8.4 End-of-Life, Palliative & Post-Mortem Care

Providing care to a resident at the end of life requires a high level of clinical competence, empathy, and respect for resident dignity. Certified Nursing Assistants (CNAs) play a critical role in ensuring comfort, managing symptoms, and supporting both the resident and their family members during the active dying process. Under Oregon State Board of Nursing (OSBN) standards, care at the end of life must focus on comfort, quality of life, and the preservation of resident rights.

Palliative Care vs. Hospice Care

While both palliative care and hospice care focus on providing comfort and improving quality of life, they differ significantly in their clinical goals and eligibility criteria:

• Palliative Care: Comfort care provided to residents facing serious, chronic, or life-limiting illnesses. It can be initiated at any stage of the disease, and residents may continue to receive curative treatments (such as chemotherapy, radiation, or kidney dialysis) alongside comfort measures. The goal is to relieve pain and symptoms while the resident manages their condition.
• Hospice Care: A specialized program of care for terminally ill residents who have a certified physician's prognosis of six months or less to live. When entering hospice, curative treatments are stopped, and the clinical focus shifts entirely to pain and symptom management (comfort care) and emotional and spiritual support. Hospice care can be provided in the home, in a nursing facility, or in a dedicated hospice facility.

Physical Signs of Approaching Death

As a resident enters the active dying phase, their body systems begin to slow down and fail, resulting in several characteristic physical changes:

• Nervous System Changes: The resident sleeps more, becomes increasingly difficult to arouse, and may experience periods of confusion, restlessness, or agitation.
• Sensory Decline: Pupils may become dilated, fixed, or unequal. Vision becomes blurred, and the resident may stare blankly into the room. Because hearing is widely believed to be the last sense to fail during the dying process, the CNA must continue to speak to the resident in a normal tone, explain all care procedures, and maintain a quiet, peaceful environment.
• Cardiovascular Failure: Blood pressure drops significantly. The pulse becomes weak, rapid, or irregular. Circulation slows, causing the hands, feet, and nose to feel cold. The skin may appear pale, cyanotic (blue-tinged around the lips and nailbeds), or mottled (a splotchy, purple discoloration on the legs and back caused by blood pooling).
• Respiratory Changes: Breathing patterns become irregular. The resident may exhibit Cheyne-Stokes respirations, which are characterized by periods of deep, rapid breathing followed by periods of apnea (no breathing at all). Secretions accumulate in the back of the throat due to the loss of the swallowing reflex, causing a wet, gurgling sound known as the 'death rattle.'
• Elimination and Metabolic Decline: Appetite and fluid intake decrease significantly. The resident may develop dysphagia, making swallowing fluids high-risk. Bowel and bladder muscles relax, causing incontinence. Urinary output decreases significantly, and the urine becomes very dark, concentrated, and scanty.

The CNA’s Role in Comfort Care

The primary focus of the CNA during end-of-life care is comfort, dignity, and honoring the resident's preferences as outlined in the care plan:

• Pain Management Support: While CNAs cannot administer pain medications, they must monitor for non-verbal signs of pain (facial grimacing, groaning, tensing, restlessness) and report them to the nurse immediately.
• Skin Care and Positioning: Keep the resident clean, dry, and free of soiled linens to prevent skin breakdown. Reposition the resident gently at least every two hours to prevent pressure injuries. If the resident is experiencing dyspnea (difficulty breathing), elevate the head of the bed (semi-Fowler's or high Fowler's position) to ease breathing.
• Oral and Nasal Care: Offer frequent mouth care (every 1 to 2 hours) using moistened oral swabs. Apply lip balm or petroleum jelly to dry, cracked lips. Gently clean the nose and apply a water-soluble lubricant if dry.
• Environment: Keep the room clean, quiet, and peaceful. Use soft, indirect lighting, play gentle music if desired by the resident, and ensure adequate ventilation and temperature control.
• Legal and Regulatory Context: Under OSBN standards, CNAs must respect the resident’s advance directives (such as Do Not Resuscitate - DNR orders) and honor their cultural, spiritual, and religious preferences. This includes allowing family members to perform specific religious rituals at the bedside.
• Family Support: Provide a welcoming environment for family members. Offer chairs, water, and privacy. Listen actively when they express grief, but refer any medical questions regarding prognosis or time of death to the licensed nurse.

Post-Mortem Care Procedures

Post-mortem care is the care of the body after death. It must be performed with the utmost respect and dignity. The standard steps (aligned with Oregon Headmaster/TMU clinical skills exam guidelines) include:

1. Verification: Confirm that the licensed nurse has officially declared the resident deceased.
2. Preparation: Wash hands, apply clean gloves, and pull privacy curtains. Ensure the roommate, if present, is moved or shielded.
3. Positioning: Place the body in a supine position with the arms at the sides or folded over the abdomen. Critical Step: Place a pillow under the head to prevent facial discoloration (post-mortem lividity) caused by blood pooling in the face.
4. Closing Features: Gently close the eyes. A rolled towel can be placed under the chin to keep the mouth closed. If the resident wore dentures, insert them if required by facility policy.
5. Cleaning: Bathe the body: clean feces, urine, or other fluids, and dry the skin. Replace soiled dressings and remove tubes only if instructed by the licensed nurse.
6. Dressing: Put on a clean gown and place an incontinence pad under the buttocks to catch any escaping fluids.
7. Personal Belongings: Inventory all personal belongings and secure them for the family. Document what was sent with the body and what was handed to the family.
8. Shroud and Identification: Apply identification tags to the body (usually on the great toe) and the shroud per facility policy.
9. Environment: Prepare the room for family viewing by removing soiled items, straightening the bed linens, and ensuring a neat, quiet environment. Always handle the deceased resident with the same respect shown to a living resident.