Recommendation 1.1

Nurses identify individuals who are in the last days and hours of life.

Recommendation 1.1.1

Use clinical expertise, disease-specific indicators and validated tools to identify these individuals.

Recommendation 1.1.2

Understand the end-of-life trajectories.

Recommendation 1.2

Nurses understand common signs and symptoms present during the last days and hours of life.

Recommendation 1.2.1

Common signs of imminent death, may include, but are not limited to:

• progressive weakness
• bedbound state
• sleeping much of the time
• decreased intake of food and fluid
• darkened and/or decreased urine output
• difficulty swallowing (dysphagia)
• delirium not related to reversible causes
• decreased level of consciousness not related to other causes
• noisy respiration/excessive respiratory tract secretion
• change in breathing pattern (Cheyne-Stokes respiration, period of apnea)
• mottling and cooling extremities

Recommendation 1.3

Nurses complete a comprehensive, holistic assessment of individuals and their families based on the Canadian Hospice Palliative Care Association Domains of Care, which include the following:

• disease management
• physical
• psychological
• spiritual
• social
• practical
• end-of-life care/death management
• loss, grief

Recommendation 1.3.1

Include information from multiple sources to complete an assessment. These may include proxy sources, such as the family and other health-care providers.

Recommendation 1.3.2

Use evidence-informed and validated symptom assessment and screening tools when available and relevant.

Recommendation 1.3.3

Reassess individuals and families on a regular basis to identify outcomes of care and changes in care needs.

Recommendation 1.3.4

Communicate assessments to the interprofessional team.

Recommendation 1.3.5

Document assessments and outcomes.

Recommendation 1.4

Nurses:

• reflect on and are aware of their own attitudes and feelings about death;
• assess individuals’ preferences for information
• understand and apply the basic principles of communication in end-of-life care
• communicate assessment findings to individuals (if possible and desired) and the family on an ongoing basis
• educate the family about the signs and symptoms of the last days and hours of life
• with attention to their: faith and spiritual practices, age-specific needs, developmental needs, cultural needs
• evaluate the family’s comprehension of what is occurring during this phase

Recommendation 2.1

Nurses recognize and respond to factors that influence individuals’ and their families’ involvement in decision-making.

Recommendation 2.2

Nurses support individuals and families to make informed decisions that are consistent with their beliefs, values and preferences in the last days and hours of life.

Recommendation 3.1

Nurses are knowledgeable about pain and symptom management interventions to enable individualized care planning.

Recommendation 3.2

Nurses advocate for and implement individualized pharmacologic and non-pharmacologic care strategies.

Recommendation 3.3

Nurses educate and share information with individuals and their families regarding:

• reconciliation of medications to meet the individual’s current needs and goals of care
• route and administration of medications
• potential symptoms
• physical signs of impending death
• vigil practices
• self-care strategies
• identification of a contact plan for family when death has occurred
• care of the body after death

Recommendation 3.4

Nurses use effective communication to facilitate end of life discussions related to:

• cultural and spiritual values, beliefs and practices
• emotions and fears
• past experiences with death and loss
• clarifying goals of care
• family preference related to direct care involvement
• practical needs
• informational needs
• supportive care needs
• loss and grief
• bereavement planning