Palliative care versus hospice care
Candidates lose points confusing these terms. Palliative care is specialised care focused on relief of symptoms and stress for anyone with serious illness, at any stage, and it can be delivered alongside aggressive curative treatment — a client receiving chemotherapy can and should receive palliative support for nausea, pain and fatigue. Hospice is a specific model of palliative care for clients whose prognosis is generally six months or less if the illness runs its expected course, and it focuses entirely on comfort and quality of life rather than cure.
Hospice services are delivered wherever the client lives — home, care facility or inpatient hospice unit — and include an interdisciplinary team of nurses, physicians, social workers, chaplains, aides and trained volunteers, with bereavement support for the family for a period after death. Clients may leave hospice if their condition improves or if they choose to resume curative treatment; enrolment is not irreversible, and saying otherwise is a wrong answer.
Both models treat the family as part of the unit of care. Respite care for exhausted caregivers, anticipatory grief support and practical teaching about what to expect are legitimate nursing interventions the exam rewards.
| Feature | Palliative care | Hospice |
|---|---|---|
| Timing | Any stage of serious illness | Prognosis of about 6 months or less |
| Curative treatment | Continues alongside | Generally discontinued |
| Goal | Symptom relief and quality of life | Comfort and dignity at end of life |
| Setting | Hospital, clinic, home | Usually home or hospice facility |
| Family support | Included | Included, with bereavement follow-up |
Advance directives, DNR and ethical principles
An advance directive documents a competent adult's wishes in advance. A living will states which treatments the client does or does not want, and a durable power of attorney for health care names a proxy to decide if the client loses capacity. Nurses do not complete these documents for clients or influence their content; they provide information, ensure the documents are on the chart and honoured, and involve social work when needed. A competent client may change or revoke a directive at any time, verbally included.
A do-not-resuscitate order is a provider order reflecting the client's wishes about cardiopulmonary resuscitation. Its scope is narrow and specific: no CPR. Clients with a DNR still receive oxygen, pain and symptom management, hygiene, positioning, nutrition as tolerated, antibiotics if goals support them, and full nursing presence. Any answer implying that a DNR reduces care is wrong. When family disagrees with a documented wish, the nurse arranges a care conference; the client's expressed wishes, or those of the legally appointed proxy, prevail.
The ethical principles behind these items are worth naming. Autonomy supports the client's right to refuse treatment even when the team disagrees. Beneficence and non-maleficence support aggressive symptom relief. The principle of double effect explains why giving enough opioid to relieve severe pain or dyspnoea is ethical even if it may shorten life, because the intent is comfort. Fear of hastening death is not a reason to withhold analgesia, and a nurse who under-medicates a dying client in pain is not acting safely.
Symptom management in the final weeks
Pain is managed around the clock with long-acting medication plus breakthrough doses, not on an as-needed basis alone, and doses are titrated upward as tolerance and disease progression require. There is no ceiling dose for pure opioid agonists when titrated to effect. Constipation from opioids is anticipated with a bowel regimen from the outset, because it does not resolve with tolerance.
Dyspnoea is treated with low-dose opioids, a fan directed at the face, upright positioning, oxygen if it relieves distress, and calm reassurance. Excessive respiratory secretions producing the so-called death rattle are managed with repositioning to the side, reduced fluid intake and antimuscarinic medication; suctioning is generally avoided because it distresses the client without lasting benefit, and family teaching that the sound is not causing suffering is an important intervention.
Other common symptoms include nausea, anorexia, delirium, restlessness, dry mouth and skin breakdown. Anorexia and reduced intake near death are expected physiological changes rather than starvation, and pushing food or fluids can increase discomfort and aspiration risk. Frequent mouth care, ice chips, lip moisture and permission for the family to stop urging food are the therapeutic answers.
Signs of imminent death and care after death
As death approaches, circulation centralises and metabolism slows. Expected findings include cool, mottled extremities, decreased urine output, hypotension, weak and irregular pulse, Cheyne-Stokes or irregular respirations with periods of apnoea, decreased responsiveness, and noisy breathing from pooled secretions. Vision fades early and hearing is believed to persist longest, so the nurse encourages the family to continue speaking to the client and to avoid conversations at the bedside they would not want overheard.
Nursing care remains active: reposition gently for comfort, provide mouth and eye care, keep the client clean and dry, manage pain proactively, keep the environment calm and softly lit, and support the family's presence including cultural and religious practices. Ask rather than assume which rituals matter — practices around touching the body, who may be present, washing, direction of the body and timing of removal vary widely, and cultural humility is the tested attitude.
After death, care continues with dignity: verify time of death per policy, provide post-mortem care by removing tubes only when permitted, positioning the body naturally with the head elevated, cleaning and covering, and allowing the family time at the bedside. If the death is a coroner's case, lines and tubes stay in place. Organ donation discussions are handled by trained requestors from the procurement organisation, not by the bedside nurse acting alone.
Communication and how items are written
Therapeutic communication carries most end-of-life items. Correct answers reflect feelings, invite the client or family to say more, and tolerate silence: sitting with a crying spouse, asking a client what worries them most, acknowledging that this is hard. Wrong answers reassure falsely, change the subject, deflect to the provider unnecessarily or impose the nurse's values. When a client says they are dying, the nurse explores that statement rather than contradicting it.
Grief content also appears. Anticipatory grief happens before the loss, complicated grief is prolonged and disabling, and disenfranchised grief is loss that others do not acknowledge. Nurses normalise varied grief responses, avoid timelines, and refer when grief becomes prolonged, functionally disabling or accompanied by suicidal thinking.
In prioritisation items, an actively dying client in uncontrolled pain outranks routine tasks, because comfort is a physiological need. And in ethics-flavoured items, the answer that clarifies and honours the client's own stated wishes is nearly always correct.