patient’s eyes are open, provide artificial
for moisture
• Moisturize and cleanse mouth frequently to
prevent dryness and crusting
• Dry skin by gentle not firm rubbing
• If bleeding potential is present, take extra care
with shaving and hold pressure to any
injection site for 10 mins
 CIRCULATION
• Keep the patient warm, but avoid electric or
heavy blankets
• Provide good wound care
• Give cool sponge bath and/or paracetamol if
the patient is restless with fever
 RESPIRATION
• Decrease perception of dyspnea with cool clothes,
fan or open window
• Utilize low dose of morphine sulfate to make RR to
normal
• Administer codein to relieve cough
• Consider anxiolytics agents to address anxiety
• Use scopolamine to dry secretions
• Elevate the HOB
• Provide reassuring, calm presence
 ELIMINATION
• Keep the patient dry and clean
• Catheterize if the patient is in retention
• Treat constipation
 THE SENSES
• Always assume the dying person can hear
• Speak directly to the dying person, even when
there is no response
• Touch the patient gently and remain present
• Provide a calm atmosphere with minimal
stimulation
• Use artificial tears if the patients eyes are
partially open
 MENTATION
• Continue talking to dying person
• Assess the restlessness is sign of pain or other
discomfort
• Offer calm reassurances, gentle massage or
discussion of pleasant memories
• Medicate for restlessness or agitation
• Administer muscle relaxants to help reduce
muscle twitching
 MENTATION
• Try to make connection with the patient words
• Identify yourself to the patient: do not ask the
patient to identify you
• Explain to the patient what is happening to
them
• Provide soothing music or readings
• Avoid restraints unless absolutely necessary
 SOCIAL AND EMOTIONAL STATUS
• Listen to last wishes and confessions
• Be aware & respect the fact than an
occasional patient will wish to be alone
• Communicate to the patient that what is
happening is natural and OK
 SPIRITUAL
• Allow and encourage patient to share experiences
• Do not restrain the patient or insist on different
behavior
• Listen for meaning or meaningful experience
• Be present in case the patient wishes to do the
“right” things
• Do not impose your belief or interpretations
• Be willing to pray, read scriptures or play music if the
patient desires
 • The danger is that the only acceptable
education, therefore, from a palliative
perspective, is oriented towards the control of
physical pain and symptoms and the skilled
use of pharmacology at the expense of the
equally important elements such as truth
telling, spiritual care, dealing with ethical
issues, understanding grief and loss, lived
experience and family.
 ASSIGNMENT
• Each will be assigned a symptom to research
on the symptom control of the MOST common
symptoms in palliative wards (with emphasis
on non pharmacological interventions but
enumerate also pharmacological
interventions)
• Copy will be send through e mail and then
sharing on the next meeting
 ASSIGNMENT
1. Anxiety 9. DOB (pulmonary edema)
2. Insomnia 10. Fluid retention
3. Confusion, agitation & 11. Hiccups
delirium 12. Pruritus
4. Constipation 13. Seizures
14. Stomatitis
5. Cough
15. Intestinal obstruction
6. Depression
16. Urinary problems
7. Diarrhea 17. Weakness, fatigue and
8. Dysphagia syncope
 ASSIGNMENT
18. Nausea and vomiting
19. Skin problems
20. Oncologic
emergencies
21. Terminal airway
secretions and
restlessness
22. Pleural effusion
23. Heart problems
 Terms defined:
• Grief- the process of psychological, social and
somatic reactions to perceived loss
• Mourning- cultural reaction to or outward
social expression of the loss
• Bereavement- state of deprivation following
the loss of something held to be significant,
whether positive or negative
KUBLER-ROSS’S STAGES OF
DEATH & DYING
DENIAL
Disbelief that event could be true
Creation of alternative
explanations
Functions as a buffer after
unexpected shocking news
KUBLER-ROSS’S STAGES OF
DEATH & DYING
ANGER
Reaction of rage, envy,
resentment, or why me?
Usually displaced at random
Results in outbursts and
unreasonable demands
KUBLER-ROSS’S STAGES OF
DEATH & DYING
BARGANING
An attempt to postpone the
inevitable
Mostly with God: promises good
behavior
Promises sometimes associated
with quiet guilt
KUBLER-ROSS’S STAGES OF
DEATH & DYING
DEPRESSION
Normal reaction to realization of loss
Necessary to experience and express
sorrow to facilitate state of acceptance
Not to be ignored or reasoned way
KUBLER-ROSS’S STAGES OF
DEATH & DYING
ACCEPTANCE
More void feeling than “happy”
Circle of interests diminishes
Sitting silence may be most
meaningful communication
 Byock’s Tasks of Dying Patients
• 1. DEVELOP A RENEWED SENSE OF
PERSONHOOD AND MEANING
Find meanings in life review and personal
narrative
Develop a sense of worthiness, both in the
past and in the current situation
 Byock’s Tasks of Dying Patients
• 2. BRING CLOSURE TO PERSONAL &
COMMUNITY RELATIONSHIPS
Say good bye to family members and friends
Ask for & grant forgiveness
Say good bye to community relationships with
expressions of regret, gratitude, forgiveness
and appreciation
 Byock’s Tasks of Dying Patients
• 3. BRING CLOSURE TO WORLDY AFFAIRS
Arrange for the transfer of fiscal, legal and
social responsibilities
Accept the finality of death and surrender to
the transcendent
Express the depth of personal tragedy that
dying may represent and acknowledge the
totality of personal loss
 Byock’s Tasks of Dying Patients
• 3. BRING CLOSURE TO WORLDY AFFAIRS
Withdraw from the world and accept
increased dependency
Develop a sense of awe and accept the
seeming chaos that can prefigure
transcendence
 Children’s Developmental Stages
and Concept of Death
• AGES 0-2 (there is no real concept of death.
Fear of abandonment)
• AGES 3-4 (death may be thought as
temporary. Children at this age may see death
as mutilation if they have seen a dead animal
by the road)
• AGES 5-7 (death can be comprehended as a
permanent event versus a temporary absence)
 Children’s Developmental Stages
and Concept of Death
• AGES 8-11 (fears of mutilation and
abandonment is present. Children at this age
can associate religious ideas of heaven and
hell)
• ADOLECENSE (tempted to regress, withdraw,
over react)
 Interacting with children when
they are experiencing death:
• Assure children of all ages that they are not at
fault
• Answer questions truthfully, within the child’s
ability to understand
• Give simple explanations: there is no need to
be complicated or elaborate
• Use correct language (e.g. “He died,” not “He
passed away”)
 Interacting with children when
they are experiencing death:
• Avoid euphemisms that may result in
detrimental fears (eg “she is asleep,” “God
took her,” “mother has gone on a long trip”)
• Assure the child that he or she is loved and
will be taken care of, even though a sad thing
has happened
• Encourage the child to talk about thoughts
and feelings
 Interacting with children when
they are experiencing death:
• Permit the child to decide whether or not to
go to funeral
• Expect the child to talk or participate only
when he or she wishes to do so
• Expect that a child’s expression of grief will be
intermittent
• Share pictures and talk about the good times
that have been enjoyed with the dying person
 THERAPEUTIC APPROACHES
 Permit tears
 Permit and encourage expressions of pain and
agony: phrases like “be brave” are not
therapeutic- they imply a suffer-in-silence
value
 Encourage individuals to list things they did for
the deceased when they berate themselves
for “not having done enough”
 THERAPEUTIC APPROACHES
 Patiently listen as the detailed story of the
death is repeated over and over
 Remember you are not the answer to the
persons grief
 Be comfortable with not having an answer for
every question asked, such as “Why me?” or
“why God is punishing me?”
 THERAPEUTIC APPROACHES
 Encourage the griever to pay attention to the
personal needs
 Maintain an appropriate psychological
distance-close enough to share the suffering
but not so close as to tempted to succumb to
the despair
 Listen to an open mind; never respond with
judgment or interpretation
 THERAPEUTIC APPROACHES
 Encourage the griever to talk realistically
about the deceased and their relationship
 Assist the griever to identify problems or
unfinished business
 UNIVERSAL SPIRITUAL NEEDS
• 1. NEED FOR BELONGING & RELATIONSHIPS
 To be cared for, not abandoned or isolated
 To give comfort and receive love
 For comfort and peace
 Relationship needs; family, SO, Deity
 UNIVERSAL SPIRITUAL NEEDS
• 2. NEED TO EXPLORE MEANING OF LIFE,
SUFFERING & DEATH
 Experience affirmation of self worth
 For acceptance of self, others & human events
 To recognize sources of strength to face death
 To contemplate what gives a sense of purpose
and fulfillment
 UNIVERSAL SPIRITUAL NEEDS
• 2. NEED TO EXPLORE MEANING OF LIFE,
SUFFERING & DEATH
 To discover personal meaning of pain & death
 To redefine hopes & goals
 To move on to detachment and solitude
 UNIVERSAL SPIRITUAL NEEDS
• 3. NEED FOR RECONCILATION
 To acknowledge unfinished/ unresolved
conflicts
 To recognize nagging resentment and
bitterness
 To recognize feelings of guilt and blame
 To be able to forgive & accept forgiveness
 PAIN MANAGEMENT
• NONPHARMACOLOGIC MEASURES
 Physical modalities

 Psychosocial/ spiritual modalities

 PAIN MANAGEMENT
 Physical modalities
Position changes
Heat or cold applications
Massage
Counterstimulation (TENS or acupuncture)
Whirpool
Exercise/ physical therapy
 PAIN MANAGEMENT
 Psychosocial/ Spiritual Modalities
Diversional activities
Relaxation & imagery techniques
Cognitive reframing of control and hopes
Celebration of normal life events
Prayer & meditation
Pastoral visits
Patient education
 Patients Rights in Terminal Illness
• 1. RIGHT TO KNOW THE TRUTH
About condition, prognosis & options
• 2. RIGHT TO CONSENT TO OR REFUSE Tx
with input into plan of care
• 3. RIGHT TO EXPERT CARE
To alleviate emotional and physical symptoms
 Patients Rights in Terminal Illness
• 4. RIGHT TO CONFIDENTIALITY & PRIVACY
and respect for personal values
• 5. RIGHT TO CONTROL ENVIORNMENT &
SETTING
For the final days of life
• 6. RIGHT TO DETERMINE CARE
And disposition of the body upon death
 Hospice and Palliative Nursing
Practice challenges (some):
• Inadequate provision of palliative care for
patient dying
• Teams inability to manage an active bleeding
episode that occurred when a patient is dying
• Lack of advance directives
• Conflict between family members over a
terminally ill patients decision not to receive
artificial hydration
“Age is an issue of
mind over matter. If
you don’t mind, it
doesn’t matter.”

-Mark Twain
 References
• Matzo, Marianne L & Sherman, Deborah W
(2001) Palliative Care Nursing. Springer
Publishing Company: New York
• Smith, Shirley Ann (2000) Hospice Concepts: A
Guide to Palliative Care in Terminal Illness.
Research Press: Illinois
 Related websites
• www.helpthehospices.org.uk
• http://www.ijpn.co.uk/
• http://www.discovernursing.com
• http://www.ovid.com
• SALAMAT!