Palliative Care at the Very End of Life - Dartmouth-Hitchcock
Palliative Care at the Very End of Life - Dartmouth-Hitchcock Palliative Care at the Very End of Life - Dartmouth-Hitchcock
Palliative Care at the Very End of Life Brenda Jordan, MS, ARNP, BC-PCM BC PCM Nurse Practitioner Dartmouth-Hitchcock Dartmouth Hitchcock•Kendal Kendal Hanover, NH
- Page 2 and 3: Why Plan End of Life Care “How Ho
- Page 4 and 5: Objectives... Objectives... Descri
- Page 6 and 7: Who Needs to be Prepared Family F
- Page 8 and 9: Site of Death No “place place”
- Page 10 and 11: Preparation for Death What Type of
- Page 12 and 13: Institute of Medicine 1997 “Good
- Page 14 and 15: Study tudy to Understand nderstand
- Page 16 and 17: Improving Care in the Last 48hours
- Page 18 and 19: Common symptoms that occur at the v
- Page 20 and 21: Barriers to Recognize the Dying De
- Page 22 and 23: Physiologic Changes During the Dyin
- Page 24 and 25: Decreasing Appetite/Food Fears Re
- Page 26 and 27: Benefits and Burdens Unproven Benef
- Page 28 and 29: Benefits and Burdens Burdens of Ar
- Page 30 and 31: Alternatives to Artificial Feeding/
- Page 32 and 33: Decreasing Fluid Intake…. Intake
- Page 34 and 35: Decreasing Blood Perfusion Tachyca
- Page 36 and 37: Communication with the Unconscious
- Page 38 and 39: Preparation for Death Consider how
- Page 40 and 41: Changes in Respiration… Respirati
- Page 42 and 43: Loss of Sphincter Control Incontin
- Page 44 and 45: Medications Limit essential medica
- Page 46 and 47: As Expected Death Approaches Reinf
- Page 48 and 49: Emotional Symptoms anxiety/fear d
- Page 50 and 51: Comfort Measures Only (CMO) DNR Rev
<strong>Palli<strong>at</strong>ive</strong> <strong>Care</strong> <strong>at</strong> <strong>the</strong><br />
<strong>Very</strong> <strong>End</strong> <strong>of</strong> <strong>Life</strong><br />
Brenda Jordan, MS, ARNP, BC-PCM BC PCM<br />
Nurse Practitioner<br />
<strong>Dartmouth</strong>-<strong>Hitchcock</strong><br />
<strong>Dartmouth</strong> <strong>Hitchcock</strong>•Kendal Kendal<br />
Hanover, NH
Why Plan <strong>End</strong> <strong>of</strong> <strong>Life</strong> <strong>Care</strong><br />
“How How people die<br />
remains in <strong>the</strong><br />
memories <strong>of</strong><br />
those who live<br />
on”. on .<br />
Cicely Saunders
Like every birth, every de<strong>at</strong>h is unique<br />
Preparing for de<strong>at</strong>h is like<br />
preparing for birth<br />
Unexpected events<br />
Timing uncertain<br />
Wh<strong>at</strong> will be needed<br />
Wh<strong>at</strong> can we do to make it<br />
a “good good” experience for<br />
p<strong>at</strong>ient, family and<br />
ourselves
Objectives...<br />
Objectives...<br />
Describe <strong>the</strong> possibilities during <strong>the</strong> last<br />
hours <strong>of</strong> life for any dying p<strong>at</strong>ient.<br />
Describe assessments (physical,<br />
psychological, social, cultural, and spiritual)<br />
and interventions to improve care for<br />
imminently dying p<strong>at</strong>ients and <strong>the</strong>ir families. families.
...Objectives<br />
... Objectives<br />
Describe p<strong>at</strong>ient and family care <strong>at</strong> time<br />
<strong>of</strong> de<strong>at</strong>h and immedi<strong>at</strong>ely following<br />
de<strong>at</strong>h.
Who Needs to be Prepared<br />
Family<br />
Friends<br />
Health <strong>Care</strong><br />
Personnel
Where do people die<br />
Hospital-50%<br />
Hospital 50%<br />
Nursing Home-25%<br />
Home 25%<br />
Hospice in nursing homes<br />
improves care <strong>of</strong> all<br />
residents<br />
Home->25%?<br />
Home >25%?<br />
With hospice support-50%<br />
support 50%<br />
Cancer p<strong>at</strong>ients<br />
Without hospice support
Site <strong>of</strong> De<strong>at</strong>h<br />
No “place place” is best or worst to die<br />
Need to establish m<strong>at</strong>ch between pt/family<br />
preferences and needs in order to have a<br />
“good good de<strong>at</strong>h”<br />
de<strong>at</strong>h
Dementias<br />
Pneumonia<br />
Urosepsis<br />
<strong>End</strong> stage dementia<br />
Common Causes<br />
<strong>of</strong> De<strong>at</strong>h in Elders<br />
<strong>End</strong> Stage Heart Disease<br />
<strong>End</strong> Stage Respir<strong>at</strong>ory Disease<br />
Cancers<br />
<strong>End</strong> Stage Renal Disease<br />
Failure to Thrive<br />
Dehydr<strong>at</strong>ion<br />
Malnutrition
Prepar<strong>at</strong>ion for De<strong>at</strong>h<br />
Wh<strong>at</strong> Type <strong>of</strong> De<strong>at</strong>h<br />
Expected- Expected Most de<strong>at</strong>hs<br />
Requests for assisted de<strong>at</strong>h<br />
Prolonged “dying dying” phase<br />
“Unexpected<br />
Unexpected” – minority <strong>of</strong> de<strong>at</strong>hs<br />
Happen quickly<br />
Usually unexpected complic<strong>at</strong>ions<br />
Completely unrel<strong>at</strong>ed event<br />
Suicide
Wh<strong>at</strong> Is “Good Good De<strong>at</strong>h” De<strong>at</strong>h<br />
Definitions<br />
–Institute Institute Of Medicine<br />
(1997)<br />
–Steinhauser<br />
Steinhauser et al.<br />
(2000)
Institute <strong>of</strong> Medicine 1997<br />
“Good Good De<strong>at</strong>h” De<strong>at</strong>h<br />
“… people should be able to expect and<br />
achieve a decent or good de<strong>at</strong>h—one de<strong>at</strong>h one th<strong>at</strong><br />
is free from avoidable distress and<br />
suffering for p<strong>at</strong>ients, families, and<br />
caregivers: in general accord with p<strong>at</strong>ients’ p<strong>at</strong>ients<br />
and families’ families wishes; and reasonably<br />
consistent with clinical, cultural, and<br />
ethical standards.”p. standards. . 4.
Steinhauser et al. 2000<br />
“…pain “…pain<br />
and<br />
symptom control,<br />
clear decision-<br />
making, prepar<strong>at</strong>ion,<br />
completion, giving to<br />
o<strong>the</strong>rs, and<br />
affirm<strong>at</strong>ion <strong>of</strong> <strong>the</strong><br />
whole person”<br />
person
Study tudy to Understand nderstand Prognoses rognoses and<br />
Preferences references for Outcomes utcomes and Risks isks <strong>of</strong><br />
Tre<strong>at</strong>ment re<strong>at</strong>ment (SUPPORT)<br />
Based on interviews with 3357 survivors<br />
5 academic medical centers<br />
40% <strong>of</strong> p<strong>at</strong>ients died in severe pain<br />
55% were conscious<br />
63% had difficulty toler<strong>at</strong>ing symptoms
Symptom Frequency in Last 48 Hours<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Pain Anxiety Confusion Dyspnea Nausea<br />
GW<br />
<strong>Dartmouth</strong><br />
SUPPORT
Improving <strong>Care</strong> in <strong>the</strong> Last 48hours<br />
Carrying Out Advanced<br />
Directives<br />
Living Will<br />
DPOA-HC DPOA HC
Clinical Assessments and<br />
Interventions Needed<br />
Physiologic Changes<br />
Emotional<br />
Social<br />
Spiritual
Common symptoms th<strong>at</strong> occur <strong>at</strong><br />
<strong>the</strong> very end <strong>of</strong> life<br />
Pain / Discomfort<br />
Anxiety/Fear<br />
Dyspnea / Respir<strong>at</strong>ory distress<br />
Restlessness / Muscle spasms<br />
Excessive secretions /Pulmonary edema<br />
Moaning / Agonal respir<strong>at</strong>ions<br />
Confusion/Delirium<br />
Nausea / Vomiting
(Blues & Zerwekh, 1984)<br />
From Wilkie, 2002<br />
Signs <strong>of</strong> Approaching De<strong>at</strong>h:<br />
6. Bubbling sounds in<br />
thro<strong>at</strong> and chest<br />
(de<strong>at</strong>h r<strong>at</strong>tle)<br />
5. Laborious<br />
bre<strong>at</strong>hing;periods <strong>of</strong><br />
apnea; Cheyne-Stokes<br />
bre<strong>at</strong>hing<br />
The Last 48 Hours<br />
1. Reduced level <strong>of</strong> consciousness<br />
2. Taking no fluids or only sips<br />
3. No urine output or small<br />
amount <strong>of</strong> very dark urine<br />
(anuria or oliguria)<br />
4. Progressing coldness<br />
and purple discolor<strong>at</strong>ion in<br />
legs and arms
Barriers to Recognize <strong>the</strong> Dying<br />
Denial-hope Denial hope it gets better<br />
No definitive diagnosis<br />
Failure to recognize key<br />
symptoms<br />
Lack <strong>of</strong> knowledge <strong>of</strong><br />
de<strong>at</strong>h trajectory<br />
Pursuing futile<br />
interventions<br />
Process<br />
Poor communic<strong>at</strong>ion<br />
skills<br />
Ethical/Legal Concerns<br />
about withholding or with<br />
drawing tre<strong>at</strong>ment<br />
<strong>of</strong> hastening de<strong>at</strong>h<br />
about CPR<br />
Legal issues<br />
Cultural/spiritual practices
Overcoming Barriers<br />
Recognize key sign and symptoms<br />
Skilled communic<strong>at</strong>ion <strong>of</strong> prognosis<br />
Team approach within your facility<br />
Know ethical & legal principles supporting care<br />
Appreci<strong>at</strong>e cultural and religious traditions
Physiologic Changes During <strong>the</strong><br />
Dying Process<br />
Increasing weakness, f<strong>at</strong>igue<br />
Decreasing appetite/fluid intake<br />
Decreasing blood perfusion<br />
Neurological dysfunction<br />
Pain<br />
Loss <strong>of</strong> ability to close eyes
Weakness/F<strong>at</strong>igue<br />
Decreased ability to move<br />
Joint position f<strong>at</strong>igue<br />
Increased risk <strong>of</strong> pressure ulcers<br />
Increased need for care<br />
ADLs<br />
Turning, movement, massage
Decreasing Appetite/Food<br />
Fears<br />
Reminders<br />
Intake, Wasting<br />
Food may be nause<strong>at</strong>ing<br />
Anorexia may be protective<br />
Risk <strong>of</strong> aspir<strong>at</strong>ion<br />
Clenched teeth express desires, control<br />
Pulling out NG or G-tube G tube<br />
Help family find altern<strong>at</strong>ive ways to care
Benefits and Burdens <strong>of</strong><br />
Artificial Nutrition/Hydr<strong>at</strong>ion<br />
Benefits <strong>of</strong> Artificial Nutrition/Hydr<strong>at</strong>ion<br />
Prolongs life if time is needed<br />
May improve or forestall delirium<br />
Maintains appearance <strong>of</strong> life giving sustenance<br />
Maintains hope for future clinical improvement<br />
Removal/avoidance <strong>of</strong> guilt by family members<br />
Weissman, D.E. , Biern<strong>at</strong>, K. & Rehm, J. (2003)
Benefits and Burdens<br />
Unproven Benefits <strong>of</strong> Artificial<br />
Hydr<strong>at</strong>ion<br />
Unproven<br />
Improves quality <strong>of</strong> life<br />
Improves survival across a popul<strong>at</strong>ion<br />
<strong>of</strong> dying p<strong>at</strong>ients<br />
Improves symptom <strong>of</strong> thirst<br />
Weissman, D. E., Biern<strong>at</strong>, K., & Rehm, J. (2003)
Unproven Benefits <strong>of</strong> Artificial<br />
Feeding<br />
Unproven<br />
Benefits and Burdens<br />
Reduction in aspir<strong>at</strong>ion pneumonia<br />
Reduction in p<strong>at</strong>ient suffering<br />
Reduction in infections or skin<br />
breakdown<br />
Improves survival dur<strong>at</strong>ion (in a<br />
popul<strong>at</strong>ion <strong>of</strong> similar p<strong>at</strong>ients)<br />
Weissman, D.E., Biern<strong>at</strong>, K., & Rehm, J. (2003)
Benefits and Burdens<br />
Burdens <strong>of</strong> Artificial Hydr<strong>at</strong>ion<br />
Maintaining parenteral access<br />
Increased secretions, ascites, effusions,<br />
edema<br />
Fuss factor: site care, IV bag changes<br />
Weissman, D.E., Biern<strong>at</strong>, K., & Rehm, J. (2003)
Benefits and Burdens<br />
Burdens <strong>of</strong> Artificial Feeding *<br />
Risk <strong>of</strong> aspir<strong>at</strong>ion pneumonia is <strong>the</strong> same or<br />
gre<strong>at</strong>er than without non-oral non oral feeding<br />
Increased need to use restraints<br />
Wound infections, abdominal pain and tube-<br />
rel<strong>at</strong>ed discomfort<br />
O<strong>the</strong>r tube problems<br />
Cost; Indignity<br />
* Much <strong>of</strong> this d<strong>at</strong>a comes from use <strong>of</strong> tube feeding in advanced dementia<br />
(see next slide)<br />
Weissman, D.E., Biern<strong>at</strong>, K., & Rehm, J. (2003)
Altern<strong>at</strong>ives to Artificial<br />
Feeding/Hydr<strong>at</strong>ion<br />
Allowing p<strong>at</strong>ient to e<strong>at</strong>/drink ad lib, even if<br />
aspir<strong>at</strong>ion risk is present<br />
No oral or non-oral non oral nutrtion/fluids<br />
nutrtion/fluids<br />
expect<strong>at</strong>ion th<strong>at</strong> de<strong>at</strong>h will result in 14 days<br />
Aggressive comfort measures will always<br />
provided
Summary <strong>of</strong> Benefits/Burdens<br />
Few medical benefits<br />
Substantial morbidity for p<strong>at</strong>ient<br />
But maybe positive psychological<br />
benefit for family
Decreasing Fluid Intake…. Intake<br />
Fears: dehydr<strong>at</strong>ion, thirst<br />
Remind family and caregivers<br />
Dehydr<strong>at</strong>ion does not cause distress<br />
Dehydr<strong>at</strong>ion may be protective
…Decreasing Decreasing Fluid Intake<br />
Frequent mouth care<br />
Swabs, artificial saliva<br />
Eye care<br />
Saline drops<br />
Skin care<br />
Frequent massage with lotions
Decreasing Blood Perfusion<br />
Tachycardia, hypotension<br />
Peripheral cooling, cyanosis<br />
Mottling <strong>of</strong> skin<br />
Diminished urine output<br />
Parenteral fluids will not reverse
Neurologic dysfunction<br />
Decreasing level <strong>of</strong> consciousness<br />
Communic<strong>at</strong>ion with <strong>the</strong> unconscious<br />
p<strong>at</strong>ient<br />
Change in respir<strong>at</strong>ion<br />
Loss <strong>of</strong> ability to swallow, sphincter control<br />
Terminal delirium
Communic<strong>at</strong>ion with <strong>the</strong><br />
Unconscious P<strong>at</strong>ient<br />
Distressing to <strong>the</strong> family<br />
Awareness>ability to respond<br />
Assume p<strong>at</strong>ient hears everything
…Communic<strong>at</strong>ion Communic<strong>at</strong>ion with <strong>the</strong><br />
Unconscious P<strong>at</strong>ient<br />
Cre<strong>at</strong>e familiar environment<br />
Include in convers<strong>at</strong>ion<br />
Assure presence and safety<br />
Give permission to die<br />
touch
Prepar<strong>at</strong>ion for De<strong>at</strong>h<br />
Consider how well your system<br />
deals with tre<strong>at</strong>ments <strong>of</strong> “last last<br />
resort” resort<br />
Voluntary stopping <strong>of</strong> e<strong>at</strong>ing and<br />
drinking<br />
Withdrawal <strong>of</strong> life support<br />
Requests for assisted suicide<br />
High dose pain management<br />
<strong>Palli<strong>at</strong>ive</strong> sed<strong>at</strong>ion
<strong>Palli<strong>at</strong>ive</strong> <strong>Care</strong> Interventions: Sed<strong>at</strong>ion<br />
•Use sed<strong>at</strong>ion for control <strong>of</strong> refractory symptoms in p<strong>at</strong>ients<br />
who are dying<br />
•There is no evidence th<strong>at</strong> sed<strong>at</strong>ion hastens de<strong>at</strong>h (Morita et<br />
al.2001)<br />
•Effective sed<strong>at</strong>ion can be achieved through <strong>the</strong> skilled,<br />
judicious use <strong>of</strong> a variety <strong>of</strong> medic<strong>at</strong>ions including<br />
–Opioids – Barbitur<strong>at</strong>es – O<strong>the</strong>r<br />
–Benzodiazepines – Thiopental<br />
NCCN<br />
Practice Guidelines<br />
in Oncology - v.1.2001
Changes in Respir<strong>at</strong>ion…<br />
Respir<strong>at</strong>ion<br />
Altered bre<strong>at</strong>hing p<strong>at</strong>terns<br />
Diminished tidal volume<br />
Apnea<br />
Cheyne-Stokes Cheyne Stokes respir<strong>at</strong>ions<br />
Accessory muscle use<br />
Last reflex bre<strong>at</strong>hs
Fears<br />
…Changes Changes in Respir<strong>at</strong>ion<br />
Suffoc<strong>at</strong>ion<br />
Management<br />
OPIOIDS!!! (Cochrane review-evidence review evidence strong)<br />
Evalu<strong>at</strong>e use <strong>of</strong> fans or fresh air<br />
Position<br />
Provide O 2 via nasal cannula<br />
Tre<strong>at</strong> anxiety from bre<strong>at</strong>hlessness<br />
Tre<strong>at</strong> “de<strong>at</strong>h de<strong>at</strong>h r<strong>at</strong>tle” r<strong>at</strong>tle as appropri<strong>at</strong>e-Positioning,<br />
appropri<strong>at</strong>e Positioning,<br />
anticholinergics, anticholinergics,<br />
do not deep suction-suction suction suction only<br />
oral secretions if helpful
Loss <strong>of</strong> Sphincter Control<br />
Incontinence <strong>of</strong> Urine<br />
Family needs knowledge and support<br />
Cleaning, skin care<br />
Urinary c<strong>at</strong>heters<br />
Absorbent pads, surfaces
Pain<br />
Fear <strong>of</strong> increased pain<br />
Assessment <strong>of</strong> <strong>the</strong> unconscious p<strong>at</strong>ient<br />
Persistent vs fleeting expression<br />
Grimace or physiologic signs<br />
Incident vs rest pain<br />
Distinction from terminal delirium
Medic<strong>at</strong>ions<br />
Limit essential medic<strong>at</strong>ions<br />
Choose less invasive route <strong>of</strong><br />
administr<strong>at</strong>ion<br />
Buccal mucosal oral first, <strong>the</strong>n consider rectal<br />
Subcutaneous, intravenous<br />
Intramuscular almost never
As Expected De<strong>at</strong>h Approaches<br />
Discuss<br />
st<strong>at</strong>us <strong>of</strong> p<strong>at</strong>ient and realistic care goals<br />
Role <strong>of</strong> all team members<br />
Wh<strong>at</strong> <strong>the</strong> p<strong>at</strong>ient experiences, wh<strong>at</strong><br />
onlookers see
As Expected De<strong>at</strong>h Approaches<br />
Reinforce signs events <strong>of</strong> dying process<br />
Person, cultural, religious, rituals, funeral<br />
planning<br />
Family support throughout <strong>the</strong> process
• Discontinue diagnostic tests<br />
• Discontinue vital sign assessment<br />
• Avoid unnecessary needle sticks<br />
• Allow p<strong>at</strong>ient and family uninterrupted time toge<strong>the</strong>r<br />
• Ensure th<strong>at</strong> family understands wh<strong>at</strong> to expect<br />
• Ensure th<strong>at</strong> caretakers understand and will honor<br />
advance directives<br />
NCCN<br />
Final Days to Hours<br />
Practice Guidelines<br />
in Oncology - v.1.2001
Emotional Symptoms<br />
anxiety/fear<br />
depression
Social Concerns<br />
P<strong>at</strong>ient<br />
Preference<br />
family vigil<br />
friends<br />
alone
Comfort Measures Only<br />
(CMO)<br />
DNR<br />
Review all diagnostics and<br />
tre<strong>at</strong>ments for contribution to<br />
comfort<br />
Addresses Hunger & Thirst<br />
Standardized Nursing <strong>Care</strong><br />
Symptom Management<br />
Medic<strong>at</strong>ions Ordered – PRN or<br />
Scheduled/Continuous
Spiritual <strong>Care</strong><br />
Unfinished business<br />
Sacraments and o<strong>the</strong>r<br />
rituals<br />
Peaceful<br />
Awareness <strong>of</strong> De<strong>at</strong>h
From Wilkie, 2002<br />
Uncommon Uncontrollable<br />
Events Prior to De<strong>at</strong>h<br />
Uncontrollable pain (when <strong>the</strong><br />
pain was controlled prior to de<strong>at</strong>h)<br />
F<strong>at</strong>al Hemorrhage<br />
Seizures<br />
Human Senses: Pain<br />
F<strong>at</strong>al Seizure
Signs <strong>of</strong> De<strong>at</strong>h<br />
• Cess<strong>at</strong>ion <strong>of</strong> heart be<strong>at</strong> and respir<strong>at</strong>ion<br />
• Pupils fixed and dil<strong>at</strong>ed<br />
• No response to stimuli<br />
• Eyelids open without blinking<br />
• Decreasing body temper<strong>at</strong>ure<br />
• Jaw relaxed and slightly open<br />
• Body color is a waxen pallor<br />
(From Wilkie 2002)
After De<strong>at</strong>h <strong>Care</strong>: <strong>Care</strong>:<br />
Various<br />
Cultural & Religious Groups<br />
Cultural and religious beliefs and practices<br />
are important to nursing care <strong>at</strong> <strong>the</strong> end-<strong>of</strong> end <strong>of</strong>-<br />
life and immedi<strong>at</strong>ely after de<strong>at</strong>h<br />
(From Wilkie 2002)
PRONOUNCEMENT OF<br />
DEATH<br />
When you are called to pronounce a p<strong>at</strong>ient:<br />
•Recognize Recognize <strong>the</strong> extreme emotional significance<br />
<strong>of</strong> <strong>the</strong> actual pronouncement <strong>of</strong> de<strong>at</strong>h to family<br />
members in room.<br />
•Establish Establish eye contact with family members(s)<br />
present.<br />
•Introduce Introduce self to family.
PRONOUNCEMENT OF<br />
DEATH<br />
• Examine p<strong>at</strong>ient for absence <strong>of</strong> bre<strong>at</strong>h sounds and heart<br />
sounds.<br />
Note time <strong>of</strong> de<strong>at</strong>h.<br />
After confirm<strong>at</strong>ion <strong>of</strong> de<strong>at</strong>h, acknowledge p<strong>at</strong>ients de<strong>at</strong>h to<br />
family if <strong>the</strong>y are present and express<br />
condolences in a way th<strong>at</strong> is comfortable for you.<br />
Determine legal next-<strong>of</strong> next <strong>of</strong>-kin kin if family is not present<br />
Ask legal next-<strong>of</strong> next <strong>of</strong>-kin kin about autopsy, organ/body don<strong>at</strong>ion,<br />
funeral home name (family can call it in l<strong>at</strong>er).
Pronouncing De<strong>at</strong>h and<br />
Beyond<br />
Know and carry out<br />
cultural/religious rituals<br />
Know regul<strong>at</strong>ions (eg ( eg<br />
who can complete de<strong>at</strong>h<br />
certific<strong>at</strong>e, etc.)<br />
Know funeral home<br />
Provide resources for<br />
family bereavement<br />
support
Summary<br />
Each de<strong>at</strong>h is unique experience and we are<br />
privileged to <strong>at</strong>tend to dying p<strong>at</strong>ients<br />
The memory <strong>of</strong> <strong>the</strong> dying experience (good and<br />
bad) remains with survivors.<br />
The quality <strong>of</strong> <strong>the</strong> hours and days prior to de<strong>at</strong>h<br />
can be influenced by early palli<strong>at</strong>ive care planning<br />
with p<strong>at</strong>ient & family, and staff and system<br />
prepar<strong>at</strong>ions.<br />
P<strong>at</strong>hways and standards may influence and<br />
improve quality <strong>of</strong> dying.