End-of-Life Care

Scope of Practice for End-of-Life Care

End-of-life care (EOLC) in the CNA scope focuses on providing comfort, dignity, and support to dying patients and their families. Certified Nursing Assistants (CNAs) play a vital role in direct bedside care, symptom monitoring, and emotional presence during the final stages of life. On the CNA exam, question items often emphasize the CNA’s role in supporting comfort measures, observing changes in breathing patterns, and maintaining respectful care standards.^[1]

Clinical Terminology for Dying Patient Care

• Palliative care – Holistic care aimed at relieving suffering and improving quality of life for patients with serious illnesses, regardless of prognosis.^[2]
• Hospice care – A specific type of palliative care for patients with a life expectancy of six months or less, when curative treatment is no longer pursued.^[3]
• Active dying – The final days or hours before death; the body begins shutting down, often marked by specific physical signs.^[4]
• Cheyne‑Stokes respiration – A pattern of breathing characterized by gradual increases in depth and rate followed by periods of apnea (no breathing). Common near death.^[5]
• Terminal secretions (“death rattle”) – Gurgling sounds caused by saliva and mucus accumulating in the throat and airways when the patient cannot cough or swallow.^[6]
• Advance directive – Legal documents (e.g., living will, durable power of attorney for healthcare) that communicate a patient’s wishes about medical treatment if they become unable to speak for themselves.^[7]

Essential Care Principles for the Dying Patient

Patient-Centered Dignity

• Treat the patient with respect, regardless of altered consciousness.
• Speak to the patient as though they can hear you; hearing is often the last sense to fade.^[8]
• Maintain privacy during care (close curtains, cover the body).

Comfort & Symptom Management

• Reposition the patient every 2 hours or as needed to prevent pressure injuries and promote comfort.
• Provide mouth care every 2 hours – moisten lips with swabs, use artificial saliva or lubricant. Dry mouth is very common.^[9]
• Keep the patient clean and dry; change linens and pads as needed.
• Offer ice chips or fluids if the patient can swallow safely.

Emotional & Spiritual Support

• Allow family members to be present; offer a quiet space for them.
• Respect cultural and religious practices (e.g., prayer, rituals).
• Simply sitting quietly with the patient can be a powerful intervention.

Clinical Indicators of Active Dying

What the CNA should recognize and report to the nurse:

• Changes in breathing: Cheyne‑Stokes respiration, irregular shallow breaths, periods of apnea.^[5]
• Decreased consciousness: Patient becomes more difficult to arouse, eventually unresponsive.
• Changes in circulation: Cool or mottled extremities, especially hands, feet, knees; nail beds may appear bluish or pale.
• Decreased urine output: Urine becomes dark or concentrated; output may stop completely.
• Terminal secretions: Audible rattling or gurgling from the throat; turn the patient on their side (lateral position) to help drain secretions, if not contraindicated.^[6]
• Changes in vital signs: Blood pressure decreases, pulse becomes weak and irregular, temperature may rise or fall.

Assessment Parameters and Documentation Duties

• Observe and document: Breathing pattern, level of consciousness, skin condition, pain behaviors (grimacing, moaning, restlessness).
• Pain assessment: If the patient cannot self-report, use a behavioral pain scale (e.g., PAINAD).^[10]
• Report changes immediately to the supervising nurse – especially signs of uncontrolled pain, sudden respiratory changes, or new skin breakdown.
• Never assume a patient is not aware because they are unresponsive; provide gentle explanations before touching or turning.

Comfort Measures and Family Support During Active Dying

CNA Actions During Active Dying

1. Positioning: Elevate the head of the bed (30–45 degrees) to ease breathing unless contraindicated. Use pillows to support body alignment.
2. Oral care: Clean mouth with soft sponge towelettes; avoid excess fluid to prevent aspiration. Apply lip balm.
3. Skin care: Frequent turning, use of pressure‑relief mattresses, and keeping skin clean and dry.
4. Eye care: If eyes remain open, apply artificial tears or a gentle gel to prevent corneal drying.
5. Catheter care: Note urine amount and color; empty and measure output as per facility policy.
6. Family support: Offer tissues, water, and a quiet area. Encourage family to talk to or hold the patient’s hand.

Key Communication Points

• Use a calm, gentle voice.
• Avoid whispering in the room; it may cause anxiety.
• Introduce yourself each time; state what you are going to do.
• Acknowledge the family’s grief – say “I’m here if you need anything.”

Preventing Complications and Ensuring Safety

• Fall risk: The patient may become restless or try to get out of bed. Keep side rails up (if not contraindicated) and bed in lowest position.
• Skin breakdown: Immobility increases risk; perform scheduled turns and inspections.
• Choking/aspiration: Use caution with oral fluids; assess gag reflex before offering anything by mouth. Oral care using moist swabs is safer than a cup of water.
• Infection: Use standard precautions when handling body fluids.
• Family grief reactions: Be prepared for emotional outbursts; stay calm and alert the nurse if support is needed.

CNA Exam Priorities in End-of-Life Care

• Know the difference between hospice (terminal prognosis) and palliative care (any serious illness).
• Remember the “death rattle” is not painful – it is caused by secretions. Repositioning (side‑lying) helps – never suction routinely unless ordered.^[6]
• Cheyne‑Stokes breathing is a common exam question – pattern: increasing depth → decreasing depth → apnea.
• Mouth care is repeatedly tested as a key comfort measure (every 2 hours).
• Never start CPR if the patient has a valid “Do Not Resuscitate” (DNR) order. Verify the order before acting.
• CNA scope: CNA cannot diagnose death, pronounce a patient, or remove any medical devices (e.g., IV, NG tube) – that is the nurse's or physician's role.
• Memory aid for signs of approaching death: “C‑BED” – C hanges in breathing, B lood pressure drop, E xtremities cool, D ecreased urine output.

References & Sources

1. American Red Cross. "CNA Skills and End-of-Life Care." Nurse Assistant Training Curriculum. 2022. https://www.redcross.org/take-a-class/nurse-assistant-training
2. World Health Organization. "Palliative Care." 2020. https://www.who.int/news-room/fact-sheets/detail/palliative-care
3. National Hospice and Palliative Care Organization (NHPCO). "Hospice Care." 2023. https://rarediseases.org/organizations/national-hospice-and-palliative-care-organization/
4. Ferrell, B. R., & Coyle, N. "Understanding the Dying Process." Oxford Textbook of Palliative Nursing, 5th ed. Oxford University Press. 2020. https://doi.org/10.1093/med/9780190862374.001.0001
5. Hallenbeck, J. L. "Palliative care in the final days of life." JAMA. 2005;293(17):2186-2192. https://pubmed.ncbi.nlm.nih.gov/15886382/
6. Bennett, M. I., & O'Connor, B. "Management of terminal secretions." BMJ Supportive & Palliative Care. 2018;8(3):250-253. https://spcare.bmj.com/content/8/3/250
7. American Hospital Association. "Advance Directives." 2021. https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care
8. Weisse, C. S. "End-of-life care: Hearing is last to go." Nursing. 2020;50(6):14-15. https://journals.lww.com/nursing/Fulltext/2020/06000/Hearing_is_last_to_go.9.aspx
9. Sorensen, C. S., & Fox, K. "Oral care at end of life." American Journal of Nursing. 2019;119(3):38-44. https://pmc.ncbi.nlm.nih.gov/articles/PMC9141643/
10. Warden, V., Hurley, A. C., & Volicer, L. "Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale." Journal of the American Medical Directors Association. 2003;4(1):9-15. https://doi.org/10.1097/00130535-200301000-00003