Nursing Care of Terminally ill Patients

Terminal Illness

Definition :

It is a disease that cannot be cured or adequately treated and that is reasonably expected to result in the death of patient with a short period of time. A patient who has such illness may be referred as terminal patient or terminally ill patient : often a patient is considered terminally ill when their estimated life expectancy is six months or less.

Stages of Terminally Illness:

Different patients react to the news that they have a terminal illness in different ways. In general , almost all patients go through various stages of acceptance when disease like cancer has been diagnosed.

A) First stage :

The first stage is disbelief. There is extreme anxiety  especially about unknown. Shock , despair and anger are common in this phase . The patient may also experience guilt about feeling angry and this can increase the feeling of anger . This phase usually lasts from few days to few months . 

B ) Second stage :

The second stage is depression, which is usually a reaction to diagnosis. The depression is mild to moderate in intensity and needs family support . The use of antidepressants  like dopamine , serotonin can be used. Duration of depression often can last several weeks to throughout the illness. The goal is to help the person go into the final stage of acceptance.

Systemic Effects in Terminally Illness:

1. Musculoskeletal System :

Due to poor activities , the bones start to demineralise as there will be depletion in the strength and density of bones. Due to long term illness and treatment, the muscle size atrophies. This leads to osteoporosis, atrophy and pain .

2. Cardiovascular System :

Because of decreased movement in heart and thickening of muscle leads to various problems. The conditions like cardiomegaly, congestive heart failure can be seen . 

3. Respiratory System :

As terminally ill patient will be in recumbent position due to which their lungs can not expand properly.The atrophy of muscles leads to decreased movement. Accumulation of secretions may also be present that leads to decreased respiratory movement and atelectasis. 

4. Gastrointestinal System :

Decreased gastric motility and use of high dose of medicines lead the patient nauseated . Weakness in skeletal muscle affects the peristalsis movement causing constipation and diarrhea. 

5. Urinary System :

In terminally ill patients, muscle atrophies . The urinary pelvis, nephron atrophies . To function the body system normally, the person should be healthy. But the terminally ill patients cannot perform it properly. The voiding capacity may be decreased and urine may be retained. This may further lead to infection. 

6. Integumentary System :

Due to treatment modalities, the skin can atrophy. The medications can hamper the cells due to which the fluids shift from the its original site due to which nutrients supplement will not be proper enough. This makes skin turgor reduced and breakdown. 

Management :

According to definition, there is no cure or adequate treatment for terminal illness. However, some medications may be appropriate to reduce pain and ease breathing. Some terminally ill patients stop all debilitating treatment to reduce unwanted side effects . Others continue aggressive treatment in the hope of an unexpected success. 

There can be different kinds of cares which are listed out as :

1. Palliative care :

It is a multidisciplinary approach to specialised medical care for people with specialised medical care for people with serious illness. The goal of palliative care is the achievement of the best possible quality of life for patients and their families. 

Palliative care is based on five major principles. ( Foley and Carver, 2001 )

• It respects the goals, likes and choices of the dying person. 
• It looks after the medical, emotional, social and spiritual needs of the dying person. 
• It supports needs of the family members.
• It helps gain access to needed health care providers and appropriate care settings.
• It builds ways to provide excellent care at the end of life. 

2. Hospice care :

It is a type of care received in the final stage of life when one is stricken with a terminal illness. The goal is to make patient as comfortable as possible during their last days. Hospice care is given when a patient no longer responds effectively to treatment and has a life expectancy of six months or less. It doesn't speed up death or delay it. 

Nursing management 

Nursing Assessment :

• Assess the condition of patient.
• Assess the level, intensity , location of pain.
• Assess the vital signs of patient.
• Monitor intake and output of patient.
• Assess the IV site. 

Nursing Diagnosis :

1. Activity intolerance related to pain/ generalised weakness/ bed rest /extreme stress .
2. Imbalanced nutrition less than body requirement related to nausea and vomiting .
3. Impaired urinary elimination related to impairment in neurologic sensing and control.

Nursing Interventions :

1) Increase activity intolerance :

• Perform a comprehensive pain evaluation including location , characteristics ,onset ,duration , frequency , quality, severity ( e.g: 0-10 scale ) 
• Keep patient in comfortable position. 
• Encourage to have rest in leisure time.
• Assess the sleep pattern and note changes in
• Promote patient's normal sleeping.
• Assist patient to carry out activities as tolerable.
• Demonstrate proper performance of ambulation and positioning. 
• Monitor breath sounds . Note feelings of panic or air hunger .
• Administer analgesics as prescribed.

2) Maintain nutritional level:

• Assess intake and output .
• Provide food according to patient's choice.
• Adjust diet before and after drug administration.
• Avoid unpleasant environment.
• Encourage adequate fluid hydration.
• Encourage oral hygiene.
• Administer prescribed antiemetics. 

 3) Promote urinary elimination :

• Assess the condition of bladder.
• Assess the voiding pattern and compare the urinary output with intake .
• Advice patient to void when the urge is felt.
• Encourage patient to drink adequate water 2 to 4 litres in accordance to disease condition.
• Provide bed pan.
• Perform catheterization if necessary. 
• Cleanse perineal area and keep it dry . Provide Catheter care as appropriate.
• Obtain periodic urinalysis and urine culture and sensitivity as indicated for any presence of infection.

4) Psychosocial and emotional support :

• Develop a level of comfort and expertise in communicating with seriously and terminally ill patients.
• Listen to patient in order to learn the level of knowledge of patient .
• Educate patient about illness.
• Give honest answers to patient .
• Maintain quiet and favourable environment with minimum noise.
• Consider their values and experiences concerning illness and death.
• If patient wants family to be present for discussion, arrange time and area. 
• Assist patient and families with life reviews, clarification, treatment decision making and end of life closure. 
• Aware patient and family about death .
• Never bring spiritual matters that patient has not discussed.
• Encourage family to verbalise their feelings.
• Encourage them to ask questions and maintain calmness.
• Allow family to be comfortable while staying overnight at hospital.

5) Maintain breathing pattern:

• Assess and record respiratory rate and depth of patient at least every 4 hours.
• Observe for breathing patterns.
• Note for changes in level of consciousness as it can be early indicator of insufficient oxygen to brain.
• Evaluate nutritional status( weight , electrolyte level , albumin level)
• Keep the patient in comfortable position.
• Provide oxygen therapy.
• Encourage deep breathing by demonstration , utilising incentive spirometer because it increases oxygenation, prevents atelectasis. 
• Encourage diaphragmatic breathing as it relaxes muscles and increases oxygen level of patient.
• Administer bronchiodilators and corticosteroids as prescribed.
• Maintain clear airway by encouraging patient to mobilize own secretions with coughing 
• Suction secretions as necessary to clear blockage in airway

  

                                                                                                    - Dawa Lhomu Sherpa ( Yangla )

                                                                                                          RN (BSc.Nurse ), Nepal