Palliative Sedation in End-of-Life Care

Susan D. Bruce, RN, BSN, OCN; Cristina C. Hendrix, DNS, APRN-BC, GNP, FNP; Jennifer H. Gentry, RN, MSN, ANP, APRN-BC, PCM


Journal of Hospice and Palliative Nursing. 2006;8(6):320-327. 

In This Article

The Role of The Nurse in Palliative Sedation

The nurse plays a vital role in the process of palliative sedation and EOL care. By virtue of spending more time with patients and their families than other healthcare providers, nurses are often the ones to discuss goals of care with the patient and family and represent these goals to the healthcare team. It is the nurse who ensures that the DNR document is in place and that proper consent to palliative sedation is obtained. More often than not, it is also the nurse who is the source of information and support for family members because they are often beset with inquiries and worries throughout the patient's dying process. It is pertinent for the nurse to be not only knowledgeable about palliative sedation but also sensitive to the emotional nature of this situation. The nurse links the patient and family to other members of the healthcare team so that their needs are holistically and promptly met.

The nurse plays a vital role in monitoring the patient who is receiving palliative sedation. Monitoring the patient aims to achieve comfort and symptom control. Instead of monitoring for respiratory depression, the nurse monitors for signs of respiratory distress or air hunger. Nurses must be adept at assessing the nonverbal cues that indicate ongoing pain, unrelieved symptoms, or severity of suffering. These cues may manifest as facial expressions, body movements, or agitation. The nurse should monitor the patient's level of consciousness. The eyelash reflex can be used to assess the level of sedation; the nurse makes a soft tactile stroke over the closed eyelid, which should elicit a diminished flicker or reflex. Lack of flicker indicates deep sedation, and adjustments in the dose of medication may be needed.

As the patient experiences increasing levels of sedation he or she loses protective mechanisms. Family members and caregivers need to be informed about this and the implications for care. Patients eventually lose their gag, cough, and blink reflexes. Oral intake will be difficult and pose the risk of aspiration. Eye care and oral care become important at this point to provide lubrication and moisture to oral mucous membranes of the mouth and prevent corneal irritation. A willing and capable family or caregiver can be taught the basic skills, such as oral, eye, and skin care, and positioning and other comfort measures. Providing the family or caregivers with something that they can do for the patient can be quite meaningful and can make all the difference in carrying out the wishes of the patient who wants to die at home.

Equally important as the care nurses provide to the patient is the care they provide to the family and caregivers during this stressful time. The final days and hours before a patient dies can leave a lasting impression on the family and evoke much anxiety. The nurse can alleviate some of this anxiety by providing information about what to expect during the dying process and providing compassionate care. It is important to remind the family that the signs and symptoms of the dying process only serve as a guide because each person is unique. The psychological support and power of presence that nurses have can assist with the anticipatory grieving process that most families already have started by this time.

Nurses play a vital role in the education and support of nurses and other members of the palliative care team. It is helpful for members of the team to have education and support regarding personal death awareness. Personal death awareness is defined as one's comfort with death and can be affected by personality and the cultural, social, and spiritual belief system.[26] Nurses involved in caring for patients who are receiving palliative sedation should be allowed to abstain from doing so if they feel uncomfortable with palliative sedation because of their religious, cultural, moral, or ethical beliefs.


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