End-of-Life Care Order Arrangements

Introduction

Patients under hospice care or acute care environments nearing their end-of-life often have significant spiritual, physical and emotional unmet needs. End-of-life care aims to manage pain and other life-threatening symptoms to make the patient comfortable. Implementing standardized end-of-life care order set/protocol can increase patient comfort and improve family satisfaction. Because of the surge in the number of patients who pass on in the inpatient care setting, it essential to implement the best evidence-based practice when managing end-of-life care.

Clinical Question in PICO Format

Population (P): End-of-life care inpatients

Intervention (I): End-of-life care protocol/order set

Comparison (C): Individualized patient protocols/order set or protocols from end-of-life care providers

Outcome (O): Enhanced patient comfort and family satisfaction when managing end-of-life patients.

Question: For the end-of-life inpatients, how is having an end-of-life protocol/care order set increase patient comfort and improve family satisfaction?

Literature Search

Study shows that death is not sudden for some people. Instead, dying is an inevitable outcome of a disease or a combination of illnesses that need to be managed compassionately and carefully for a given period, which can be weeks, months or years, characterized by several ups and downs (Jones, 2016). Evidence indicates that irrespective of whether curative care is also incorporated, palliative care often provides the opportunity for upholding the premier quality of life for the most prolonged period possible for patients living with advanced acute health conditions. Death is not primarily a medical event (Stilos et al., 2016). In an ideal world, medical care complements psychological, social, and spiritual supports to ensure the patient and family comfort.

Comprehensive health care programs contribute immensely as the patient approaches the end-of-life, relieving pain, effects of the disease, discomfort and other life-threatening symptoms. End-of-life order arrangements have also proven to facilitate optimal possible functioning attainment, prevent anxiety and depressions that characterize such a critical moment in a person’s life. It also helps to ease the care burden on the family members, facilitating constructive family dynamics and even extending the patient’s life for time (Ong, Ting and Chow, 2018). End-of-life order set an arrangement to attain all these by integrating science with compassion, considering the patient’s and family’s cultural and spiritual contexts, roles, interests and roles, and adjusting the treatment or care to the patient’s individual needs. Evidence-based care, hence, suggests that caring for individuals approaching end-of-life should be predominantly patient-centered and family-centred (Jones, 2016).

The literature on the family perspective on end-of-life care emphasizes the need to increase healthcare workers’ education on the dying process and enhance early and open communication to families on the prognosis for their dear ones (Sutherland, 2019). Even though several other factors affect the family’s sense of peace when caring for loved ones, the two facts have been cited as vital for families’ decision-making capability during the end-of-life process (Canzona et al., 2018). Stilos and colleagues described the quality of the dying process and death as “the degree to which a person’s preferences for dying and the moment of death are consistent with observations of how the person actually died as reported by others” (Stilos et al. 2016). End-of-life care is vital and specific individuals and their family members. In a study, Jackson et al. (2012) asserted that family members are more prepared to make decisions concerning end-of-life care where they adequately informed that death is a potential outcome. Communication and providing recommendations is not an assurance that the families or the patient will adhere to the guideline or clinician’ directions. Nevertheless, evidence shows that minus effective communication, the likelihood of poor end-of-life decision-making is likely to increase (Jackson et al., 2012).

In their study, Ong, Ting and Chow (2018) argued that nurses are critical in facilitating end-of-life discussions, acting as the patient advocates. They are also capable of assessing the families’ skills and perceptions and advice as appropriate.  Even though it is not within the nursing scope to discuss anything to do with the patient progress, evidence suggests that nurse-initiated discussions concerning the prognosis, possible outcomes of care, and patient information integration help reduce conflict and improve decision-making. End-of-life care interventions in an inpatient setting also entail transferring the patient from the intensive care section to the medical unit to minimize the adoption of uncomfortable and painful interventions and provide more time for the family to spend adequate time with their loved ones (Ong, Ting & Chow,2018).

Currently, most of the end-of-life orders are entered based on the patient’s exhibition of the symptoms. On study indicated that report by most of the patients’ families’ shows that about 60% of the patients showed sign of emotional and physical distress three days before their demise (Canzona et al. 2018). The order sets or protocols often initiated for end-of-life care include pain and secretion controls, symptoms management, anxiety, nausea, constipation, and dyspnea. Other order sets include the termination of vital signs monitoring, minimizing non-essential devices and lines, and laboratory checking. The caregiver achieves optimal patient comfort by consulting with spiritual caregivers, social service providers, and palliative care experts (Sutherland, 2019). Studies have noted several barriers, including unrealistic patient or family expectations, caregiver comfort with end-of-life care, and continuity of medical teams, which may delay adequate holistic end-of-life care and should be managed with care to achieve an optimal patient outcome (Sutherland, 2019).

The article that Supports Implementing End-of-Life Care Order

“Berton, T. C. (2015). Increasing comfort with end-of-life discussions. University of Nevada, Las Vegas.”

The article by Berton (2015) emphasizes the need for communication to increase patient comfort during end-of-life care. The author argues that communication at the end-of-life phases is essential for patients’ optimal outcomes, including improving satisfaction, relief from stress, and enhancing coping skills. Berton’s assertions support the earlier literature findings in this paper that open communication both to the patient and their families is imperative to promote optimal care outcomes and the patient’s and families’ satisfaction. Successful palliative care significantly depends on the healthcare provider’s capacity to provoke and understand the dying patient’s problems and comprehend the client’s end-of-life care goals. Constant communication and discussion ensure that the treatment is consistent with patients’ needs and preferences during the end-of-life to eliminate unnecessary pain and increase the client’s comfort. The healthcare provider’s inability to have open communication with the patient or the family about dying can lead to failure to understand some of the client’s needs, which may exacerbate pain (Berton 2015). Some healthcare providers would even refute that addressing and discussing end-of-life care strategies is an essential facet of health provider-patient communications, which is wrong.

This paper argues that because of the surge in the number of patients who pass on in the inpatient care setting, it vital to implement the best evidence-based practice when managing end-of-life care. Study evidence has proven that having an end-of-life protocol/care order set increases patient comfort and improve family satisfaction in an inpatient care setting. Palliative care has proven to uphold the best quality of life for the most prolonged period possible during the end-of-life stage.

References

Berton, T. C. (2015). Increasing comfort with end-of-life discussions. University of Nevada, Las Vegas

Canzona, M. R., Love, D., Barrett, R., Henley, J., Bridges, S., Koontz, A., & Daya, S. (2018). “Operating in the dark”: Nurses’ attempts to help patients and families manage the transition from oncology to comfort care. Journal of clinical nursing, 27(21-22), 4158-4167.

Jackson, J., Derderian, L., White, P., Ayotte, J., Fiorini, J., Hall, R. O., & Shay, J. T. (2012). Family perspectives on end-of-life care: a meta-synthesis. Journal of Hospice & Palliative Nursing, 14(4), 303-311.

Jones, L. (2016). Care of People When They Face Death and Dying: Definitions, International Context and the Development of Research. In Care at the End of Life (pp. 3-15). Adis, Cham.

Ong, K. K., Ting, K. C., & Chow, Y. L. (2018). The trajectory of experience of critical care nurses in providing end‐of‐life care: A qualitative descriptive study. Journal of clinical nursing, 27(1-2), 257-268.

Stilos, K., Wynnychuk, L., DasGupta, T., Lilien, T., & Daines, P. (2016). Improving end-of-life care through quality improvement. International journal of palliative nursing, 22(9), 430-434.

Sutherland, R. (2019). Focus: Death: Dying Well-Informed: The Need for Better Clinical Education Surrounding Facilitating End-of-Life Conversations. The Yale journal of biology and medicine, 92(4), 757.