Jane, a nurse, receives a late-night phone call that Aunt Marge may not make it through the night. She hops in the car and drives 30 minutes to the local hospital where her favorite aunt was admitted. Her aunt has metastatic breast cancer. As Jane rushes to her bedside, Aunt Marge is barely conscious, yet she opens her glassy eyes and looks at Jane as if to thank her for coming. Jane realizes that she — a nurse who can effectively communicate in just about any situation — is now at a loss for words.
John, a hospice patient, has just entered an inpatient nursing unit. Although he seems to be in his last moments, he’s having a conversation with his deceased mother. The family and nursing staff are baffled that he could be speaking to someone who has been dead for 30 years. That evening, he says his good-byes to his family. When they say they will be back in the morning, he remarks, “I don’t think so.”
Jeanne is dying from an incurable glioblastoma, and her family has maintained a vigil at the bedside for the past three days. After their sleepless nights and many missed meals, the primary care nurse encourages the family to go down to the cafeteria to have something to eat. When they return, Jeanne is no longer breathing and has passed away. They are angry that they left the bedside and abandoned Jeanne during her last moments of life.
These scenes are common to the practice of most nurses. Caring for a patient approaching the end of life continues to challenge the most skilled, educated and talented practitioners. Nurses can help people who are dying deal with their special needs and concerns, such as fear of abandonment, losing control over body functions, and being overwhelmed with pain or distress.1
Nurses have an obligation to address these end-of-life issues with patients and families. As delineated in the 2001 Code of Ethics for Nurses,
identifying problems, providing and clarifying information, and supporting decision-making to define and provide appropriate care are emphasized as fundamental to the practice of nursing.2 (Level C)
This becomes particularly important to help prevent or relieve pain and suffering, and support patients and families during this end-of-life transition.
Goals that guide care at the end of life focus on patients’ comfort by addressing physical, social, emotional, spiritual, and financial pain3,4 while maintaining their dignity, identity and self-respect.5 Goals also extend to preserving the quality of life and providing support and grief counseling to family members, friends and caregivers. As those providing the most consistent, visible, hands-on care, nurses hold a unique place to influence the quality of end-of-life care for patients and families.6
Facilitating communication between patients, families, and the healthcare team to elicit and honor a patient’s wishes allows nurses to help clarify these goals of care.7
Several strategies that foster therapeutic communication have been identified: active listening, attention to physical environment, use of open-ended questions and rephrasing, and timely provision of discussion.8 (Level B)
Nurses can help achieve the ultimate objective in these situations — to create a setting that fosters a caring, sensitive, supportive environment for patients and families.