ARELLANO UNIVERSITYGRADUATE SCHOOL OF NURSING

END-OF-LIFE CARE

In partial fulfillment of the requirement of the course:Medical-Surgical Nursing III

Submitted by:ARIF RAKHMAN

MANILA2014END-OF-LIFE CARE

INTRODUCTIONNurses can have a significant and lasting effect on the way in which patients live until they die, the manner in which the death occurs, and the enduring memories of that death for the families. Nursing has a long history of holistic, person-centered and family-centered care. Indeed, the definition of nursing highlights nursings commitment to the diagnosis and treatment of human responses to illness (American Nurses Association [ANA], 2003). There may be no setting or circumstance in which nursing carethat is, attention to human responsesis more important than in caring for dying patients. Knowledge about end-of-life principles of care and patients and families unique responses to illness are essential to supporting their unique values and goals. There is an opportunity to bring research, education, and practice together to change the culture of dying, bringing much-needed improvement to care that is relevant across practice settings, age groups, cultural backgrounds, and illnesses.Education about death helps healthcare professionals to be better informed about dying and death and to incorporate this knowledge into the care they give clients. Nurses who care for dying clients share emotional pain with them and their families. Denying death creates a barrier to becoming involved with clients and families and interferes with personal growth.Death can occur in any healthcare setting; therefore, facing the death of clients is necessary for nurses. It is not partial to a particular age group or population. Death can be slow and tortuous or very sudden and unexpected. Preparing clients and their families for an expected death is usually very different from caring for grieving family members after an unexpected death. Recognizing that nursing care always requires sensitivity and compassion for clients, families, and significant others is an essential component of quality care.

HOSPICE CAREHospice is a coordinated program of interdisciplinary services provided by professional caregivers and trained volunteers to patients with serious, progressive illnesses that are not responsive to cure. Hospice in the United States is not a place but a concept of care in which the end of life is viewed as a developmental stage. The root of the word hospice is hospes, meaning host. According to Cicely Saunders, who founded the world-renowned St. Christophers Hospice in London, the principles underlying hospice are as follows:1. Death must be accepted.2. The patients total care is best managed by an interdisciplinary team whose members communicate regularly with one another.3. Pain and other symptoms of terminal illness must be managed.4. The patient and family should be viewed as a single unit of care.5. Home care of the dying is necessary.6. Bereavement care must be provided to family members.7. Research and education should be ongoing.A hospice is a facility for the care of terminally ill clients, who can live out their final days with comfort, dignity, and meaningfulness. Hospice care emphasizes helping clients live however the wish until they die. Clients receive services that relieve their physical symptoms and emotional distress and promote spiritual support. Pain is liberally controlled (Timby & Smith, 2010).The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means. Hospice care hinges on the competent patients full or open awareness of dying; it embraces realism about death and helps patients and families understand the dying process so that they can live each moment as fully as possible.Since 1983, the Medicare Hospice Benefit has covered costs of hospice care for Medicare beneficiaries. State Medical Assistance (Medicaid) also provides coverage for hospice care, as do most commercial insurers. To receive Medicare payment for hospice services, programs are required to comply with rules known as conditions of participation, which are enforced by the Centers for Medicare and Medicaid Services. In many aspects, Medicare standards have come to largely define hospice philosophy and services.Eligibility criteria for hospice vary depending on the hospice program, but generally patients must have a progressive, irreversible illness and limited life expectancy and must opt for palliative care rather than cure-focused treatment. According to Medicare, the patient who wishes to use his or herMedicare Hospice Benefit must be certified by a physician as terminally ill, with a life expectancy of 6 months or less if the disease follows its natural course. Thus, hospice has come to be defined as care provided to terminally ill persons and their families in the last 6 months of the patients life. Because of additional Medicare rules concerning completion of cure-focused medical treatment before the Medicare Hospice Benefit may be accessed, many patients delay enrollment in hospice programs until very close to the end of life.Federal rules for hospices require that patients eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged if their physician and the hospice medical director continue to certify that the patient is terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course). Once a patient meets eligibility criteria and elects to use the benefit, the Medicare-certified hospice program assumes responsibility for providing and paying for the care and treatment related to the terminal illness for which hospice care was elected. The Medicare-certified hospice is paid a predetermined dollar amount for each day of hospice care that each patient receives. Four levels of hospice care are covered under Medicare and Medicaid hospice benefits: 1. Routine home care: All services provided are included in the daily rate to the hospice.2. Inpatient respite care: A 5-day inpatient stay, provided on an occasional basis to relieve the family caregivers.3. Continuous care: Continuous nursing care provided in the home for management of a medical crisis. Care reverts to the routine home care level after the crisis is resolved. (For example, seizure activity develops and a nurse is placed in the home continuously to monitor the patient and administer medications. After 72 hours, the seizure activity is under control, the family has been instructed how to care for the patient, and the continuous nursing care is discontinued.)4. General inpatient care: Inpatient stay for symptom management that cannot be provided in the home. This is not subject to the guidelines for a standard hospital inpatient stay.Most hospice care is provided at the routine home care level and includes the services as follow:1. Nursing care provided by or under the supervision of a2. registered nurse, available 24 hours a day3. Medical social services4. Physicians services5. Counseling services, including dietary counseling6. Home health aide/homemaker7. Physical/occupational/speech therapists8. Volunteers9. Bereavement follow-up (for up to 13 months after the death of the patient)10. Medical supplies for the palliation of the terminal illness11. Medical equipment for the palliation of the terminal illness12. Medications for the palliation of the terminal illnessHospice programs are reaching out to patients with very advanced illness and seeking ways to provide them with hospice services while they are completing courses of treatment that many programs previously defined as lifeprolonging, such as disease-modifying therapies for dementia, enteral or parenteral nutritional support, and certain types of chemotherapy.

PALLIATIVE CAREPalliative care is whole-person care provided by an interdisciplinary team of physicians, nurses, social workers, chaplains, and other health care professionals. The interdisciplinary care model aims to relieve suffering and improve quality of life for patients with chronic, serious, and advanced disease and their families. Palliative treatment can consist of many different interventions, including aggressive interventions to control pain and other distressing symptoms. Palliative care is offered along with all other appropriate medical treatments.According to World Health Organization (as cited in Monahan, et al., 2007), palliative care is a model of care that improves the quality of life of patients and their families facing problems associated with life-threatening illness, through the prevention and belief of suffering by means of early identification and treatment of pain and other distressing symptoms (physical, psychological, and spiritual). The purpose of palliative care as follow:1. Provide relief from pain and other distressing symptoms2. Affirms life and regards dying as a normal process3. Intends to neither hasten nor postpone death4. Integrates the psychologic and spiritual aspects of patient care5. Offers a support systems to help patients live as actively as possible until death6. Offers a support system to help the family cope during the patients illness and their own bereavement 7. Uses a team approach to address the need of patients and their families, including bereavement counseling8. Enhances quality of life, positively influences the course of illness, and support death with dignity9. Is applicable early in the course of illness, offered simultaneously with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy

PALLIATIVE CARE PLANCare provided by all team members is holistic and directed by the patient and family. Best practice in palliative care uses the strengths of the interdisciplinary team. The leader of the team is the person, regardless of discipline, who knows the most about issue at hand. This strategic, since not all symptoms arise from a physical need. Dyspnea may occur due to anxiety, pain can be exacerbated by depression and restlessness may be a result of spiritual conflict. Palliative care nurses act as patient advocates, case managers, and symptoms assessment and management experts. The nurses primary role in palliative care is to establish a trusting relationship with the patient and family and to coordinate care across all disciplines and health care settings. Quality of life and death with dignity can be achieved with a treatment plan that fosters the patients physical, psychosocial, spiritual and family well-being. Patients perceive high quality end of life care as including adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving the burden of loved ones, and strengthening relationship with loved ones and a higher power. Other factors important to high quality end of life care vary by role, developmental stage and personal preferences. Developmental Vies of Death:AGE DEVELOPMENTAL STAGES TASK AREA OF RESOLUTION

Birth to 2 yrInfancy Sense of separation with no concept of death

2-5 yrEarly childhood Death perceived as temporary

6-12 yrLate childhood Beginning awareness of the reality of death

13-25 yrAdolescenceYoung adulthood Realization of mortality and eventual deathDeath anxiety more prevalentDeath perceived as a future event

26-65 yrMiddle ageOther auldthood More awareness and accepting death

The palliative care plan includes care goals, advance care planning, financial planning, symptom management, family support, spiritual care, functional support status and rehabilitation, and comorbid disease management.1. Palliative care goalThe nurse ascertains the patients understanding and desire to know about the diagnosis and prognosis so that the palliative care interdisciplinary team can construct the most effective plan to manage the disease and its symptoms. Family meeting are an effective forum to discuss the patient and familys goals, hopes, and expectations of treatment. Acting as facilitator, the nurse provides information on benefits versus burdens of treatments and allows everyone to express concerns.Communication is essential for achieving consensus on a course of action. To the extent possible, communication includes all who are emotionally invested in the outcome and who provide information about the patients wishes and best interest regarding quality of life.2. Advance care planningAdvance care planning is important part of palliative care medicine and end of life care. Exploration of a patients life and treatment goals are the foundation for future health care decision making. Advance care planning discussions should occur with healthy, competent, adult patients in the primary care setting. Such discussions include living wills, durable power of attorney for health care, an advance medical care directive and a patient-completed values history, which serves as a foundation for advance care decisions.An advance medical care directive combines the living will and durable power of attorney for health care, providing specific instructions for various medical situations. Like the durable power of attorney, an advance medical care directive may appoint a health care proxy to aid in the treatment decision making when the patient is no longer able to communicate medical wishes.A values history reveals the patients values and beliefs and directs health care clinicians, proxies, and family members through difficult treatment decisions. When the clinicians and health care proxy are aware of the patients treatment choices and the values that support those decisions, medical treatment efficacy increases. This, in turn, enhances the patients and familys quality of life by preserving autonomy. Nurses in all setting provide opportunities for the patient to discuss medical wishes. Advance directives can be in verbal or written form. Any verbal statements made by the patients regarding treatment choices should be documented in the patients medical file brought to the attention of other interdisciplinary team members. Advance directives are not recognized for dying children; however, allowing a child to share in his or her own medical care decision is critical.3. Financial PlanningWhen considering the patients ability to adhere in a treatment plan, the nurse must assess the resources available. For example, if the patient is unable to pay for pain medication, then it is likely that pain will not be managed at home and hospitalization will be routinely required. The nurse can work with the social worker on the interdisciplinary team to obtain assistance for the patient and family with estate planning, long-term care, other insurance options, and community medication reimbursement programs. The care providers assess the patients understanding of health care coverage (medical, home care, prescription, long term care, and family support needs) and make referrals as needed.4. Comorbid diseaseThe nurse must monitor for coexisting illness coordinate with other health care specialist. This is necessary to provide high quality, coordinated care and achieve the goal of maintaining health and function. The nurse reviews medications on an ongoing basis to identify potential drug interactions and make changes as needed. The nurses also review treatment options offered by specialist and help patient understand the benefit versus burden of treatment in terms of quality and length of life. When the patient can no longer benefit from treatment, the nurse recommends that it be discontinued. At that point all the members of palliative care team are involved in providing emotional support.5. Symptom managementSymptom management is the cornerstone to ensuring a high quality of life and death with dignity. Nurses caring for individuals with chronic, serious, and terminal illness must monitor symptoms such as pain, nausea and vomiting, anorexia, constipation, and changes in level of consciousness. A whole patient assessment is a spiritual aspect of the patient, family members, and caregiver, examining a range of issues that may cause suffering. Nurses should be aware also with the perideath period. Perideath period encompasses the symptoms and experiences right before death, the actual death, and the care of the body after death. At this time inpatients live they rely on the nurses skills to help them and their families, through uncharted waters. Perideath period includes:a. Phase 1: Preparation for deathThe sign and symptoms before death occur are indicative of the first phase of the perideath period as the body prepares for death. Sign and symptoms such as coolness, sleeping, fluid and food decrease, incontinence, congestion, breathing pattern change, disorientation, and restlessness might be occur. Furthermore patient may experience of withdrawal, visionlike experience, letting go and the final is saying good-bye. b. Phase 2: DeathThe sign of death include no heartbeat, release of bowel and bladder, no response, eyelids slightly open, pupils enlarged, eyes fixed on a certain spot, no blinking, jaw relaxed, and mouth slightly open.Throughout the dying process, and particularly at the very end of life, the nurse must be aware of cultural and religious values, practices, and traditions of the patient and the family. Religious and ethnic group practices regarding postmoterm care vary in the worldwide. Although it is possible to generalize about the practices of various group or religious, the nurse must avoid stereotyping. c. Phase 3: After deathOnce he patient has died, the family has many decisions to make or plans to carry out, depending on whether the patient has already arranged to funeral. Choices include organ donation, cremation, traditional burial or internment the body. For same family, the wake, or visitation, is the first component of postdeath ritual. It is a time for family and friends to view the death body emphasize that the person is dead; declining to see the body may delay grieving.The second component of postdeath ritual is the funeral. It is a ceremonial service that typically includes music, prayers, poetry, and eulogies. Some people plan their funeral before they die, which can be comforting to both the dying person and family. The last ritual is the committal service, the concluding funeral rite. It is the final act of caring for the deceased and is celebrated at the grave, tomb, or crematorium. 6. Family supportIn palliative care the family is whomever the patient calls family; another term is family of choice. The nurse asks the patient and family about practical support needs such as transportation, prescription drug coverage, respite care and personal care. Counseling can help patient and family reconnect and build relationships. The nurse should establish relationships with all significant family and friends so that he or she can provide follow-up bereavement support after patients death. The nurse encourages family and friends to assist in care if they desire. The patient and the family together are considered the unit of care. Care givers are prone to negative physical, social, and emotional effect of caring for individuals with chronic and serious conditions. By including the care givers in the unit of care, the nurse can ensure all benefit from the positive outcomes of palliative care.7. Cultural careIt is assumed in Western culture that the patient is the best person to make health care decisions. In non-Western cultures the family or community has a vital role in receiving, organizing, and disclosing information needed to make a decision regarding care. Establishing rapport with the patient and family allows the nurse to foster an individualized care plan addressing personal beliefs, wishes, and needs.There are some cultural diversity and death according to Mazanec and Tyler (2003):

8. Spiritual careNurses are not expected to be experts in spiritual assessment and care giving, yet they may assist the patient in acknowledging the meaning and last effects of a life lived. Nurses are pivotal in the process of spiritual assessment because of their frontline health care position, role as coordinator, intimacy with the patient and holistic perspective on care. Individuals who life with an irreversible disease often consider aspects of spirituality a major contributing factor to quality of life and death with dignity.Spirituality is an important component of many patients physical well-being and mental health. The nurse addresses it at each visit, since spirituality is an ongoing issue. The nurse portrays an attitude of acceptance by respecting the patients right to privacy regarding spiritual beliefs, not imposing personal beliefs on others, and referring the patient to the clergy of choice or palliative care clergy for additional spiritual support as needed. Personal spiritual beliefs overflow in encounters with patients. When health care providers understand their own values and beliefs, it allows the nurse-patient encounter to become more humanistic and effective. The following overview of religious and cultural beliefs and views on death and dying in many religions according to Firth (2005), Dorff (2005),Keown (2005), Sachedina (2005), Engelhardt & Smith (2005).:

GRIEF, MOURNING, AND BEREAVEMENTA wide range of feelings and behaviors are normal, adaptive, and healthy reactions to the loss of a loved one. Grief refers to the personal feelings that accompany an anticipated or actual loss. Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors. Bereavement refers to the period of time during which mourning takes place. Both grief reactions and mourning behaviors change over time as people learn to live with the loss. Although the pain of the loss may be tempered by the passage of time, loss is an ongoing developmental process, and time does not heal the bereaved individual completely. That is, the bereaved do not get over a loss entirely, nor do they return to who they were before the loss. Rather, they develop a new sense of who they are and where they fit in a world that has changed dramatically and permanently.Denial, sadness, anger, fear, and anxiety are normal grief reactions in people with life-threatening illness and those close to them. Kbler-Ross (1969) described five common emotional reactions to dying that are applicable to the experience of any loss. StageNursing Implications

Denial: This cannot be true. Feelings of isolation. May search for another health care professional who will give a more favorable opinion. May seek unproven therapies.Denial can be an adaptive response, providing a buffer after bad news. It allows time to mobilize defenses but can be maladaptive when it prevents the patient or family from seeking help or when denial behaviors cause more pain or distress than the illness or interfere with everyday functions. Nurses should assess the patients and familys coping style, information needs, and understanding of the illness and treatment to establish a basis for empathetic listening, education, and emotional support. Rather than confronting the patient with information he or she is not ready to hear, the nurse can encourage him or her to share fears and concerns. Open-ended questions or statements such as Tell me more about how you are coping with this new information about your illness can provide a springboard for expression of concerns.

Anger: Why me? Feelings of rage, resentment or envy directed at God, health care professionals, family, others.Anger can be very isolating, and loved ones or clinicians may withdraw. Nurses should allow the patient and family to express anger, treating them with understanding, respect, and knowledge that the root of the anger is grief over impending loss.

Bargaining: I just want to see my grandchilds birth, then Ill be ready. . . . Patient and/or familyplead for more time to reach an important goal. Promises are sometimes made with God.Terminally ill patients are sometimes able to outlive prognoses and achieve some future goal. Nurses should be patient, allow expression of feelings, and support realistic and positive hope.

Depression: I just dont know how my kids are going to get along after Im gone. Sadness, grief, mourning for impending losses.Normal and adaptive response. Clinical depression should be assessed and treated when present. Nurses should encourage the patient and family to fully express their sadness. Insincere reassurance or encouragement of unrealistic hopes should be avoided.

Acceptance: Ive lived a good life, and I have no regrets. Patient and/or family are neither angry nor depressed.The patient may withdraw as his or her circle of interest diminishes. The family may feel rejected by the patient. Nurses need to support the familys expression of emotions and encourage them to continue to be present for the patient.

Not every patient or family member experiences every stage; many patients never reach a stage of acceptance, and patients and families fluctuate on a sometimes daily basis in their emotional responses. Furthermore, although impending loss stresses the patient, people who are close to him or her, and the functioning of the family unit, awareness of dying also provides a unique opportunity for family members to reminisce, resolve relationships, plan for the future, and say goodbye.The nurse should assess the characteristics of the family system and intervene in a manner that supports and enhances the cohesion of the family unit. The nurse can suggest that familymembers talk about their feelings and understand them in the broader context of anticipatory grief and mourning. Acknowledging and expressing feelings, continuing to interact with the patient in meaningful ways, and planning for the time of death and bereavement are adaptive family behaviors. Professional support provided by grief counselors, whether in the community, at a local hospital, in the long-term care facility, or associated with a hospice program, can help both the patient and the family sort out and acknowledge feelings and make the end of life as meaningful as possible.When a loved one dies, the family members enter a new phase of grief and mourning as they begin to accept the loss, feel the pain of permanent separation, and prepare to live a life without the deceased. Even if the loved one died after a long illness, preparatory grief experienced during the terminal illness does not preclude the grief and mourning that follow the death. With a death after a long or difficult illness, family members may experience conflicting feelings of relief that the loved ones suffering has ended, compounded by guilt and grief related to unresolved issues or the circumstances of death. Grief work may be especially difficult if a patients death was painful, prolonged, accompanied by unwanted interventions, or unattended. Families who had no preparation or support during the period of imminence and death may have a more difficult time finding a place for the painful memories.After-death rituals, including preparation of the body, funeral practices, and burial rituals, are socially and culturally significant ways in which family members begin to accept the reality and finality of death. Preplanning of funerals is becoming increasingly common, and hospice professionals in particular help the family make plans for death, often involving the patient, who may wish to play an active role. Preplanning of the funeral relieves the family of the burden of making decisions in the intensely emotional period after a death.In general, the period of mourning is an adaptive response to loss during which mourners come to accept the loss as real and permanent, acknowledge and experience the painful emotions that accompany the loss, experience life without the deceased, overcome impediments to adjustment,and find a new way of living in a world without the loved one. Particularly immediately after the death, mourners begin to recognize the reality and permanence of the loss by talking about the deceased and telling and retelling the story of the illness and death. Societal norms in the United States are frequently at odds with the normal grieving processes of people; time excused from work obligations is typically measured in days, and mourners are often expected to get over the loss quickly and get on with life.In reality, the work of grief and mourning takes time, and avoiding grief work after the death often leads to long-term adjustment difficulties. According to Rando (2000), mourning for a loss involves the undoing of psychosocial ties that bind mourners to the deceased, personal adaptation to the loss, and learning to live in the world without the deceased. Six key processes of mourning allow people to accommodate to the loss in a healthy way:1. Recognition of the loss2. Reaction to the separation, and experiencing and expressing the pain of the loss3. Recollection and reexperiencing the deceased, the relationship, and the associated feelings4. Relinquishing old attachments to the deceased5. Readjustment to adapt to the new world without forgetting the old6. Reinvestment Although many people complete the work of mourning with the informal support of families and friends, many find that talking with others who have had a similar experience, such as in formal support groups, normalizes the feelings and experiences and provides a framework for learning newskills to cope with the loss and create a new life. Hospitals, hospices, religious organizations, and other community organizations often sponsor bereavement support groups. Groups for parents who have lost a child, children who have lost a parent, widows, widowers, and gay men and lesbianswho have lost a life partner are some examples of specialized support groups available in many communities.

WITHHOLDING OR WITHDRAWING TREATMENTIt is appropriate to consider withholding or withdrawing specific therapy when the therapy offers no reasonable expectation of helping the patient attain any human awareness; the therapy is proving medically ineffective and useless after sufficient trial; or patient (or decision-making representative) has expressed that the therapy is cumulatively a greater burden than a benefit.When decision are made to withhold or withdraw life sustaining treatment, the goal of medical and nursing care focuses on keeping the patient comfortable; preventing suffering and pain; and providing support, comfort, and care on physical, emotional, and spiritual levels. Indentifying those procedures not directed to supportive care becomes more difficult once medical procedures designed to prolong life are withheld of withdrawn. Perhaps the most controversial area is that of determining the proportionate benefit and burden of medical (artificial) nutrition and any hydration. The issue of withdrawing treatment, once it is started, is also difficult.1. Do not resuscitate (DNR)Do not resuscitate(DNR), orno code, is a legal order written either in the hospital or on a legal form to withholdcardiopulmonary resuscitation(CPR) oradvanced cardiac life support(ACLS), in respect of the wishes of a patient in case theirheart were to stopor they were tostop breathing. "No code" is a reference to the use of "code" as jargon for "calling in aCode Blue" to alert a hospital's resuscitation team. The DNR request is usually made by the patient or health carepower of attorneyand allows the medical teams taking care of them to respect their wishes. In the health care community,allow natural death(AND), is a term that is quickly gaining favor as it focuses on what is being done, not what is being avoided.[citation needed]Some criticize the term "do not resuscitate" because it sounds as if something important is being withheld, while research shows that only about 5% of patients who require CPR outside the hospital and only 15% of patients who require CPR while in the hospital survive.Patients who are elderly, are living in nursing homes, have multiple medical problems, or who have advanced cancer are much less likely to survive. A DNR does not affect any treatment other than that which would requireintubationorCPR. Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate treatments. In 1991 Congress passed into law the Patient Self-Determination Actthat mandated hospitals honor an individual's decision in their healthcare. 2. Assisted suicideAssisted suicide refers to providing another person the means to end his or her own life. Physician-assisted suicide involves the prescription by a physician of a lethal dose of medication for the purpose of ending someones life.Assisted suicideissuicidecommitted with the aid of another person, sometimes a physician.The term is often used interchangeably with physician-assisted suicide (PAS), which involves a doctor "knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counselling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs.Assisted suicide and euthanasia are sometimes combined under the umbrella term "assisted dying", an example of a trend by advocates to replace the word "suicide" with "death" or ideally, "dying". Other euphemisms in common use are "physician-assisted dying", "physician-assisted death", "aid in dying", "death with dignity", "dying with dignity", "right to die" "compassionate death", "compassionate dying", "end-of-life choice", and "medical assistance at the end of life".Physician-assisted suicide is often confused witheuthanasia(sometimes called "mercy killing"). In cases of euthanasia the physician administers the means of death, usually a lethal drug. Physician-assisted suicide (PAS) is always at the request and with the consent of the patient, since he or she self-administers the means of death.In 1994-1997, Oregon voters approved the Oregon Death With Dignity Act - 341 persons who have died. In November 2008, voters approved The Washington Death with Dignity Act. ANA: nursing participation in assisted suicide is a violation of the Code for Nurses. 3. EuthanasiaGreek words meaning good or pleasant death. Euthanasia is the act of deliberately ending a person's life to relieve suffering.Euthanasia can be classified in different ways, including:a. Active euthanasiawhere a person deliberately intervenes to end someones lifefor example, byinjecting them with a large dose of sedativesb. Passive euthanasiawhere a person causes death bywithholding or withdrawing treatment that is necessary to maintain life, such as withholdingantibioticsfrom someone withpneumoniaThe 2002 statement from the American Medical Association Council on Ethical and Judicial Affairs holds that the patient or immediate family can decide to discontinue all means of life-prolonging medical treatment.Euthanasia can also be classified as:a. Voluntary euthanasiawhere a person makes a conscious decision to die and asks for help to do thisb. Non-voluntary euthanasiawhere a person is unable to give theirconsent(for example, because they are in acomaor are severely brain damaged)and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in suchcircumstancesc. Involuntary euthanasiawhere a person is killed against their expressed wishesDepending on the circumstances, voluntary and non-voluntary euthanasia could be regarded as either voluntary manslaughter (where someone kills another person, but circumstances can partly justify their actions) or murder.Involuntary euthanasia is almost always regarded as murder.

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