End-of-Life Nursing Care

Communication also means clarifying patient/family understanding of what is happening. It's easy to assume that they understand what is being told to them, when in reality they don't. For example, in one situation with a terminally ill cancer patient, the physician explained to him what would happen if his heart stopped. He used the phrase, “if your heart goes into asystole, we will have to call a code and intubate you.” The patient and wife nodded in agreement. After the doctor left, the nurse asked about their understanding of the conversation. The wife replied, “I haven't a clue.”

Helpful phrases when talking with patients and families about end-of-life care include:

• “What is your understanding of your illness?”
• “Can you tell me what the doctor has said?”
• “What is most important to you right now?”

Identify the Decision-Maker

The patient is generally considered the primary decision-maker when it comes to treatment. However, many times at the end of life, the patient is unable to communicate his or her wishes. It is therefore important to identify the person who is designated to make the medical decisions if the patient cannot speak. If the patient has an advance directive (living will), the decision-maker is known as the healthcare proxy, health care agent, or durable power of health care attorney. This is the person who is legally designated as the proxy decision-maker. Communication with this person is particularly important in cases where the family is in conflict about care decisions. Always ask:

• Who is the designated proxy?
• Who else needs to be communicated with?

When significant disagreement exists, and the patient cannot make decisions, a family conference that includes the physician and other members of the health care team can help; and nurses should advocate and be involved in these conferences. If the conflict cannot be resolved, nurses can play an important role in advocating for an ethics consult.

Standards of Practice

Nursing standards of practice exist regarding care for patients at the end of life. (See the American Nurses Association position paper on providing expert care at the end of life. http://bit.ly/14Axg7y.) These standards outline nursing responsibility for the provision of comfort, and include the expectation of expertise in the relief of physical, emotional and existential suffering.

Most liability claims arising from the care of dying patients are centered on treatment for pain, particularly the use of morphine and other opioids' (e.g., Dilaudid, Oxycodone, Fentanyl). Both under-treatment of pain and over-treatment of pain can trigger malpractice suits. Patients, families and medical providers often fear that the use of these drugs will cause “addiction” or will hasten death. Nurses can address these fears by:

• Assuring the patient/family that taking medications for their intended purpose does not cause addiction. (Addiction is defined as a psychological dependence that often results in anti-social or destructive behavior.)
• Conducting a thorough pain assessment that includes asking the patient his or her pain relief goals. Some patients want higher doses even if it makes them more sedated. Others prefer to tolerate certain levels of pain in order to be more alert.
• Engaging the physician and the patient/family in the discussion about use of opioids and other medications to manage end-of-life symptoms.
• Following evidence-based practices and protocols in conjunction with the physician and pharmacist.

Withholding and Withdrawing Life-sustaining Therapy

Many nurses fear that they can be held liable if they participate in the withholding or withdrawing of life-sustaining therapy. This could mean withholding intravenous (IV) fluids for hydration, removing a patient from life-support or discontinuing a feeding tube. The United States Supreme Court, in the 1990 case of Cruzan v. Director, Missouri Department of Health, 497 US 261, confirmed that there is no ethical or legal distinction between withholding or withdrawing treatments. At end of life, many of the life-sustaining treatments can cause pain and suffering for the patient. It is important for nurses to understand what the patient wants. To avoid liability, nurses should also follow institutional guidelines as well as state law.

Document, Document, Document

The old nursing adage, “If it wasn't documented, it wasn't done,” holds true in the case of a liability claim. Documentation means identifying the problem, demonstrating skilled assessment and intervention, and recording the results. Documentation should also include any discussion with the patient and family regarding treatment and care wishes.

Liability claims are least likely to occur when a patient or family feels they've been listened to and heard, when accepted standards of end-of-life care have been upheld and when the documentation reflects skilled and thoughtful intervention.

Linda Norlander, RN, BSN, MS , is the author of the book, “To Comfort Always: A Nurse's Guilde to End-of-Life Care.”

Medical malpractice suits involving nurses who are caring for patients at the end of life are rare. However, they can occur. Nurses can protect themselves by understanding the needs of patients and families at this critical time, by following approved standards of care and by thoroughly documenting their work.

Communication Is Key

A lawsuit is unlikely to occur if a patient/family understands and agrees with the care that is being given. First and foremost, nurses should listen to what patients and families are telling them. If a patient says, “I'm in pain,” it's important to say, “Tell me more about it.” Listening involves acknowledging what is being said, exploring patient goals and using body language that says “I hear you.”

Communication also means clarifying patient/family understanding of what is happening. It's easy to assume that they understand what is being told to them, when in reality they don't. For example, in one situation with a terminally ill cancer patient, the physician explained to him what would happen if his heart stopped. He used the phrase, “if your heart goes into asystole, we will have to call a code and intubate you.” The patient and wife nodded in agreement. After the doctor left, the nurse asked about their understanding of the conversation. The wife replied, “I haven't a clue.”

Helpful phrases when talking with patients and families about end-of-life care include:

• “What is your understanding of your illness?”
• “Can you tell me what the doctor has said?”
• “What is most important to you right now?”

Identify the Decision-Maker

The patient is generally considered the primary decision-maker when it comes to treatment. However, many times at the end of life, the patient is unable to communicate his or her wishes. It is therefore important to identify the person who is designated to make the medical decisions if the patient cannot speak. If the patient has an advance directive (living will), the decision-maker is known as the healthcare proxy, health care agent, or durable power of health care attorney. This is the person who is legally designated as the proxy decision-maker. Communication with this person is particularly important in cases where the family is in conflict about care decisions. Always ask:

• Who is the designated proxy?
• Who else needs to be communicated with?

When significant disagreement exists, and the patient cannot make decisions, a family conference that includes the physician and other members of the health care team can help; and nurses should advocate and be involved in these conferences. If the conflict cannot be resolved, nurses can play an important role in advocating for an ethics consult.

Standards of Practice

Nursing standards of practice exist regarding care for patients at the end of life. (See the American Nurses Association position paper on providing expert care at the end of life. http://bit.ly/14Axg7y.) These standards outline nursing responsibility for the provision of comfort, and include the expectation of expertise in the relief of physical, emotional and existential suffering.

Most liability claims arising from the care of dying patients are centered on treatment for pain, particularly the use of morphine and other opioids' (e.g., Dilaudid, Oxycodone, Fentanyl). Both under-treatment of pain and over-treatment of pain can trigger malpractice suits. Patients, families and medical providers often fear that the use of these drugs will cause “addiction” or will hasten death. Nurses can address these fears by:

• Assuring the patient/family that taking medications for their intended purpose does not cause addiction. (Addiction is defined as a psychological dependence that often results in anti-social or destructive behavior.)
• Conducting a thorough pain assessment that includes asking the patient his or her pain relief goals. Some patients want higher doses even if it makes them more sedated. Others prefer to tolerate certain levels of pain in order to be more alert.
• Engaging the physician and the patient/family in the discussion about use of opioids and other medications to manage end-of-life symptoms.
• Following evidence-based practices and protocols in conjunction with the physician and pharmacist.

Withholding and Withdrawing Life-sustaining Therapy

Many nurses fear that they can be held liable if they participate in the withholding or withdrawing of life-sustaining therapy. This could mean withholding intravenous (IV) fluids for hydration, removing a patient from life-support or discontinuing a feeding tube. The United States Supreme Court, in the 1990 case of Cruzan v. Director, Missouri Department of Health , 497 US 261, confirmed that there is no ethical or legal distinction between withholding or withdrawing treatments. At end of life, many of the life-sustaining treatments can cause pain and suffering for the patient. It is important for nurses to understand what the patient wants. To avoid liability, nurses should also follow institutional guidelines as well as state law.

Document, Document, Document

The old nursing adage, “If it wasn't documented, it wasn't done,” holds true in the case of a liability claim. Documentation means identifying the problem, demonstrating skilled assessment and intervention, and recording the results. Documentation should also include any discussion with the patient and family regarding treatment and care wishes.

Liability claims are least likely to occur when a patient or family feels they've been listened to and heard, when accepted standards of end-of-life care have been upheld and when the documentation reflects skilled and thoughtful intervention.

Linda Norlander, RN, BSN, MS , is the author of the book, “To Comfort Always: A Nurse's Guilde to End-of-Life Care.”