End-of-Life Care
Key Takeaways
- Connecticut uses MOLST (Medical Orders for Life-Sustaining Treatment) — a physician/APRN-signed medical order for end-stage illness; the CNA honors it like any order but never signs or interprets it.
- A DNR (Do Not Resuscitate) order means the CNA does NOT begin CPR if the resident stops breathing — call the nurse immediately; DNR is not the same as 'do not care for.'
- Hospice and palliative care focus on comfort, not cure: pain control, symptom relief, dignity, and emotional and spiritual support for the resident and family.
- Know the physical signs of approaching death — mottling, cool extremities, Cheyne-Stokes breathing, decreased urine output, and decreasing responsiveness — and report them to the nurse.
- Postmortem care means treating the body with dignity and respect, following facility policy, supporting the grieving family, and honoring cultural and religious wishes.
Advance Directives, MOLST, and DNR Orders
An advance directive is a legal document stating a person's wishes for medical care if they cannot speak for themselves. The two common types are a living will (treatment preferences) and a healthcare proxy / durable power of attorney (a person chosen to decide).
Connecticut translates those wishes into actionable orders using MOLST (Medical Orders for Life-Sustaining Treatment) — the CT equivalent of what other states call POLST. A MOLST is a bright-form medical order signed by a physician, APRN (advanced practice registered nurse), or physician assistant for residents with an end-stage, life-limiting illness or advanced frailty.
Key scope rules for the exam:
- The CNA honors a MOLST or DNR exactly like any other physician order, but never signs, completes, or interprets it — that exceeds CNA scope.
- A DNR (Do Not Resuscitate) order means: if the resident stops breathing and has no pulse, the CNA does NOT start CPR — instead, call the nurse immediately.
- A DNH (Do Not Hospitalize) order means the resident stays in the facility for comfort care rather than being sent to the hospital.
A common trap: a resident with a DNR stops breathing, and the test offers "begin CPR." That is wrong — honoring the DNR and calling the nurse is correct. DNR does not mean abandon care; you still provide comfort and report.
Hospice and Palliative Care
Palliative care is comfort-focused care that relieves symptoms and stress at any stage of a serious illness. Hospice care is palliative care for residents expected to live six months or less who have chosen to forgo curative treatment.
The CNA's focus shifts from cure to comfort:
- Pain and symptom control — report pain, nausea, breathlessness, or restlessness promptly so the nurse can medicate.
- Dignity — keep the resident clean, repositioned, and free of odors; provide gentle mouth care for dryness.
- Emotional support — sit with the resident, listen, and use therapeutic communication.
- Spiritual support — honor religious and cultural practices and offer to contact the chaplain.
- Family involvement — allow family to remain at the bedside and support them.
When a dying resident says, "I'm afraid of dying," the best response is not to change the subject or offer false cheer. Acknowledge it: "That sounds frightening. Would you like to talk about it, or would you like me to call the chaplain?"
The Five Stages of Grief
Elisabeth Kubler-Ross described five stages residents and families may move through — not always in order. Recognizing them helps the CNA respond with patience rather than judgment.
| Stage | What it can look like |
|---|---|
| Denial | "This can't be happening to me." |
| Anger | Hostility toward staff or family for no clear reason |
| Bargaining | "If I get better, I'll change my life." |
| Depression | Withdrawal, sadness, loss of interest |
| Acceptance | Calm, peaceful readiness |
If a dying resident becomes angry and hostile "for no reason," it may be grief. Stay calm, do not take it personally, and give the resident space while staying available.
Recognizing the Signs of Approaching Death
The CNA must observe and report physical changes as death nears. Hearing is believed to be the last sense to go, so always speak gently and assume the resident can hear you. Common signs include:
- Mottling — blotchy, bluish-purple skin, usually starting at the knees and feet, as circulation slows.
- Cool, pale extremities — hands and feet feel cold.
- Cheyne-Stokes respirations — irregular breathing with periods of deep breaths followed by pauses (apnea).
- Decreased urine output — output drops, sometimes to very small amounts in a catheter bag.
- Decreasing responsiveness — more sleeping, then unresponsiveness.
- Loss of bladder/bowel control and the death rattle (noisy, congested breathing).
Report these changes to the nurse. Continue comfort care: reposition for comfort, keep the mouth moist, keep the resident clean and warm, and let family stay if they wish.
Postmortem Care and Supporting the Family
After death, postmortem care is the respectful preparation of the body. Within the CNA scope and per facility policy this includes: positioning the body in good alignment, gentle cleansing, applying an identification tag, and treating the body with dignity and respect.
Always honor cultural and religious wishes. For example, if a Jewish resident's family asks that postmortem care wait until after the Sabbath, respect that request and inform the nurse so the care plan is adjusted. Never rush the family.
Caring for Yourself and the Family
- Allow family to remain with the body and grieve; offer privacy and a quiet presence.
- Avoid clichés like "It was for the best"; simple, sincere words and listening help more.
- It is normal for the CNA to grieve too — accept support from colleagues and supervisors and use the Employee Assistance Program (EAP) if available.
Common Exam Mistakes
- Starting CPR on a resident with a valid DNR order.
- Treating DNR or DNH as a reason to provide less comfort care — the opposite is true.
- Sending a DNH resident to the hospital instead of providing comfort and reporting to the nurse.
- Failing to honor a family's religious request for the body, or rushing postmortem care.
A Connecticut resident has a valid DNR (Do Not Resuscitate) order. During the CNA's rounds, the resident stops breathing and has no pulse. What should the CNA do?
Which group of findings BEST indicates that a resident is approaching death and should be reported to the nurse?
A Jewish resident dies on a Saturday, and the family asks the CNA to delay postmortem care until after sunset for religious reasons. What is the CNA's BEST response?
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