LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your knowledge of end-of-life care. Specific learning objectives to address potential learning gaps include:

• Discuss the need for end-of-life care in the United States.
• Differentiate between palliative care and hospice care.
• Explain legal and ethical principles in end-of-life care.
• Discuss the essential elements of effective communication with patient and family.
• List pain management interventions for the dying patient.
• Identify the psychosocial and support needs of the patient and family.
• Describe the end-of-life care needs of special populations.
• Explain the care of the patient just prior to and following their death.

THE NEED FOR END-OF-LIFE CARE

The Burden of Chronic Illness

Seventy percent of all deaths among Americans are from chronic diseases. Chronic diseases are those that last one or more years, require continuous medical treatment, and limit activities of daily living. In the United States, 60% of adults have a chronic illness, and 40% have more than one chronic illness. The most common chronic diseases include heart disease, cancer, lung disease, diabetes, cardiovascular accident, Alzheimer’s disease, and chronic kidney disease. The most common causes for chronic disease include smoking (including secondhand smoke), alcohol consumed in excess, poor nutritional intake, and lack of physical activity.

The vast majority of all healthcare funding ($4.1 trillion) pays for the treatment of chronic medical and mental illnesses (CDC, 2022). On average, Americans with chronic illness will also need help with routine activities of daily living for two or more of their final years of life.

Increasing Population of Older Adults

The graying of the Baby Boom generation (born 1946 to 1964) threatens to intensify this burden of chronic illness. The first Baby Boomers turned 65 in 2011, and the last will turn 65 in 2029. In 2020, 16.67% of the United States population was older than 65, and by 2030 it will be 20%. Research has also shown that Baby Boomers are living longer than people roughly 20 years older but that they are not healthier. While they are less likely to smoke, have emphysema, or have heart disease, they are more likely to be obese and/or have diabetes and/or hypertension than the previous generation due to the link between advanced age and obesity as risk factors for diabetes (FIFARS, 2020).

Sixty percent of patients ages 75 and older visited emergency departments (ED) in 2018, a statistic that outnumbered all other groups combined except for 1-year-olds. Much research has gone into ways to reduce the number of ED visits for older adults, such as fall prevention. Comparatively, the percentage of patients ages 65–74 years with ED visits has more recently been reduced to 35% (CDC, 2021).

Healthcare Shortage

Together, the burdens of chronic illness and cancer point to an exponential escalation in the demand for palliative care over the next several decades. Experts are concerned that there will be too few physicians and nurses certified in palliative care to meet the needs of this aging cohort.

Boomers make up a significant part of the healthcare workforce as well. Nearly 40% of nurses will retire by 2030 and will be seeking more healthcare themselves. Just over one third of nurses surveyed say they will be quitting their jobs by the end of 2022, and 44% of those cite burnout and stress as the cause. Working through the COVID-19 pandemic caused many of these nurses to quit their jobs. Also, when health professionals who are Baby Boomers retire, the existing nursing shortage will worsen (Landi, 2022).

Lack of Knowledge about End-of-Life Care

In general, Americans are reluctant to talk about death or to express their wishes about end-of-life care. Less than one third of Americans express in writing their wishes about how they want to be cared for at the end of life. Fewer still have not thought about end-of-life care at all, while some have thought about it but not told anyone else what they want. Avoiding the subject of death has created woeful ignorance about end-of-life issues, resulting in less than optimum care and diminished quality of life for the dying and their families.

While about 80% of people in the United States would prefer to be cared for and die at home, 60% actually die in acute-care hospitals, 20% die in nursing homes, and only 20% actually die at home. Conversely, 70% of family members prefer that their loved ones be treated in a hospital at the end of life, compared to 20% of patients with this preference (Stanford, 2022). Often, the family members are in a position to make end-of-life decisions that are not in agreement with patients when there is no formal advance directive in place.

Dying in hospitals not only increases the cost of care but often subjects patients to uncomfortable and unnecessary procedures. For example, increasing numbers of older patients are being admitted to intensive care units (ICUs), where they require ventilator assistance, tracheostomies, aggressive treatment for sepsis, suctioning, catheterization, more frequent monitoring and interventions, and an upsurge in diagnostic tests.