Purposful dehydration in a terminally ill cancer patient

The management of terminally ill patients who are unable to maintain their own hydration, or who express a wish to discontinue artificial hydration, is a significant controversial topic among healthcare professionals, patients and families. Evidence-based research suggests a number of medical and nursing indications and contraindications for dehydration. The purpose of this article is to review the current research, consider the factors involved in decision-making and clarify the complex issues which have implications for nursing surrounding the management of dehydration in terminally ill patients. The article uses the case of a patient nursed by the author and is written as a reflective account of practice.     

The management of hiccups in terminally ill patients

There is a reasonable amount of literature on the subject of hiccups. However, the evidence shows that existing practice relies heavily on anecdotal case reports and clinical experience. Hiccups affect talking, eating and sleeping, and can lead to weight loss, exhaustion, anxiety and depression, all factors affecting quality of life.     

The use of urinary catheters in terminally ill cancer patients.

Recent reports have commented on the need to improve our knowledge and management of urinary problems in terminally ill patients. We conducted a prospective study in 61 consecutive patients admitted to our palliative care unit (PCU), who were assessed for urinary problems, use of urinary catheters, and management of problems associated with the catheters. A total of 74% (45 of 61) of the patients required a catheter before death, with 23 (38%) being admitted to the PCU with a catheter, and 22 patients (36%) requiring a catheter during admission to PCU. We present our findings regarding the duration of catheter use, indications for catheters, type of catheters used, and complications of catheters. The data collected suggest that, although urinary problems and catheter use are common in terminal illness, if strict guidelines are followed there is no demonstrable mortality, and morbidity associated with catheter use is outweighed by patient benefit.     

The ethics of pacemaker deactivation in terminally ill patients

A core principle of American medical ethics holds that an informed and capacitated patient has the right to have treatments withdrawn or withheld. Nevertheless, many clinicians remain reluctant to honor a request to deactivate a patient's pacemaker. This article describes a case in which a patient was denied her request for pacemaker deactivation. Several reasons for this reluctance are discussed, including historical, practical, and ethical considerations for opposing pacemaker deactivation. Ultimately, however, from an ethical standpoint, pacemaker deactivation is similar to withdrawal of other therapies. Fortunately, a recent expert consensus statement supports a patient's right to have her pacemaker deactivated. Pacemaker deactivation should only be performed after robust informed consent, which must include discussion of risks, benefits, and all viable alternatives based on the patient's values and goals.     

Pain management in terminally ill patients

Successful management of pain in terminally ill patients depends on the physician's temperament, skill, and available time. Proper selection and regularly scheduled administration of medications, judicious use of adjunctive agents, and coordination of other professional services are vital. Drs Silverman and Croker explain the skills necessary to control the pain of terminal cancer patients.     

Nurses' attitudes to terminally ill patients

BACKGROUND: The care of terminally ill patients is a challenge for nurses that has raised special interest in recent years. Several studies have shown a stereotyped negative attitude in nurses towards terminally ill patients. However, all have used methods with several limitations. AIM: The aim of the study presented in this paper was to identify the nurses' attitude to the terminally ill patient in Catalonia, Spain, and the relationship of this attitude to different socio-demographic data (type of centre, shift, years of experience, age and sex) by means of a new quantitative method based on the free word-association test. METHODS: One hundred and seventy-five nurses working in 18 hospitals and hospices in Catalonia, Spain were included in the study. Data were analysed by the Associative Semantic Field Differential method by means of the computer programme CONTEXT and a quantitative evaluation of the degree of attitudes positivity was obtained. RESULTS: The study revealed a general slight negative trend in attitudes towards the terminally ill patient. A more positive attitude was observed in older caregivers and in women. The positivity in attitude decreased from morning to night shift. No differences were observed between nurses working in hospitals and those working in hospices. CONCLUSIONS: We conclude that nursing attitudes can be analysed by methods such as that used in this study. Attempts can be made to modify this attitude in caregivers by means of training programmes and stimulating awareness of an adequate professional approach.     

Pain relief in terminally ill patients

A systematic approach to identifying the cause of pain and rational use of drug therapy are keys to providing pain relief to cancer patients. Aspirin, acetaminophen and nonsteroidal anti-inflammatory drugs are effective for mild to moderate pain, and they enhance the effectiveness of weak oral narcotics, such as codeine. For severe pain, morphine is the drug of choice. A variety of adjuvant drugs can be used to enhance the effect of narcotics and to treat specific side effects of the disease or of therapy. For the terminally ill patient, a peaceful death with dignity should always be possible.     

Anxiety in terminally ill cancer patients

Context

Anxiety in terminal cancer is linked to diminished quality of life, yet overall it is poorly understood with regard to prevalence and relationship to other aspects of psychological distress.

Objectives

This study examines anxiety in terminally ill cancer patients, including the prevalence of anxiety symptoms, the relationship between anxiety and depression, differences in anxiety between participants receiving inpatient palliative care and those receiving outpatient care, and characteristics that distinguish highly anxious from less anxious patients.

Methods

Participants were 194 patients with terminal cancer. Approximately half (n = 103) were receiving inpatient care in a palliative care facility and half (n = 91) were receiving outpatient care in a tertiary care cancer center. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression, and was administered along with measures of hopelessness, desire for hastened death, and social support.

Results

Moderately elevated anxiety symptoms were found in 18.6% of participants (n = 36) and 12.4% (n = 24) had clinically significant anxiety symptoms. Level of anxiety did not differ between the two treatment settings. However, participants receiving palliative care reported significantly higher levels of depression and desire for hastened death. A multivariate prediction model indicated that belief in an afterlife, social support, and anxiolytic and antidepressant use were unique, significant predictors of anxiety.

Conclusion

Severity of anxiety symptoms did not differ between the study sites, suggesting that anxiety may differ from depression and desire for hastened death in the course that it takes over the duration of terminal cancer.     

Fostering hope in terminally ill patients

AIM: To investigate the meaning of hope, identify strategies that terminally ill patients use in maintaining and fostering hope during the final stage of life, explore changes in hope during the dying trajectory and investigate whether the results of a North American study by Herth (1990a), that explored the meaning of hope and identified strategies to promote it, could be replicated in England. METHOD: A total of 16 adults receiving palliative care took part in the study. Cross-sectional data were collected on all participants. Longitudinal data were collected on four of the 16 participants using methodological triangulation, which encompassed a background data form, the Herth Hope Index and a semi-structured interview (Herth 1990a). FINDINGS: Hope remained present regardless of nearness to death. Seven hope-fostering categories and three hope-hindering categories were identified based on interview responses. CONCLUSION: The study supported Herth's original study (Herth 1990a), and could serve as a guide to individual practitioners and the nursing team in developing an environment and interventions that foster hope in people receiving palliative care in any setting.     

Artificial nutrition and hydration for the terminally ill: a reasoned approach

Knowledge about evidence-based research findings on the physiologic effects of artificial nutrition and hydration (ANH) can be used as a framework for assisting patients and families with decision making at the end of life. This article provides a review of the credible evidence related to ANH obtained through scientifically sound research, supplies a framework for discussion about ANH with patients and families, and lists basic educational recommendations and resources that both home health and hospice nurses can use to assist with patient and family supportive efforts. The charge to nurses caring for dying patients and their families is consistently to honor patient beliefs about life--their goals and values--in a supportive, unbiased, and informational manner, which will improve the quality of life--at the end of life.     

Management of constipation in terminally ill patients

This small study was carried out to assess the effectiveness of lactulose syrup (Duphalac) in the management of constipation in forty-six patients with terminal illnesses. The daily dose of lactulose was titrated to meet the individual patients requirements and was found to be in the region of 20 to 30 mls twice daily, despite the almost universal administration of opiates as analgesics. The study lasted 21 days in each patient capable of completing the assessment. Constipation was relieved within a an average of 3 to 4 days, and of the 512 days observed, there were 203 days in which a bowel movement occurred. Of these motions 71% were recorded as easy to move, rather than hard (21%) of loose (8%). Faecal incontinence and nausea attributable to lactulose treatment were extremely rare. Therefore, lactulose appeared to be a useful treatment for constipation in the terminally ill patient.     

Acute confusion in terminally ill hospitalized patients

Knowledge about acute confusion (AC) has grown rapidly during the past decade, but very few studies have focused specifically on AC episodes associated with the end of life. Although experienced oncology clinicians accept that AC is common near the end of life, little is known about the frequency, nature, course, and timing of AC during this critical stage of life in patients with terminal cancer. Data suggest patients with advanced cancer have reversible causes of delirium, where appropriate treatment can result in improved outcomes. The data for this article are drawn from a larger study investigating the incidence, prevalence, behaviors, and outcomes of AC in acutely ill medical patients. The diagnosis of AC was ascertained using the NEECHAM Confusion Scale. Of the 117 participants included in the larger study, 16 developed delirium (cumulative incidence estimate, 14%) and 10 died within 1 year of the index hospitalization. These 10 cases were categorized in two groups: those with a cancer-related diagnosis (n = 6) and those without cancer (n = 4). To further describe the nature of AC near the end of life, two case studies are presented. Because all previous studies were conducted using samples consisting of patients with cancer, it is unknown whether the findings reported in previous studies hold for other terminal illnesses, such as chronic obstructive pulmonary disease or heart failure. The data presented in this article suggest there are differences in baseline vulnerability (e.g., cognitive status) and the timing of AC in relation to death. These differences need to be explored in a larger sample of individuals both with and without a diagnosis of cancer. The severity and course of AC in the terminally ill population needs to be described to gain a better understanding of end-of-life AC phenomenology (e.g., signs, patterns, subtypes). Armed with this information, health care providers will then be able to develop and test AC-specific treatments of patients, as well as counsel and support family members of patients experiencing AC.