When the end of life is near
editors-note
EDITOR'S NOTE: Eileen Williamson, MSN, RN, is senior vice president and chief nurse executive at OnCourse Learning, where she leads nursing programs and initiatives. She writes for Nurse.com; heads the national nursing excellence GEM Awards program; chairs company advisory board meetings; and represents OnCourse Learning on various healthcare committees and boards and at regional and national nursing and healthcare programs and meetings. She also is a board member and past president of the New Jersey League for Nursing, a constituent league of the National League for Nursing.
Early in our nursing education we learned we would have to deal with patient care situations that could be upsetting and stressful at the least, and pose ethical questions and dilemmas at worst.
Given the continued changes and complexities in our healthcare system, most of us have faced such situations. And the possibility of having to face more of them will only increase, especially where care at the end of life is involved.

Patients are living longer and using more healthcare services well into their 80s and 90s, particularly in their final days. Providers are faced with more legal and regulatory agency guidelines and government agencies have increasing oversight of Medicaid and Medicare costs regarding long-term and end-of-life care. Along with all of this there are ongoing mandates to ensure safety and quality; safeguard patient rights; and be cost-effective.
End-of-life care is complex. In addition to the nutrition, hydration, medication, palliative care and pain management needs patients have, there also are psychological, emotional, spiritual and social needs to be met. Patients who may be dealing with anger, depression, fear or financial worries will need help with insurance, legal decisions, advance directives, wills and more. Their needs and the needs of their families are not always easy to predict and sometimes difficult to fulfill, yet they must be met.
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Their needs and the needs of their families are not always easy to predict and sometimes difficult to fulfill, yet they must be met." — Eileen Williamson, RN

Nurses' vital role in end-of-life care often places them in situations that can cause ethical conundrums. This can happen whenever there’s a conflict between two strongly held principles, or when a choice between so-called “right” and “wrong” is being considered.

Each time we minister to patients in their last days, our belief systems and personal values are tested because we know our care decisions can ameliorate or aggravate suffering or make the dying process better or worse. We have guidelines to assist us, but because we spend more time with patients than any other caregiver group, we most often serve as their confidantes, advocates and sources of information. And there’s not always a rule book nearby to help us.
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Individually as nurses and collectively as a profession we’ve spent time exploring ways to prepare for how to deal with these complex issues. Some of us may have reflected on our colleagues’ varying viewpoints regarding what end-of-life care should and should not include. Others may have thought about differences in how life, death or quality of life can be defined. Maybe we’ve examined of our own responses to ethical dilemmas, such as a no-hope prognosis, a patient’s right to refuse care or aggressive attempts to extend life when doing so would only prolong suffering. Do we and our colleagues feel differently or the same about these crucial issues? Even if there are disagreements, we can work together toward greater understanding and agreement on the vital role we play in our patients' final days. And when the end is near, we can provide the special care they need and deserve.
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Patients need nurses more than ever in their final days
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By Eileen P. Williamson, MSN, RN
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Contents
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Helm an ethics team
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RNs can successfully lead interprofessional ethics committees with the right tools.
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Address your moral distress
Liaisons help nurses feel supported in voicing and discussing ethical concerns.
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When the end of life is near
Nurses must see to patients’ both physical and psychological needs during this difficult time.
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Call out unsafe practices
Speaking out if a colleague is not operating by ethical standards can be intimidating, but is necessary.
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8 key assumptions
Nurse leaders draft a blueprint for a healthcare culture that is more supportive of nursing ethics.
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Who's your go-to person?
RNs share whom they turn to for support when faced with an ethical dilemma at work.
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How to make ethical decisions
What a patient wants should be of paramount importance when a decision needs to be made.
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Make every day count
A nurse helps a dying patient spend as much time as possible with his young daughter.
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Know the code
Being familiar with the Code of Ethics can help nurses prepare for tough ethical dilemmas that are bound to happen.
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Choose your words wisely
A patient tapes his medical employees making inappropriate comments about him while he is sedated.
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Live by the code
Base your practice on strong moral principles.
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Learn about the health needs of the LGBTQ community with a new series of courses.
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6 key ethical principles
Discover how fidelity, beneficence, autonomy and other principles come into play in ethics.
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Are you an ethics champion?
Operate within three core responsibilities to make a critical difference in patients’ lives.
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CE catalog
From bioethics to palliative care, several education modules provide important ethics lessons for nurses.
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Detect human trafficking
The first steps in patient care for potential victims is identification and assessment.
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Keep it confidential
Nurses who work in the community are obligated to follow confidentiality and privacy policies.
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Protect whistleblowers
The ANA Code of Ethics says nurses have a responsibility to assist whistleblowers.
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A beautiful death
Nurse learns valuable lessons about end-of-life care and experiencing a beautiful death.
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