NLE Oncology Nursing — Palliative, Hospice and End-of-Life CareCheat Sheet
Palliative, Hospice and End-of-Life Care cheat sheet — the reference card you wish you had on exam day. Condensed from the full study notes, this is the high-yield core of Palliative, Hospice and End-of-Life Care for NLE Oncology Nursing. Download, print, revise.
Exam context
For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Oncology Nursing under a "Core" label, with Palliative, Hospice and End-of-Life Care in the 3rd slot across 3 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Oncology Nursing questions. Date to watch: Bi-annual.
Palliative, Hospice and End-of-Life Care - Cheat Sheet
Your last-minute revision companion for Oncology Nursing Chapter: Palliative, Hospice and End-of-Life Care. Master pain management, the dying process, and Filipino cultural considerations in 30 minutes.
Sections
Section Title
Palliative vs Hospice Care — Core Distinction
Important Facts
- Palliative care ≠ giving up — it can run alongside curative treatment from any stage of serious illness.
- Hospice is a TYPE of palliative care, not separate; the key difference is the terminally ill status and 6-month prognosis.
- Core principle: Affirm life and regard dying as a NORMAL process — neither hasten nor postpone death.
- Interdisciplinary team includes nurse, physician, social worker, chaplain, aides, volunteers, and family.
- Goals focus on QUALITY OF LIFE, not prolonging life at all costs.
- Family is a unit of care in both palliative and hospice settings.
- Support extends to bereavement care AFTER the patient's death in hospice.
Key Definitions
Term
Palliative Care
Example
A cancer patient receiving chemotherapy + palliative care to manage pain and nausea simultaneously.
Definition
Specialized care focused on relieving symptoms, pain, and stress of serious illness to improve quality of life; can be provided at ANY STAGE alongside curative treatment.
Term
Hospice Care
Example
A patient with stage 4 cancer with no further chemo options receives hospice care at home focused on comfort and family presence.
Definition
Form of palliative care for TERMINALLY ILL patients (prognosis ~6 months or less) when curative treatment has ceased; holistic, includes bereavement support to family.
Term
Comfort Care
Example
Managing dyspnea, constipation, nausea, and anxiety in a dying patient using medications, positioning, and reassurance.
Definition
Nursing focus on relief of pain and distressing symptoms while maintaining dignity and quality of life; the cornerstone of palliative and hospice practice.
Diagrams To Know
- Timeline showing where palliative care fits (early diagnosis through end of life) vs hospice (terminal phase only)
- Interdisciplinary team structure in palliative/hospice care
Section Title
WHO Analgesic Ladder — Pain Management Framework
Important Facts
- The ladder is PROGRESSIVE — move UP as pain worsens, not DOWN to improve side effects (manage side effects instead).
- Give analgesics ATC (around-the-clock) on a FIXED SCHEDULE, not PRN only — prevents pain breakthrough.
- PROVIDE BREAKTHROUGH (RESCUE) DOSES on top of scheduled regimen for incident pain.
- By mouth, by the clock, by the ladder — use oral route when possible, fixed schedule, follow WHO ladder.
- NO CEILING DOSE for opioids in cancer pain (unlike paracetamol max 4g/day or NSAIDs which have toxic limits).
- Correct dose = the dose that relieves pain; titrate upward as needed.
- Do NOT withhold opioids for fear of addiction — addiction is rare with genuine pain; suffering relief is priority.
- Tolerance and physical dependence are EXPECTED physiological effects, NOT addiction.
- Dosing principle: Start low, titrate up to effect; individualize for each patient.
Key Definitions
Term
WHO Analgesic Ladder — Step 1
Example
Acetaminophen 650 mg QID for patient with mild bone discomfort.
Definition
Mild pain: NON-OPIOID medications (paracetamol, NSAIDs) ± adjuvants; no opioids yet.
Term
WHO Analgesic Ladder — Step 2
Example
Codeine 30 mg + acetaminophen 500 mg tablet, 1–2 tabs every 4–6 hours.
Definition
Mild-to-moderate pain: WEAK OPIOIDS (codeine, tramadol) ADDED to non-opioids ± adjuvants.
Term
WHO Analgesic Ladder — Step 3
Example
Morphine 10 mg oral every 4 hours ATC + breakthrough dose, titrated up as needed.
Definition
Moderate-to-severe pain: STRONG OPIOIDS (morphine, fentanyl, oxycodone, hydromorphone) ± non-opioids ± adjuvants.
Term
Adjuvant Medication
Example
Gabapentin 300 mg TID for neuropathic pain from chemotherapy.
Definition
Drug that enhances pain relief for SPECIFIC pain types: corticosteroids (bone/nerve pain), anticonvulsants (neuropathic), antidepressants (neuropathic), bisphosphonates (bone).
Diagrams To Know
- WHO 3-Step Analgesic Ladder progression (non-opioid → weak opioid → strong opioid)
- Decision tree: which rung to start based on pain intensity
Common Values
Value
1 unit (baseline for equianalgesic dosing)
Symbol
= 10 mg oral morphine
Quantity
Morphine potency reference
Value
50–100 times
Symbol
vs morphine
Quantity
Fentanyl potency
Value
5–7 times
Symbol
vs morphine
Quantity
Hydromorphone potency
Section Title
Opioid Medications & Pharmacology
Important Facts
- Opioid selection based on: pain intensity (WHO ladder), patient age, renal/hepatic function, prior opioid exposure, route available.
- Potency comparisons: Fentanyl >> Hydromorphone > Morphine = Oxycodone > Codeine/Tramadol.
- Equianalgesic dosing: When switching opioids, convert dose using equianalgesic charts (example: morphine 10 mg oral ≈ oxycodone 6.7 mg oral).
- Opioid rotation: If side effects unbearable or tolerance plateaus, switch to different opioid (incomplete cross-tolerance may improve analgesia/tolerability).
- Long-acting formulations: Use for chronic baseline pain; short-acting for breakthrough/incident pain.
- Metabolism: Most opioids liver-metabolized; renal excretion of metabolites → caution in renal impairment.
- CNS Depression: All opioids depress CNS; risk of respiratory depression, sedation, drowsiness (especially at start or escalation).
- Drug interactions: Avoid opioids with CNS depressants (alcohol, benzodiazepines, barbiturates), CYP3A4 inhibitors (increase levels), tramadol with SSRIs.
Key Definitions
Term
Morphine
Example
Morphine 10 mg oral every 4 hours, or morphine 30 mg extended-release every 12 hours.
Definition
Gold-standard strong opioid for moderate-to-severe cancer pain; available oral, IM, IV, SC, rectal; short-acting (4 hrs) or long-acting (extended-release, 12–24 hrs).
Term
Fentanyl
Example
Fentanyl patch 25 mcg/72 hours for stable chronic pain; avoid in opioid-naive patients.
Definition
Potent strong opioid, 50–100× more potent than morphine; transdermal patch ideal for stable pain; faster onset than morphine.
Term
Oxycodone
Example
Oxycodone 5 mg oral every 4–6 hours for moderate-to-severe pain.
Definition
Strong opioid, oral route primarily; 1.5× more potent than morphine; short-acting (~4 hrs) and extended-release available.
Term
Hydromorphone
Example
Hydromorphone 2 mg oral every 4–6 hours; preferred in renal failure.
Definition
Strong opioid, 5–7× more potent than morphine; shorter duration; useful in renal impairment as metabolites less problematic.
Term
Codeine
Example
Codeine/acetaminophen tablet for mild-to-moderate pain (Step 2 of ladder).
Definition
Weak opioid; prodrug (converted by liver to morphine); poor pain relief at high doses; combined with acetaminophen/NSAID.
Term
Tramadol
Example
Tramadol 50–100 mg every 4–6 hours for mild-to-moderate pain.
Definition
Weak opioid with serotonin/norepinephrine reuptake inhibition; lower abuse potential; avoid in patients on SSRIs (serotonin syndrome risk).
Diagrams To Know
- Opioid potency ranking chart
- Equianalgesic dose conversion reference
Section Title
Opioid Side Effects & Nursing Management
Important Facts
- Constipation: PROPHYLACTIC bowel regimen MUST start when opioid begins — waiting for constipation to develop is poor practice.
- Bowel regimen essentials: Stimulant laxative + stool softener; encourage fluids, fiber, activity as tolerated; reassess frequently.
- Respiratory depression: Monitor RR, SpO₂, level of consciousness; risk higher with IV/SC routes, rapid escalation, renal/hepatic impairment, CNS depressant co-meds.
- Naloxone use at end of life: Use CAUTIOUSLY — can reverse needed analgesia, precipitate acute pain crisis, and withdrawal distress; only if patient cannot breathe/altered mental status poses danger.
- Nausea/sedation: Educate patient tolerance usually develops in 2–3 days; treat with antiemetics; adjust schedule if daytime sedation problematic (e.g., give larger dose at bedtime).
- Other common side effects: Pruritus (treat with antihistamines or opioid rotation), urinary retention (monitor, catheterize if needed), miosis (pinpoint pupils — sign of toxicity if with altered mental status).
- Overdose signs: Respiratory depression, altered mental status, pinpoint pupils, loss of consciousness; treat with naloxone + supportive care.
- Do NOT withhold opioids out of fear of addiction — suffering relief takes priority; addiction risk in pain patients is <1%.
- Educate patient: Opioids are for pain relief, not euphoria; tolerance is normal; abrupt stopping causes withdrawal (use slow taper); report side effects.
Key Definitions
Term
Constipation (Opioid-Induced)
Example
Patient on morphine must start bowel regimen (senna + docusate) from day 1; assess bowel function at every visit.
Definition
Decreased GI motility from opioid mu-receptor activation in bowel; THE ONE SIDE EFFECT with NO TOLERANCE development — persists for life of opioid use.
Term
Bowel Regimen
Example
Senna 2 tabs at bedtime + docusate 100 mg BID + fluids; assess for effectiveness daily.
Definition
Prophylactic protocol started when opioid begins: stimulant laxative (senna, bisacodyl) + stool softener (docusate); ± osmotic agent (polyethylene glycol); encourage fluid and fiber.
Term
Respiratory Depression
Example
Monitor RR, SpO₂, and sedation level; hold dose if RR <10/min or altered mental status; have naloxone ready.
Definition
Opioid-induced depression of respiratory centers in brainstem; decreased RR, shallow breathing, hypoxia; most feared but RARE with careful titration.
Term
Naloxone
Example
Naloxone 0.4–2 mg IV/IM/SC for respiratory depression; may repeat q2–3 min; monitor for re-sedation as naloxone has shorter duration than opioid.
Definition
Opioid ANTAGONIST; reverses opioid effects including respiratory depression; antidote for opioid overdose; used cautiously at end of life (can precipitate acute withdrawal and severe pain).
Term
Sedation & Nausea (Opioid-Related)
Example
Patient reports drowsiness day 1–2 on morphine; reassure it usually subsides; use antiemetic for nausea; monitor closely.
Definition
Common on initiation or dose escalation; usually improve within 24–72 hours as tolerance develops; manage with reduced dose, schedule adjustment, or antiemetics.
Term
Tolerance
Example
After weeks on same morphine dose, pain recurs; increase dose or rotate opioid; this is normal pharmacology, not abuse.
Definition
Physiological adaptation where increasing doses needed for same effect; EXPECTED with prolonged opioid use; NOT the same as addiction.
Term
Physical Dependence
Example
Patient on long-term morphine experiences withdrawal (anxiety, sweating, muscle aches) if stopped suddenly; taper over days/weeks.
Definition
Physiological state where withdrawal symptoms occur if opioid abruptly stopped (not addiction); managed by slow taper.
Term
Addiction
Example
True addiction: patient seeks opioids not for pain but for euphoria despite negative consequences; extremely rare in cancer populations.
Definition
Psychological/behavioral compulsion to use opioid despite harm; RARE in patients with genuine pain; not the same as tolerance or dependence.
Diagrams To Know
- Opioid side effect management flowchart
- Bowel regimen algorithm
Section Title
Other Symptom Management at End of Life
Important Facts
- Dyspnea: Common near end of life; low-dose opioids most effective (suppress respiratory drive perception, anxiety); supplemental oxygen if hypoxic, but not obligatory if no distress.
- Death rattle: Occurs in up to 50% of dying patients; reassure family it is NOT cause of discomfort; anticholinergic + positioning best approach.
- Gentle suctioning ONLY: Aggressive suctioning can stimulate more secretions and distress patient; gentle oral swabs preferable.
- Nausea management: Address reversible causes first (constipation, drug side effects, pain); choose antiemetic by mechanism (5-HT3 blocker if chemo-related, etc.).
- Anxiety/restlessness: Assess for unmet needs (pain, full bladder, family conflict); benzodiazepines help; non-pharmacological comfort (presence, music, reminiscence) equally important.
- Mouth care: Dry mouth common; frequent sips, ice chips, artificial saliva, lip balm; oral thrush possible (treat with nystatin swish/spit or fluconazole).
- Skin and pressure care: High risk for pressure ulcers; frequent position changes, moisture barriers, assess skin q shift; dignity and comfort paramount.
- Decreased appetite/thirst: NORMAL at end of life; do NOT force feeding/hydration; small sips if patient wishes; accept refusal as sign of natural dying.
Key Definitions
Term
Dyspnea (End-of-Life)
Example
Patient with dyspnea at end of life: morphine 2–5 mg SC q2h PRN + oxygen if SpO₂ <90% + elevate head of bed + calm, reassuring presence.
Definition
Sensation of breathlessness; managed with low-dose opioids, oxygen, positioning, fan, reassurance, anxiolytics if anxiety-driven.
Term
Death Rattle (Noisy Respirations)
Example
Hyoscine (scopolamine) patch or atropine drops to dry secretions; elevate head 30°; gentle suctioning only if patient distressed (suctioning can stimulate more secretions).
Definition
Excessive pooled secretions in upper airway from decreased cough reflex and inability to swallow; distressing to family; managed with anticholinergics and repositioning.
Term
Anticholinergic Medications
Example
Hyoscine patch 1.5 mg applied, changed every 72 hours; or atropine ophthalmic drops 1–2 drops sublingually every 4–6 hours.
Definition
Drugs that block parasympathetic activity, reducing secretion production; used for death rattle: hyoscine/scopolamine (patch or IM), atropine, glycopyrrolate.
Term
Nausea & Vomiting (End-of-Life)
Example
Patient nauseous from morphine: give antiemetic (ondansetron 4 mg IV/PO q8h) + adjust opioid timing or rotation; ensure constipation prevention.
Definition
Managed with antiemetics (metoclopramide, ondansetron, prochlorperazine), treatment of reversible causes (constipation, medications, metabolic), and dietary adjustment.
Term
Anxiety & Restlessness (End-of-Life)
Example
Patient agitated at end of life: lorazepam 0.5–2 mg IV/SC q4h PRN + quiet environment + family presence + reassurance.
Definition
Managed with benzodiazepines (lorazepam, midazolam), presence, calm reassurance, and management of underlying causes (pain, uncontrolled symptoms, unfinished business).
Diagrams To Know
- End-of-life symptom management decision tree
- Antiemetic selection by mechanism and indication
Section Title
Kübler-Ross Grief Stages & Grief Types
Important Facts
- Kübler-Ross stages are NOT fixed in order — patients may skip stages, move back and forth, or revisit stages.
- Not all patients experience all 5 stages; some experience only a few or in different sequence.
- Nursing role: Meet the patient WHERE THEY ARE — listen, stay present, do NOT try to move them to acceptance.
- Anticipatory grief can be positive (family has time to say goodbye, resolve conflicts) or complicated if unprocessed.
- Normal grief duration: Acute phase 4–12 weeks; gradual acceptance over 1–2 years; individual variation large.
- Complicated grief red flags: Intense anger/guilt years later, inability to engage in life, suicidal ideation, substance abuse, social isolation, or obsessive focus on the deceased.
- Family members (spouse, children, parents) may grieve at different stages and rates; validate each person's process.
- Assess for depression vs normal grief: Both involve sadness, but depression includes anhedonia, guilt over everything, inability to feel love, and suicidal ideation.
- Provide grief resources: Support groups, bereavement counseling, spiritual guidance, peer support; normalize grief as healthy process.
Key Definitions
Term
Denial
Example
Patient tells nurse, 'The doctors are wrong; I don't have cancer. I'm going to be fine.'
Definition
Stage 1: 'No, not me; this can't be happening.' Protective first reaction; patient may refuse to accept diagnosis or prognosis.
Term
Anger
Example
Patient snaps at nurse: 'Why are you being so slow with my medication? You don't care about my pain!'
Definition
Stage 2: 'Why me?' Anger directed at staff, family, God, or circumstances; may manifest as hostility or blame.
Term
Bargaining
Example
Patient prays, 'God, if you let me live until my daughter's wedding, I'll change my life.'
Definition
Stage 3: 'If I can just live to see...' Negotiating for more time; may involve religious promises or 'if-then' thinking.
Term
Depression
Example
Patient lies in bed quietly, refusing visitors, expressing sadness about 'never seeing grandchildren grow up.'
Definition
Stage 4: Sadness and mourning as reality sinks in; patient may withdraw, cry, or express hopelessness.
Term
Acceptance
Example
Patient speaks quietly with family about final wishes, says goodbye calmly, seems at peace with impending death.
Definition
Stage 5: Calm, peaceful readiness; NOT happiness, but acknowledgment and peace with reality; patient may be alert to surroundings or withdrawing.
Term
Anticipatory Grief
Example
Wife of dying husband begins grief work before his death — sorting through belongings, making plans, saying goodbyes.
Definition
Grieving that begins BEFORE the loss, while the dying person is still alive; family and patient may both experience this.
Term
Normal (Uncomplicated) Grief
Example
Widow feels intense sadness first months after husband's death but continues daily activities, maintains relationships, gradually adjusts.
Definition
Expected reaction to loss that gradually eases over time; involves sadness, crying, yearning, but does not prevent functioning.
Term
Complicated (Dysfunctional) Grief
Example
Parent unable to return to work 2 years after child's death; isolates from family, expresses persistent anger, expresses hopelessness.
Definition
Prolonged, unresolved grief that impairs functioning; may involve intense anger, guilt, isolation, or denial years after loss; needs professional help.
Diagrams To Know
- Kübler-Ross 5 stages (non-linear progression model)
- Grief trajectory: anticipatory → acute → adjustment → adaptation
Section Title
Physical Signs of Approaching Death
Important Facts
- These are NORMAL signs of dying, not medical emergencies to reverse.
- EDUCATE FAMILY beforehand so changes are expected, less frightening, and they understand they are part of natural dying process.
- Cool extremities can coexist with normal or high core temperature (vasoconstriction preserves central organs).
- Cheyne-Stokes: Not distressing to patient (brain hypoxic); can be distressing to family; reassure it is normal breathing pattern near death.
- Weak pulse + low BP: In comfort-focused care, do NOT start IV fluids or vasopressors; accept as sign of failing organ systems.
- Decreasing oral intake: NORMAL; forcing food increases risk of aspiration, discomfort, and vomiting; offer small sips if patient wishes.
- HEARING IS THE LAST SENSE TO GO — continue speaking to patient gently and reassuringly even if unconscious; avoid statements about worsening condition in patient's presence.
- Urine output change: Reassure family; catheter or frequent bed changes maintain comfort; dark urine is from concentration, not kidney failure to reverse.
- Skin changes (mottling, pallor): Cosmetically distressing to family; explain circulation failing; continue comfort measures (moisturizer, gentle touch).
- Timeline: These signs may occur over hours to days; no predictable exact sequence; death can be very rapid or slow.
Key Definitions
Term
Decreased Level of Consciousness
Example
Patient intermittently opens eyes to voice, does not speak, withdraws from commands.
Definition
Patient increasingly drowsy, difficult to arouse, minimal response to stimuli; occurs as perfusion and oxygenation decline near end of life.
Term
Cool & Mottled Extremities
Example
Patient's hands, feet, legs appear pale and blue-grey; skin mottled like puzzle pieces; core temp may be normal.
Definition
Peripheral vasoconstriction; skin becomes pale, cyanotic, blotchy (mottled) in lower extremities and dependent areas; core body maintained by internal organs.
Term
Weak, Thready Pulse
Example
Radial pulse barely felt; rate 120–140 bpm; carotid pulse still present but weak.
Definition
Cardiac output ↓; pulse becomes rapid, faint, barely palpable; systolic BP drops progressively; radial pulse may disappear while carotid still palpable.
Term
Falling Blood Pressure
Example
BP 140/90 → 110/70 → 80/50 → unmeasurable in final hours.
Definition
Progressive drop in systolic/diastolic BP as organ perfusion fails; systolic may drop from 120 → 80 → 60 mmHg over hours/days before death.
Term
Cheyne-Stokes Respirations
Example
Patient breathes rapidly and deeply × 20–30 sec, then slows, then stops for 20 sec, then cycle repeats.
Definition
Irregular breathing pattern: periods of rapid, deep breathing (hyperpnea) followed by slowing, then apnea (15–30 sec pause); due to decreased CO₂ responsiveness and brain hypoxia.
Term
Noisy Breathing (Death Rattle)
Example
Gurgling, rattling sound with each breath; managed with hyoscine, head elevation; reassure family patient not drowning.
Definition
Stertor or rattling sound from pooled respiratory secretions; occurs as swallowing and cough reflex decline; managed with anticholinergics and positioning.
Term
Decreased Urine Output
Example
Patient with normal urine output now producing <100 mL in 24 hours; concentrated, dark amber; this is normal end-of-life change.
Definition
Oliguria or anuria; kidneys fail as perfusion drops; urine becomes concentrated, dark amber or tea-colored; often no void for 12+ hours before death.
Term
Loss of Sphincter Control
Example
Patient unable to control bowel/bladder; use protective pads or catheter; clean frequently; manage odor respectfully.
Definition
Incontinence of urine and stool from decreased muscle tone and consciousness; bladder and bowel muscles relax; managed with indwelling catheter or absorbent pads.
Term
Decreased Appetite & Thirst
Example
Family offers food; patient refuses, says 'not hungry'; this is natural and expected, not starvation.
Definition
Patient no longer interested in food or fluids; metabolic rate drops; normal sign of dying process; do NOT force feeding/hydration.
Diagrams To Know
- Physical progression toward death timeline
- Checklist of end-of-life physical signs for patient/family education
Section Title
Advance Directives, DNR Orders & Ethical Considerations
Important Facts
- Advance directives are LEGAL DOCUMENTS — must be signed, witnessed (some jurisdictions require notarization), kept accessible (copy to physician, hospital chart).
- Patient must be mentally COMPETENT when signing advance directive; if capacity questioned, have documented assessment by physician.
- Patients can CHANGE or REVOKE advance directives at any time; most recent signed document is valid.
- DNR does NOT mean 'do not treat' — patient gets all other medications, oxygen, antibiotics, fluids, positioning, comfort care, and presence.
- DNR conversation should be held EARLY (not emergently) in serious illness; repeats if goals of care change.
- Nurse's role: Advocate for patient's wishes, ensure directive is documented and accessible, educate patient/family, clarify DNR meaning (not abandonment of care).
- If family conflicts with DNR order: Involve social work, ethics committee, or chaplaincy; clarify patient's wishes were competent, informed, and voluntary.
- RESPECT physician-assisted suicide is ILLEGAL in Philippines — nurse must not facilitate nor encourage; if asked, clarify this, offer palliative options.
- Cultural/religious consideration: Some religions oppose advance directives (belief in God's will); nurse respects while ensuring legal rights protected.
- Organ donation: If patient wishes to donate, clarify timing, process, and that donation is separate from DNR status; in Philippines, family consent typically needed per local law.
Key Definitions
Term
Advance Directive
Example
Patient signs advance directive naming spouse as proxy and stating, 'No intubation or mechanical ventilation; palliative care only.'
Definition
Legal document stating patient's wishes for care if they later become unable to decide; includes LIVING WILL (desired/refused treatments) and HEALTH CARE PROXY (surrogate decision-maker).
Term
Living Will
Example
Living will states: 'In event of terminal illness with no recovery, I refuse intubation, mechanical ventilation, and feeding tube; comfort care only.'
Definition
Component of advance directive; specifies desired or refused treatments (CPR, mechanical ventilation, feeding tube, antibiotics, ICU admission) in specific end-of-life scenarios.
Term
Durable Power of Attorney for Health Care (Health Care Proxy)
Example
Patient appoints daughter as health care proxy; if patient becomes comatose, daughter can consent to treatments, decline interventions per patient's wishes.
Definition
Legal document naming a surrogate/proxy to make health care decisions on patient's behalf if patient unable; survives patient incompetence ('durable').
Term
Do-Not-Resuscitate (DNR) Order
Example
Physician writes DNR order in chart based on patient's informed choice; if cardiac arrest occurs, no CPR; but antibiotics, pain meds, oxygen continue.
Definition
Written MEDICAL ORDER (not a law) directing that CPR (chest compressions, intubation, defibrillation) NOT be performed if heart/breathing stops; patient still receives all other care and comfort measures.
Term
Informed Consent
Example
Physician explains DNR: 'CPR is not performed if your heart stops; you will still receive pain management and comfort care. Do you want a DNR order?'
Definition
Patient (or proxy) given accurate information, understands implications, and voluntarily agrees or declines treatment without coercion or pressure.
Term
Autonomy
Example
Patient refuses chemotherapy despite prognosis; nurse supports this choice even if different from nurse's preference; respects patient autonomy.
Definition
Ethical principle: patient's right to self-determination, to make decisions about their own body and treatment based on personal values, beliefs, and preferences.
Term
Palliative Sedation
Example
Patient in severe pain, unable to eat/drink, expresses wish to sleep peacefully; palliative sedation given to relieve suffering; patient may naturally die during sedation.
Definition
Use of sedative medications (benzodiazepines, opioids) to relieve intractable suffering at end of life; ethically distinct from euthanasia (hastening death); goal is symptom relief, not death.
Term
Euthanasia
Example
Administering lethal dose of medication to end patient's life is euthanasia and a crime; NOT the same as allowing death or palliative sedation.
Definition
Deliberately hastening patient's death (e.g., by lethal injection); ILLEGAL in the Philippines; distinct from withdrawing futile treatment or palliative sedation.
Diagrams To Know
- Advance Directive components and legal process
- DNR vs other care options decision tree
Section Title
Philippine Cultural & Religious Considerations in End-of-Life Care
Important Facts
- Family is UNIT OF CARE, not just support — include family in all teaching, assessment, and care planning; respect collective decision-making.
- Philippines is ~81% Roman Catholic; Anointing of the Sick is valued spiritual ritual; proactively offer to arrange priest visit for dying patients.
- Muslim Filipinos (primarily Mindanao): May have different death rituals (immediate ritual washing, prayer); inquire respectfully about practices; facilitate imam access.
- Bahala na attitude: NOT fatalism that prevents care — explain health choices as part of God's plan; reframe end-of-life care as respecting God's timing (comfort, not prolonging).
- Information disclosure: Family may request limited disclosure to patient; nurse balances this with patient autonomy — assess patient's wishes directly (does patient want to know?).
- Advance directives & DNR: Frame as honoring God's will and family wishes, not giving up; clarify that comfort care IS providing care.
- Death at home: Support this preference — arrange home health, hospice support, pain meds, equipment (bedpan, incontinence pads); teach family symptom management.
- Wakes/lamay: Provide private room/area for family gathering, meals, prayers; maintain patient dignity post-death; do NOT rush to remove body without family readiness.
- Extended family attendance: Multiple visitors expected; establish visiting protocols (quiet hours), but be flexible; family presence is part of cultural grieving.
- Religious items & symbols: Display crucifixes, religious images, prayer beads; allow family to bring religious items; respect prayer times and practices.
- Bathing/grooming: Family may want to bathe patient or be present; respect this; provide supplies, privacy, and assist as needed.
- Post-mortem wound care, organ donation, autopsy: Explain clearly; family may refuse autopsy for religious/cultural reasons; document wishes; handle body respectfully per customs.
Key Definitions
Term
Family-Centered Care (Philippine Context)
Example
Patient's family holds 'family meeting' to discuss treatment options; mother, siblings, spouse all present; consensus sought before patient decides.
Definition
Extended family (parents, siblings, children, in-laws, godparents) deeply involved in decision-making and caregiving; decisions often collective, not individual alone.
Term
Anointing of the Sick (Sacrament of the Sick)
Example
Catholic patient near death; family calls priest for Anointing of the Sick; nurse facilitates by providing quiet space, assisting patient to receive sacrament.
Definition
Roman Catholic sacrament; priest administers blessed oil, prayer, and blessing for healing or peace; important spiritual ritual for Filipino Catholic patients and families.
Term
Bahala na
Example
Family says, 'Bahala na si God' (God will provide); may be hesitant to sign DNR despite prognosis; nurse respects while ensuring informed choices possible.
Definition
Filipino cultural attitude: 'leave it to God's will' or 'let God handle it'; brings peace but may also delay treatment-seeking or end-of-life discussions.
Term
Protective Truth-Telling (Disclosure Practices)
Example
Doctor tells family of terminal diagnosis; family requests, 'Don't tell Mama; it will make her sad.' Nurse navigates patient's right to know with cultural sensitivity.
Definition
Filipino family preference to shield patient from grave prognosis, believing harsh truth causes harm; balances patient autonomy with family role in decision-making.
Term
Lamay (Wake)
Example
After patient dies, family maintains all-night vigil by the body; nurse respects this practice, provides space, privacy, and support.
Definition
Filipino post-mortem ritual: family and friends gather with the deceased's body for prayers, meals, conversation; traditionally lasts 1–3 nights before burial.
Term
Home-Based Dying & Care
Example
Family requests to take patient home on comfort care; nurse arranges home health support, teaches family symptom management, provides 24/7 phone contact.
Definition
Filipino cultural preference for patient to die at home surrounded by family rather than hospital; practical and spiritual reasons; hospice care in home setting.
Term
Post-Mortem Care (Philippine Custom)
Example
After death, family washes and dresses body in white clothing per Catholic tradition; nurse allows time, provides basin/supplies, documents respectfully.
Definition
Respectful care of deceased; family may request time with body, specific washing/dressing rituals based on religion (Catholic, Muslim, etc.); nurse honors these practices.
Diagrams To Know
- Cultural considerations decision tree for Filipino end-of-life care
- Family communication and inclusion flowchart (collective vs individual decision-making)
Section Title
Nursing Assessment, Diagnosis & Interventions (NANDA/NCM Framework)
Important Facts
- Nursing diagnoses PRIORITIZE by Maslow: physiological (pain, constipation, dyspnea) > safety > love/belonging (grief, family support) > esteem > self-actualization (spiritual peace).
- In palliative/hospice, physiological comfort is TOP priority — relieve pain/symptoms aggressively; only THEN address psychosocial needs.
- Assessment tools: Pain rating scales (0–10 numeric, Faces scale), symptom burden assessment (Edmonton Symptom Assessment System), functional status (Karnofsky scale), spiritual distress screening.
- Outcomes for palliative care: Pain ≤3/10, patient reports 'comfortable,' vital signs stable, no constipation, patient/family state readiness, spiritual needs addressed.
- Interventions cluster around: Pharmacological (analgesics, antiemetics, anticholinergics) + Non-pharmacological (massage, positioning, music, presence, prayer).
- Family as unit: Include family in goal-setting, teach symptom management, offer respite care, provide bereavement resources; family satisfaction is key outcome.
- Reassessment frequency: Pain and symptoms assessed EVERY visit, Q2–4 hours in acute settings, after every intervention; continuous monitoring essential.
- Documentation: Chart patient's pain trajectory, medication response, family wishes, advance directive status, spiritual practices; communicate clearly to team.
Key Definitions
Term
NANDA Nursing Diagnosis: Acute Pain
Example
Acute Pain r/t bone metastasis AEB patient rating pain 8/10, grimacing with movement, guarding position.
Definition
Related to: cancer progression, metastasis, treatment side effects, etc.; Characterized by: verbal report of pain, grimacing, splinting, vital sign changes, behavioral changes.
Term
NANDA Nursing Diagnosis: Constipation
Example
Constipation r/t opioid analgesic use AEB no bowel movement × 4 days, hard stool, patient report of straining.
Definition
Related to: opioid medication effects, decreased mobility, decreased fluid intake, decreased GI motility; Characterized by: fewer than 3 bowel movements/week, hard stool, straining.
Term
NANDA Nursing Diagnosis: Dyspnea/Ineffective Breathing Pattern
Example
Ineffective Breathing Pattern r/t respiratory depression from opioid use and anxiety AEB RR 26, shallow breathing, use of accessory muscles.
Definition
Related to: decreased respiratory drive, respiratory muscle weakness, anxiety, fluid accumulation; Characterized by: RR >24, use of accessory muscles, orthopnea, gasping.
Term
NANDA Nursing Diagnosis: Anticipatory Grieving
Example
Anticipatory Grieving r/t terminal cancer diagnosis AEB patient crying, stating 'I won't see my grandchildren,' withdrawing from visitors.
Definition
Related to: terminal diagnosis, dying process; Characterized by: expression of distress about impending death, crying, withdrawn behavior, inability to maintain usual relationships.
Term
NANDA Nursing Diagnosis: Risk for Complicated Grieving
Example
Risk for Complicated Grieving (family member) r/t sudden death and lack of closure AEB persistent anger, isolation 3 months post-death.
Definition
Risk factors: previous unresolved losses, psychiatric history, lack of support; Characterized by: intense anger, guilt, isolation, depression persisting beyond expected timeframe.
Term
NANDA Nursing Diagnosis: Ineffective Coping
Example
Ineffective Coping r/t terminal illness AEB patient refusing pain medication, stating 'What's the point,' neglecting hygiene.
Definition
Related to: terminal illness, loss of independence, unresolved spiritual issues; Characterized by: inability to meet basic needs, substance abuse, self-harm ideation, withdrawal.
Term
NCM (Nursing Care Model) — Levels of Care
Example
Patient with terminal cancer in hospice receives NCM Level 4 care: comfort, symptom relief, spiritual support, family presence; focuses on quality not quantity of life.
Definition
Philippine framework: NCM Level 1 (Promotion/Prevention), Level 2 (Cure/Treatment), Level 3 (Rehabilitation), Level 4 (Palliation); palliative/hospice = NCM Level 4.
Diagrams To Know
- Maslow's hierarchy applied to palliative nursing priorities
- Nursing care cycle in palliative/hospice setting
Section Title
Patient & Family Teaching & Communication Strategies
Important Facts
- Teaching readiness: Assess patient/family's emotional state, knowledge level, readiness to learn; use simple language (avoid jargon); provide written materials.
- Teach-back method: Have patient/family explain back what they learned; clarifies understanding and allows nurse to correct misconceptions.
- Address fears explicitly: Common fears = pain not controlled, dying alone, abandonment by staff, burdening family, unfinished business; validate, problem-solve, normalize.
- Empower patient/family: Teach symptom recognition (when to call nurse), medication self-administration where appropriate, comfort measures (positioning, sipping, ice chips).
- Pain management teaching: Emphasize pain prevention (ATC dosing, not waiting for severe pain), breakthrough dose availability, side effect management (bowel regimen first).
- Manage expectations: Explain that not all pain/symptoms fully relieved; goal is 'acceptable comfort level' where patient can interact, sleep, have quality time with loved ones.
- Bereavement preparation: Anticipatory grief is NORMAL; offer resources (support groups, counseling, hospice bereavement program); many continue 1–2 years after death.
- Cultural sensitivity in teaching: Adjust communication style to family values; involve family patriarch/matriarch in decision-making (Philippine context); respect religious practices.
- Use teach moments: Use patient's questions, symptom changes, family visits as teachable moments; don't overwhelm with all info at once.
- Reinforce frequently: Teaching is ongoing; reinforce key messages at each interaction; check understanding regularly.
Key Definitions
Term
Therapeutic Communication in Palliative Care
Example
Patient: 'I'm scared I'll be in pain.' Nurse: [sits at bedside] 'Tell me more about your fear. What would help you feel more in control?' [listens without interrupting].
Definition
Active listening, open-ended questions, validation, presence; avoid platitudes ('Everything will be OK'); sit at eye level; allow silences; use touch appropriately.
Term
Educating About Pain Control & Opioids
Example
Teach patient: 'We'll give your morphine every 4 hours to prevent pain from starting. If you hurt between doses, tell us and we'll add a breakthrough dose. This is NOT addiction.'
Definition
Teach patient/family: pain CAN be controlled; opioids used for real pain rarely cause addiction; tolerance is normal; constipation prevention essential; breakthrough doses available.
Term
Bowel Regimen Teaching
Example
Teach caregiver: 'Give 2 senna tablets at bedtime and docusate 100 mg twice daily. Offer water and prune juice. Call me if he hasn't had a bowel movement in 2 days.'
Definition
Teach family to give stimulant laxative (senna) at bedtime + stool softener (docusate) BID + fluids, fiber as tolerated; expect bowel movement within 1–2 days; report if none.
Term
Educating Family About Signs of Dying
Example
Teach family: 'As her body shuts down, her hands and feet will feel cool and look bluish. Her breathing may become irregular with gaps. These are normal. Keep talking to her; she may hear you.'
Definition
Explain physical changes (cool skin, weak pulse, irregular breathing, decreased urine, loss of appetite) as NORMAL and expected; hearing last sense to go; continue speaking gently.
Term
Clarifying DNR Does NOT Mean Abandonment
Example
Tell family: 'A DNR order means if his heart stops, we won't do chest compressions. But he'll still get pain medicine, oxygen if needed, and we'll stay with him. It's about letting nature take its course peacefully.'
Definition
Explain DNR means CPR not performed if heart stops, but ALL other comfort care, medications, pain relief, and presence continue.
Term
Supporting Emotional & Spiritual Needs
Example
To grieving spouse: 'It's OK to feel angry/sad. Would it help to talk to our chaplain? I can also connect you with a widow support group after...'
Definition
Offer presence, acknowledge feelings, facilitate spiritual care (priest, imam, etc.), connect with support groups, bereavement counseling, social work.
Diagrams To Know
- Effective communication strategies in palliative care flowchart
Must Remember
- PALLIATIVE CARE = ANY STAGE of serious illness + can run alongside curative treatment; HOSPICE = terminal (<6 months) + comfort only. They are NOT the same.
- WHO ANALGESIC LADDER: Non-opioid (Step 1) → Weak opioid (Step 2) → Strong opioid (Step 3). Progress UP based on pain severity; do NOT skip steps unless inadequate relief.
- GIVE ANALGESICS AROUND-THE-CLOCK (ATC) on FIXED SCHEDULE, not just PRN. Add BREAKTHROUGH (RESCUE) DOSES on top for incident pain. Prevents pain from recurring.
- NO CEILING DOSE for opioids in cancer pain — titrate UP as needed for relief. Contrast: paracetamol max 4 g/day, NSAIDs have toxic limits.
- DO NOT WITHHOLD OPIOIDS for fear of addiction. Addiction risk in pain patients is <1%. TOLERANCE & PHYSICAL DEPENDENCE are expected physiology, NOT addiction.
- CONSTIPATION is THE opioid side effect with NO TOLERANCE — starts Day 1, persists for life of opioid use. PROPHYLACTIC BOWEL REGIMEN (stimulant laxative + stool softener) MUST start when opioid begins.
- KÜBLER-ROSS STAGES: Denial → Anger → Bargaining → Depression → Acceptance. NOT fixed order; patients skip/revisit stages. MEET PATIENT WHERE THEY ARE — do NOT push acceptance.
- PHYSICAL SIGNS OF DYING: Decreased consciousness, cool mottled skin, weak rapid pulse, low BP, Cheyne-Stokes respirations, noisy secretions, decreased urine, sphincter loss, decreased appetite. HEARING IS LAST SENSE TO GO — keep speaking to patient gently.
- ADVANCE DIRECTIVE = Living Will (desired/refused treatments) + Health Care Proxy (surrogate decision-maker). DNR order = CPR NOT performed; ALL OTHER comfort care continues.
- PHILIPPINES: Family-centered (collective decision-making), largely Catholic (facilitate Anointing of the Sick), prefer dying at home (lamay/wake afterward); respect cultural/spiritual practices; balance patient autonomy with family role in decisions.
Last Minute Tips
- PAIN MANAGEMENT: Remember 'by mouth, by the clock, by the ladder' — use oral route when possible, fixed schedule (not PRN only), follow WHO ladder. Around-the-clock + breakthrough doses = gold standard.
- BOWEL REGIMEN: BEFORE constipation happens, start senna + docusate when opioid starts. This single intervention prevents hours of patient/family suffering. Reassess bowel function at EVERY visit.
- DNR ≠ ABANDONMENT: Students often confuse DNR with stopping all care. DNR means CPR not done; pain meds, oxygen, positioning, presence = ALL CONTINUE. Explain clearly to family to reduce guilt/fear.
- FAMILY IS THE UNIT: In Filipino context especially, include extended family in teaching, goal-setting, and decision-making. Collective wisdom and consent valued. Single-patient focus = incomplete assessment.
- HEARING LAST: This appears frequently on NLE. Patient cannot respond but CAN hear even if unconscious. Encourage family to speak reassuringly. Do NOT discuss patient's worsening in presence as if they cannot hear — they CAN.
Comparison Tables
Rows
Values
- Can start at ANY stage of serious illness (early diagnosis onward)
- Only when terminally ill (prognosis ~6 months or less)
Property
Timing in Illness
Values
- Runs ALONGSIDE curative treatment (chemo, radiation, surgery may continue)
- STOPS curative treatment; comfort only
Property
Curative Treatment
Values
- Improve quality of life; relieve pain and symptoms
- Comfort, dignity, quality of life; allow peaceful death
Property
Goal
Values
- Hospital, outpatient clinic, home, facility
- Typically home; may be hospice facility
Property
Setting
Values
- Support and teaching; family as support
- Family as unit of care; intensive involvement in caregiving
Property
Family Involvement
Values
- Physician, nurse, social worker, chaplain; multidisciplinary
- Interdisciplinary: nurse, physician, social worker, chaplain, aides, volunteers
Property
Team
Values
- Limited; focused on patient/family during illness
- Extended bereavement follow-up after death (13 months or more typical)
Property
Bereavement Support
Values
- Varies; months to years depending on illness
- Typically weeks to months; average ~30–60 days
Property
Duration
Columns
- Characteristic
- Palliative Care
- Hospice Care
Table Title
Palliative Care vs Hospice Care
Rows
Values
- Mild (1–3/10)
- Non-opioid: Paracetamol, NSAIDs (ibuprofen, diclofenac) ± adjuvants
- Paracetamol 650 mg Q6h or Ibuprofen 400 mg Q6–8h
- If inadequate relief after 1–2 days or pain worsens
Property
Step 1
Values
- Mild-Moderate (4–6/10)
- Weak opioid: Codeine, Tramadol + Non-opioid ± adjuvants
- Codeine 30 mg + Paracetamol 500 mg; 1–2 tabs Q4–6h
- If pain remains inadequate after 1–2 days or escalates to severe
Property
Step 2
Values
- Moderate-Severe (7–10/10)
- Strong opioid: Morphine, Fentanyl, Oxycodone, Hydromorphone ± non-opioid ± adjuvants
- Morphine 10 mg oral Q4h + breakthrough dose; titrate up by 25–50%
- Titrate UP as needed for pain control; no ceiling dose; rotate if side effects
Property
Step 3
Columns
- Step
- Pain Intensity
- Drug Class & Examples
- Typical Dosing Example
- When to Escalate
Table Title
WHO Analgesic Ladder Steps & Drug Selection
Rows
Values
- NO tolerance — persists for life of opioid use
- Start prophylactic bowel regimen DAY 1: senna + docusate; encourage fluids, fiber, activity
- Stimulant laxative (senna, bisacodyl) + stool softener (docusate); osmotic agent (PEG); assess daily
Property
Constipation
Values
- Tolerance develops — risk higher at initiation/escalation
- Start low dose, titrate slowly; monitor RR, SpO₂, sedation; avoid CNS depressants
- Hold dose if RR <10/min or altered mental status; naloxone if severe; support respiration
Property
Respiratory Depression
Values
- YES — tolerance usually develops in 24–72 hours
- Educate patient; reassure it passes; consider timing (give larger dose at bedtime)
- Wait 2–3 days for tolerance; reduce dose if intolerable; schedule adjustment; stimulant (caffeine) if mild
Property
Sedation/Drowsiness
Values
- YES — tolerance usually develops in 2–3 days
- Prophylactic antiemetic with first dose; small frequent meals; ginger, peppermint
- Antiemetic (ondansetron 4 mg Q8h, metoclopramide 10 mg Q6h); opioid rotation if severe
Property
Nausea/Vomiting
Values
- May or may not develop tolerance
- Monitor; not always preventable
- Antihistamine (diphenhydramine); opioid rotation; topical emollients; cool environment
Property
Pruritus (Itching)
Values
- Some tolerance may develop
- Monitor intake/output; encourage voiding
- Catheterization if unable to void; bethanechol PRN; monitor post-void residual
Property
Urinary Retention
Columns
- Side Effect
- Tolerance Development?
- Prevention Strategy
- Management/Treatment
Table Title
Opioid Side Effects: Prevention & Management
Rows
Values
- Shock, disbelief, protective avoidance
- 'No, not me.' 'The doctors are wrong.' 'I don't have cancer.'
- Listen without judgment; do NOT argue or push acceptance; provide factual information when ready; allow time
Property
Denial
Values
- Frustration, powerlessness, blame
- 'Why me?' 'This is unfair.' 'You don't care about my pain.' Anger at family, staff, God
- Stay calm, do NOT take anger personally; validate feelings; listen; set boundaries professionally; offer control where possible
Property
Anger
Values
- Attempting to negotiate, postpone reality
- 'If I can just live to see...' 'Maybe if I pray harder...' 'If I change my ways...'
- Listen; do NOT criticize 'if-then' thinking; support spiritual practices; gently reality-check without cruelty; be present
Property
Bargaining
Values
- Sadness, withdrawal, mourning, hopelessness
- 'What's the point?' Crying, refusing visitors, 'I won't see my grandchildren.'
- Normalize grief; be present; listen; avoid false cheerfulness; offer comfort measures; assess for suicidal ideation; offer counseling/spiritual support
Property
Depression
Values
- Calm, peaceful, readiness; NOT happiness
- 'It's OK.' Quiet conversations about life/death. Making peace.
- Support quietly; facilitate goodbyes, legacy work; allow time with family; respect wishes; honor spiritual practices; be present
Property
Acceptance
Columns
- Stage
- Emotional Tone
- Typical Statements
- Nursing Approach
Table Title
Kübler-Ross Grief Stages: Characteristics & Nursing Response
Rows
Values
- BEFORE death, while patient dying
- Family begins grief process; may say goodbye, resolve conflicts, cry; patient also grieves loss of future
- SUPPORT this process; provide time together; facilitate unfinished business; normalize pre-death grieving; offer resources; prepare for death
Property
Anticipatory Grief
Values
- Acute phase ~4–12 weeks; gradual acceptance 1–2 years
- Waves of sadness/crying, yearning, memories, gradual adjustment; maintains daily functioning, relationships
- Validate; provide social support; connect with support groups; normalize timeline; reassure improvement expected; offer bereavement resources
Property
Normal (Uncomplicated) Grief
Values
- Persists intensely >12 months; impairs functioning
- Intense, unresolved anger/guilt; isolation; inability to engage in life; substance abuse; obsession with deceased; suicidal ideation
- REFER to mental health professional, grief counselor, or psychiatrist; not normal process; needs therapeutic intervention; assess suicide risk; medication may help
Property
Complicated (Dysfunctional) Grief
Columns
- Grief Type
- Timeline
- Characteristics
- Nursing/Support Action
Table Title
Types of Grief: Characteristics & Interventions
Rows
Values
- Days to hours before death
- Patient drowsy, hard to rouse, doesn't respond to voice
- Brain hypoxia, organ failure progressing
- Reassure family hearing persists; encourage them to speak gently; keep environment calm; offer comfort care
Property
Decreased Consciousness
Values
- Hours to minutes before death
- Hands, feet, legs pale, blue-grey, patchy (mottled) appearance
- Peripheral vasoconstriction; blood diverted to vital organs
- Reassure skin will feel cool but patient not in pain; provide blanket (warmth), gentle touch; continue presence
Property
Cool, Mottled Extremities
Values
- Final 24–48 hours
- Radial pulse barely felt, rapid; systolic BP drops progressively
- Cardiac output failing; organs shutting down
- Do NOT initiate IV fluids, vasopressors (comfort-focused); explain this is part of natural dying; maintain comfort measures
Property
Weak, Rapid Pulse; Falling BP
Values
- Hours before death (variable)
- Breathing pattern: fast-deep, then slow, then 15–30 sec pause, repeat
- Brain hypoxia, CO2 sensitivity declining
- Reassure family this is not painful; patient not suffocating; normal dying process; gentle positioning, calm presence; oxygen if distressed
Property
Cheyne-Stokes Respirations
Values
- Hours to minutes before death
- Gurgling, rattling sound with each breath
- Pooled respiratory secretions; decreased cough/swallow reflex
- Reassure family patient not drowning; hyoscine (anticholinergic) to dry secretions; elevate head 30°; gentle oral care; calm presence
Property
Noisy Respirations (Death Rattle)
Values
- Days before death (progressive)
- Little or no urine; dark amber/tea-colored if any
- Kidney perfusion failing; fluids pooling
- Reassure this is normal; no need for aggressive IV hydration; catheter or absorbent pads for dignity; maintain skin care
Property
Decreased Urine Output
Values
- Hours before death
- Incontinence of urine and stool; bowel/bladder relaxed
- Sphincter muscles relax as consciousness fades
- Use absorbent pads or indwelling catheter for dignity; frequent skin care, cleaning; matter-of-fact approach; reassure family this is normal
Property
Loss of Sphincter Control
Values
- Days to weeks before death (progressive)
- Patient refuses food, water; 'not hungry'
- Metabolic needs decreasing; GI shutdown
- Do NOT force feeding/fluids (risk aspiration); offer small sips if wants; reassure family this is normal, not starvation; explain comfort not quantity
Property
Decreased Appetite/Thirst
Columns
- Physical Sign
- Timeline (Approximate)
- What Family Sees/Hears
- What It Means
- Nursing Action
Table Title
Physical Signs of Approaching Death — Timeline & Family Guidance
Rows
Values
- Physiological adaptation requiring ↑ dose for same effect over time
- Develops gradually with prolonged use (days to weeks)
- YES — expected with ongoing opioid therapy
- Normal; increase dose as needed per pain; NOT abandonment of opioid therapy
Property
Tolerance
Values
- Physiological state: withdrawal symptoms if opioid abruptly stopped
- Develops with prolonged use; withdrawal begins 6–12 hrs after last dose
- YES — expected with chronic opioid therapy
- Managed by SLOW TAPER (over days/weeks), NOT abrupt cessation; not addiction
Property
Physical Dependence
Values
- Psychological/behavioral compulsion to use opioid despite harm; loss of control
- Can develop in susceptible individuals but RARE (<1%) with genuine pain treatment
- NO — not expected; NOT normal pharmacology
- VERY rare in cancer pain; DO NOT withhold opioids out of fear; addressing real pain is priority
Property
Addiction
Columns
- Concept
- Definition
- Development
- Is It Expected?
- Clinical Implication
Table Title
Tolerance vs Dependence vs Addiction — Critical Distinctions
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