In today’s society, we have seen many great advances in medicine, science, and technology that have resulted in an aging population with chronic illnesses. Often times, these issues require frequent or prolonged acute care admissions. With this in mind, choices need to be made that involve discussing end-of-life care goals with patients and their families. As nurses, we must work hard to provide high value end-of-life care for these patients in the acute care setting when death is near.
Although many patients would prefer to die at home, the truth is a majority will die in acute care settings and other healthcare institutions. Over the years, end-of-life care in acute care settings has taken great stride in the implementation of specialty practices such as palliative care.1 However, in a healthcare organization that does not benefit from such a specialty, how is end-of-life care provided?
The first step in being able to plan and provide good end-of-life care is for the patient, family, and nursing staff to accept that death is the outcome.1 Next, all active life sustaining medications should be discontinued. These medications would include but not limited to: intravenous fluids, antibiotics, insulin, steroids, and blood pressure medications, but intravenous access should be maintained in order to administer end-of-life medications. Typically, in the acute care setting before transition to hospice is made, or if the patient is awaiting a hospice bed, the standard appropriate medical procedure for transitioning a patient to end-of-life care is started. A morphine bolus and/or relaxant such as Ativan is administered. These medications are given in end-of-life cases in order to decrease anxiety that the patient may experience as well as ease any feeling of breathlessness. It is very important to remember that the administration of these medications is not to promote death, but to aid the patient with the symptoms that often accompany dying.
Next, a continuous morphine drip which should be titrated for patient comfort is initiated. Often times, medications to aid with the patient’s secretions (such as levsin) is administered. Basic nursing care such as mouth care, turning, and repositioning of the patient should also be continued.
With life, comes death. As good as a healthcare professional may be, we, as a profession have yet to keep anyone from dying. We have kept people alive longer, but everyone dies at some point. Much of this understanding should not be when, but how. As a profession, when a patient’s care transitions to end-of-life care, we are not failing them. We often times begin to fail the dying patient when the health care team does not provide what the patient needs. If the outcome of the disease process or admission is death, then as a health care system, we are failing that patient by not providing a death for them that is good. Curing everyone is simply impossible, but what we can do as a profession and as patient advocates, is to provide a death that is comfortable for the patient’s final life journey.
Bloomer, M., Moss, C., & Cross, W. (2011). End of life care in acute hospitals: an integrative literature review. Journal of Nursing and Healthcare of Chronic Illnesses, 3(3), 165-173.
William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN
Acute Care NP at Penn Medicine Chester County Hospital
Adjunct faculty at Drexel University, College of Nursing and Health Sciences