The types of advance directives are the power of attorney, and a living will. Most advance directives are written by older or seriously ill people (American Family Physician (AAFP), 2020). However, experts agree that people should document their wishes at a younger age before a serious accident or illness occurs, when they are in good health (The Conversation Project, 2021). Research shows that if a person has this documentation, their wishes are more likely to be followed (AAFP, 2020). Many people have difficulty understanding the differences in these documents and how to complete them. ● A power of attorney, or healthcare proxy, is a type of advance directive in which you name a person (family member, friend, guardian) to make medical decisions for you when you are unable to do so (The Conversation Project, 2021). ● A living will is a written, legal document that indicates medical treatments a person would and would not want to be used to sustain life, as well as other medical decisions, such as pain management or organ donation (AAFP, 2021). In addition to these documents, a do-not-resuscitate (DNR) or allow natural death (AND) order can be placed in an advance directive document (CCH, 2021). This legal document can be placed in the medical record and is a request that medical personnel do not perform cardiopulmonary resuscitation (CPR) on a patient if they are pulseless and/or have no respiratory rate/ effort (CCH, 2021). Weeks before death, patients often sleep for most of the day and night. Marked weight loss is common because of poor appetite secondary to lack of hunger, gastritis, nausea, or oral lesions (CCH, 2021). However, as the body shuts down, those who are dying need and want less food; therefore, anorexia is often an unavoidable consequence of an end-stage disease process (NHPCO, 2020). It is also common for patients during these last weeks of life to have a short-lived “rally” and spontaneously ask for a meal or be alert, oriented, and ready for a conversation when previously they were withdrawn or lethargic (NHPCO, 2020).
Toward the last few weeks or days of life, patients may come to terms with dying. Clinicians can explore patients’ values, beliefs, and meaning in life. McClement and Thompson (2018) found that clinicians who worked in palliative and hospice care were competent in their knowledge about what dying meant to the patient. They also learn what living means—to have relationships and friendships, a belief system, a culture, and a history that meld to form significance throughout one’s life (McClement & Thompson, 2018). Clinicians who support patients at the end of life often do not know each patient’s detailed personal history but should be aware of individual characteristics (e.g., relationships and friendships, belief system, culture) of their lives (McClement & Thompson, 2018). The best method to obtain this information is by asking questions that reflect the patient’s roles and accomplishments throughout their lifetime (McClement & Thompson, 2018). In the last days of life, the patient may reduce their physical activity and experience symptoms/behaviors as described in Table 1 (CCH, 2021). Shortness of breath, which can include labored and noisy breathing, is common in the days before death as respiratory dysfunction and the loss of the ability to swallow occur (CCH, 2021). Cheyne–Stokes respirations (several rapid breaths followed by periods of apnea for up to 30 seconds) can occur along with coughing as the body’s fluids begin to build up in the lungs (Hospice Foundation of America ([HFA], 2018). These symptoms can be alleviated with opioids, benzodiazepines, atropine, and/or scopolamine, along with positioning the patient on their side (HFA, 2018). Pain should be aggressively treated throughout the dying process and especially during the final days and hours before death (American Nurses Association [ANA] & Hospice and Palliative Care Nurses Association [HPNA], 2021). Clinicians should speak with patients and their families about their beliefs and misconceptions about pain management and help patients and family members overcome fears about using narcotics (ANA & HPNA, 2021).
Table 1. End of Life Timeline: Signs, Symptoms, and Interventions as Death Approaches Signs and Symptoms Interventions
Last three months of life
● Getting their affairs in order ● Less interested in activities or acquaintances outside of family or close friends ● Eating decreases to smaller meals and preferred foods ● Much less active: if active one day, may sleep the entire next day ● Restlessness/agitation ● May talk about travel or getting ready to “go on a trip” ● Sleeping 20–23 hours a day; awake only brief periods at a time ● Talking to people who have already died; may speak of angels in the room ● Eating little to no food/ taking only sips of liquid ● May have brief periods of alertness and hunger ● Loss of ability to control urine and bowel movements
● Support the patient and family in decision making ● Provide resources and information ● Encourage patient to talk about needs and end-of-life goals ● Provide consults as needed (social work, nutrition)
Last week or days of life
● Talk to the patient calmly; light room dimly and use distraction techniques to help reduce restlessness ○ Consider the use of medications (Haldol, Ativan) if patient agitation causes discomfort (requires order) ● Continue to encourage the patient to verbalize thoughts and feelings ● Educate family about the process of dying, including sleeping more, decreasing eating or drinking, and verbalizing needs and dreams ● Pressure care prevention and positioning is important as the patient becomes more immobile and less able to eat or drink ○ Elevate head slightly ○ Turn and reposition patient every two hours or as policy requires ○ Use slide boards/draw sheet when turning to prevent tearing injuries ○ If wound develops, ensure to document, and treat according to wound type/ size and provider order; consider wound consult if extensive ● Skin care: Keep patient clean via bed bath once a day and provide gentle massage of extremities and back ○ Can use lotion with massage to help moisturize skin ● Use adult briefs for incontinence of urine and feces and change immediately to prevent skin breakdown ○ Consider foley catheter or rectal tube placement (physician order required) if excessive or required to prevent skin breakdown
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Book Code: PYFL4024
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