Palliative care is specialized medical care for people living with serious illnesses. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and their family. Palliative care can be provided at any stage of illness and alongside curative treatment. When a patient transitions to palliative care, nursing diagnoses play a crucial role in guiding individualized care plans. These diagnoses address the holistic needs of patients facing life-limiting illnesses, ensuring comfort, dignity, and the best possible quality of life.
Near-death signs and symptoms, which are often managed within palliative care, can include a range of physical changes as the body begins to shut down. Recognizing these signs is important for providing appropriate and compassionate care:
- Sensory Changes: Patients may experience blurred vision, a diminished sense of taste and smell, and reduced perception of pain and touch. They may also exhibit blank stares due to the loss of the blink reflex. It’s important to note that hearing is often thought to be the last sense to be lost.
- Respiratory Changes: Breathing patterns can become irregular, ranging from rapid and shallow to slow. Noisy and wet-sounding breathing, often referred to as the “death rattle,” may occur. Cheyne-Stokes respiration, characterized by alternating periods of apnea and deep, rapid breathing, is another common pattern.
- Circulatory Changes: Blood pressure and heart rate tend to decrease. The skin may become cool to the touch, pale, mottled, or cyanotic, particularly in the extremities. The skin can also take on a waxy appearance.
- Genitourinary Changes: Urine output decreases, and urinary incontinence may develop.
- Gastrointestinal Changes: The digestive system slows down, leading to diminished motility and peristalsis. This can result in constipation, gas accumulation, abdominal distention, and incontinence.
- Musculoskeletal Changes: Muscle weakness is common, affecting the ability to move, speak, and swallow. The gag reflex may also be lost.
- Integumentary Changes: Kennedy terminal ulcers, dark sores that appear rapidly as part of the dying process, may develop. These are often mistaken for deep tissue injuries.
The Nursing Process in Palliative Care
The nursing process is fundamental in palliative care, focusing on both the patient’s and family’s psychosocial and physical needs. Nursing care at this stage aims to provide comprehensive support and comfort, ensuring a dignified death, enhancing the patient’s quality of life, and offering emotional support to the family. Nurses must recognize the psychological, interpersonal, and spiritual dimensions of a patient’s well-being. They play a vital role in decision-making regarding palliative care, end-of-life choices, and advance directives, working collaboratively with patients and their families. Effective palliative care requires a multidisciplinary approach, involving physicians, social workers, volunteers, chaplains, and other healthcare professionals.
Nursing Care Plans in Palliative Care
Once a nurse identifies relevant nursing diagnoses for a patient receiving palliative care, nursing care plans become essential. These plans prioritize assessments and interventions to meet both short-term and long-term care goals. They provide a structured framework for addressing the unique challenges and needs of patients and families facing serious illness. Below are examples of common nursing diagnoses in palliative care and associated care plan considerations:
Compromised Family Coping
Family coping can be significantly compromised in palliative care settings. This is often related to the stress and anxiety associated with the progression of a terminal illness, depression, changes in family roles, and a lack of understanding about the palliative care process.
Nursing Diagnosis: Compromised Family Coping
Related Factors:
- Impending death of a loved one
- Sudden or progressive health status changes
- Prolonged illness duration
- Disease progression and symptom burden
- Stress, anxiety, and depression within the family system
- Role changes and shifts in responsibilities
- Family disorganization and communication difficulties
- Inadequate knowledge of palliative and end-of-life care
- Misunderstandings about palliative care concepts and goals
As evidenced by:
- Expressed concerns or complaints about the patient’s response to treatment or care plan
- Limitations in communication and emotional expression between the patient and family support system
- Frequent inquiries and uncertainty about the patient’s current and changing health condition
- Withdrawal of family members or caregivers from the patient or healthcare team interactions
- Uncooperative or resistant behaviors from the caregiver or family members
- Neglectful attitudes or actions towards the patient’s needs by family or caregiver
- Complicated or anticipatory grieving processes within the patient and family
Expected Outcomes:
- Patient and family will verbalize an understanding of palliative care principles and demonstrate acceptance of the patient’s condition and prognosis.
- Patient and family will actively participate in developing and implementing effective coping strategies throughout the palliative care journey.
- Patient and family will demonstrate cooperative behaviors in care activities and shared decision-making processes related to the patient’s condition and care.
- Patient and family will openly express thoughts, feelings, and concerns in a supportive and honest manner.
Assessment:
1. Assess the duration of the illness and patient demographics. A sudden terminal diagnosis may lead to more complex coping challenges compared to a prolonged illness trajectory. Factors like the patient’s age or role within the family (e.g., primary caregiver) can significantly impact family coping abilities.
2. Evaluate the family’s stress, anxiety, and depression levels. Palliative care often evokes intense and conflicting emotions in patients and families. Assess for signs of anxiety and depression, as these can hinder effective coping and communication. Inquire about feelings of overwhelm, fear, and sadness.
3. Consider cultural and spiritual norms. Cultural beliefs and spiritual values significantly influence how families perceive and cope with serious illness, palliative care, and end-of-life. Understanding these factors is crucial for culturally sensitive care planning.
4. Determine the family’s understanding of advance care planning. The presence of advance directives can greatly reduce the burden of decision-making during palliative care. Assess the family’s knowledge and attitudes towards advance care planning, including living wills and power of attorney for healthcare.
Interventions:
1. Build rapport with the patient and family. Establishing a trusting relationship between the nurse, patient, and family is foundational. Rapport fosters open communication and facilitates a more supportive and peaceful palliative care experience.
2. Evaluate the family’s responses to palliative care. Palliative care can significantly impact family dynamics and coping mechanisms. Recognize that family members may have varying levels of acceptance and understanding of the palliative care process. Continuously assess their emotional and practical needs. Ensure the patient’s pain and symptoms are managed according to their preferences.
3. Engage the patient and family in care planning. Proactive and collaborative care planning empowers patients and families. It reduces feelings of helplessness, regret, and depression. Involving them in decisions promotes acceptance and ensures care aligns with their values and wishes.
4. Ensure understanding of advance directives and goals of care. Initiate conversations about patient preferences for care, especially if advance directives are not in place. Nurses can facilitate family discussions about goals of care, ensuring patient wishes are honored.
5. Facilitate referrals to social work and spiritual care services. Social workers are invaluable in addressing the financial, logistical, and emotional challenges families face during palliative care. They can also provide bereavement support. Chaplains and spiritual advisors offer spiritual and emotional comfort, supporting patients and families in finding meaning and peace.
Death Anxiety
Death anxiety is a significant concern for patients in palliative care, often stemming from the loss of physical well-being, changes in health status, and the anticipation of death itself.
Nursing Diagnosis: Death Anxiety
Related Factors:
- Anticipation of death and the unknown
- Pain and uncontrolled symptoms
- Stress and anxiety related to impending death
- Depression and feelings of hopelessness
- Spiritual distress and existential concerns
- Low self-esteem and feelings of worthlessness
- Uncertainty regarding disease prognosis and the future
- Concerns about life after death or lack thereof
- Fear of leaving loved ones behind and causing them burden
As evidenced by:
- Verbal expressions of fear, worry, or preoccupation with death and its impact on family
- Manifestations of depression, sadness, or persistent low mood
- Feelings of loneliness, isolation, or detachment from others
- Fear of changes in health status and potential decline
- Expressions of fear of the dying process, death itself, and separation from loved ones
- Fear of the unknown and what lies beyond death
- Feelings of powerlessness and loss of control over life and death
- Reports of negative thoughts, rumination, and distressing imagery related to death and dying
Expected Outcomes:
- Patient and family will openly discuss and verbalize their understanding of the dying process and its potential impact on their lives.
- Patient and family will express a sense of acceptance regarding impending death and the limitations of curative treatments.
- Patient will progress through the stages of grief in a way that is comfortable and supported, acknowledging their emotional and spiritual needs.
Assessment:
1. Determine the patient’s role within the family. If the patient is a primary caregiver or financial provider, their anxiety about the well-being of their family after their death may be intensified.
2. Explore the patient’s past experiences with death. Previous experiences with death, especially traumatic or unresolved losses, can shape a patient’s current fears and anxieties about dying. Assess for any history of complicated grief or negative associations with death.
3. Identify physical and emotional symptoms of anxiety. Anxiety can manifest physically and emotionally. Recognize and assess for symptoms such as:
- Dyspnea (shortness of breath)
- Insomnia (difficulty sleeping)
- Palpitations (heart racing)
- Nausea
- Trembling or shaking
- Irritability and restlessness
- Feelings of despair or hopelessness
- Panic attacks
4. Assess the patient’s physical condition and functional status. Physical decline and loss of independence associated with terminal illness can exacerbate fear and feelings of despair. Evaluate the patient’s level of physical comfort, mobility, and ability to perform daily activities.
Interventions:
1. Establish realistic goals with the patient and family. Setting achievable goals together can reduce death anxiety by fostering a sense of control and purpose. Focus on comfort, quality of life, and meaningful experiences.
2. Support patient and family in decision-making. Empowering patients and families to make choices about their palliative care journey provides a sense of control and agency. Encourage their active participation in care decisions.
3. Explain the expected signs and symptoms of impending death. Openly and honestly discuss what to expect during the dying process. Provide reassurance and normalize the physical and emotional changes that may occur. Address any misconceptions or fears.
4. Encourage reminiscence and life review. Facilitate conversations about positive memories, accomplishments, and life experiences. Reminiscing can provide comfort, meaning, and a sense of legacy.
5. Integrate mental health, spiritual, and social support. Address feelings of guilt, grief, spiritual distress, and social isolation. Provide access to counseling, spiritual care, and support groups to help patients and families process their emotions and find inner peace.
6. Propose hospice care as an option. When curative treatments are no longer desired or effective, hospice care offers specialized symptom management and holistic support. Explain the benefits of hospice in providing comfort, dignity, and quality of life during the final stages of illness.
Powerlessness
Powerlessness is a common nursing diagnosis in palliative care, reflecting a patient’s perceived lack of control over their health situation, disease progression, and impending death.
Nursing Diagnosis: Powerlessness
Related Factors:
- Death anxiety and fear of the unknown
- Changes in health status and functional decline
- Pain and unrelieved symptoms
- Low self-esteem and feelings of inadequacy
- Ineffective coping mechanisms and overwhelmed emotions
- Inadequate social support and feelings of isolation
- Insufficient knowledge about palliative care options and resources
- Decreased motivation or perceived inability to improve one’s situation
As evidenced by:
- Expressions of depression, hopelessness, and despair
- Manifestations of anxiety, irritability, and agitation
- Passivity, withdrawal, and reluctance to engage in self-care
- Doubts about role performance and ability to fulfill responsibilities
- Verbalizations of regret, shame, or guilt
- Statements indicating a lack of purpose or meaning in life
- Reports of an inadequate sense of control over their situation
- Fatigue, exhaustion, and lack of energy
- Loss of independence and reliance on others for basic needs
- Lack of participation in decision-making related to their care
Expected Outcomes:
- Patient and family will verbalize acceptance of the patient’s current situation and limitations, while identifying areas of continued control.
- Patient and family will actively participate in decision-making processes related to the patient’s care and end-of-life preferences.
- Patient and family will engage in palliative care activities and interventions, fostering a sense of collaboration and shared purpose.
Assessment:
1. Assess factors contributing to feelings of powerlessness. Explore the specific circumstances and experiences that contribute to the patient’s and family’s sense of helplessness. Consider physical limitations, emotional distress, social isolation, and spiritual struggles.
2. Assess understanding of palliative care. Evaluate the patient’s and family’s knowledge about palliative care and its goals. Address any misconceptions and provide education to empower them with information and realistic expectations.
3. Note available resources and support systems. Lack of social support exacerbates feelings of powerlessness. Identify available support networks, including family, friends, community resources, and healthcare team members. Assess for any gaps in support.
Interventions:
1. Avoid arguing or offering false reassurance. Patients experiencing powerlessness are unlikely to be comforted by logical arguments or empty platitudes. Avoid minimizing their feelings or offering false hope. Instead, focus on empathetic listening and validation.
2. Help patient and family identify areas of control. Even in the face of serious illness, patients retain control over certain aspects of their lives. Help them identify these areas, such as healthcare decisions, pain management preferences, daily routines, and personal interactions. Emphasize their autonomy and agency.
3. Encourage participation in routine activities and meaningful hobbies. Maintaining involvement in self-care activities, hobbies, and social connections can enhance a sense of normalcy and control. Support the patient in engaging in activities that bring them joy and purpose, to the extent possible.
4. Advocate for patient and family wishes and preferences. Act as a patient advocate within the interdisciplinary team. Ensure that the patient’s advance directives, values, and preferences guide care planning and decision-making. Facilitate communication and collaboration to honor their wishes.
These nursing diagnoses and care considerations provide a framework for addressing the complex needs of individuals receiving palliative care. By focusing on holistic assessment, individualized planning, and compassionate interventions, nurses can significantly enhance the quality of life, comfort, and dignity of patients and their families during this sensitive time.
References
- NurseTogether – Nursing Diagnoses
- NurseTogether – Nursing Care Plans
- NurseTogether – Hearing Loss Nursing Diagnosis & Care Plan
- NurseTogether – Hypotension Nursing Diagnosis & Care Plan
- NurseTogether – Constipation Nursing Diagnosis & Care Plan
- NurseTogether – Psychosocial Nursing Diagnosis & Care Plan
- NurseTogether – Stress Overload Nursing Diagnosis & Care Plan
- NurseTogether – Anxiety Nursing Diagnosis & Care Plan
- NurseTogether – Major Depression Nursing Diagnosis & Care Plan
- NurseTogether – Ineffective Coping Nursing Diagnosis & Care Plan
- NurseTogether – Acute Pain Nursing Diagnosis & Care Plan
- NurseTogether – Shortness of Breath (Dyspnea) Nursing Diagnosis & Care Plan
- NurseTogether – Insomnia Nursing Diagnosis & Care Plan
- NurseTogether – Nausea Nursing Diagnosis & Care Plan
- NurseTogether – Fatigue Nursing Diagnosis & Care Plan
