Care and Comfort at the End of Life

 

OVERVIEW

Older people are often faced with numerous comorbid conditions that can lead to progressive functional and/or cognitive decline or a life-limiting illness, such as heart failure, cancer, or dementia. These people deserve evidence-based interdisciplinary care that can offer them comfort at the EOL (Carey et al., 2008; NHPCO, 2020).

 

BACKGROUND

Hospice care is a model of care focused on caring for, not curing, individuals with a terminal illness with a life expectancy of 6 months or less (NHPCO, 2020). It can be delivered in a variety of settings and comprised an interdisciplinary team of providers to help provide physical, psychosocial, and spiritual care and comfort to the patient and their family. About 61% of Medicare hospice patients are older than 75 years, and the leading diagnoses for persons under hospice care include cancer, heart disease, and dementia (NHPCO, 2020).

PRINCIPLES OF CARE AND COMFORT AT THE END OF LIFE

A. Assessment and management of physical symptoms

  1. Pain is the most common symptom at the EOL (Alexander et al., 2016). Pain should be assessed often, tailored to the patient’s cognitive ability and using appropriate scales. Management of pain should include pharmacological and nonpharmacological measures (Dalacorte et al., 2011).
  2. Constipation is common in older adults at the EOL. Constipation should be assessed for often, and pharmacological management should be initiated when opioids are started or when the patient has no bowel movement in 2 to 3 days (McIlfatrick et al., 2019).
  3. Dyspnea is a common symptom at the EOL and can often be traced to cardiovascular and/or pulmonary diseases, but can also be impacted by psychosocial and spiritual factors (Crombeen & Lilly, 2020). Dyspnea should be assessed often and not only with objective measures such as pulse oximetry, but also through patient/caregiver reports. Management of dyspnea should include pharmacological and nonpharmacological measures (Alexander et al., 2016; Crombeen & Lilly, 2020).
  4. Nausea is also a common symptom at the EOL and should be assessed often and can occur without the presence of vomiting. Management of nausea should include pharmacological and nonpharmacological treatments (Moorthy & Letizia, 2018).
  5. Terminal secretions (death rattle) can be distressing to loved ones near the EOL of an older patient. Patients should be assessed for terminal secretions often and preventive measures used to attempt to minimize this, including repositioning the patient and using pharmacological agents, such as atropine drops (Kolb et al., 2018).

B. Assessment and management of psychosocial symptoms

  1. Anxiety is a common symptom at the EOL and may manifest as feelings of impending doom, excessive worry, shortness of breath, and more. Anxiety should be managed using pharmacological and nonpharmacological treatments (Cherny et al., 2015).
  2. Depression often occurs in older adults at the EOL. Patients may exhibit anorexia, sleep disturbances, and weight loss, along with feelings of hopelessness and sadness. Patients should be assessed for depression using reliable and valid tools and treated with both pharmacological and nonpharmacological measures (Cherny et al., 2015).
  3. Delirium, agitation, and restlessness are common psychological changes in older adults at the EOL. Individuals may present with disorientation, delusions, or hallucinations, which can also be distressing to family members. Patients should be assessed for delirium often, and both pharmacological and nonpharmacological measures should be included in the treatment plan. Medications should be reviewed, and noncritical medications should be discontinued (Travis et al., 2001).

C. Care of the family

  1. The family often serves as caregivers to older persons at the EOL, especially if hospice care is delivered in the home setting (Kimar et al., 2021).
  2. It is important to provide these caregivers with support from the hospice team, including teaching and coaching from the nurse, help from the nurse and nurses’ aide in care of the patient, and access to a social worker and a chaplain for psychosocial and spiritual support, respectively. It is also important for them to understand that care is available 24 hours a day from a nurse (Ellington et al., 2018; Hughes et al., 2019).
  3. Patients should have the autonomy to direct their medical care, and thus it is critical that ACP be done before cognitive decline occurs. Advance care plans can help improve an older person’s quality of life, decrease the number of unnecessary hospitalizations and invasive procedures, and help family members with making important decisions (Van Den Noortgate & Van den Block, 2022).
  4. Pre-death anticipatory grief bereavement counseling for both the older person and their family and post-death bereavement programs for family members should be implemented by hospice agencies and may include support groups, follow-up phone calls, and memorial services. All hospice services provide services for bereaved loved ones for at least 13 months (Hughes et al., 2019; Tabler et al., 2015).

D. Spirituality

  1. Spirituality can be a major source of support for older people at the EOL. Chaplains and other religious persons should be available to meet with the hospice patient and also their loved ones. A strong spiritual sense can help ease the transition to death at the EOL (Cherny et al., 2015; Kukla et al., 2022).

EVALUATION AND EXPECTED OUTCOME

The older patient will die comfortably, and their loved ones will be provided with support to help with the grieving process.

ABBREVIATIONS

ACP     advance care planning

EOL     end of life

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 38, Evans, M.M., Riley, K. & Kowalchik, K. (2025) Care and Comfort at the End of Life

 

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