Geriatric considerations - End-of-life care: Nursing

End-of-life care involves the supportive care provided to an individual as they near death. As the nurse, you’ll provide end-of-life care for older adults by recognizing and managing the physiologic changes that occur at the end of life and providing emotional support for the patient and their family.

Now, there are certain physiologic changes that occur during the dying process. Starting with the cardiovascular system, these changes are mostly related to diminishing cardiac output and blood pressure. As a result, heart sounds become faint, peripheral pulses weaken, and circulation slows. Subsequently, the skin becomes cool, pale, and mottled, with bluish coloring, known as cyanosis, especially in the extremities.

Next, in the respiratory system, patients often report feelings of dyspnea, including a feeling of chest tightness or breathlessness, which is due to factors like respiratory congestion and weakened respiratory muscles. Keep in mind that patients experience dyspnea, even when typical signs like decreased oxygen saturation or rapid breathing are not observed.

Other respiratory changes include slow and irregular respirations, often with Cheyne-Stokes respirations which are alternating episodes of apnea and hyperventilation. Patients may also develop distinctive wet, gurgled, noisy breathing, called the death rattle, which is caused by saliva and mucus building up in the back of the throat and upper airways.

Okay, moving on to the neurologic system, decreased cerebral perfusion and metabolic disturbances can result in acute episodes of confusion, or delirium, which can alternate with moments of lucidity. Other symptoms include agitation, excessive sleepiness, or insomnia.

They can also have sensory changes like diminished sight, visual hallucinations, and hypersensitivity to light and sound; although hearing typically remains intact up until the moment of death. As death nears, responsiveness decreases, and they eventually lose consciousness altogether.

Now, patients may also experience debilitating pain which can interfere with their ability to cope at the end of life. Pain can be related to the disease process itself or treatment, potentially leading to severe fatigue, depression, changes in appetite, and even acceleration of death. Concerningly, pain can interfere with communication and interaction with loved ones during this crucial time.

Lastly, the gastrointestinal system slows down, and anorexia, or loss of appetite, is common. Anorexia is related to a variety of factors, such as nausea and vomiting, changes in taste, oral ulcers, and even emotional factors like depression.

As a result, patients can experience xerostomia, or dry mouth; dehydration; decreased weight; and muscle wasting, known as cachexia. Other gastrointestinal symptoms can include abdominal distention, intestinal obstruction, constipation, or bowel incontinence.

As the nurse caring for an older adult at the end of life, you’ll identify and manage physiologic symptoms and provide emotional support.

Begin by identifying system-specific symptoms and address them as needed.
For patients experiencing cool extremities from decreased circulation, adjust the room temperature for comfort and provide blankets and socks as needed.