End-of-Life Care

I. PURPOSE

To ensure that patients at the end-of-life receive compassionate, respectful, and individualized care that aligns with their values, wishes, and needs.

II. POLICY STATEMENT

At Lake Chelan Health, maximizing our patient’s comfort is a priority at all times during the course of their care. When a patient is rapidly approaching end-of-life, and, death is anticipated in the next few hours or days, the overall focus is prioritized to their comfort and symptom management. End-of-life care will focus on symptom management, emotional, and spiritual support to comfort the patient and family. Therapeutic presence is essential to provide appropriate, supportive, end-of-life care. This includes an expanded tolerance for medication side effects such as sedation or respiratory depression and an abandonment of goals for recovery. The patient’s (or their surrogates) declarations of value will hold the most significant influence upon which interventions are added, continued, discontinued, or avoided.

III. SCOPE

This policy applies to all healthcare professionals, support staff, and volunteers caring for patients in the hours/days approaching the anticipated end-of-life within the hospital.

IV. ROLES & RESPONSIBILITIES

1. Provider Role:
   1. The provider will discuss with the patient/surrogate decision-maker/family member that imminent death is approaching. Explore with them their definitions of quality in their final hours/days. Do not presume what their preference will be; many will prioritize avoiding the side effects of medications to preserve the ability to communicate with loved ones at the expense of experiencing physical symptoms. Others will request all symptoms to be maximally managed despite side effects such as sedation or respiratory suppression.
      1. Priority of Decision Making:
         1. The patient
         2. The surrogate decision-maker/durable power of attorney for healthcare (DPOAHC)
         3. Next of kin (if no surrogate decision maker/DPOAHC has been identified)
            1. The patient can declare their surrogate decision-maker even if DPOAHC has not been formally documented.
      2. There are instances where the requests of the family or surrogate decision-maker are medically futile and are not in the patient’s best interest; in this scenario, it is appropriate for the provider to declare the medical futility and enact treatments that maintain patient dignity and adhere to what is known about how the patient would speak for themselves if they were able regarding symptom management.
      3. All providers at Lake Chelan Health are expected to respond to any patient’s query about life-ending medication with openness and compassion. Lake Chelan Health believes our providers have an obligation to openly discuss the patient’s concerns, unmet needs, feelings, and desires about the dying process. Providers should seek to learn the meaning behind the patient’s questions and help the patient understand the range of available options, including but not limited to comfort care, hospice care, and pain control. Ultimately, Lake Chelan Health & Clinics’ goal is to help patients make informed decisions about end-of-life care.
   2. The provider will make decisions regarding medications, artificial fluid, nutrition, and other treatments on a case-by-case basis.
      1. Some of the patient’s medications may be continued due to the likelihood of adding to the patient’s burden of suffering if they are removed (e.g., rate control medications for atrial fibrillation)
      2. Many of the patient’s medications may need to be discontinued as they are intended for prevention (e.g., lipid-lowering medications) or could cause risk with the anticipated decreased intake of food and fluids in the coming hours/days (e.g., diabetes medications).
      3. Guidelines for intervention will also need to be adjusted; for example, sliding scale insulin should be adjusted for when a patient has a profound blood sugar elevation, when/if naloxone will need to be administered, etc.
      4. Scheduled future radiographs and recurring lab testing should be discontinued in most circumstances.
      5. There is no substantial evidence that artificial hydration or nutrition during the end-of-life is helpful; in many cases, it may even be harmful, as it can cause discomfort and complications without improving quality of life. Decisions regarding artificial nutrition and hydration at the end-of-life should be made on a case-by-case basis.
      6. The provider may discontinue or minimize vital signs frequency; decisions regarding vital signs at the end-of-life should be made on a case-by-case basis.
         1. This does not apply to pain scale measurements.
      7. It is imperative to document medical decision-making conversations with the family in adequate detail to ensure the healthcare team members understand how to proceed in their role.
2. Nursing Role:
   1. Provide Patient-Centered Care:
      1. Respect the patient’s wishes and values in all aspects of care.
   2. Communication:
      1. Ensure clear, compassionate, and honest communication with patients and their families.
   3. Interdisciplinary Approach:
      1. Involve a team of healthcare professionals to address the patient’s physical, emotional, social, and spiritual needs.
   4. Comfort and Dignity:
      1. Prioritize the comfort and dignity of the patient at all times.
      2. The nurse will support the focus of symptom management consistent with and respectful of the patient/surrogate decision-maker requests.
      3. The patient’s wishes should guide personal care.
      4. Advocate for discontinuing any interventions that appear to have lost value or contribute to patient discomfort or distress.
   5. Assessments:
      1. Continue ordered assessments to help identify any developing issues that may need to be addressed to prevent additional symptom burden.
      2. Post-intervention assessments are essential to ensure symptoms are efficiently managed during end-of-life care.
      3. Communicate rapid escalation of symptoms to the provider; medication doses, intervals, or other orders may be necessary if the patient’s symptom management is incomplete.
      4. Care Plans should be adjusted to reflect new goals of care.
   6. Standard safety measures such as bar-code medication administration and skin protection should continue.
   7. Vital signs frequency can and should be minimized or even discontinued. The provider will place an order to either discontinue vital signs or specify the reduced frequency that is appropriate for the patient’s needs.
      1. This does not apply to pain scale measurements.

V. DEFINITIONS

1. End-of-Life:
   1. The time period for patients with little likelihood of cure, further aggressive therapy is judged to be futile, and comfort is the primary goal of health care.
2. DNR:
   1. Do Not Resuscitate.
3. Palliative Care:
   1. Symptom management for a terminal/non‐curable illness:
      1. Treatment for disease control may be aggressively occurring but without the goal of a cure. Life expectancy is measured in years.
4. Hospice Care:
   1. This term should be limited to care provided as part of a formal hospice program. As a Critical Access Hospital, we are not eligible to participate in providing this Medicare benefit while also providing Swing Bed services (both are Medicare part B services, and only one can be utilized at a time). Our use of the term should only be used as a transition of care recommended upon discharge and should not be used to describe the care provided by us.
5. Comfort Care:
   1. This term is to be AVOIDED at LCH. Regardless of a patient’s status, we are always considerate of their comfort.
6. End-of-Life Care:
   1. PREFERRED LANGUAGE – This phrase will be used to indicate we are managing the active dying process with a focus on symptom management. While maximizing our patient’s comfort is a priority at all times during the course of their care, when a patient is rapidly approaching end-of-life, and, death is anticipated in the next few hours or days, the overall focus is prioritized to their comfort and symptom management. End-of-life care will focus on symptom management, emotional, and spiritual support to comfort the patient and family. Therapeutic presence is essential to provide appropriate, supportive, end-of-life care. This includes an expanded tolerance for medication side effects such as sedation or respiratory depression and an abandonment of goals for recovery. The patient’s (or their surrogates) declarations of value will hold the most significant influence upon which interventions are added, continued, discontinued, or avoided.
7. Death with Dignity:
   1. Death with dignity allows Washington residents who are terminally ill, competent adults medically predicted to die within six months to request and self-administer lethal medication prescribed by a physician.

VI. PROCEDURE

NA

VII. REFERENCES

RCW 70.245.010

Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Medicine. 2021;9. doi:10.1177/20503121211000918

WAC 246-320-141

Advance Directives

Physician Orders for Life-Sustaining Treatment (POLST) Policy

Death with Dignity

VIII. ATTACHMENTS

NA

*This policy may be revised at any time without prior notice. All revisions supersede prior policy and are effective immediately upon approval.
*Any printed policy is not valid past the print date and should not be relied on for official purposes. Current versions of all policies can be found in PolicyStat.