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and being silent are important tools that can help build all have a role in supporting the family and the patient
a trusting relationship with patients and their families. when they are making decisions about how they want
However, there are also things that should be asked and themselves or their family to be cared for at the end of
answered. We can do this by asking questions while their life. We can impact this experience in a positive way
we are also listening. We need to take time to become by supporting their decisions and by caring for their family
familiar with the patient, their family and their support as if they were our own.
system. How does their family see them, and how do they
“At least two kinds of courage are required in aging and
see themselves? What are the things that are the most
sickness. The first is the courage to confront the reality
important to them, and what things do they still enjoy
of mortality – the courage to seek out the truth of what
doing? Do they have fears about their illness, what might
is to be feared and what is to be hoped. Such courage is
happen, or treatments that they may have to endure? Are
difficult enough. We have many reasons to shrink from it.
there important spiritual, religious, philosophical or cultural
But even more daunting is the second kind of courage –
beliefs that guide their medical decision making? If the
the courage to act on the truth we find. The problem is that
choice was better quality of life or living longer, what would
the wise course is so frequently unclear. When it is hard to
the patient choose? Would the patient prefer to die in the
know what will happen, it is hard to know what to do. But
hospital or at home? Find out who the important people are
the challenge is more fundamental than that. One has to
in the patient’s life. Make sure that the patient or his family
decide whether one’s fears or one’s hopes are what should
have an opportunity to share and express their thoughts.
matter most.” (Gawande 2014) The courage patients find
The patient’s thoughts, wishes and values will guide them
to make choices at the end of their life may depend on how
in deciding about their goals of care at the end-of-life.
those choices are presented.
Identifying the Surrogate Decision Maker (SDM) for
Remember that “open honest communication fosters
medical decisions can be critically important for the acute
trust and informed decision making.” “Nurses are able to
and critically ill patient. If there is no Advance Directive
address hopes, by not destroying them, and by allowing
(AD), it is important for the patient to select someone to
them to be voiced. Then, if these hopes are not possible,
make decisions for them if they cannot make decisions for
talking about what else they might hope for? Nurses can
themselves. If the patient cannot speak to us and there is
be available to listen, reflect and connect with patients
no AD and no clear SDM, it can become more challenging.
and families. They can assure patients and families that
Now is the time to ask the family to place themselves into
someone will always be available during the dying process.
the shoes of the patient and think about what the patient
Nurses play an important role in keeping the conversation
would want. At this point, the conversation continues
going, listening to patient’s and families’ voices, and
until the family can agree on the kind of care that will be
accurately communicating the information from patients
provided moving forward.
and families to the interdisciplinary team.” (COH & AACN,
We need to remember that religious beliefs and values 2015)
affect the decisions that are made by the patient or family
Goals of Care conversations at the end-of-life will have
at the end-of-life. These beliefs and values have guided
the greatest impact on the patient who is dying, but the
patients and families throughout their lives, and they are
impact will also be felt by the family and those of us who
not something that we can expect to change. We must
care for the patient. “Family members who witness the
learn to respect those beliefs, just as we expect our beliefs
last days, hours and minutes of their loved one’s life will
to be respected.
remember the death for as long as they live. Nurse have
The last and most difficult step is for the family to decide a unique role in making sure that patients die with dignity
how to proceed. Will it be Full Code or Partial/No Code, and great peace.”
ventilatory support for the long term, short term, or not at
all, tube feedings or not? You will need to explain what it
all means and answer more questions. Is it time to stop
the aggressive measures that are keeping the patient alive? RefeRences
Reflect on whether we are helping the patient or prolonging
COH & AACN. (2015) Module 6: Communication, ELNEC Core
the dying process. Decisions and choices will be made Curriculum Faculty Outline.
and we will need to support the patient and family in the
COH & AACN. (2015) Module 8: Final Hours, ELNEC Core
decision that they make. And always keep talking to the Curriculum Faculty Outline.
family, offering support and explaining what is happening. Gawande, Atul. (2014) Being Mortal- Medicine and What Matters in
Before engaging in conversations about end-of-life, the End, Metropolitan Books Henry Holt and Company, New York, N.Y.
make sure that you have identified you own emotions, Volandes, Angelo E. M.D. (2015) The Conversation A
REVOLUTIONARY PLAN FOR END-OF-LIFE CARE, Bloomsbury USA,
and be prepared to disagree with the patient or family’s
New York, N.Y.
decision. You must be prepared to address and identify
conflict, even if it cannot be resolved. Give the patient
and family the time that they need to make their decision
based on the information that you have provided and their
own beliefs and values. Nurses and healthcare providers
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