Caring for the Hospitalized Dying Patient

The American Cancer Society reports that one of the key differences between hospitalization and hospice care is that family and friends often provide the majority of care for those under home-based hospice care. In a hospital setting, doctors, nurses, and other healthcare specialists provide the majority of care. Hospital professionals focus primarily on the health of the body, but hospice professionals address spiritual and psychological needs, as well.

Death was a statement of fact years ago, but today it has become a series of painful choices. As recently as 50 years ago, most people died at home. Now nearly 65 percent die in hospitals, and that percentage is rising steadily. This New York Times article offers more information.

In an interview with Oncology Times, Dr. Anne Walling explained that clinicians can help their dying hospitalized patients by doing these three things:

These three things were part of a study Oncology Times reported on in an article titled “Improving Care for Hospitalized Dying Patients: A Modest First-Step Proposal.” Areas for improvement identified in the study included “assessment of dyspnea, deactivating implantable cardioverter-defibrillators, and bowel regimens for patients taking opioids.” Dr. Walling said the findings at her institution might be different today, since palliative care has become more recognized since the study was conducted.

When medical care can no longer prevent dying, the nurse provides supportive care to the patient and the family. The main goals are:

• Keep the patient comfortable and free of pain. In the nonverbal patient, we have to look for signs that the patient is in pain. For example, when I walk into a room to assess a dying patient at the beginning of my shift, I may learn in a report that the patient had a good night and required no pain medication. But if the patient is breathing 46 breaths a minute, then I feel like the patient is in some discomfort, and medication is required.
• Make the patient’s final days as good as possible for both patient and family, with as little suffering as possible. We should take the time out of our jam-packed schedules to talk with family members and answer their questions to the best of our knowledge.
• Help the patient die peacefully.
• Provide comfort to the family before and/or after the patient’s death. Sometimes they may just need you to listen to a memory they have of the patient. They may need to vent their anger to you regarding one or more of the other family members.

Western Pacific Education in Action has suggested some guidelines to consider when your patient is in the last stages of illness. One of the main goals of nursing is to relieve or stop suffering. The following guidelines may be helpful.

• Always trust what patients say about pain. Never just make your own decision about how much pain they are suffering. Use a pain scale for the nonverbal patient when needed.
• Many patients fear that they will die in agony. Be kind when people express or show fear. Comfort them, and tell them that you can take care of the pain, and that they do not need to fear. I tell my patients and their families that I will do everything I can to try and make the patient as comfortable as possible. I have taken care of patients who have required numerous narcotics to make their pain tolerable, if not eliminate it. If the patient needs something for anxiety, the doctor may prescribe Phenobarbital, Ativan, or Valium. Other medications may be used, but these are the ones I administer the most, with Valium being the least administered of the three.
• Give doses of pain medication that give the most pain control with the least side effects. I always start with the least dosage ordered and then go up if needed.
• Give pain medication all through the day and night (around the clock) to make sure the patient has enough pain relief. It is important to provide physical comfort. It is also important to make the patient feel secure, calm any fears, and provide hope.