NLE Oncology Nursing — Palliative, Hospice and End-of-Life CareRevision Notes

Exam Tips

• If a scenario says a patient is still receiving chemotherapy and also getting symptom management — that is PALLIATIVE care, not hospice.
• If a scenario says prognosis is 6 months or less and curative treatment has been stopped — that is HOSPICE.
• Key NLE trigger phrase: 'comfort-focused, curative treatment discontinued' = hospice.
• Remember: hospice includes bereavement support AFTER death — this makes it unique.

Key Points

• Palliative care = comfort-focused care that can be given at ANY stage of a serious illness, even alongside chemotherapy or radiation. It is NOT only for the dying.
• Hospice care = a specialized form of palliative care reserved for TERMINALLY ILL patients with a prognosis of SIX MONTHS OR LESS, when curative treatment has been stopped.
• Both share the same core goals: relieve suffering, improve quality of life, support family.
• Hospice extends bereavement support to the family AFTER the patient's death — up to 13 months in standard practice.
• The interdisciplinary hospice team includes: nurse, physician, social worker, chaplain, home health aide, and volunteers.
• Core principle: AFFIRM life and treat dying as a normal process — do NEITHER hasten NOR postpone death.
• Palliative care can be delivered in hospitals, outpatient clinics, or at home; hospice is commonly home-based in the Philippine setting.
• Under RA 9173, nurses are obligated to provide safe and quality nursing care, which includes ensuring dignity and comfort at end of life.

Definitions

Section Title

Palliative Care versus Hospice Care

Common Mistakes

• Thinking palliative care is ONLY for dying patients — it can be given at any stage alongside curative treatment.
• Confusing hospice with simply 'giving up' — hospice is an ACTIVE, compassionate choice to prioritize comfort and dignity.
• Forgetting that the nurse's role under RA 9173 includes advocating for the patient's end-of-life wishes.
• Omitting the family from the plan of care — in hospice, the patient AND family are the unit of care.

Exam Tips

• Memorize the '3 Bys': By mouth, By the clock, By the ladder.
• The NLE loves to ask: 'A patient with cancer pain is on paracetamol but still in pain. What is the NEXT step?' — Add a weak opioid (Step 2), not jump to morphine.
• Remember: MORPHINE = Step 3 (strong opioid); CODEINE/TRAMADOL = Step 2 (weak opioid); PARACETAMOL/NSAIDs = Step 1.
• When the question asks about neuropathic pain (burning, tingling, shooting) — think ADJUVANTS: gabapentin or amitriptyline.
• No ceiling dose for morphine — titrate to relief. Paracetamol ceiling = 4 g/day in adults (lower in liver disease).

Key Points

• Pain is SUBJECTIVE — it is whatever the patient says it is, whenever they say it exists. Never dismiss the patient's pain report.
• The WHO Analgesic Ladder has THREE steps based on pain intensity — not on the disease stage.
• Step 1 (Mild pain): Non-opioids — PARACETAMOL (acetaminophen) and/or NSAIDs ± adjuvants.
• Step 2 (Mild to Moderate pain): WEAK OPIOIDS (codeine, tramadol) added to non-opioids ± adjuvants.
• Step 3 (Moderate to Severe pain): STRONG OPIOIDS (morphine, fentanyl, oxycodone, hydromorphone) ± non-opioids ± adjuvants.
• Adjuvant drugs enhance analgesia for specific pain types: corticosteroids (bone/nerve pain, swelling), gabapentin/pregabalin (neuropathic pain), amitriptyline (neuropathic pain), bisphosphonates (bone pain).
• The '3 Bys' of the WHO: By MOUTH (oral route preferred), By the CLOCK (fixed schedule), By the LADDER (follow the steps).
• Around-the-clock (ATC) dosing maintains a STEADY blood level to PREVENT pain from returning — superior to PRN-only dosing.
• Breakthrough (rescue) doses are given ON TOP of the scheduled regimen for sudden pain flares.
• There is NO CEILING DOSE for strong opioids in cancer pain — titrate upward until pain is relieved.
• Paracetamol and NSAIDs DO have ceiling/toxic limits — exceeding them causes harm without added benefit.
• Morphine is the prototype strong opioid — given orally, IV, SC, or epidurally; reassess 30–60 min after IV dose.
• Do NOT withhold opioids out of fear of addiction — addiction is rare in genuine pain treatment; tolerance and physical dependence are EXPECTED physiological effects, not addiction.

Definitions

Section Title

Pain and Symptom Control: The WHO Analgesic Ladder

Common Mistakes

• Withholding opioids because of fear the patient will become 'addicted' — this is incorrect nursing practice in cancer pain management.
• Treating breakthrough pain by simply skipping to the next scheduled dose instead of giving an additional rescue dose.
• Applying a ceiling dose concept to strong opioids (morphine) — only non-opioids (paracetamol, NSAIDs) have toxic ceilings.
• Giving analgesics PRN only in cancer pain — always use ATC with rescue doses available.
• Confusing Step 2 drugs (codeine, tramadol) with Step 3 drugs (morphine) — tramadol is a WEAK opioid.
• Forgetting adjuvant drugs — if a patient has neuropathic (burning, shooting) pain, gabapentin or amitriptyline should be added.

Exam Tips

• NLE CLASSIC: 'A patient started on morphine. Which nursing action is MOST IMPORTANT?' — Start a BOWEL REGIMEN (senna + docusate).
• NLE CLASSIC: 'A patient on opioids has RR of 8/min and is difficult to arouse. What is the PRIORITY action?' — Administer NALOXONE.
• For dyspnea, remember: opioids REDUCE the SENSATION of breathlessness — this is NOT the same as stopping the disease process.
• Death rattle: explain to the family it does NOT mean the patient is 'drowning' or in pain — it is a normal end-of-life change.
• Palliative sedation question: 'The INTENT is to relieve suffering, not to hasten death' — this is the key ethical distinction.

Key Points

• CONSTIPATION is the #1 opioid side effect that patients NEVER develop tolerance to — it persists for as long as the patient takes opioids.
• PROPHYLACTIC bowel regimen is MANDATORY when starting any opioid: stimulant laxative (senna/bisacodyl) + stool softener (docusate); encourage fluids and fiber as tolerated.
• RESPIRATORY DEPRESSION is the most feared but LEAST common with proper titration; monitor respiratory rate and sedation level.
• The antidote for opioid respiratory depression is NALOXONE (Narcan) — given IV; used cautiously in comfort-care dying patients to avoid reversing analgesia and precipitating severe pain.
• SEDATION and NAUSEA — usually improve within a few days as tolerance develops; treat nausea with antiemetics (metoclopramide, ondansetron).
• DYSPNEA management: low-dose opioids (reduce the sensation of breathlessness), supplemental oxygen, positioning (head of bed elevated), fan directed at face, and reassurance.
• DEATH RATTLE (excessive respiratory secretions): caused by accumulated secretions the patient can no longer clear; managed with ANTICHOLINERGICS (hyoscine/scopolamine, glycopyrrolate) and repositioning — suctioning is generally avoided as it is distressing.
• ANXIETY AND RESTLESSNESS (terminal restlessness): managed with benzodiazepines (lorazepam, midazolam), presence, calm environment, and reassurance.
• Assess pain and symptoms CONTINUOUSLY and reassess after every intervention — the pain score should decrease after a nursing or pharmacological intervention.
• Palliative sedation (for intractable, refractory suffering) is ethically DISTINCT from euthanasia — euthanasia remains ILLEGAL in the Philippines.

Definitions

Section Title

Opioid Side Effects and Nursing Management

Common Mistakes

• Waiting for constipation to develop before starting a bowel regimen — it must be PROPHYLACTIC (started when opioid is started).
• Using naloxone aggressively in a comfort-care patient — this reverses pain relief and can cause severe withdrawal.
• Suctioning a patient with a death rattle repeatedly — this is distressing and not recommended; use anticholinergics instead.
• Confusing palliative sedation with euthanasia — they are ethically and legally different.
• Stopping opioids abruptly in a terminal patient due to fear of side effects — taper gradually or continue for comfort.

Exam Tips

• DABDA memory aid: Denial, Anger, Bargaining, Depression, Acceptance.
• NLE scenario: 'Patient says: Why is God doing this to me?' — Stage = ANGER. Nurse response = listen, do not argue or defend.
• NLE scenario: 'A wife who lost her husband 18 months ago still cannot leave the house or maintain daily activities' — Type = COMPLICATED GRIEF. Action = refer to mental health professional.
• NLE scenario: 'A patient's family member is grieving even though the patient is still alive' — Type = ANTICIPATORY GRIEF.
• Signs of approaching death: cool + mottled skin + Cheyne-Stokes + decreased urine + noisy secretions + falling BP = IMMINENT DEATH.
• Hearing is the LAST sense — this is almost certainly on the NLE: 'The nurse should encourage the family to TALK TO and TOUCH the patient.'

Key Points

• Kübler-Ross identified FIVE stages of grief: Denial, Anger, Bargaining, Depression, Acceptance (memory aid: DABDA).
• The stages do NOT occur in a fixed order — patients and families move back and forth, skip stages, or experience several at once.
• DENIAL — 'This can't be happening to me' — a protective initial reaction; allow expression, do not force acceptance.
• ANGER — 'Why me?' — may be directed at nurses, doctors, family, or God; do not take it personally; remain therapeutic.
• BARGAINING — 'If I can just see my child graduate...' — patient tries to negotiate for more time; listen and support.
• DEPRESSION — deep sadness and mourning as reality sets in; sit with the patient, listen, and refer to mental health resources if needed.
• ACCEPTANCE — peaceful readiness; NOT necessarily happiness — the patient has come to terms with dying.
• Nursing role: MEET THE PATIENT WHERE THEY ARE — do not rush them toward acceptance.
• ANTICIPATORY GRIEF — grief that begins BEFORE the loss while the person is still alive; experienced by both patient and family.
• NORMAL (UNCOMPLICATED) GRIEF — expected reaction that gradually eases over time.
• COMPLICATED (DYSFUNCTIONAL) GRIEF — prolonged, unresolved grief (lasting >12 months per DSM criteria) that significantly impairs daily functioning; requires professional mental health referral.
• Physical signs of approaching death: decreased LOC, cool and mottled extremities, weak/thready/absent peripheral pulses, falling BP, irregular breathing (Cheyne-Stokes respirations), noisy secretions, decreased urine output, loss of sphincter control, decreased appetite and thirst.
• HEARING IS THE LAST SENSE TO GO — always speak gently and reassuringly to the patient even when unconscious; instruct the family to do the same.
• Cheyne-Stokes respirations: cycles of gradually increasing then decreasing depth and rate, with periods of APNEA — a hallmark of impending death.

Definitions

Section Title

Grief, Loss, and the Dying Process

Common Mistakes

• Assuming grief stages are LINEAR and must occur in the DABDA order — they are not fixed; patients move between stages.
• Telling a patient in denial or anger 'You need to accept this' — this is therapeutically incorrect; meet the patient where they are.
• Confusing ANTICIPATORY grief (before death) with COMPLICATED grief (prolonged, dysfunctional) — these are different types.
• Failing to continue speaking to an unconscious, actively dying patient — hearing is the LAST sense to go.
• Describing mottling or Cheyne-Stokes breathing to the family without explaining what it means — this causes unnecessary panic.

Exam Tips

• NLE CLASSIC: 'A patient with a DNR order goes into cardiac arrest. What does the nurse do?' — WITHHOLD CPR; call the physician; provide comfort.
• NLE CLASSIC: 'A patient with a DNR is in pain. What should the nurse do?' — GIVE PAIN MEDICATION. DNR does not stop other care.
• Living Will = the DOCUMENT. Health Care Proxy = the PERSON who decides.
• Euthanasia is ILLEGAL in the Philippines — if an NLE option mentions it as a correct nursing action, it is WRONG.
• Nurses under RA 9173 must advocate for the patient's autonomy — if the family disagrees with a DNR, the nurse supports the patient's documented wishes.

Key Points

• An ADVANCE DIRECTIVE is a legal document expressing a patient's wishes for care if they become unable to make decisions.
• Two main types of advance directives: LIVING WILL and DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Health Care Proxy).
• LIVING WILL: specifies which treatments the patient WANTS or REFUSES (e.g., 'I do not want a ventilator if I am in a permanent vegetative state').
• DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Health Care Proxy): designates a SURROGATE DECISION MAKER who will make health decisions on the patient's behalf.
• A DNR (Do-Not-Resuscitate) ORDER is a PHYSICIAN'S WRITTEN ORDER directing that CPR will NOT be performed if the patient's heart stops or breathing ceases.
• DNR applies ONLY to CPR — the patient still receives ALL other comfort and care measures: pain medications, IV fluids if desired, wound care, emotional support, and more.
• A DNR order NEVER means 'do not care' or 'do not treat' — it is a specific order about resuscitation only.
• DNR must be based on INFORMED CONSENT — the patient's or surrogate's informed wishes, documented as a physician order.
• Nurses UPHOLD patient AUTONOMY and RIGHT TO SELF-DETERMINATION — one of the ethical pillars of RA 9173.
• Euthanasia (intentional ending of a patient's life) is ILLEGAL in the Philippines and is ethically distinct from palliative sedation.
• Withdrawing/withholding burdensome treatment (e.g., turning off a ventilator when the patient has requested it) is ethically different from euthanasia — it allows natural death.
• The nurse's role: ensure advance directives are documented in the medical record, visible, and HONORED; advocate for the patient's expressed wishes.

Definitions

Section Title

Ethical and Legal Considerations: Advance Directives and DNR

Common Mistakes

• Thinking a DNR order means stopping all care — it ONLY means no CPR; all comfort care continues.
• Performing CPR on a patient with a valid DNR order — this violates the patient's documented wish and is an ethical/legal violation.
• Confusing a Living Will (document of wishes) with a Health Care Proxy (person designated to decide).
• Allowing family pressure to override a valid, documented DNR order — the nurse must advocate for the patient's expressed wishes.
• Confusing palliative sedation with euthanasia — euthanasia is intentional killing; palliative sedation is relieving suffering.

Exam Tips

• NLE scenario: 'A dying Filipino patient's family requests a priest. What should the nurse do FIRST?' — Contact the hospital chaplain or pastoral care to arrange clergy IMMEDIATELY.
• NLE scenario: 'The patient asks the nurse if they are dying. The family has asked the nurse not to tell them.' — The nurse must balance honesty with cultural sensitivity; the patient's right to know must ultimately be respected while involving the team.
• Philippine context questions often appear in the 'nursing care of the community' and 'nursing ethics' clusters — know lamay, bahala na, and the family-centered model.
• Post-mortem care in the NLE: allow family time with the body, perform care respectfully, and follow institutional and cultural protocols.

Key Points

• Filipino culture is FAMILY-CENTERED — the extended family is deeply involved in both caregiving and decision-making; include and engage the family in all aspects of care.
• Decisions are often made COLLECTIVELY (family consensus) rather than by the individual patient alone — respect this while still protecting individual patient rights.
• The Philippines is PREDOMINANTLY ROMAN CATHOLIC — religious rituals are central to end-of-life care.
• The ANOINTING OF THE SICK (Sacrament of the Sick) is a Roman Catholic sacrament administered by a priest to the seriously ill or dying — facilitate access to clergy promptly when requested.
• The LAST RITES (now called Sacrament of the Sick) and Last Communion are deeply meaningful — do not delay or dismiss these requests.
• In Mindanao and other areas, be aware of MUSLIM faith traditions (e.g., specific prayers, burial rites, position toward Mecca) and other faith traditions (INC, Protestant denominations).
• BAHALA NA — a cultural attitude of leaving outcomes to God's will or fate — can bring peace and acceptance but may also delay care-seeking; approach with respect, not judgment.
• TRUTH-TELLING AND DISCLOSURE — families may wish to PROTECT the patient from a grave prognosis (paternalistic protective truth-telling); the nurse balances honesty with cultural sensitivity while upholding the patient's right to know.
• DYING AT HOME is strongly preferred by many Filipino families — support home-based hospice and coordinate with Barangay Health Centers and community health nurses where applicable.
• LAMAY (wake/vigil) — the Filipino cultural practice of a wake lasting several nights after death, with prayers, food, and community gathering — is an important mourning ritual; support the family's ability to observe it.
• POST-MORTEM CARE — perform respectfully, allow the family time with the deceased, and observe cultural and religious customs in care of the body.
• Apply CULTURALLY SENSITIVE COMMUNICATION at all times — use the patient's and family's language/dialect when possible, and involve a cultural or religious liaison as needed.

Definitions

Section Title

Cultural and Philippine Considerations in End-of-Life Care

Common Mistakes

• Excluding the family from the care plan — in Filipino culture, family involvement is not optional; it is expected and therapeutic.
• Delaying or dismissing a patient's or family's request for a priest (Anointing of the Sick) — this is an urgent spiritual need.
• Imposing a Western individualistic framework of decision-making on Filipino families who decide collectively.
• Ignoring the patient's religious or cultural preferences in post-mortem care.
• Failing to recognize that Muslim and INC patients have different end-of-life religious needs from Roman Catholic patients.