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  • Thursday, November 15 2018

End of Life Care

We can provide comforting, end-of-life care for your loved one and assist the family during this difficult time. When a family member is diagnosed with limited life expectancy, he or she often has a strong desire to spend the final days in the comfort of home. However, caring for a loved one at the end of life can be emotionally challenging and physically exhausting. Home Health Solutions Group can support you and your loved one by working with a hospice agency to fully meet the family’s care needs. We will help care for your loved one and help around the house as well as provide the family with emotional and moral support. End-of-life nursing encompasses many aspects of care: pain and symptom management, culturally sensitive practices, assisting patients and their families through the death and dying process, and ethical decision-making.

In the United States in the 20th century, with advances in medical technology and science, the care of the dying patient shifted from family and community to health professionals. Throughout history, nurses have sought ways to improve quality of life for individuals, families, and communities during every phase of life's journey.

Studies have found that nurses can articulate the benefits of advance directives; however, nurses generally lack the knowledge and training to conduct such discussions.3 We need to develop programs to encourage clinicians and healthcare systems to conduct regular advance care planning to ensure patients and families understand their options for EOL care. Only then can we make progress in achieving the right intensity for each individual patient at the EOL. Providing EOL care that is appropriate, compassionate, and in accordance with the patient's wishes is an essential component of the nurse's role, but nurses could be more effective in working with patients. Nurses must be willing and able to begin the difficult dialogue with patients and their loved ones, assist them in understanding their disease state, and explore specific recommendations for care based on their personal values.

The Grieving Process

Another problem is the failure of nurses to recognize the stages of grief during EOL decision discussions.

  • Denial: “I feel fine”; “There must be some mistake.” Denial is usually only a temporary defense for the individual.
  • Anger: “Why me? It's not fair!” Once individuals reach the anger stage, they recognize that they can no longer continue denial. During this stage, the individual is often very difficult to care for because of misplaced feelings of resentment and jealousy.
  • Bargaining: “If only… then I'll….” In the bargaining stage, the individual searches for a way to postpone the inevitable: death. The usual form of the dialogue is to bargain for extended life in exchange for a reformed lifestyle.
  • Depression: “What's the use, I'm going to die anyway.” During this fourth stage, the dying individual begins to understand the certainty of death and may refuse treatments/medications and visitors. Some individuals become silent and/or cry all the time. Because the depression stage enables the person to disconnect from people and objects of love and affection, attempts to cheer up the individual during this time are not recommended.
  • Acceptance: “It's going to be OK. I'm prepared to die.” During this last stage, the individual begins to come to terms with his or her mortality or that of loved ones. However, not all individuals reach this stage. Some continue to struggle with death until the very end.

According to the American Family Physician, ethnic minorities currently compose approximately one-third of the US population. In the 2000 census, about 65% identified themselves as white, with the remaining percentages representing the following ethnic groups: African American (13%), Hispanic (13%), Asian-Pacific Islander (4.5%), and American-Indian/Alaskan native (1.5%).
Family physicians are challenged to learn how cultural factors influence patients' responses to medical issues, as well as the physician-patient relationship. Cultural proficiency guidelines do exist; however, few resources are available regarding ways to apply these guidelines to direct patient care. Many physicians are unfamiliar with common cultural variations regarding physician-patient communication, medical decision-making, and attitudes about formal documents such as code status guidelines and advance directives.
The challenge of respecting cultural diversity is great. The cultural values and beliefs that inform bioethics practices in many American hospitals are white, middle class, and based on Western philosophical and legal traditions that emphasize the individual and individual decision-making. We must bear in mind that many other cultures do not share these traditions. For example, in many Asian cultures, directly informing a patient of a cancer diagnosis is perceived as unnecessarily cruel. In Hispanic, Chinese, and Pakistani communities, family members actively protect terminally ill patients from knowledge of their condition. African Americans have more negative attitudes toward hospice and differ considerably from European-Americans regarding advance directives. Surveys have documented the disparities between bioethics innovations and minority populations in the United States. Substantially more African Americans and Hispanics wanted their physicians to keep them alive regardless of how will they were compared to European-Americans, who agreed that under certain circumstances life-prolonging treatment should be discontinued.
Nurses and physicians alike must increase their awareness of cultural disparities and their impact on EOL issues, including the grieving process. As patient advocates, nurses must ensure that patients and families of all ethnicities experience death with dignity. First, we must be educated about the grieving process and how cultural differences affect that process. Our duty is then to communicate the dying individual's beliefs to the physician(s) caring for that individual. Communication between physician and nurse is the key to successful advocacy.

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