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End-of-life care is a challenging and sensitive field that requires hospice nurses to be prepared for various crises that may arise in their patients. These crises can cause significant discomfort and distress for the patients and their caregivers and must be addressed promptly and effectively. In this article, I will share my insights as a hospice nurse with extensive experience in end-of-life care and discuss the top five crises I encounter in my practice and how I manage them.

Delirium

Delirium is a condition that affects the brain and makes it hard for the patient to think, remember things, or communicate with others. It can happen suddenly and last for a few hours or days, or it can come and go over time. Delirium is not a normal part of aging or dying, but it is common among people who are very sick or near the end of life. Some of the causes of delirium are infections, medications, dehydration, organ failure, or lack of oxygen. Sometimes, delirium can be prevented or treated by addressing these causes, but other times, it is irreversible and part of the dying process.

If your loved one is experiencing delirium, you may notice that they are confused, restless, agitated, or hallucinating. They may not recognize you or their surroundings or say things that do not make sense. This can be very distressing for you and them, but please know they are not doing this intentionally or trying to hurt you. They are suffering from a medical condition that affects their brain function.

As a caregiver, you can help your loved one by providing comfort, safety, and support. Here are some tips on how to do that:

Try to keep the environment calm and quiet. Avoid loud noises, bright lights, or too many people in the room. You can also play soft music, read to them, or hold their hand.
Speak to them in a gentle and reassuring tone. Use simple words and sentences, and repeat them if needed. Do not argue with them or correct them if they say something wrong. Instead, validate their feelings and emotions and redirect their attention to something positive or familiar.
Follow the doctor's orders on how to manage their symptoms. They may prescribe medications to help them relax or sleep, such as morphine or lorazepam. These drugs can also reduce pain and anxiety, which can worsen delirium. Please do not give them more or less than the prescribed dose, and monitor them for any side effects or changes in their condition.
Seek help from professionals if you feel overwhelmed or need a break. Caring for someone with delirium can be very challenging and exhausting, both physically and emotionally. You do not have to do this alone. You can contact your hospice team, palliative care team, or other support services for guidance and assistance. They can also provide you with more information and resources on how to cope with this situation.

Delirium is a challenging and complex phenomenon that affects both the patient and the caregiver. It is important to remember that it is not your fault or your loved one's fault and that you are doing the best you can. Following these tips can help your loved one feel more comfortable and peaceful.

Anxiety and Agitation

Anxiety and agitation are feelings of nervousness, worry, or uneasiness that can affect people who are very sick or dying. They may feel anxious or agitated because of physical pain, breathing problems, fear of death, guilt over past actions, or unfinished business. These feelings can make them restless, angry, or scared, making it hard for them to relax or sleep. Anxiety and agitation can also affect their loved ones and caregivers, who may feel helpless, frustrated, or sad.

As a nurse, I have some ways to help patients and their families cope with anxiety and agitation. One of the ways is to give them medications that can calm them down and ease their pain, such as benzodiazepines and opioids. These drugs can help them feel more comfortable and peaceful, but they can also have some side effects, such as drowsiness, confusion, or nausea. I follow the doctor's orders on how much and how often to give these medications and closely monitor the patient's response and condition.

Another way to help them is to create a soothing and supportive environment. I try to keep the room quiet and dim and avoid unnecessary noise or disturbance. I also play soft music, read to them, or hold their hand. I speak to them in a gentle and reassuring tone, and I listen to their concerns and wishes. I do not argue with them or correct them if they say something wrong. Instead, I validate their feelings and emotions and redirect their attention to something positive or familiar.

Sometimes, anxiety and agitation can be caused or worsened by some underlying issues that need to be addressed. These can be physical, emotional, or spiritual issues, such as discomfort, distress, or doubts. I try to identify and address these issues as much as possible by asking the patient questions, observing their behavior, or checking their vital signs. I also involve other care team members, such as social workers, chaplains, or counselors, who can provide more specialized support and guidance. They can help the patient and their family deal with any unresolved conflicts, regrets, fears, or questions that they may have.

Anxiety and agitation are common and normal reactions to a complex and stressful situation. They are not a sign of weakness or failure but a sign of human nature and emotion. By following these steps, I hope to help the patient and their family cope with these feelings and find some comfort and peace.

Nausea and Vomiting

Nausea and vomiting are unpleasant sensations that make the patient feel sick or want to throw up. They can happen to anyone, but they are more likely to happen to people who are very ill or dying. Some of the reasons why nausea and vomiting can occur are:

Medications: Some medications that are used to treat pain, anxiety, or other symptoms can have side effects that make the patient feel nauseous or vomit. These medications include opioids, benzodiazepines, antibiotics, steroids, or chemotherapy drugs.
Infections: Some infections that affect the stomach, intestines, or other organs can cause inflammation, irritation, or ulcers that can make the patient feel nauseous or vomit. These infections include gastritis, colitis, pancreatitis, or sepsis.
Bowel obstruction: Sometimes, the patient's bowels can become blocked or twisted, preventing the food or waste from moving through the digestive system. This can cause pressure, pain, bloating, or gas, making the patient feel nauseous or vomit. This can happen because of tumors, adhesions, hernias, or constipation.
Increased intracranial pressure: Sometimes, the pressure inside the patient's skull can increase, affecting the brain and the nerves that control the vomiting center. This can happen because of brain tumors, bleeding, swelling, or infection. It can also cause headaches, dizziness, vision problems, seizures, and nausea and vomiting.
Gastrointestinal bleed: Sometimes, the patient can bleed internally from the stomach, esophagus, or intestines, which can be a severe complication that can lead to shock or death. This can happen because of ulcers, varices, or erosion. This can cause the patient to vomit blood or something that looks like coffee grounds and to have black or tarry stools.
Electrolyte imbalance: Sometimes, the patient can lose or gain too many of certain minerals or salts in their body, affecting the balance of fluids and the function of muscles and nerves. This can happen because of dehydration, kidney failure, or medications. It can also cause muscle weakness, cramps, twitching, seizures, nausea, and vomiting.

Nausea and vomiting can make patients uncomfortable and unhappy, affecting their health and well-being. They can cause the patient to lose their appetite, weight, or fluids, making them weaker and more prone to infections or complications. They can also affect their mood, sleep, or quality of life, making them more depressed, anxious, or hopeless.

As a nurse, I have some ways to help the patient and their family cope with nausea and vomiting. One of the ways is to give them medications that can prevent or stop nausea and vomiting, such as antiemetics. These medications can block the signals that make the patient feel nauseous or vomit and can also help them relax or sleep. These medications include ondansetron, metoclopramide, or haloperidol, and they are available in the comfort pack/kit that I can bring to the patient's home. I follow the doctor's orders on how much and how often to give these medications and closely monitor the patient's response and condition.

Another way to help them is to avoid or reduce triggers that may cause or worsen nausea and vomiting, such as certain foods, smells, or movements. I try to find out what the patient likes or dislikes and what makes them feel better or worse. I also ask the patient's family to help me with this by keeping the patient's room clean and fresh, offering small and frequent meals or snacks, avoiding spicy, greasy, or strong-smelling foods, and encouraging the patient to drink fluids or suck on ice chips. I also suggest some non-medical remedies that may help, such as ginger, peppermint, or acupressure.

Sometimes, nausea and vomiting can be persistent or severe, and they may not respond to the usual treatments. In that case, I consult with the pharmacist or the doctor to see if there are any other options or alternatives that we can try, such as changing the dose, route, or type of medication or adding another medication or supplement. I also check the patient's hydration and electrolyte status and see if they need any fluids or supplements to correct any imbalances or deficiencies. I also report any signs of complications, such as bleeding, seizures, or shock, and seek urgent medical attention if needed.

Nausea and vomiting are challenging and distressing symptoms that affect the patient and the family. It is important to remember that they are not the patient's or the family's fault and are not a sign of giving up or losing hope. They are a sign of a medical condition that needs to be treated and managed. I hope to help the patient and the family cope with these symptoms and find relief and comfort by following these steps.

Uncontrolled Pain

Uncontrolled pain is a severe and unbearable pain that does not respond to the usual treatments or medications. It can happen to people who are very sick or dying, especially those who have cancer or other terminal illnesses. It can have different causes, such as:

Cancer progression: Sometimes, cancer can spread to other parts of the body, such as the bones, nerves, or organs, causing more pain and damage.
Tumor growth: Sometimes, the tumor can grow bigger or press on nearby tissues, such as the spinal cord, and cause more pain and pressure.
Unexpected events: Sometimes, the patient can experience a sudden or unforeseen event, such as a fracture, infection, or bleeding, that can cause more pain and inflammation.

Uncontrolled pain can make the patient suffer a lot and can also affect their vital signs and functions. It can cause the patient to have difficulty breathing, high blood pressure, or fast heart rate. It can also make the patient feel scared, angry, or hopeless, affecting their mood, sleep, or quality of life. Uncontrolled pain can also make the patient's family or facility panic and make them want to call 911 or take the patient to the hospital. However, this can lead to more problems, such as unwanted tests, procedures, or treatments, that can cause more harm than good.

As a nurse, I have some ways to help the patient and their family cope with uncontrolled pain. One of the ways is to assess the patient's pain and adjust the pain medication accordingly. I use a pain scale, such as the numeric rating scale or the faces pain scale, to ask the patient how much pain they feel, from 0 (no pain) to 10 (worst pain imaginable). I also ask the patient about the type, location, and frequency of their pain, such as whether it is sharp, dull, throbbing, or burning, where it is located, and how often it occurs. Based on this information, I change the dose, route, or type of pain medication that the patient is receiving, such as morphine, fentanyl, or hydromorphone. These medications are called opioids, and they are very effective in relieving pain, but they can also have some side effects, such as drowsiness, nausea, or constipation. I follow the doctor's orders on how much and how often to give these medications and closely monitor the patient's response and condition.

Another way to help them is to use non-pharmacological methods, such as massage, heat, cold, or distraction, to complement the pain medication. These methods can help the patient relax, reduce muscle tension, or divert their attention from the pain. For example, I can gently massage the patient's back, neck, or shoulders or apply a warm or cold pack to the painful area. I can also play soft music, read to them, or talk about something they enjoy or find interesting. These methods can also help patients feel more comfortable and cared for and improve their mood and well-being.

Sometimes, uncontrolled pain can be challenging to treat or manage, and it may not improve with the usual methods. In that case, I consult with the pharmacist or the doctor to see if there are any other options or alternatives that we can try, such as adding another medication or supplement or using a different technique or device. For example, we can add an anti-inflammatory, an antidepressant, or a steroid to enhance the effect of the opioid, or we can use a nerve block, a spinal cord stimulator, or a pump to deliver the medication directly to the source of the pain. These options can be more effective or suitable for some patients but can have risks or complications, such as infection, bleeding, or malfunction. I always explain the benefits and drawbacks of these options to the patient and their family and obtain their consent before proceeding.

Uncontrolled pain is a rare and severe crisis affecting the patient and the family. It is important to remember that it is not the patient's or the family's fault, nor is it a sign of giving up or losing hope. It is a sign of a medical condition that needs to be treated and managed. Following these steps, I hope to help the patient and the family cope with this crisis and find relief and comfort.

Respiratory Distress (Air Hunger)

Respiratory distress, or air hunger, is a feeling of not getting enough air or oxygen that can make the patient feel uncomfortable and scared. It can happen to people who are very sick or dying, especially those who have problems with their lungs or heart. It can have different causes, such as:

Lung disease: Some diseases that affect the lungs, such as chronic obstructive pulmonary disease (COPD), pneumonia, or cancer, can make it hard for the patient to breathe because they damage the airways or the lung tissue or fill the lungs with fluid or mucus.
Heart failure: Some conditions that affect the heart, such as coronary artery disease, heart attack, or arrhythmia, can make it hard for the patient to breathe because they reduce the blood flow or the pumping function of the heart or cause the heart to beat too fast or too slow.
Fluid overload: Sometimes, the patient can have too much fluid in their body, making it hard for them to breathe because it puts pressure on their lungs or chest or causes swelling in their legs or abdomen. This can happen because of kidney failure, liver failure, or medications.
Anxiety: Sometimes, the patient can feel anxious or nervous, which can make it hard for them to breathe because it causes them to hyperventilate, breathe too fast or too shallow, or tense up their muscles or their throat.

Respiratory distress can make the patient feel very distressed and fearful and can also affect their vital signs and functions. It can cause the patient to have low oxygen levels, high carbon dioxide levels, or low blood pressure, affecting their brain and other organs. It can also make the patient feel restless, agitated, or confused, affecting their mood, sleep, or quality of life. Respiratory distress can also make the patient's family or caregivers worry and make them want to do something to help the patient or ease their suffering.

As a nurse, I have ways to help patients and their families cope with respiratory distress. One of the ways is to give them medications that can improve their breathing and reduce their distress, such as oxygen therapy, bronchodilators, opioids, and anxiolytics. These medications can help the patient by:

Oxygen therapy: This treatment provides extra oxygen to the patient through a mask, a nasal cannula, or a tube. It can help the patient breathe more easily and increase their oxygen levels, but it can also have some side effects, such as dryness, irritation, or infection. I follow the doctor's orders on how much and how often to give oxygen therapy and closely monitor the patient's oxygen saturation and condition.
Bronchodilators: These medications relax the muscles around the airways and make them wider, which can help the patient breathe more easily and reduce wheezing or coughing. They can be given as inhalers, nebulizers, or pills, including albuterol, ipratropium, or theophylline. They can also have side effects like jitteriness, palpitations, or nausea. I follow the doctor's orders on how much and how often to give bronchodilators and closely monitor the patient's response and condition.
Opioids: These are medications that relieve pain and anxiety and also reduce the sensation of air hunger by acting on the brain and the nerves that control the breathing center. They can be given as injections, patches, or liquids, and they include morphine, fentanyl, or hydromorphone. They can also have some side effects, such as drowsiness, constipation, or respiratory depression. I always follow the doctor's orders on how much and how often to give opioids, and I monitor the patient's response and condition closely.
Anxiolytics: These medications relieve anxiety and nervousness and reduce the sensation of air hunger by acting on the brain and the nerves that control the emotions and the stress response. They can be given as injections, pills, or liquids, and they include lorazepam, diazepam, or midazolam. They can also have side effects like drowsiness, confusion, or dependence. I follow the doctor's orders on how much and how often to give anxiolytics and closely monitor the patient's response and condition.

Another way to help them is to provide comfort measures to ease their breathing and reduce their distress, such as elevating their head and using a fan or a cool cloth. These measures can help the patient by:

Elevating their head: This position raises the patient's head and chest above their heart and abdomen, which can help them breathe more easily and reduce pressure on their lungs or chest. It can be done by using pillows, wedges, or adjustable beds, and it can also help the patient feel more comfortable and relaxed.
Using a fan or a cool cloth: This technique provides a sensation of airflow or coolness to the patient's face or neck, which can help them breathe more efficiently and reduce the feeling of air hunger. It can be done by using a fan, a blow dryer, or a cool cloth, and it can also help the patient feel more refreshed and calm.

Sometimes, respiratory distress can be very hard to treat or manage, and it may not improve with the usual treatments or measures. In that case, I communicate with the patient's family and other care team members, such as the doctor, triage nurse, or hospice aide, to ensure a coordinated and timely response to the respiratory distress. I also reassure the patient and their family and explain that respiratory distress is a common and expected symptom at the end of life and that it does not mean that the patient is suffocating or suffering. I also educate them about the signs of impending death, such as Cheyne-Stokes breathing, mottling, or cyanosis, and the importance of providing comfort care and emotional support to the patient.

Respiratory distress is a challenging and frightening symptom that can affect both the patient and the family. It is important to remember that it is not the patient's or the family's fault nor a sign of giving up or losing hope. It is a sign of a medical condition that needs to be treated and managed. I hope to help the patient and the family cope with this symptom by following these steps and finding relief and comfort.

Conclusion

Crisis management at end-of-life is a vital skill that hospice nurses must master as they encounter various crises affecting their patients' comfort and dignity. As we have seen in this article, these crises include delirium, anxiety and agitation, nausea and vomiting, uncontrolled pain, and respiratory distress. To manage these crises, hospice nurses must act quickly and effectively, using pharmacological and non-pharmacological interventions, communication, and collaboration with the patient's family and other care team members. By doing so, hospice nurses can provide their patients with the best possible care and support and help them achieve a peaceful and dignified death. This is not only a professional duty but also a moral obligation, as hospice nurses are entrusted with the responsibility and the privilege of caring for people in their most vulnerable and sacred moments of life. Therefore, hospice nurses must be well-trained, well-equipped, and well-supported to handle these crises with competence and compassion. It is also essential that the patient's family and other care team members are well-informed, well-prepared, and well-involved in the crisis management process, as they play a crucial role in providing comfort and support to the patient and each other. Together, we can make a difference in the lives of those who are facing the end of life and help them die with dignity and grace.