Balancing Optimal End-of-Life Care with Resident Wishes

Anaheim­­—The goal of end-of-life care is to provide patients with the highest quality of care and the highest quality of life possible.

Attaining this standard of care can become challenging for healthcare providers when each patient’s needs are taken into account. During a session at the NADONA conference, William M. Vaughan, RN, BSN, vice president, education and clinical affairs, Remedi SeniorCare^®, discussed balancing optimal end-of-life care with residents’ requests. He also reviewed obstacles faced by end-of-life healthcare providers when attempting to achieve a balance.

Mr. Vaughan stressed that a decline in a patient’s health at the end of life does not signal a deficiency in care, as the patient’s clinical status may make it impossible for caregivers to maintain certain health standards. This is something that even F-Tag 325 takes into consideration, noting, “The facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible.

”Furthermore, if care is consistent with the resident’s goals, reasonable attempts at altering the rate of decline are being made. It is important for caregivers to remember that the resident always makes the final decision regarding his or her care at the end of life. If the resident is incapacitated, an
appointed healthcare proxy needs to serve as the decision-maker.

Although pain management should be a top priority in end-of-life care, some residents might experience pain despite receiving high-quality care, as numerous barriers to pain management exist. Residents may be unable to communicate that they are in pain or express their level of pain. Those with cognitive impairment or those who are nonverbal are at an especially high risk of uncontrolled pain. In other cases, patients’ medication regimens may prohibit physicians from providing pain medications due to the risk of adverse drug–drug interactions, or patients may not want to take pain medications. In such cases, alternative treatments and strategies should be considered, such as providing a comfortable environment and positioning; use of cold packs and warm compresses, as appropriate; and ensuring proper nutrition and hydration.

It is normal for end-of-life caregivers to feel obligated to prolong life, but healthcare providers need to remember that not all interventions are required when it comes to end-of-life care. In addition, certain interventions may not be consistent with a resident’s goals. Residents or their healthcare proxies may choose not to allow an intervention, such as cardiopulmonary resuscitation or the use of feeding tubes. When a resident’s wishes are unclear, such as the resident is unable to communicate or there is no designated healthcare proxy to make decisions, Mr. Vaughan noted that healthcare providers must administer sound rationale for the interventions they provide. Ultimately, the actions of end-of-life caregivers must align with the goals of the patient.—Melissa Cooper