Nursing care involves the support of general well-being of our patients, the provision of
episodic acute care and rehabilitation, and when a return to health is not possible, a
peaceful death. Dying is a profound transition for the individual. As healthcare
providers, we become skilled in nursing and medical science, but the care of the dying
person encompasses much more. Certain aspects of this care are taking on more
importance for patients, families, and healthcare providers.
Hospice care provides comprehensive physical, psychological, social, and spiritual care
for terminally ill patients. Most hospice programs serve terminally ill patients from the
comforts and relaxed surroundings of their own home, although there are some located
in inpatient settings. The goal of hospice care team is to help the patient achieve as full
life as possible, with minimal pain, discomfort, and restriction. It also emphasizes a
coordinated team effort to help the patient and family members overcome the severe
anxiety, fear, and depression that occur with terminal illness. To that end, hospice staffs
encourage family members to help and participate in patient care, thereby providing
the patient with warmth and security and helping the family caregivers begin the
grieving process even before the patient dies.
Everyone involved in this method of care must be committed to high-quality patient
care, unafraid of emotional involvement, and comfortable with personal feelings about
death and dying. Good hospice care also requires open communication among team
members, not just for evaluating patient care but also for helping the staff cope with
their own feelings.
Recent studies have identified barriers to end-of-life care including patient or family
members avoidance of death, influence of managed care on end-of-life care, and lack
of continuity of care across settings. In addition, if the dying patient requires a lengthy
period of care or complicated physical care, there is the likelihood of caregiver fatigue
(psychological and physical) that can compromise the care provided.
The best opportunity for quality care occurs when patients facing death, and their
family, have time to consider the meaning of their lives, make plans, and shape the
course of their living while preparing for death.
Nursing Care Plans
Nursing Priorities
1. Control pain.
2. Prevent/manage complications.
3. Maintain quality of life as possible.
4. Plans in place to meet patients/familys last wishes (e.g., care setting,
Advance Directives, will, funeral).
1. Ineffective Family Coping
Nursing Diagnosis
Ineffective Family Coping
Risk for Compromised or Disabled Caregiver Role Strain
May be related to
Inadequate or incorrect information or understanding by a primary person;
unrealistic expectations
Temporary preoccupation by significant person who is trying to manage
emotional conflicts and personal suffering and is unable to perceive or to act
effectively with regard to patients needs; does not have enough resources to
provide the care needed
Temporary family disorganization and role changes; feel that caregiving
interferes with other important roles in their lives
Patient providing little support in turn for the primary person
Prolonged disease/disability progression that exhausts the supportive capacity
of significant persons
Significant person with chronically unexpressed feelings of guilt, anxiety,
hostility, despair
Highly ambivalent family relationships; feel stress or nervousness in their
relationship with the care receiver
Possibly evidenced by
Patient expressing/confirming a concern or complaint about SOs response to
patients health problem, despair about family reactions/lack of involvement;
history of poor relationship between caregiver and care receiver
Neglectful relationships with other family members
Inability to complete caregiving tasks; altered caregiver health status
SO describing preoccupation about personal reactions; displaying intolerance,
abandonment, rejection; caregiver not developmentally ready for caregiver
role
SO attempting assistive/supportive behaviors with less than satisfactory
results; withdrawing or entering into limited or temporary personal
communication with patient; displaying protective behavior disproportionate
(too little or too much) to patients abilities or need for autonomy
Apprehension about future regarding care receivers health and the
caregivers ability to provide care
Desired Outcomes
Identify resources within themselves to deal with situation.
Visit regularly and participate positively in care of patient, within limits of
abilities.
Express more realistic understanding and expectations of patient.
Provide opportunity for patient to deal with situation in own way.
Nursing Interventions
Rationale
Anxiety level needs to be dealt with before
Assess level of anxiety present in family
and/or SO.
problem solving can begin. Individuals
may be so preoccupied with own reactions
to situation that they are unable to
respond to anothers needs.
Establish rapport and acknowledge
difficulty of the situation for the family.
May assist SO to accept what is happening
and be willing to share problems with
staff.
Determine the level of impairment of
perceptual, cognitive, and/or physical
Information about family problems will be
abilities. Evaluate illness and current
helpful in determining options and
behaviors that are interfering with the
developing an appropriate plan of care.
care of the patient.
Note patients emotional and behavioral
responses resulting from increasing
weakness and dependency
Approaching death is most stressful when
patient and/or family coping responses are
strained, resulting in increased frustration,
guilt, and anguish.
Nursing Interventions
Rationale
When family members know why patient
Discuss underlying reasons for patient
is behaving differently, it may help them
behaviors with family.
understand and accept or deal with
unusual behaviors.
Assist family and patient to understand
When these boundaries are defined, each
who owns the problem and who is
individual can begin to take care of own
responsible for resolution. Avoid placing
self and stop taking care of others in
blame or guilt.
inappropriate ways.
Determine current knowledge and/or
perception of the situation.
Provides information on which to begin
planning care and make informed
decisions.
Lack of information or unrealistic
Assess current actions of SO and how they
perceptions can interfere with caregivers
are received by patient.
and/or care receivers response to illness
situation.
Involve SO in information giving, problem
solving, and care of patient as feasible.
SO may be trying to be helpful, but
Instruct in medication administration
actions are not perceived as being helpful
techniques, needed treatments, and
by patient. SO may be withdrawn or can
ascertain adeptness with required
be too protective.
equipment.
Information can reduce feelings of
Include all family members as appropriate
in discussions. Provide and/or reinforce
information about terminal illness and/or
death and future family needs.
helplessness and uselessness. Helping a
patient or family find comfort is often
more important than adhering to strict
routines. However, family caregivers need
to feel confident with specific care
activities and equipment.
2. Activity Intolerance
Nursing Diagnoses
Activity Intolerance
Fatigue
May be related to
Generalized weakness
Bedrest or immobility; progressive disease state/debilitating condition
Imbalance between oxygen supply and demand
Cognitive deficits/emotional status, secondary to underlying disease
process/depression
Pain, extreme stress
Possibly evidenced by
Report of lack of energy, inability to maintain usual routines
Verbalizes no desire and/or lack of interest in activity
Lethargic; drowsy; decreased performance
Disinterested in surroundings/introspection
Desired Outcomes
Identify negative factors affecting performance and eliminate/reduce their
effects when possible.
Adapt lifestyle to energy level.
Verbalize understanding of potential loss of ability in relation to existing
condition.
Maintain or achieve slight increase in activity tolerance evidenced by
acceptable level of fatigue/weakness.
Remain free of preventable discomfort and/or complications.
Nursing Interventions
Rationale
Multiple factors can aggravate fatigue,
Assess sleep patterns and note changes in
including sleep deprivation, emotional
thought processes behaviors.
distress, side effects of medication, and
progression of disease process.
Recommend scheduling activities for
Prevents overexertion, allows for some
periods when patient has most energy.
activity within patient ability.
Adjust activities as necessary, reducing
intensity level and/or discontinuing
Nursing Interventions
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activities as indicated.
Encourage patient to do whatever
possible: self-care, sit in chair, visit with
family or friends.
Instruct patient, family, and/or caregiver
in energy conservation techniques. Stress
necessity of allowing for frequent rest
periods following activities.
Provides for sense of control and feeling of
accomplishment.
Enhances performance while conserving
limited energy, preventing increase in level
of fatigue.
Demonstrate proper performance of ADLs,
ambulation or position changes. Identify
safety issues: use of assistive devices,
temperature of bath water, keeping travel-
Protects patient or caregiver from injury
during activities.
ways clear of furniture.
Encourage nutritional intake and use of
Necessary to meet energy needs for
supplements as appropriate.
activity.
Document cardiopulmonary response to
activity (weakness, fatigue, dyspnea,
arrhythmias, and diaphoresis).
Can provide guidelines for participation in
activities.
Monitor breath sounds. Note feelings of
Hypoxemia increases sense of fatigue,
panic or air hunger.
impairs ability to function.
Provide supplemental oxygen as indicated
Increases oxygenation. Evaluates
and monitor response.
effectiveness of therapy.
3. Anticipatory Grieving
Nursing Diagnoses
Anticipatory Grieving
Death Anxiety
May be related to
Anticipated loss of physiological well-being (e.g., change in body function)
Perceived death of patient
Possibly evidenced by
Changes in eating habits; alterations in sleep patterns, activity levels, libido,
and communication patterns
Denial of potential loss, choked feelings, anger
Fear of the process of dying; loss of physical and/or mental abilities
Negative death images or unpleasant thought about any event related to
death or dying; anticipated pain related to dying
Powerlessness over issues related to dying; total loss of control over any
aspect of ones own death; inability to problem-solve
Worrying about impact of ones own death on SOs; being the cause of others
grief and suffering; concerns of overworking the caregiver as terminal illness
incapacitates
Desired Outcomes
Identify and express feelings appropriately.
Continue normal life activities, looking toward/planning for the future, one
day at a time.
Verbalize understanding of the dying process and feelings of being supported
in grief work.
Experience personal empowerment in spiritual strength and resources to find
meaning and purpose in grief and loss.
Desired Family Outcome:
Verbalize understanding of the stages of grief and loss, ventilate conflicts and
feelings related to illness and death.
Nursing Interventions
Rationale
Trust is necessary before patient and/or
Facilitate development of a trusting
family can feel free to open personal lines
relationship with patient and/or family.
of communication with the hospice team
and address sensitive issues.
Assess patient and/or SO for stage of grief
currently being experienced. Explain
process as appropriate.
Knowledge about the grieving process
reinforces the normality of feelings and/or
reactions being experienced and can help
patient deal more effectively with them.
Nursing Interventions
Rationale
Provide open, nonjudgmental
environment. Use therapeutic
Promotes and encourages realistic
communication skills of active listening,
dialogue about feelings and concerns.
affirmation, and so on.
Encourage verbalization of thoughts
and/or concerns and accept expressions of
sadness, anger, rejection. Acknowledge
normality of these feelings.
Patient may feel supported in expression
of feelings by the understanding that deep
and often conflicting emotions are normal
and experienced by others in this difficult
situation.
Be aware of mood swings, hostility, and
Indicators of ineffective coping and need
other acting-out behavior. Set limits on
for additional interventions. Preventing
inappropriate behavior, redirect negative
destructive actions enables patient to
thinking.
maintain control and sense of self-esteem.
Patient may be especially vulnerable when
Monitor for signs of debilitating
recently diagnosed with end-stage disease
depression, statements of hopelessness,
process and/or when discharged from
desire to end it now. Ask patient direct
hospital. Fear of loss of control and/or
questions about state of mind.
concerns about managing pain effectively
may cause patient to consider suicide.
Reinforce teaching regarding disease
Patient and/or SO benefit from factual
process and treatments and provide
information. Individuals may ask direct
information as requested or
questions about death, and honest
appropriate about dying. Be honest; do
answers promote trust and provide
not give false hope while providing
reassurance that correct information will
emotional support.
be given.
Opportunity to identify skills that may help
Review past life experiences, role changes,
sexuality concerns, and coping skills.
Promote an environment conducive to
talking about things that interest patient.
individuals cope with grief of current
situation more effectively. Issues of
sexuality remain important at this stage:
feelings of masculinity or femininity, giving
up role within family, ability to maintain
sexual activity (if desired).
Investigate evidence of conflict;
Interpersonal conflicts and/or angry
Nursing Interventions
Rationale
behavior may be patients or SOs way of
expressions of anger; and statements of
expressing or dealing with feelings of
despair, guilt, hopelessness, inability to
despair and/or spiritual distress,
grieve.
necessitating further evaluation and
support.
Determine way that patient and/or SO
understand and respond to death.
Determine cultural expectations, learned
These factors affect how each individual
behaviors, experience with death (close
faces death and influences how they may
family members and/or friends), beliefs
respond and interact.
about life after death, faith in Higher
Power (God)
Assist patient/SO to identify strengths in
self or situation and support systems.
Be aware of own feelings about death.
Accept whatever methods patient/SO have
chosen to help each other through the
process.
Provide open environment for discussion
with patient/SO (when appropriate) about
desires and/or plans pertaining to death;
e.g., making will, burial arrangements,
tissue donation, death benefits, insurance,
time for family gatherings, how to spend
remaining time.
Recognizing these resources provides
opportunity to work through feelings of
grief.
Caregivers anxiety and unwillingness to
accept reality of possibility of own death
may block ability to be helpful to
patient/SO, necessitating enlisting the aid
of others to provide needed support.
If patient/SO are mutually aware of
impending death, they may more easily
deal with unfinished business or desired
activities. Having a part in problem solving
or planning can provide a sense of control
over anticipated events.
Encourage participation in care and
Allows patient to retain some control over
treatment decisions.
life.
Visit frequently and provide physical
Helps reduce feelings of isolation and
contact as appropriate or desired, or
abandonment.
provide frequent phone support as
appropriate for setting. Arrange for care
Nursing Interventions
Rationale
provider and/or support person to stay
with patient as needed.
Provide time for acceptance, final farewell,
and arrangements for memorial or funeral
service according to individual spiritual,
cultural, ethnic needs.
Accommodation of personal and family
wishes helps reduce anxiety and may
promote sense of peace.
Providing for spiritual needs, forgiveness,
Determine spiritual needs or conflicts and
prayer, devotional materials, or
refer to appropriate team members
sacraments as requested can relieve
including clergy and/or spiritual advisor.
spiritual pain and provide a sense of
peace.
Refer to appropriate counselor as needed
Compassion and support can help alleviate
(psychiatric clinical nurse specialist, social
distress or palliate feelings of grief to
worker, psychologist, pastoral support)
facilitate coping and foster growth.
Refer to visiting nurse, home health
agency as needed, or hospice team, when
appropriate.
Provides support in meeting physical and
emotional needs of patient and/or SO, and
can supplement the care family and
friends are able to give.
Identify need for and appropriate timing of
May alleviate distress, enhance coping,
antidepressants and/or anxiety
especially for patients not requiring
medications.
analgesics.
4. Pain
Nursing Diagnosis
Pain, acute/chronic
May be related to
Injuring agents (biological, chemical, physical, psychological)
Chronic physical disability
Possibly evidenced by
Verbal/coded report; preoccupation with pain
Changes in appetite/eating, weight; sleep patterns; altered ability to continue
desired activities; fatigue
Guarded/protective behavior; distraction behavior (pacing/repetitive activities,
reduced interaction with others)
Facial mask; expressive behavior (restlessness, moaning, crying, irritability);
self-focusing; narrowed focus (altered time perception, impaired thought
process)
Alteration in muscle tone (varies from flaccid to rigid)
Autonomic responses (diaphoresis, changes in BP, respiration, pulse);
sympathetic mediated responses (temperature, cold, changes of body
position, hypersensitivity)
Desired Patient Outcomes
Report pain is relieved/controlled.
Verbalize methods that provide relief.
Follow prescribed pharmacological regimen.
Demonstrate use of relaxation skills and diversional activities as indicated.
Desired Family Outcomes
Cooperate in pain management program.
Nursing Interventions
Rationale
Perform a comprehensive pain evaluation,
Provides baseline information from which
including location, characteristics, onset,
a realistic plan can be developed, keeping
duration, frequency, quality, severity (e.g.,
in mind that verbal/behavioral cues may
010 scale), and precipitating or
have little direct relationship to the degree
aggravating factors. Note cultural issues
of pain perceived. Often patient does not
impacting reporting and expression of
feel the need to be completely pain-free
pain. Determine patients acceptable level
but is able to be more functional when
of pain.
pain is at lower level on the pain scale.
Determine possible pathophysiological
and/or psychological causes of pain
Pain is associated with many factors that
may be interactive and increase the
degree of pain experienced.
Assess patients perception of pain, along
Helps identify patients needs and pain
with behavioral and psychological
control methods found to be helpful or not
Nursing Interventions
Rationale
responses. Determine patients attitude
helpful in the past. Individuals with
toward and/or use of pain medications and
external locus of control may take little or
locus of control (internal and/or external).
no responsibility for pain management.
Encourage patient and family to express
feelings or concerns about narcotic use.
Verify current and past analgesic and
narcotic drug use (including alcohol).
Inaccurate information regarding drug use
or fear of addiction or oversedation may
impair pain control efforts.
May provide insight into what has or has
not worked in the past or may impact
therapy plan.
Assess degree of personal adjustment to
These factors are variable and often affect
diagnosis, such as anger, irritability,
the perception of pain and ability to cope
withdrawal, acceptance.
and need for pain management.
Discuss with SO(s) ways in which they can
assist patient and reduce precipitating
factors.
Promotes involvement in care and belief
that there are things they can do to help.
Identify specific signs and symptoms and
Unrelieved pain may be associated with
changes in pain requiring notification of
progression of terminal disease process, or
healthcare provider and medical
be associated with complications that
intervention.
require medical management.
Involve caregivers in identifying effective
Managing troubling symptoms such as
comfort measures for patient: use of non-
nausea, dry mouth, dyspnea, constipation
acidic fluids, oral swabs, lip salve, skin
can reduce patients suffering and family
and/or perineal care, enema. Instruct in
anxiety, improving quality of life and
use of oxygen and/or suction equipment
allowing patient/family to focus on other
as appropriate.
issues.
Demonstrate and encourage use of
relaxation techniques, guided imagery,
meditation.
May reduce need for/can supplement
analgesic therapy, especially during
periods when patient desires to minimize
sedative effects of medication.
Monitor for/discuss possibility of changes
Although causes of deterioration are
in mental status, agitation, confusion,
numerous in terminal stages, early
restlessness.
recognition and management of the
Nursing Interventions
Rationale
psychological component is an integral
part of pain management.
Inadequate pain management remains
Establish pain management plan with
one of the most significant deficiencies in
patient, family, and healthcare provider,
the care of the dying patient. A plan
including options for management of
developed in advance increases patients
breakthrough pain.
level of trust that comfort will be
maintained, reducing anxiety.
Schedule and administer analgesics as
indicated to maximal dosage. Notify
physician if regimen is inadequate to meet
pain control goal.
Instruct patient, family or caregiver in use
of IV pump (PCA) for pain control.
Helps maintain acceptable level of pain.
Modifications of drug dosage or
combinations may be required.
When patient controls dosage and
administration of medication, pain relief is
enhanced and quality of life improved.
Other Possible Nursing Care Plans
Risk for moral Distressrisk factors may include conflict among decision
makers, cultural conflicts, end-of-life decisions, loss of autonomy, physical
distance of decision makers.
