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Purpose
This procedure examines the strategies a nurse can use to address the symptoms that a patient may experience as they near the end of their life. It should be noted that some of the issues present as signs, rather than symptoms, the nomenclature is to term them symptoms. Symptoms generally refer to the sensations a patient experiences (Ellis and Standing, 2023) while signs can be seen and measured based on observations made by healthcare professionals. For example, pain is a symptom, while high blood pressure is a sign.
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Assessment
The symptoms a person experiences at the end-of-life will be determined by a number of factors, which may include:
- primary diagnosis
- concomitant diseases
- individual’s level of consciousness
- effectiveness of current symptom management
Symptoms at the end-of-life may not all be physical, and may also be psychological, social and/or spiritual.
Relieving serious health-related suffering, be it physical, psychological, social, or spiritual, is a global ethical responsibility
It is important for the nurse to understand that there can be an interplay between the physical and psychological causes of symptoms. Therefore, symptom management requires the nurse to be patient-centred and holistic (National Institute for Health and Care Excellence (NICE), 2021a).
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Equipment
Nurses undertaking a holistic and person-centred approach to symptom management at the end of life must consider any wishes the person may have previously recorded about their care, including any:
- advance care planning
- recommended summary plan for emergency care and treatment (ReSPECT) form
- treatment escalation plan (Jiminez et al, 2018)
The equipment needed for assessing and managing symptoms will depend on the symptoms being managed and may include things like pain assessment tools, equipment for monitoring oxygenation and the means to monitor the patient’s temperature. Nurses will also need access to different ways of administering medications, which might include tablet pots, syringes and syringe drivers, depending on the medication needs of the patient. It might also include equipment, such as hospital beds and pillows to enable repositioning and electronic fans to aid with temperature management and breathlessness.
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Procedure
While there is a marked interplay between the symptoms at the end of life, for example pain and fatigue, it is more appropriate to consider them individually in terms of their management.
Pain
While pain may be common at the end of life, it is not a universal phenomenon. Nevertheless, pain is distressing both for the patient and those around them and is often the first symptom people consider managing.
- Prior to management, the pain should be quantified where possible (Chapman et al, 2020). This also allows the nurse to measure the impact of any pain management procedure
- It is important to consider if the cause of the pain can be removed or modified, this may include using non-pharmacological means of pain control, for example:
- repositioning
- complementary therapies (eg therapeutic massage)
- relaxation techniques
- distraction therapy
- transcutaneous electrical stimulation (Wilson and Stanczak, 2020)
- Non-pharmacological pain relief should be used alongside
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Risks and complications
Failing to identify and manage symptoms at the end of life might result in a patient approaching death with distressing symptoms that could have been alleviated. There is also a risk of the end of life becoming over medicalised (Riley and Droney, 2021) rather than being a time for family- and patient-centred care.
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3.1 observe and assess comfort and pain levels and rest and sleep patterns
10. Use evidence-based, best practice approaches for meeting needs for care and support at the end of life, accurately assessing the person’s capacity for independence and selfcare and initiating appropriate interventions
10.2 manage and monitor effectiveness of symptom relief medication, infusion pumps and other devices
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Resources
Chapman S, Carvalho F, Dinen C. Pain assessment and management. In: Lister S, Hofland J, Grafton H and Wilson C (eds). The Royal Marsden Manual of Clinical Nursing Procedures. 10th edn. Chichester: Wiley Blackwell; 2020: 457-496
Ellis P, Standing M. Patient assessment and care planning in nursing. 4th edn. London: Sage; 2023
Gillon S, Clifton IJ. Breathlessness in palliative care: a practical guide. Br J Hosp Med, 2019;80(2):72-77. https://doi.org/10.12968/hmed.2019.80.2.72
Kirshbaum MN, Olson K, Pongthavornkamol K, Graffigna G. Understanding the meaning of fatigue at the end of life: an ethnoscience approach. Eur J Oncol Nurs, 2013;17(2):146-53. https://doi.org/10.1016/j.ejon.2012.04.007
Moorthy GS, Letizia M. The management of nausea at the end of life. J Hospice & Pall Nurs, 2018;20(5):442-449 https://doi.org/10.1097/NJH.0000000000000453
Muldrew DH, Hasson F, Carduff E et al. Assessment and management of constipation for patients receiving palliative care in specialist palliative care settings: A systematic review of the literature. Palliative Medicine. 2018;32(5):930-938. https://doi.org/10.1177/0269216317752515
National Institute for Health and Care Excellence (NICE). End-of-lifecare for adults: service delivery. 2019.
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