However, it is much more likely, when a patient becomes gravely ill suddenly, that if a directive ex ists, the patient's choices will not be clearly related to the specific circumstances the patient is experiencing the specific or, most likely of all, that no advance directive exists. when the patient is gravely il, it is often the nurse who notices first that death is approaching. Clear commu nication to the family and physician is essential at this time because the family frequently has not considered death as an alternative(Caswell& omery, 1990). Fami lies need adequate, consistent information in terms that they can understand. Woods, Beaver, and Luker(2000) describe this as having the family get the whole story Norton and Talerico(2000) caution that families need healthcare providers to use words such as"death and dying"; vague language makes families become confused it is especially important, as Norton and Talerico state, that healthcare providers not use terms like "better when a patient's condition has temporarily stabilized but the overall prognosis is unchanged, because this leads to conflicting impressions among family members and family disagreement about treatment. Another term that confuses family members is "hope Healthcare providers often use the term when there is hope for a good death or pain control: while for family members, hope primarily means survival. Norton and Talerico (2000) recommend that nurses be specific in identifying that they are hoping for a good death or pain control for the patient, not continued life.
When death appears imminent, nurses may introduce the discussion of withholding or withdrawing life sustaining interventions, such as CPR, intubation, and ventilation. There are two common ways that nurse begin a discussion of these interventions (Norton&Talerico, 2000). One of them is as follows: The state requires that all people receive CPR (even when it is unlikely to be of any benefit to the person unless a DNR order is written. This is often an easier way to begin the discussion if the family has not completely
Acknowledged that the patient is probably dying. However, it may prevent the family from acknowledging and discussing the nearness of the patient's death. Another common approach is to acknowledge that the patient is gravely ill, probably dying, and ask the family which vision of the patient's death would be in the patient's best interests: one in which they were surrounded by family with the lights lowered and were receiving medication for pain and symptom relief, or one in which they were personnel who were provide surrounded by healthcareing CPR. A discussion of the likelihood of survival following CPR should also be included.
Most patients and families want to discuss end-of life care with their nurse; but they need to hear the physician. Thus, the same message from the patient's nurse must be in communication with the physician about the elder patient's prognosis and the patient and family's preferences about end-of-life care. Hanson et al. 1997) note that one reason for delays in the withdrawal of patient treatments is that, although patient preferences are documented, they are not communicated to physicians so that the physicians actually appreciate the patient's wishes. When there are differences in expectations of patient outcome or confusion over the appropriateness of various therapies, interdisciplinary patient care conferences are very appropriate. Discussion about CPR with families or patients in crisis cannot come as a barrage of questions all at once from multiple healthcare providers. It is best if the patient or family has some time to consider end life care. Thus, often, withholding CPR is discussed first, and gradually questions concerning withholding or withdrawal of other life sustaining interventions introduced.
As the ANA has stated in its position statement, it is the responsibility of nurses to facilitate informed decision making for patients at the end of life. This responsibility begins when the nurse has a patient consider what would be important to him or her at the end of life, continues with the nurse educating the person about end of life care options, and is completed when the nurse advocates for and delivers the type of care the patient desires at the end of her/his life. However, this process of communication about end-of-life care is not solely the responsibility of the patient and the nurse: it is an interdisciplinary process that includes at least the physician and family in addition to the patient and nurse.