Can We Talk? End of Life Discussions
In this article the author provides some guidance about how to proceed with end of life discussions.
Jan busied herself at the bedside of her patient, a woman she had seen before during a similar admission for COPD. As the woman struggled to breathe, Jan could easily read the panic in her patient's eyes. She changed a sweaty pillowcase, put the head of the bed up slightly and readjusted the fingertip pulse ox that beeped repeatedly.
She started to back away to look at the patient's med list and see what was due, when the patient caught her hand, "Can we talk?" Jan's mind raced ahead to the other patients she was responsible for, before settling back into place and focusing in on her struggling patient's face. She knew, in her heart, what this conversation would be about. It was important and not the kind of talk that could be rushed. She pulled up a chair and sat up to maintain eye contact.
She held the woman's fingers and asked, "What have you got on your mind? How can I help?"
"I don't want this," the woman said, while rolling her eyes in an arch to indicate the bedside with its surrounding drips and machines. "I want to go home."
Broaching the subject of death is hard for anyone. Sometimes, being at the bedside, we are the ones that patients open up to. How do we handle it when it happens? Whether we are at the bedside in the hospital, or in home health, and even in an office setting, we can be at the front lines of a critical discussion. Do we know what to say and do?
Here are some points to consider when we face a similar discussion:
Be fully present
Eye contact, physical touch, body posture all play an important part in sending the message that we are really here, ready to listen and help. Many of us feel distinctly uncomfortable about having end of life discussions-after all we work to make life better, to prolong active life, to maximize function. But there are times in our profession when we need to be the midwives that help our patients find their way forward when they feel they are at a dead end. If we are able to allow them to talk, help them express their wishes, we can help them find a way toward peace and hope even in the face of death.
Listen and ask questions
In nursing school we all learn about asking "open-ended questions." This is the time to employ that skill, allowing the patient to say what they need to say, even if it's not pleasant or even if it's not what you are hoping they will say. Being a good listener is hard work, especially when the person is struggling to express themselves or when we feel hurried by other pressures.
Help define goals
Goals can engender hope and focus. At this stage, the goals sometimes seem rather small-to get home and sit in a favorite recliner with their dog, to hold a grandchild, to enjoy some time on the porch. Knowing what they want can help us know how to proceed. But what if their wishes seem completely unreasonable given their fragile condition? Again, listening is key. Sometimes simply verbalizing their goals is enough to satisfy the longing for reality to be different; it can be enough to help them get through this day.
Know your resources
As nurses, it is important to know the resources we have available to us, whatever our setting might be. Whether it is a palliative care team, the hospice liaison nurse, the case manager or a physician, having a solid knowledge of how to proceed from this point can be valuable to our patients. Do you know the difference between Advance Directives and the POST form? Do you know what qualifies as a hospice diagnosis? Do you know what services are available at home for those who want palliative care while continuing to pursue treatment? Can we be gentle guides along the way as we help our patients understand what "Full Treatment" means vs. "Limited Additional Treatments?" Being well versed in this subtle, but important aspects of end of life care can make us even better nursing professionals.
Sometimes having this conversation can take a long time. It is important, critical really, to know how to direct the conversation and begin the process of referring the patient to the doctor or the case manager. Depending on the setting, we may need to continue to help the patient clarify their wishes or we may need to introduce the concept of another person who can discuss this fully with them, at length, and fill out the appropriate forms to document their wishes.[/INDENT]
In a few minutes, Jan was able to ascertain that her patient would need further counseling and the opportunity to fill out paperwork. She outlined the steps she planned to take in calling the doctor to come in and discuss next steps. Then she went on to offer some medication for symptom management before moving on to her other patients. As she left with her cart, she looked back to see the woman breathing more easily and dozing off.
End of life discussions need to happen, and sometimes we are the ones who are there. Being prepared and willing to listen, we can provide valuable care to our patients who desire to make choices about their end of life care.
Joy Eastridge, BSN, RN, CHPN
Reading a recent news article about a man who was found with a Do Not Resuscitate message tattooed on his chest prompted me to write this article. To read more about that news story, go to Living Will TattooLast edit by Joe V on Jun 14, '18
Joy has been a nurse for 30+ years, practicing in a variety of settings. She is currently serving as a Faith Community Nurse.
Joined: Jan '15; Posts: 346; Likes: 1,187Dec 9, '17Agree. Great points. Hopefully most hospitals also have a palliative care dept. Its very difficult for staff nurses (at least in the facilities that I go to) have the time to discuss much about end of life.Dec 10, '17It can be difficult sometimes to ensure the patient's wishes are carried out and respected when there are family members with completely different ideas about what mom/dad/aunt Millie needs - and are vehemently demanding that the opposite type of care be aggressively carried out instead.
Sadly, even when the appropriate paperwork has been filled out, I've witnessed the patient's wishes overrided because the provider or team feared legal repercussions. When this happens it's never a positive outcome, and it's absolutely heartbreaking to watch unfold.
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