Purpose and scope
The purpose of this best practice guideline (BPG) is to provide evidence-based recommendations for registered nurses and registered practical nurses on best nursing practices for end-of-life care during the last days and hours of life.
This guideline focuses on recommendations for adults aged 18 years and older who have reached the part of the illness trajectory that includes the last days and hours of life.
Registered Nurses’ Association of Ontario. (2011). End-of-life Care During the Last Days and Hours. Toronto, ON: Registered Nurses’ Association of Ontario.
Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Download and share the full best practice guideline (BPG), End-of-Life Care During the Last Days and Hours.
See below for a snapshot of the recommendations from this BPG. We strongly suggest you review the full BPG before implementing the recommendations and good practice statements. The BPG also includes further resources to support implementation and evaluation.
Recommendation 1.1: Nurses identify individuals who are in the last days and hours of life.
Recommendation 1.1.1: Use clinical expertise, disease specific indicators and validated tools to identify these individuals.
Recommendation 1.1.2: Understand the end-of-life trajectories.
Recommendation 1.2: Nurses understand the common signs and symptoms present during the last days and hours of life.
Recommendation 1.2.1: Common signs of imminent death, may include, but are not limited to:
- progressive weakness;
- bedbound state;
- sleeping much of the time;
- decreased intake of food and fluid;
- darkened and/or decreased urine output;
- difficulty swallowing (dysphagia);
- delirium not related to reversible causes;
- decreased level of consciousness not related to other causes;
- noisy respiration/ excessive respiratory tract secretion;
- change in breathing pattern (Cheyne-Stokes respiration, periods of apnea); and
- mottling and cooling extremities.
Recommendation 1.3: Nurses complete a comprehensive, holistic assessment of individuals and their families based on the Canadian Hospice Palliative Care Association Domains of Care, which include the following:
- disease management;
- end-of-life care/ death management; and
- loss, grief.
Recommendation 1.3.1: Include information from multiple sources to complete an assessment. These may include proxy sources such as the family and other health-care providers.
Recommendation 1.3.2: Use evidence-informed and validated symptom assessment and screening tools when available and relevant.
Recommendation 1.3.3: Reassess individuals and families on a regular basis to identify outcomes of care and changes in care needs.
Recommendation 1.3.4: Communicate assessments to the interprofessional team.
Recommendation 1.3.5: Document assessments and outcomes.
Recommendation 1.4: Nurses:
- reflect on and are aware of their own attitudes and feelings about death;
- assess individuals’ preferences for information;
- understand and apply the basic principles of communication in end-of-life care;
- communicate assessment findings to individuals (if possible and desired) and the family on an ongoing basis;
- educate the family about the signs and symptoms of the last days and hours of life, with attention to their: faith and spiritual practices; age-specific needs; developmental needs; cultural needs; and
- evaluate the family’s comprehension of what is occurring during this phase.
Recommendation 2.1: Nurses recognize and respond to factors that influence individuals and their families’ involvement in decision-making.
Recommendation 2.2: Nurses support individuals and families to make informed decisions that are consistent with their beliefs, values and preferences in the last days and hours of life.
Recommendation 3.1: Nurses are knowledgeable about pain and symptom management interventions to enable individualized care planning.
Recommendation 3.2: Nurses advocate for and implement individualized pharmacologic and non-pharmacologic care strategies.
Recommendation 3.3: Nurses educate and share information with individuals and their families regarding:
- reconciliation of medications to meet the individual’s current needs and goals of care;
- routes and administration of medications;
- potential symptoms;
- physical signs of impending death;
- vigil practices;
- self care strategies;
- identification of a contact plan for family when death has occurred; and
- care of the body after death.
Recommendation 3.4: Nurses use effective communication to facilitate end of life discussions related to:
- cultural and spiritual values, beliefs and practices;
- emotions and fears;
- past experiences with death and loss;
- clarifying goals of care;
- family preference related to direct care involvement;
- practical needs;
- informational needs;
- supportive care needs;
- loss and grief; and
- bereavement planning.
Recommendation 4.1: Entry to practice nursing programs and post-registration education incorporate specialized end-of-life care content including:
- dying as a normal process including the social and cultural context of death and dying, dying trajectories and signs of impending death;
- care of the family (including caregiver);
- grief, bereavement and mourning;
- principles and models of palliative care;
- assessment and management of pain and other symptoms (including pharmacologic and non-pharmacologic approaches);
- suffering and spiritual/existential issues and care;
- decision-making and advance care planning;
- ethical issues;
- effective and compassionate communication;
- advocacy and therapeutic relationship-building ;
- interprofessional practice and competencies;
- self-care for nurses, including coping strategies and self-exploration of death and dying;
- end-of-life issues in mental health, homelessness and the incarcerated;
- the roles of grief and bereavement educators, clergy, spiritual leaders and funeral directors; and
- knowledge of relevant legislation.
Recommendation 4.2: Successful education in end-of-life care includes specific attention to the structure and process of learning activities and incorporates:
- small group learning;
- dyadic and experiential learning approaches;
- integration and consolidation of theory and practice;
- opportunities to practice the skills and competencies acquired;
- constructive feedback and/or reflection on acquired knowledge, skills and competencies; and
- contact with knowledgeable and supportive clinical supervisors and mentors.
Recommendation 5.1: Models of care delivery support the nurse, individual and family relationship.
Recommendation 5.2: Organizations recognize that nurses’ well-being is a critical component of quality end-of-life care and adopt responsive strategies.
Recommendation 5.3: Organizations providing end-of-life care demonstrate evidence of a philosophy of palliative care based on the Canadian Hospice Palliative Care Association’s The Model to Guide Hospice Palliative Care.
Recommendation 5.4: Nursing best practice guidelines can be successfully implemented only when there are adequate planning, resources, organizational and administrative supports, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to implementation
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
- Dedication of a qualified individual to provide the support needed for the education and implementation process.
- Ongoing opportunities for discussion and education to reinforce the importance of best practices.
- Opportunities for reflection on personal and organizational experience in implementing guidelines.
Disclaimer: These guidelines are not binding for nurses, other health providers or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.