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End-of-Life Care During the Last Days and Hours Guideline at a Glance (Nursing Practice Guideline)

End-of-Life Care During the Last Days and Hours Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines


Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2015EArsenaultknudsen@uwhealth.org
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Guideline Title: End-of-Life Care During the Last Days and Hours
Effective Date: May 2015
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
This content is extracted from the adopted source document: Registered Nurses’ Association of
Ontario. (2011). End-of-Life Care During the Last Days and Hours. Toronto, Canada: Registered
Nurses’ Association of Ontario. Please refer to the source guideline for complete information.
Target Population:
This guideline focuses on recommendations for adults, aged 18 years and older, who have reached the
part of the illness trajectory that includes the last days and hours of life.
Nursing Practice Guideline Objectives
The purpose of this best practice guideline is to provide evidence-based recommendations for
Registered Nurses and Registered Practical Nurses on best nursing practices for end-of-life
care during the last days and hours of life. The guideline does not replace consultation with
palliative care specialists, who can support nurses to provide quality end-of-life care. The
guideline is intended to be a resource to nurses who may not be experts in this practice area.
It is acknowledged that individual competencies vary between nurses and across categories of
nursing professionals. The inclusion of recommendations on clinical, education, organization
and policy topics makes this guideline applicable to nurses in all domains and settings of
practice.
Clinical Questions Considered
1. What knowledge and skills do nurses require to identify and assess individuals and families
during the last days and hours of life?
2. What knowledge, skills and tools do nurses require to support individuals and their families in
making informed choices during the last hours and days of life?
3. What palliative care interventions are needed to address the experiences faced by individuals
and their families during the least days and hours of life?
4. What supports are needed to assist nurses in providing high-quality care in the last hours and
days of life?
II. Practice Recommendations
RNAO
Recommendati
on Number
RNAO Recommendation
(see full guideline for complete list of recommendations)
Type of
Evidence
Practice Recommendations for Assessment at the End of Life
1.2
Nurses understand common signs and symptoms present
during the last days and hours of life.
IIb - IV
1.2.1
Common signs of imminent death, may include, but are not
limited to:
• progressive weakness;
• bedbound state;
• sleeping much of the time;
• decreased intake of food and fluid;
• darkened and/or decreased urine output;
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2015EArsenaultknudsen@uwhealth.org
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• difficulty swallowing (dysphagia);
• delirium not related to reversible causes;
• decreased level of consciousness not related to other
causes;
• noisy respiration/excessive respiratory tract secretion;
• change in breathing pattern (Cheyne-Stokes
respiration, period of apnea); and
• mottling and cooling extremities.
1.3
1.3.2
1.3.3
1.3.4
1.3.5
Nurses complete a comprehensive, holistic assessment of
individuals and their families based on the Canadian Hospice
Palliative Care Association Domains of Care, which include the
following:
• disease management;
• physical;
• psychological;
• spiritual;
• social;
• practical;
• end-of-life care/death management; and
• loss, grief.
Use evidence-informed and validated symptom assessment
and screening tools when available and relevant
Reassess individuals and families on a regular basis to identify
outcomes of care and changes in care needs.
Communicate assessments to the interprofessional team.
Document assessments and outcomes.
IIb – IV*
Practice Recommendations for Decision Support at the End of Life
2.1
2.2
Nurses recognize and respond to factors that influence
individuals and their families’ involvement in decision-making.
Nurses support individuals and families to make informed
decisions that are consistent with their beliefs, values and
preferences in the last days and hours of life.
Ia,Ib, IV,
IV*
Practice Recommendations for Care and Management at the End-of-Life
3.1
Nurses are knowledgeable about pain and symptom
management interventions to enable individualized care
planning.
III-IV
3.2
Nurses advocate for and implement individualized
pharmacologic and non-pharmacologic care strategies
Ia-IV

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3.3
Nurses educate and share information with individuals and
their families regarding:
• reconciliation of medications to meet the individual’s
current needs and goals of care;
• route and administration of medications;
• potential symptoms;
• physical signs of impending death;
• vigil practices;
• self-care strategies;
• identification of a contact plan for family when death
has occurred; and
• care of the body after death.
Ib-III
3.4
Nurses use effective communication to facilitate end of life
discussions related to:
• cultural and spiritual values, beliefs and practices;
• emotions and fears;
• past experiences with death and loss;
• clarifying goals of care;
• family preference related to direct care involvement;
• practical needs;
• informational needs;
• supportive care needs;
• loss and grief; and
• bereavement planning.
III
Education Recommendations
4.1
Entry to practice nursing programs and post-registration
education incorporate specialized end-of-life care content,
including:
• dying as a normal process including the social and
cultural context of death and dying, dying trajectories
and signs of impending death;
• care of the family (including caregiver);
• grief, bereavement and mourning;
• principles and models of palliative care;
• assessment and management of pain and other
symptoms (including pharmacologic and non-
pharmacologic approaches);
• suffering and spiritual/existential issues and care;
• decision-making and advance care planning;
• ethical issues;
• effective and compassionate communication;
• advocacy and therapeutic relationship-building;
• interprofessional practice and competencies;
• self-care for nurses, including coping strategies and
self-exploration of death and dying;
• end-of-life issues in mental health, homelessness and
the incarcerated;
• the roles of grief and bereavement educators, clergy,
spiritual leaders and funeral directors; and
• knowledge of relevant legislation.
Ia – III
4.2
Successful education in end-of-life care includes specific
attention to the structure and process of learning activities and
incorporates:
• small group learning;
• dyadic and experiential learning approaches;
• integration and consolidation of theory and practice;
Ib -III

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• opportunities to practice the skills and competencies
acquired;
• constructive feedback and/or reflection on acquired
knowledge, skills and competencies; and
• contact with knowledgeable and supportive clinical
supervisors and mentors.
Organization and Policy Recommendations
5.1
Models of care delivery support the nurse, individual and
family relationship.
III-IV
5.2
Organizations recognize that nurses’ well-being is a critical
component of quality end-of-life care and adopt responsive
strategies.
III-IV
5.3
Organizations providing end-of-life care demonstrate evidence
of a philosophy of palliative care based on the Canadian
Hospice Palliative Care Association’s The Model to Guide
Hospice Palliative Care
III-IV
5.4
Nursing best practice guidelines can be successfully
implemented only when there are adequate planning,
resources, organizational and administrative supports, as well
as appropriate facilitation. Organizations may wish to develop
a plan of implementation that includes:
• An assessment of organizational readiness and
barriers to implementation
• Involvement of all members (whether in a direct or
indirect supportive function) who will contribute to the
implementation process.
• Dedication of a qualified individual to provide the
support needed for the education and implementation
process.
• Ongoing opportunities for discussion and education to
reinforce the importance of best practices.
• Opportunities for reflection on personal and
organizational experience in implementing guidelines.
IV
III. Pertinent Resources
A. Policies
• UWHC Administrative Policy 4.21: Disposition of the Body After Death
• UWHC Administrative Policy 4.31: Organ and Tissue Donation
• UWHC Administrative Policy 4.34: Patients Rights and Responsibilities
• UWHC Administrative Policy 4.37: Advance Directives
• UWHC Administrative Policy 8.23: Do Not Resuscitate/No CPR Order
• UWHC Administrative Policy 8.24: Guidelines for Treating Patients when they Refuse
Medical Treatment
• UWHC Administrative Policy 8.25: Guidelines for Decisions to Limit Life-Sustaining Medical
Treatment
• UWHC Administrative Policy 3.5.5: Pain Management
• UWHC Nursing Policy 7.12: Spiritual Care
• UWHC Nursing Policy 8.14AP: Postmortem Care (Adult & Pediatric)
B. Patient Education Resources
o Health Facts for You #5471: Living with Loss
o Health Facts For You #5883: Progressive Relaxation: Basic Script

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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C. Clinical Tools
o Pain Fast Facts
o Assessing Pain in the Nonverbal or Cognitively Impaired (Pain Fast Facts)
o Nonpharmacologic (Mind-Body) Approaches to Managing Pain (Pain Fast Facts)
o The Correct Way to Write “Titrate to Comfort” Orders (Pain Fast Facts)
o Algorithms for Unrelieved Pain (Pain Fast Facts)
o Pain Management Reference Webpage
o Principles of Pharmacologic Pain Management Reference
o Coping with Pain
o Cultural Aspects of Pain Management
o Establishing Pain Relief Goals
• Additional UWHC Resources
o Spiritual Care Services
o Palliative Care for Advanced Disease – Adult Inpatient Order set (#1377)
o Palliative Care and Hospice (general information)
o End of Life RN Care Template
IV. References
See full guideline document for list of references.
V. Rating Scheme For The Strength Of The Recommendations
Type Therapy/Prevention/Etiology/Harm Prognosis
Ia
Evidence obtained from systematic review and
meta-analysis of randomized controlled trials.
Evidence obtained from systematic review
of inception cohort studies.
Ib
Evidence obtained from at least one well-
designed randomized controlled trial.
Evidence obtained from at least one well-
designed inception cohort study with follow-
up.
IIa
Evidence obtained from at least one well-
designed controlled study without
randomization.
Evidence obtained from systematic review
of retrospective cohort studies or untreated
control groups in randomized controlled
trials.
IIb
Evidence obtained from at least one other type
of well-designed quasi-experimental study.
Evidence obtained from at least one well-
designed retrospective cohort study or
follow-up of untreated control patients in a
randomized controlled trial.
III
Evidence obtained from at least one well-
designed nonexperimental quantitative study
(i.e. comparative or correlational) or
qualitative study.
Evidence obtained from at least one well-
designed non-experimental quantitative
study (i.e. case-series, case-control studies,
cohort studies and historically controlled
studies).
IV
Evidence obtained from expert committee
reports or opinions, and/or clinical experiences
of respected authorities.
Evidence obtained from expert committee
reports or opinions, and/or clinical
experiences of respected authorities.
IV*
Evidence obtained from other clinical practice
guidelines.
Evidence obtained from other clinical
practice guidelines.