Patient Needs
Provide comfort, dignity, emotional support, and respect for the patient’s wishes during the final stages of life.
Types of care:
- Palliative Care: Relieves symptoms and improves quality of life at any stage of serious illness.
- Hospice Care: Focuses on comfort and quality of life near the end of life rather than curing the terminal illness. Usually less than 6 months left to live.
- Advance Directives: Document healthcare preferences and/or identify a healthcare decision-maker.
- DNR Order: Directs healthcare professionals not to attempt CPR if cardiac or respiratory arrest occurs.
Grief and Emotional Responses
The five commonly taught grief responses are:
| Response | Possible Experience |
|---|---|
| Denial | Shock, numbness, or disbelief |
| Anger | Frustration, blame, or feelings of unfairness |
| Bargaining | ”What if” or “if only” thoughts |
| Depression | Sadness, withdrawal, or feeling overwhelmed |
| Acceptance | Acknowledging and learning to live with a loss |
Important: Grief is individual and does not necessarily follow these stages in order. Do not pressure someone to reach acceptance.
CNA Care:
- Listen without judgment.
- Allow residents and loved ones to express emotions.
- Avoid minimizing grief or making promises about outcomes.
- Report severe distress or expressed thoughts of self-harm.
- Offer access to additional support through the nurse.
Spiritual and Family Support
- Ask about preferences rather than assuming religious beliefs.
- Respect the resident’s spiritual, cultural, and personal practices.
- Offer meaningful religious or comfort objects when appropriate.
- Ask the nurse to help arrange a chaplain, faith representative, or other requested support.
- Do not impose personal beliefs.
- Include family and loved ones according to the resident’s preferences and applicable privacy rules.
- Offer visitors privacy, seating, and opportunities to rest.
- Do not automatically require family to leave during routine care; ask the resident and follow privacy and safety requirements.
Signs of Approaching Death
Changes vary and may include:
Respiratory
- Irregular breathing or pauses between breaths.
- Cheyne-Stokes breathing.
- Noisy respiratory secretions, sometimes called a “death rattle.”
- Changes in breathing depth and effort.
Cardiovascular
- Cool or mottling (purple marbling on skin from poor blood flow) extremities.
- Lower blood pressure.
- Changes in heart rate or circulation.
- Blue or gray discoloration of peripheral skin.
Nervous System
- Increased sleeping or reduced responsiveness.
- Confusion, agitation, or altered awareness.
- Occasional involuntary movements.
Digestive and Urinary
- Reduced appetite and thirst.
- Difficulty swallowing.
- Decreased bowel activity.
- Reduced urine output or darker urine.
- Possible incontinence.
Important: These findings can also occur with potentially treatable complications. Notify the nurse about new, distressing, or unexpected changes rather than independently attributing them to dying.
Comfort Measures
- Reposition gently according to comfort, tolerance, and the individualized plan.
- Maintain clean, dry linens and comfortable clothing.
- Provide prescribed mouth care and lip moisturizer.
- Support safe positioning when breathing is difficult.
- Offer blankets or adjust the environment according to comfort.
- Observe nonverbal signs of pain, anxiety, or respiratory distress.
- Offer food and fluids only when consistent with swallowing safety, orders, and resident wishes.
- Speak respectfully even if the resident cannot respond.
- Inform the nurse when discomfort persists or worsens.
Important: Do not force food or fluids, assume fixed repositioning schedules, or independently administer medication or oxygen adjustments.
What Should I Assess?
Common end-of-life changes:
- Increased sleeping, fatigue, or reduced responsiveness.
- Decreased appetite and fluid intake.
- Difficulty swallowing.
- Changes in breathing patterns.
- Cool or discolored extremities.
- Changes in bowel and bladder control.
Signs of discomfort:
- Grimacing, restlessness, or moaning.
- Anxiety, fear, or agitation.
- Difficulty breathing.
- Nonverbal indications of pain.
How Do I Provide Care?
Physical Comfort:
- Reposition gently according to comfort and the care plan.
- Provide oral care and lip moisture as directed.
- Maintain hygiene and protect skin integrity.
- Adjust blankets, lighting, and room temperature.
- Allow rest and avoid unnecessary disturbances.
Emotional Support:
- Speak calmly and respectfully, even when the patient is unresponsive.
- Listen without judgment.
- Respect spiritual, religious, and cultural preferences.
- Support family presence according to patient wishes and facility policy.
Dignity & Autonomy:
- Respect personal preferences and advance care plans.
- Explain care before touching or moving the patient.
- Encourage choices and independence when possible.
Safety & Precautions
- Follow documented care goals and applicable medical orders.
- Do not force food or fluids when swallowing becomes difficult.
- Never assume reduced responsiveness means the patient cannot hear.
- A DNR order applies to resuscitation; it does not mean withholding routine comfort care.
- Report new or uncontrolled symptoms promptly.
What Should I Report?
- Signs of pain, distress, or breathing difficulty.
- Significant changes in responsiveness or condition.
- New skin breakdown or discomfort.
- Patient requests or concerns about treatment.
- Family concerns requiring licensed staff assistance.
Related
- Patient Rights
- Informed Consent
- Patient Refusal of Care
- Skin Integrity & Breakdown Prevention
- Pain Assessment
Sources
Flashcards
What is the focus of comfort-oriented end-of-life care?01-foundations / patient-care
Dignity, symptom comfort, preferences, and family support.
Do the five stages of grief occur in a required order?03-application / patient-care
No. Grief is individual and does not follow a predictable sequence.
What is Cheyne-Stokes breathing?01-foundations / patient-care
Cycles of changing breathing depth with periods of apnea.
What is a death rattle?01-foundations / patient-care
Noisy breathing caused by pooled respiratory secretions near death.
What physical changes may occur as death approaches?03-application / patient-care
Irregular breathing, mottled skin, reduced alertness, and decreased intake or urine output.
Should a CNA force food or fluids on a dying resident?03-application / patient-care
No. Follow resident wishes, swallowing safety, and the care plan.
What should a CNA do when a dying resident shows new signs of discomfort?03-application / patient-care
Report the symptoms promptly and follow the comfort-care plan.
How should a CNA support a resident's spiritual needs?03-application / patient-care
Respect their beliefs and arrange requested support through the nurse.