4.5 End-of-Life Care, Hospice Support, and Post-Mortem Procedures
Key Takeaways
- Hospice care focuses on comfort care for terminally ill residents with a prognosis of 6 months or less, while palliative care provides symptom relief at any stage of illness.
- Signs of approaching death include Cheyne-Stokes respirations (alternating deep breathing and apnea), skin mottling, weak rapid pulse, and reduced consciousness.
- Hearing is widely considered the last sense to remain functional; CNAs should continue speaking reassuringly to dying residents even if unresponsive.
- Post-mortem care requires dignified handling of the deceased, positioning the body supine with head elevated to prevent facial discoloration, and cleaning soiled areas.
End-of-Life Care, Hospice Support, and Post-Mortem Procedures
Providing compassionate end-of-life care is one of the most solemn and impactful duties of a nursing assistant. CNAs support dying residents by maintaining physical comfort, preserving dignity, assisting family members, and performing post-mortem care with utmost respect.
Palliative Care versus Hospice Care
Understanding the distinction between palliative care and hospice care ensures appropriate alignment with resident goals of care.
| Feature | Palliative Care | Hospice Care |
|---|---|---|
| Target Population | Individuals with any serious, chronic, or life-limiting illness at any stage of disease. | Terminally ill individuals with a certified medical prognosis of 6 months or less to live. |
| Curative Treatment | May be combined with active curative treatments (e.g., chemotherapy, surgery, dialysis). | Curative treatments are discontinued; focus shifts entirely to comfort and quality of life. |
| Primary Goal | Relieve symptom burden, pain, and stress associated with serious illness. | Provide pain management, comfort care, and emotional/spiritual support during the dying process. |
| Location of Care | Hospitals, outpatient clinics, long-term care facilities, or home. | Long-term care facilities, dedicated hospice centers, or home settings. |
The CNA Role in Hospice Care
Hospice care utilizes an interdisciplinary team (physicians, nurses, social workers, chaplains, and CNAs). CNAs spend the most direct time with dying residents, focusing on:
- Maintaining skin integrity through frequent repositioning.
- Keeping the mouth and lips moist.
- Reporting changes in pain level, breathing, or consciousness immediately to the nurse.
- Providing quiet emotional support and presence to the resident and family.
Physical Signs of Approaching Death
As biological body systems begin to shut down during the dying process, distinct physiological signs appear. CNAs must recognize these changes to ensure prompt comfort measures.
System-by-System Physical Changes
- Respiratory Changes:
- Cheyne-Stokes Respirations: A classic respiratory pattern characterized by alternating periods of deep, rapid breathing followed by shallow breathing and periods of apnea (absence of breathing lasting 10 to 30 seconds).
- "Death Rattle": A wet, gurgling sound caused by mucus and salivary secretions accumulating in the back of the throat due to loss of the swallow reflex.
- Cardiovascular & Circulatory Changes:
- Pulse becomes weak, thready, irregular, and often rapid before stopping.
- Blood pressure continuously drops.
- Mottling: A distinct bluish-purple, splotchy, lace-like discoloration appearing on the skin of the feet, knees, hands, and legs caused by poor circulation. Extremities feel cold and pale to touch.
- Neurological & Sensory Changes:
- Decreased level of consciousness, progressing from drowsiness to unresponsiveness or coma.
- Visual hallucinations or fixed, unblinking gaze.
- Hearing is the Last Sense Lost: Research indicates that dying individuals can often hear spoken words even when completely unresponsive.
- Gastrointestinal & Elimination Changes:
- Loss of appetite, refusal of food and fluids, difficulty swallowing (dysphagia).
- Incontinence of bowel and bladder or severe decrease in urine output (concentrated, dark urine).
Comfort Care Measures for Terminally Ill Residents
Nursing care during the final days and hours focuses entirely on optimizing comfort, preventing pain, and upholding dignity.
Key Nursing Assistant Comfort Interventions
- Frequent Oral Hygiene: Perform mouth care every 1 to 2 hours using water-soaked sponge swabs, moistening lips with water-soluble lip balm or petroleum jelly to prevent dry, painful cracking.
- Positioning and Airway Clearance: Position the resident on their side (semi-Fowler's or side-lying position) to allow secretions to drain from the mouth, easing the "death rattle" sound.
- Skin Care and Hygiene: Keep linen clean, dry, and wrinkle-free. Change absorbent pads promptly following incontinence. Reposition gently every 2 hours as tolerated.
- Environmental Controls: Maintain a peaceful, quiet, dimly lit room. Provide soft blanket layers for warmth rather than heavy covers that feel oppressive.
- Preserving Communication: Speak in normal, soothing tones assuming the resident can hear everything. Explain care procedures before touching the resident even if un-responsive.
[!IMPORTANT] Supporting the Family: Allow family members unrestricted visiting hours. Provide comfortable seating, tissues, water, and private space. Never dismiss family grief or make false promises. Listen empathetically and notify the nurse if family members request spiritual support.
Post-Mortem Care Procedures
Post-mortem care is the physical care performed on a resident's body after death has been officially declared by a physician or nurse according to state law.
Step-by-Step Post-Mortem Care Guidelines
- Maintain Respect and Privacy: Treat the body with dignity at all times. Close the door or pull privacy curtains.
- Apply Standard Precautions: Wear gloves (and gown/mask if drainage is present) throughout the procedure.
- Position the Body Supine: Place the body flat on its back with the head slightly elevated on a pillow. Elevating the head prevents blood from settling in the face and causing facial discoloration.
- Close Eyes Gently: Gently close the eyelids by holding them down for a few seconds.
- Handle Dentures per Policy: Insert dentures into the mouth if specified by facility policy to preserve natural facial structure, or place them in a labeled denture cup.
- Clean the Body: Wash soiled areas of the skin gently; replace soiled dressings with clean ones.
- Address Incontinence & Drainage: Place a clean absorbent pad under the buttocks and apply a clean gown to absorb any post-mortem body fluid leakage.
- Organize Personal Belongings: Carefully gather, inventory, and box all personal belongings (jewelry, photos, clothes) to return to the family according to facility policy.
- Prepare for Family Viewing: Ensure the room is tidy, light a soft lamp, remove dirty equipment, and allow the family quiet time for private viewing.
- Mortuary Transfer: Attach identification tags to the body and shroud according to facility protocol after family viewing is complete.
A terminally ill resident exhibits alternating periods of deep, rapid breathing followed by 20-second periods of apnea. The CNA recognizes this respiratory pattern as:
During post-mortem care, why does the CNA place the deceased resident in a supine position with the head slightly elevated on a pillow?
Which statement accurately describes a key distinction between hospice care and palliative care?
When providing care to an unresponsive, terminally ill resident during their final hours, which sensory system should the CNA assume remains functional until death?