16.1 Principles of Palliative & End-of-Life Nursing Care

16.1 Principles of Palliative & End-of-Life Nursing Care

Overview of Palliative Care in Singapore

Palliative care in Singapore is an essential, specialized discipline of nursing and medicine dedicated to optimizing quality of life for patients and families facing life-threatening or advanced chronic illnesses. Guided by the Ministry of Health (MOH) National Strategy for Palliative Care, the scope of palliative nursing has expanded beyond traditional terminal cancer care to encompass progressive non-cancer conditions, including end-stage organ failure (heart failure, chronic kidney disease, end-stage lung disease), neurodegenerative disorders (advanced dementia, motor neurone disease, Parkinson's disease), and severe frailty.

Unlike terminal hospice care—which focuses specifically on the final months or weeks of life when disease-modifying treatment is no longer effective—palliative care is integrated early in the disease trajectory alongside active disease-modifying therapies. The primary objective is not to hasten or postpone death, but to relieve physical suffering, alleviate psychosocial distress, address spiritual needs, and empower patients to live as actively and comfortably as possible until death.

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Multidisciplinary Care Models & Healthcare Settings

In Singapore, palliative care is delivered across an integrated continuum bridging acute tertiary hospitals, specialized inpatient hospices, community-based home palliative care services, and day hospice centres:

1. Acute Hospital Palliative Care Teams: Multidisciplinary consultative teams operating within public hospitals (e.g., Singapore General Hospital, National University Hospital, Tan Tock Seng Hospital) that provide expert symptom management, goals-of-care consultations, and complex discharge planning.
2. Inpatient Hospices: Dedicated facilities such as Dover Park Hospice, Assisi Hospice, and St. Andrew's Community Hospital Palliative Ward, offering short-term respite care, complex symptom stabilization, and terminal end-of-life care for patients who cannot be managed at home.
3. Home Palliative Care Services: Community organizations (such as HCA Hospice Care, Assisi Home Care, and Metta Hospice) that deploy registered nurses, doctors, and medical social workers directly into patients' homes to support aging in place and home deaths.
4. Day Hospices: Ambulatory care centres providing day-respite, social engagement, nursing care, rehabilitation, and symptom monitoring to support family caregivers.

The palliative care team operates under a collaborative interprofessional model comprising Registered Nurses (RNs), Palliative Care Physicians, Medical Social Workers (MSWs), Pastoral Care / Spiritual Counselors, Pharmacists, Physiotherapists, and Occupational Therapists. The RN serves as the primary clinical coordinator, conducting continuous symptom assessments, coordinating multidisciplinary care, educating family members, and advocating for patient autonomy.

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Management of Common Non-Pain End-of-Life Symptoms

End-of-life care requires evidence-based management of distressing physical symptoms that frequently manifest during advanced disease states:

Dyspnoea (Breathlessness)

Dyspnoea is a subjective, highly distressing experience of breathing discomfort. In terminal illness, dyspnoea may stem from primary lung malignancy, pleural effusion, pulmonary edema, neuromuscular weakness, or severe anemia.

• Non-Pharmacological Interventions:
  • Positioning: Seating the patient upright or in high-Fowler's position to maximize chest expansion and diaphragm excursion.
  • Air Movement: Directing a cool breeze from a handheld fan across the cheek and trigeminal nerve distribution (Cranial Nerve V), which modulates central neural perception of dyspnoea.
  • Relaxation & Energy Conservation: Reassurance, pacing nursing activities, and teaching pursed-lip breathing.
• Pharmacological Interventions:
  • Low-Dose Opioids: Oral or subcutaneous Morphine (e.g., Morphine 2.5 mg to 5 mg PO/SC Q4H or PRN) is the gold-standard first-line pharmacological treatment. Opioids reduce the brainstem respiratory center's sensitivity to hypercapnia and hypoxia, blunting the sensation of air hunger without causing clinically significant respiratory depression when titrated properly.
  • Oxygen Therapy: Supplemental oxygen is indicated ONLY if the patient is demonstrably hypoxaemic (oxygen saturation $\text{SpO}_2 < 90%$). For non-hypoxemic patients, room air supplied via a handheld fan is equally effective as oxygen therapy and avoids nasal mucosal drying.
  • Benzodiazepines: Low-dose Lorazepam (0.5 mg SL) or Midazolam (2.5 mg SC) may be added if dyspnoea is accompanied by severe anxiety or panic.

Terminal Respiratory Secretions ("Death Rattle")

Terminal respiratory secretions refer to the noisy, rattling sound produced by the movement of secretions in the pharyngeal and tracheobronchial airways in patients who are too weak or comatose to swallow or cough effectively during the final 24 to 48 hours of life.

• Nursing Actions & Communication:
  • Reassurance: Explain to family members that the "death rattle" is due to unswallowed salivary and bronchial secretions and does not cause distress or suffocation to an unconscious patient.
  • Repositioning: Reposition the patient into a side-lying (lateral recovery) position or head-elevated position to facilitate postural drainage.
  • Airway Management: Avoid deep, invasive endotracheal or nasopharyngeal suctioning. Invasive suctioning causes severe mucosal trauma, pain, coughing, laryngospasm, and reflex increase in secretion production. Gentle oral suctioning of poolings in the anterior oral cavity is permissible.
• Pharmacological Interventions:
  • Anticholinergic / Antimuscarinic Drugs: Administer early before secretions become heavy and accumulated. Hyoscine Butylbromide (Buscopan) 20 mg SC Q4H PRN (or continuous subcutaneous infusion 60-80 mg/24h) or Glycopyrronium 200-400 mcg SC Q4H PRN. These agents inhibit muscarinic receptors to dry up new salivary and bronchial secretions without penetrating the blood-brain barrier (Glycopyrronium) or causing central excitation.

Nausea and Vomiting

Etiology-targeted antiemetic selection is critical in palliative care:

• Gastric Stasis / Delayed Emptying: Metoclopramide 10 mg PO/SC Q8H (prokinetic agent targeting $D_2$ dopamine receptors).
• Chemical / Metabolic / Opioid-Induced Nausea: Haloperidol 0.5 mg to 1.5 mg PO/SC at bedtime or Q12H (potent central $D_2$ antagonist in the chemoreceptor trigger zone [CTZ]).
• Vestibular / Brain Metastases / Increased ICP: Cyclizine 50 mg SC Q8H or Dexamethasone 4-8 mg IV/SC daily.

Terminal Delirium & Agitation

Delirium occurs in up to 80% of patients in the final days of life. Hyperactive delirium manifests as restlessness, agitation, confusion, hallucinations, and picking at bedclothes.

• Assessment & Reversible Causes: Nurse must rule out acute, reversible triggers including urinary retention (distended bladder requiring catheterization), severe constipation / fecal impaction, uncontrolled pain, hypoxia, and medication toxicity.
• Environmental Interventions: Soft lighting, familiar family presence, gentle touch, and minimizing nocturnal clinical interruptions.
• Pharmacological Management: Haloperidol 0.5 mg to 2 mg SC/PO Q4H-Q8H PRN is the first-line antipsychotic. For refractory terminal restlessness, Subcutaneous Midazolam (2.5 mg to 5 mg SC PRN or continuous infusion) is administered under palliative specialist guidance.

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Symptom Management Matrix

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Psychological, Social, and Spiritual Support

In Singapore's multicultural and multi-religious context (incorporating Chinese, Malay, Indian, and Eurasian cultural paradigms), palliative nursing demands deep cultural competence:

• Family Centeredness: Decision-making often involves extended family networks. Nurses must balance individual patient autonomy with collective family dynamics while adhering to confidentiality under the Personal Data Protection Act (PDPA).
• Spiritual Rites: Facilitating access to religious leaders (Buddhist monks, Christian chaplains, Muslim ustazs, Hindu priests) for final prayers, rites of passage, and emotional comfort.
• Grief and Bereavement: Providing structured bereavement support to family members, recognizing signs of complicated grief, and connecting caregivers with MSWs and community support groups.

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Legal & Ethical Boundaries in End-of-Life Care

Palliative nursing practice in Singapore operates under strict legal and professional boundaries established by the Nurses and Midwives Act (Cap. 209), SNB Code for Nurses and Midwives (2023), and the Singapore Penal Code:

• Prohibition of Euthanasia: Euthanasia and assisted suicide are strictly illegal in Singapore. Nurses must never administer any medication or perform any action with the primary intention of ending a patient's life.
• Doctrine of Double Effect: An ethical principle justifying the administration of high-dose analgesics or sedatives (e.g., morphine or midazolam) to relieve severe, intractable pain or distress, even if an unintended secondary consequence may be the shortening of life, provided the primary intention is purely therapeutic symptom relief and the dose is clinically titrated.
• Palliative Sedation: The monitored use of non-opioid sedative drugs (e.g., midazolam) to reduce consciousness in patients with refractory, intolerable symptoms when all other interventions have failed, conducted under strict palliative care clinical protocols.