Suggested Symptom Management
Sixty percent of all deaths occur in hospitals, and 80% to 90% of the deaths will be expected. Many hospitals do not have guidelines specific to the care of the dying. If a protocol or pathway is available, it is often initiated too late or not at all because of the unwillingness of the ordering provider to make the diagnosis of dying necessary to implement the protocol. This current system results in 50% of terminally ill patients dying in pain and 80% experiencing suboptimally treated dyspnea and terminal delirium before death. These dismal statistics can be attributed to the discomfort ordering clinicians have for the use of opioids, barbiturates, antipsychotics, and sedatives during the dying process.
Knowledge deficits, misconceptions, and unfounded beliefs continue to result in barriers affecting pain and symptom management for the dying. The fear of causing harm is counterproductive for dying patients and often results in undertreatment and further suffering. Literature confirms there is no limit to opioid sedation. It can be titrated to whatever dosage is required to relieve a patient's pain and maintain desired respiratory status. The use of opiates and sedatives to manage dyspnea at end of life remains complicated by knowledge deficits and personal attitudes, often resulting in the denial of dignified comfort measures for the dying. Concepts of intent and double effect can greatly assist in guiding humane and ethical symptom management concerns but are often poorly understood. The intent or desired outcome of pain and symptom management is to relieve suffering not to provide euthanasia.
Double effect can be defined as a decision to utilize an intervention with potential adverse effects or harm when it is determined that the benefits outweigh the risks, and the health care provider's intent is to relieve the patient's suffering. If an actively dying patient writhing in pain is given a bolus of morphine and dies a few moments later, his/her death can be attributed as much to the disease process as the opioid. The double effect was the benefit of reliving a patient's pain. It outweighed the risk of causing the patient to die a few moments sooner. Relieving pain and eliminating suffering are the intent and should be the focus of end-of-life (EOL) care.
Nurses remain the primary decision makers for titration and obtaining necessary medications and orders to provide compassionate care for patients. Their role as a patient advocate can ensure that all components to provide a peaceful death are in place to support a dying patient and family in their final journey. Education and experience in care of the dying are essential, and the use of resources such as the CARES tool can assist in this process.