Terminal restlessness as perceived by hospice professionals

Hispanic Hospice Patients' Experiences of End-Stage Restlessness

End-stage restlessness, or terminal agitation, is experienced by some patients during their final days and is characterized by physical, emotional, or spiritual distress, agitation or anxiety. End-stage restlessness negatively affects the patient's death experience and can be distressing to the family and care team. Using the 2007 National Home and Hospice Care survey, this study examined factors associated with experiencing end-stage restlessness among non-Hispanic white and Hispanic hospice patients deceased at time of discharge. Results showed that being Hispanic/Latino, experiencing dyspnea, pain, and receiving palliative sedation treatment were risk factors for experiencing end-stage restlessness. The association between pain and restlessness was stronger for Hispanics compared with non-Hispanic whites. The Hispanic population remains underrepresented and little is known about the patient-centered experiences of Hispanic hospice users. Findings indicated that dying Hispanic patients continue to experience pain and other negative symptoms, even when hospice care is in place. Thus, it is important that social workers provide education to interdisciplinary team members about culturally competent practices, and advocate for a patient-centered approach to care.

A Thematic Literature Review

The purpose of this review was to investigate within the literature the link between transcendent phenomena and peaceful death. The objectives were firstly to acknowledge the importance of such experiences and secondly to provide supportive spiritual care to dying patients. Information surrounding the aforementioned concepts is underreported in the literature. The following 4 key themes emerged: spiritual comfort; peaceful, calm death; spiritual transformation; and unfinished business. The review established the importance of transcendence phenomena being accepted as spiritual experiences by health care professionals. Nevertheless, health care professionals were found to struggle with providing spiritual care to patients who have experienced them. Such phenomena are not uncommon and frequently result in peaceful death. Additionally, transcendence experiences of dying patients often provide comfort to the bereaved, assisting them in the grieving process.

A relational ethical approach to end-of-life delirium

Delirium is a condition of acute onset and fluctuating course in which a person's level of consciousness and cognition become disturbed. Delirium is a common and distressing phenomenon in end-of-life care, yet it is underrecognized and undertreated. In this article, we review qualitative descriptions of the delirium experience in end-of-life care, found through a systematic search of academic databases, to generate insight into the intersubjective nature of the delirium experience. Our analysis of retrieved studies advances an understanding of the relational ethical dimensions of this phenomenon, that is, how delirium is lived by patients, families, and health care providers and how it affects the relationships and values at stake. We propose three themes that explain the distressing nature of delirium in palliative care: 1) experiences of relational tension; 2) challenges in recognizing the delirious person; and 3) struggles to interpret the meaning of delirious behaviors. By approaching end-of-life delirium from a perspective of relational ethics, attention is focused on the implications for the therapeutic relationship with patients and families when delirium becomes part of the dying trajectory.

End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase

CONTEXT

In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.

OBJECTIVES

To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review.

RESULTS

The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan.

CONCLUSION

Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.

The Incidence of Deathbed Communications and Their Impact on the Dying Process

The purpose of this study was to determine the incidence of deathbed communications (DBCs) during the 30 days before death and their impact on the dying process. A total of 60 hospice chart audits and 75 survey responses by hospice nurses across the United States were analyzed. Chart audits revealed 5 (8.33%) of the 60 included descriptions of DBCs. The survey of 75 hospice nurses identified 363 incidences of DBCs, with an average of 4.8 patient occurrences per nurse per 30 days. In all, 89% of the hospice nurses reported patients who experienced a DBC had a peaceful and calm death, with only 40.5% reporting a peaceful and calm death without the DBC. These DBCs have a positive impact on the dying process but are underreported in patient records and under described in textbooks.

Deathbed Phenomena: Its Role in Peaceful Death and Terminal Restlessness

Dying patients and their caregivers frequently experience that which is known as deathbed phenomena, that is, visions of past deceased relatives or friends, religious figures, and a visionary language pertaining to travel. Collective research supports mounting evidence that deathbed visions typically yield peaceful deaths. Yet within the literature, numerous hospice patients experience the symptoms of terminal restlessness and frequently succumb to anguished deaths. Why are some patients and caregivers guided by peaceful deathbed phenomena and others are not? Does a relationship exist between the lack of deathbed phenomena and the onset of terminal restlessness in dying patients? This clinical paper intends to answer these questions and might elucidate the factors that contribute to a dying patient’s death ending as either a peaceful event or the one affected by terminal restlessness. This knowledge gained could lessen the occurrence of anguished deaths and perhaps change our way of viewing dying.

Peaceful Surrender to Death Without Futile Bargaining to Live Relieves Terminal Air Hunger and Anguish

The case report emphasizes the management of ``terminal air hunger and anguish'' as a major challenge for the palliative care physicians. Truthful and compassionate terminal counseling of the patient and terminal sedation allowed us to control this distressing final phase of dying in the metastatic lung disease and enabled the patient to take her last breath peacefully.

Ethical issues and clinical expertise at the end of life

Oncology care has changed markedly in the past decade. With new therapies, patients are experienced in living with life-threatening illness and believe in the abilities of science and the health care system to find new therapies. Changes in the treatment paradigm have altered oncology nursing practice. The integration of newer targeted therapies with their specific side-effect profiles also has changed end-of-life care. Strategies used to manage patients during the active treatment phase of illness can inform and improve nursing practice when active care has been set aside. Evidence-based practice provides a guide to identify, critically appraise, and use evidence to solve clinical problems.