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 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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 Discussing End-of-Life Care
Steps Actions

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

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  Identify gaps in knowledge, need for consultation with other members of
medical treatment the health care team
plan and prognosis  Use simple, everyday language

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

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 the  Provide guidance and/or referral for understanding medical options
interdisciplinary care  Make recommendations for referrals to other disciplines or services
plan  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 11th Edition Volume 1

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 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.
NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1
  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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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 reassurance Spontaneous reaction by the nurse to try to calm the client who
feels anxiety and distress over some circumstance; the nurse’s
response is intended to balance the client’s feelings.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 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 13th edition, Hinkle J.L., Cheever K.H.
https://hopewell.org.au/your-family/what-palliative-care/characteristics-palliative-care

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE PURPOSE EXAMPLE

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

NONTHERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE PURPOSE EXAMPLE

Social Engaging in superficial conversation that is Client: “I’m glad I’m being discharged
responding not client centered today.”
Nurse: “are you going to watch the
football game tonight”
Asking closed- Questions that elicit a “yes” or “no” answer Nurse: “Do you understand everything
ended instead of allowing for wider exploration of I’ve told you about electroconvulsive
questions the client’s thoughts and feeling therapy?”
Changing the Introducing an unrelated or peripherally Client: “I don’t think my husband finds
subject related(usually to avoid sensitive issues or me attractive since I had the
reduce the nurse’s anxiety) mastectomy.”
Nurse: “I didn’t realize you had breast
cancer. Does it run in your family?”
Belittling Discounting the client’s feelings or making Client: my home was totally destroyed in
comparisons that imply the client’s the fire”
problems are smaller than he or she Nurse: “At least you are alive.”
perceives
Making Offering platitudes or wise sayings that Client: “I can’t get over the loss of my
stereotyped seem automatic or contrived mother”
comments Nurse: “Time heals wound. Everything
happens for a reason.”
Offering false Attempting to cheer up the client by Client: “I’m afraid my boss will fire me if
assurance suggesting there is no real problem he finds out that I have substance abuse
problem”
Nurse: “Don’t worry. He wouldn’t do
that.”
Moralizing Passing judgment by imposing one’s own Client: “I want a divorce”
values on the client and implying that the Nurse: “Don’t you think you owe it to
client’s thinking is wrong your children to give the marriage
another try?”
Interpreting Making intrusive comments in an attempt Client: I don’t want to take this
to overanalyze or “psychoanalyze” client’s medication.”
statement Nurse: I think you’re in denial about your
illness.”
Advising Making specific suggestions instead of Client: “I feel depressed.”
offering information and asking clients Nurse: “ you should do some volunteer
what they think is most likely to work work to take your mind off things.”
Challenging Denying or diminishing the client’s Client: “nobody cares about me.”
perceptions, forcing the client to prove Nurse: “What about your sister? I saw
what he or she is saying her visiting yesterday.”
Defending Arguing or justifying your position rather Client: “I can’t get any help with this
that attempting to hear the client’s problem.”
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
NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1
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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

TECHNIQUES TO ALLOW EXPRESSION
OF FEELING,SUPPORT,IDEALISTIC AND
POSITIVE HOPE

MAGO, IRENE JESSICA

BSN 3

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

PSYCHOLOGICAL, ETHICAL, SPIRITUAL
ASPECTS & BELIEFS IN THE CARE OF
PALLIATIVE PATIENT

BRAVO, ROSEDEL
BSN 3

PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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]

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

  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=235
05-1

https://www.eurekalert.org/pub_releases/2008-04/w-hpa040808.php

PHYSIOLOGIC FUNCTIONS THAT FREQUENTLY IMPAIRED IN PEOPLE WITH TERMINAL

ILLNESS

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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/ Hygiene diaphoretic.
-Mouth care as needed for dry mouth.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

 -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.

-Antiemetics or small amount of alcoholic

4. Altered Nutrition: Less Than Body beverage to stimulate appetite.
Requirement -Encourage liquid foods as tolerated.
-Dietary fiber as tolerated.
Constipation -Laxatives as needed to prevent constipation.

-Skin care in response to incontinence of urine

5. Altered Urinary Elimination or feces.
-Bedpan, urinal, or commode chair within easy
reach.
-Call light within reach for assistance onto
bedpan; linen changed as often as ordered.
-Catheterization, if necessary.
-Keep room as clean and odor free as possible.

-Clients prefer a light room.

-Hearing is not diminished; speak clearly and
6. Sensory/ Perceptual Alterations: Visual, do not whisper.
Tactile -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.

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1

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.

-Tachypnea, dyspnea, use of accessory muscle,

3. Pulmonary acetone breath, cheyne strokes breathing,
pooling of secretions or noisy respirations.

-Diminished appetite, smaller amounts of

feces (despite not eating) incontinence.
4. Gastrointestinal
-Diminished urine output, incontinence,
concentrated urine.
5. Renal

NAVARRETE, GEOOFRIEY SANDLER|BSN3|ELECTIVE 1