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  • Guideline Summary
  • NGC:008725
  • 2011 Sep

End of life care during the last days and hours.

Registered Nurses' Association of Ontario (RNAO). End-of-life care during the last days and hours. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2011 Sep. 119 p. [229 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

Major Recommendations

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV, IV*) are defined at the end of the "Major Recommendations" field.

Practice Recommendations for Assessment at the End of Life

Recommendation 1.1

Nurses identify individuals who are in the last days and hours of life.

(Level of Evidence = IIa–IV)

Recommendation 1.1.1

Use clinical expertise, disease specific indicators and validated tools to identify these individuals.

(Level of Evidence = IIa–IV)

Recommendation 1.1.2

Understand the end-of-life trajectories.

(Level of Evidence = IIa–IV)

Recommendation 1.2

Nurses understand the common signs and symptoms present during the last days and hours of life.

(Level of Evidence = IIb–IV)

Recommendation 1.2.1

Common signs of imminent death, may include, but are not limited to:

  • Progressive weakness
  • Bedbound state
  • Sleeping much of the time
  • Decreased intake of food and fluid
  • Darkened and/or decreased urine output
  • Difficulty swallowing (dysphagia)
  • Delirium not related to reversible causes
  • Decreased level of consciousness not related to other causes
  • Noisy respiration/excessive respiratory tract secretion
  • Change in breathing pattern (Cheyne-Stokes respiration, periods of apnea)
  • Mottling and cooling extremities

(Level of Evidence = IIb–IV)

Recommendation 1.3

Nurses complete a comprehensive, holistic assessment of individuals and their families based on the Canadian Hospice Palliative Care Association Domains of Care, which include the following:

  • Disease management
  • Physical
  • Psychological
  • Spiritual
  • Social
  • Practical
  • End-of-life care/death management
  • Loss, grief

(Level of Evidence = IIb–IV*)

Recommendation 1.3.1

Include information from multiple sources to complete an assessment. These may include proxy sources such as the family and other health-care providers.

(Level of Evidence = IIb–IV*)

Recommendation 1.3.2

Use evidence-informed and validated symptom assessment and screening tools when available and relevant.

(Level of Evidence = IIb–IV*)

Recommendation 1.3.3

Reassess individuals and families on a regular basis to identify outcomes of care and changes in care needs.

(Level of Evidence = IIb–IV*)

Recommendation 1.3.4

Communicate assessments to the interprofessional team.

(Level of Evidence = IIb–IV*)

Recommendation 1.3.5

Document assessments and outcomes.

(Level of Evidence = IIb–IV*)

Recommendation 1.4

Nurses:

  • Reflect on and are aware of their own attitudes and feelings about death
  • Assess individuals' preferences for information
  • Understand and apply the basic principles of communication in end-of-life care
  • Communicate assessment findings to individuals (if possible and desired) and the family on an ongoing basis
  • Educate the family about the signs and symptoms of the last days and hours of life, with attention to their: faith and spiritual practices; age-specific needs; developmental needs; cultural needs
  • Evaluate the family's comprehension of what is occurring during this phase

(Level of Evidence = III–IV)

Practice Recommendations for Decision Support at the End of Life

Recommendation 2.1

Nurses recognize and respond to factors that influence individuals and their families' involvement in decision-making.

(Levels of Evidence = Ib, IV, IV*)

Recommendation 2.2

Nurses support individuals and families to make informed decisions that are consistent with their beliefs, values and preferences in the last days and hours of life.

(Level of Evidence = Ia–IV*)

Practice Recommendations for Care and Management at the End of Life

Recommendation 3.1

Nurses are knowledgeable about pain and symptom management interventions to enable individualized care planning.

(Level of Evidence = III–IV)

Recommendation 3.2

Nurses advocate for and implement individualized pharmacologic and non-pharmacologic care strategies.

(Level of Evidence = Ia–IV)

Recommendation 3.3

Nurses educate and share information with individuals and their families regarding:

  • Reconciliation of medications to meet the individual's current needs and goals of care
  • Routes and administration of medications
  • Potential symptoms
  • Physical signs of impending death
  • Vigil practices
  • Self care strategies
  • Identification of a contact plan for family when death has occurred
  • Care of the body after death

(Level of Evidence = Ib–III)

Recommendation 3.4

Nurses use effective communication to facilitate end of life discussions related to:

  • Cultural and spiritual values, beliefs and practices
  • Emotions and fears
  • Past experiences with death and loss
  • Clarifying goals of care
  • Family preference related to direct care involvement
  • Practical needs
  • Informational needs
  • Supportive care needs
  • Loss and grief
  • Bereavement planning

(Level of Evidence = III)

Recommendation 4.1

Entry to practice nursing programs and post-registration education incorporate specialized end-of-life care content including:

  • Dying as a normal process including the social and cultural context of death and dying, dying trajectories and signs of impending death
  • Care of the family (including caregiver)
  • Grief, bereavement and mourning
  • Principles and models of palliative care
  • Assessment and management of pain and other symptoms (including pharmacologic and non-pharmacologic approaches)
  • Suffering and spiritual/existential issues and care
  • Decision-making and advance care planning
  • Ethical issues
  • Effective and compassionate communication
  • Advocacy and therapeutic relationship-building
  • Interprofessional practice and competencies
  • Self-care for nurses, including coping strategies and self-exploration of death and dying
  • End-of-life issues in mental health, homelessness and the incarcerated
  • The roles of grief and bereavement educators, clergy, spiritual leaders and funeral directors
  • Knowledge of relevant legislation

(Level of Evidence = Ia–III)

Recommendation 4.2

Successful education in end-of-life care includes specific attention to the structure and process of learning activities and incorporates:

  • Small group learning
  • Dyadic and experiential learning approaches
  • Integration and consolidation of theory and practice
  • Opportunities to practice the skills and competencies acquired
  • Constructive feedback and/or reflection on acquired knowledge, skills and competencies
  • Contact with knowledgeable and supportive clinical supervisors and mentors

(Level of Evidence = Ib–III)

Organization and Policy Recommendations

Recommendation 5.1

Models of care delivery support the nurse, individual and family relationship.

(Level of Evidence = III–IV)

Recommendation 5.2

Organizations recognize that nurses' well-being is a critical component of quality end-of-life care and adopt responsive strategies.

(Level of Evidence = III–IV)

Recommendation 5.3

Organizations providing end-of-life care demonstrate evidence of a philosophy of palliative care based on the Canadian Hospice Palliative Care Association's The Model to Guide Hospice Palliative Care.

(Level of Evidence = III–IV)

Recommendation 5.4

Nursing best practice guidelines can be successfully implemented only when there are adequate planning, resources, organizational and administrative supports, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

  • An assessment of organizational readiness and barriers to implementation
  • Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
  • Dedication of a qualified individual to provide the support needed for the education and implementation process
  • Ongoing opportunities for discussion and education to reinforce the importance of best practices
  • Opportunities for reflection on personal and organizational experience in implementing guidelines

In this regard, a panel of nurses, researchers and administrators developed the Toolkit: Implementation of Clinical Practice Guideline (2002) based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses' Association of Ontario (RNAO) guideline End-of-life Care During the Last Days and Hours.

(Level of Evidence = IV)

Definitions:

Types of Evidence

Type Therapy/Prevention/Etiology/Harm Prognosis
Ia Evidence obtained from systematic review and meta-analysis of randomized controlled trials. Evidence obtained from systematic review of inception cohort studies
Ib Evidence obtained from at least one well-designed randomized controlled trial. Evidence obtained from at least one well-designed inception cohort study with follow-up
IIa Evidence obtained from at least one well-designed controlled study without randomization Evidence obtained from systematic review of retrospective cohort studies or untreated control groups in randomized controlled trials
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study Evidence obtained from at least one well-designed retrospective cohort study or follow-up of untreated control patients in a randomized controlled trial
III Evidence obtained from at least one well-designed nonexperimental quantitative study (i.e., comparative or correlational) or qualitative study Evidence obtained from at least one well-designed non-experimental quantitative study (i.e., case-series, case-control studies, cohort studies and historically controlled studies)
IV Evidence obtained from expert committee reports or opinions, and/or clinical experiences of respected authorities Evidence obtained from expert committee reports or opinions, and/or clinical experiences of respected authorities
IV* Evidence obtained from other clinical practice guidelines Evidence obtained from other clinical practice guidelines

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Life-limiting illnesses

Guideline Category

Evaluation

Management

Clinical Specialty

Cardiology

Family Practice

Internal Medicine

Oncology

Intended Users

Advanced Practice Nurses

Nurses

Guideline Objective(s)

  • To provide evidence-based recommendations for registered nurses and registered practical nurses on best nursing practices for end-of-life care during the last days and hours of life
  • To be a resource to nurses who may not be experts in this practice area

Target Population

Adults, aged 18 years and older, who have reached the part of the illness trajectory that includes the last days and hours of life

Interventions and Practices Considered

  1. Identifying individuals through clinical expertise, disease indicators and validated tools
  2. Understanding the common signs and symptoms of imminent death
  3. Completing a comprehensive, holistic assessment of individuals and their families, using multiple sources
  4. Reassessing individuals and families on a regular basis and communicating to interprofessional team
  5. Documenting assessments and outcomes
  6. Supporting individuals and families to make informed decisions consistent with their beliefs and values
  7. Implementing pharmacologic and non-pharmacologic care strategies
  8. Nursing program education on end-of-life care

Major Outcomes Considered

  • Accuracy of identification of individuals who are in the last days and hours of life
  • Patient and family satisfaction

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

The search strategy utilized during the development of this guideline focused on two key areas. The first was the identification of clinical practice guidelines published on the topic of end-of-life care, while the second was a literature review to identify theoretical literature, primary studies, meta-analyses and systematic reviews published in this area between 2003 and 2009.

Database Search

A database search for existing evidence related to end-of-life care was conducted by a health sciences librarian using search terms generated by the development panel. The search strategy utilized by the Cochrane Effective Practice and Organization of Care group was used to formulate the final search strategy. An initial search of the Cochrane Database of Systematic Reviews, MEDLINE, ProQuest, CINAHL, WebScience, PsycINFO, EMBASE and Ageline databases for guidelines, primary studies, theoretical literature and systematic reviews published between 2003 and 2009 was conducted using the following search terms: "Death/dying," "Terminal care," "End of life care," "Palliative care," "Hospice care," "Grief/bereavement and death/end of life/last hours and days of life," "Setting of care and death/end of life/last hours and days of life," "Traumatic death and death/end of life/last hours and days of life," "Caregiver support and death/end of life/last hours and days of life," "Chronic illness and end of life care/last hours and days of life," "Life limiting illness/life threatening," "Traumatic death," "Withdrawal and withholding of interventions," "Last days of living," "Terminal sedation," "Communication and death/end of life/last hours and days of life," "Culture and death," "Comfort care and end of life/last hours and days of life," "Do not resuscitate," "Spirituality and end of life care," "Loss and death/end of life/last hours and days of life," "Hope and death/end of life/last hours and days of life," "Dignity and death/end of life/last hours and days of life," "Good death," "Pronouncement," "Decision making and death/end of life/last hours and days of life," "Advance care planning and death/end of life/last hours and days of life," "Education and end of life care," "Interprofessional care" and "End of life care".

As directed by the panel, additional literature searches were conducted to supplement the results of the systematic review report.

Structured Website Search

One individual searched an established list of websites for content related to the topic area in March 2009. This list of websites was compiled based on existing knowledge of evidence-based practice websites, known guideline developers and recommendations from the literature. The presence or absence of guidelines was noted for each site searched, as well as the date searched. Some websites did not house guidelines, but directed readers to another website or source for guideline retrieval. Guidelines were downloaded if full versions were available online, or were ordered by telephone or email if they were not available online.

Search Engine Web Search

In addition, a website search for existing practice guidelines related to end-of-life care was conducted via the search engine Google (www.google.com), using key search terms. One individual conducted this search, and noted the results of the search, the websites reviewed and dates accessed. A summary of the search results was then written.

Hand Search/ Panel Contribution

The following key journals were hand-searched over a 12-month period, up to May 2010:

  • Palliative and Supportive Care
  • Palliative Medicine
  • Supportive Care in Cancer
  • European Journal of Palliative Care
  • Hospice and Palliative Nursing
  • International Journal of Palliative Nursing
  • Journal of Pain and Symptom Management
  • Journal of Palliative Care

Panel members were also asked to review their personal archives to identify guidelines not previously found via the search strategies noted above. Two guidelines were identified, but after careful review were deemed to be outside the scope of the guideline, and were therefore not included in the review.

Search Results

The search strategy described above resulted in the retrieval of 6,571 abstracts on the topic of end-of-life care. These abstracts were then independently screened by two research assistants to identify duplications, and assess for inclusion and exclusion criteria established by the panel.

In addition, 14 clinical practice guidelines were identified that met the screening criteria (see Appendix B in the original guideline document) and were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument (AGREE Collaboration, 2001).

Number of Source Documents

The search strategy resulted in the retrieval of 6,571 abstracts on the topic of end-of-life care. In addition, 14 clinical practice guidelines were identified that met the screening criteria and four were relevant to the scope of the current guideline, and would be used to inform the development process.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Types of Evidence

Type Therapy/Prevention/Etiology/Harm Prognosis
Ia Evidence obtained from systematic review and meta-analysis of randomized controlled trials. Evidence obtained from systematic review of inception cohort studies
Ib Evidence obtained from at least one well-designed randomized controlled trial. Evidence obtained from at least one well-designed inception cohort study with follow-up
IIa Evidence obtained from at least one well-designed controlled study without randomization Evidence obtained from systematic review of retrospective cohort studies or untreated control groups in randomized controlled trials
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study Evidence obtained from at least one well-designed retrospective cohort study or follow-up of untreated control patients in a randomized controlled trial
III Evidence obtained from at least one well-designed nonexperimental quantitative study (i.e., comparative or correlational) or qualitative study Evidence obtained from at least one well-designed non-experimental quantitative study (i.e., case-series, case-control studies, cohort studies and historically controlled studies)
IV Evidence obtained from expert committee reports or opinions, and/or clinical experiences of respected authorities Evidence obtained from expert committee reports or opinions, and/or clinical experiences of respected authorities
IV* Evidence obtained from other clinical practice guidelines Evidence obtained from other clinical practice guidelines

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

In June 2009, a multidisciplinary panel with expertise in practice, education and research, from hospital, community and academic settings, was convened under the auspices of the Registered Nurses' Association of Ontario (RNAO). The panel discussed the purpose of their work, and achieved consensus on the scope of the best practice guideline. Subsequently, a literature search was conducted for clinical practice guidelines, systematic reviews, relevant research studies and other types of evidence.

The panel members formed subgroups to undergo specific activities using the short-listed guidelines, evidence summaries, studies and other literature, for the purpose of drafting recommendations for nursing assessment and interventions. Community representatives were consulted for input and feedback. This process resulted in the development of practice, education, and organization and policy recommendations. The panel members as a whole reviewed the first draft of recommendations, discussed gaps, reviewed the evidence and achieved consensus on a final set of recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

The completed draft was submitted to a set of external stakeholders for review and feedback; acknowledgement of these stakeholders is provided at the beginning of the guideline document. Stakeholders represented various health-care professional groups, clients and family members, and professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to provide general feedback and impressions.

The feedback from stakeholders was compiled and reviewed by the development panel. Discussion and consensus resulted in revisions to the draft document prior to publication.

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

  • Appropriate end-of-life care during the last days and hours
  • Improving education on the signs of impending death and integrating the palliative philosophy of care earlier into the disease trajectory are strategies that could improve care to individuals living with life-limiting illness across health-care settings.
  • Dying individuals experience fear of pain, indignity, abandonment and the unknown. Involving individuals and their family members in discussions regarding these fears may strengthen relationships within the family and reduce the isolation experienced by the dying person.

Potential Harms

Not stated

Qualifying Statements

  • These guidelines are not binding for nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario give any guarantee as to the accuracy of the information contained in them, nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of this work.
  • This nursing best practice guideline is a comprehensive document, which provides resources necessary for the support of evidence-based nursing practice. The document must be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This guideline should not be applied in a "cookbook" fashion, but rather as a tool to enhance decision-making in the provision of individualized care. In addition, the guideline provides an overview of appropriate structures and supports necessary for the provision of best possible care.
  • The purpose of this best practice guideline is to provide evidence-based recommendations for Registered Nurses and Registered Practical Nurses on best nursing practices for end-of-life care during the last days and hours of life. The guideline does not replace consultation with palliative care specialists, who can support nurses to provide quality end-of-life care. The guideline is intended to be a resource to nurses who may not be experts in this practice area. It is acknowledged that individual competencies vary between nurses and across categories of nursing professionals. The inclusion of recommendations on clinical, education, organization and policy topics makes this guideline applicable to nurses in all domains and settings of practice.
  • There is a paucity of data to support various interventions during the last days and hours of life, largely due to the difficulty in recruiting individuals who are dying into research studies. In addition, few tools regarding care of people who are dying have been validated in the non-cancer population. There is also a lack of evidence regarding the knowledge and skills required to provide care for these individuals. Further research is clearly required in these areas. Thus, much of the evidence supporting these recommendations is based upon expert clinical consensus, consensus guidelines and standards of practice.

Description of Implementation Strategy

Best practice guidelines can be successfully implemented only if there are adequate planning and resources available, organizational and administrative support, and appropriate facilitation. To this end, the Registered Nurses' Association of Ontario (RNAO), in collaboration with a panel of nurses, researchers and administrators, has developed the Toolkit: Implementation of Clinical Practice Guidelines, www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf External Web Site Policy, based on available evidence, theoretical perspectives and consensus.

The Toolkit provides step-by-step directions to individuals and groups in health-care organizations involved in planning, coordinating and facilitating implementation of any of the RNAO's clinical practice guidelines.

Specifically, the Toolkit addresses the following key steps regarding guideline implementation:

  1. Identification of a well-developed, evidence-based clinical practice guideline
  2. Identification, assessment and engagement of stakeholders
  3. Assessment of environmental readiness for guideline implementation
  4. Identification and planning of evidence-based implementation strategies
  5. Planning and implementation of evaluation
  6. Identification and securing of required resources for implementation

Implementing guidelines that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is a key resource for managing this process.

Evaluation/Monitoring of Guideline

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation, and its impact, will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines (2002), illustrates specific indicators for monitoring and evaluation of the guideline.

Implementation Strategies

The RNAO and the guideline development panel have compiled a list of implementation strategies to assist health-care organizations or health care providers that are interested in implementing this guideline. A summary of these strategies follows:

  • Have at least one dedicated person, such as an advanced practice nurse or a clinical resource nurse, who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
  • Conduct an organizational needs assessment related to end-of-life care to identify current knowledge base and future educational requirements.
  • Initial needs assessment may include an analysis approach, survey and questionnaire, group format approaches (e.g., focus groups), and critical incidents.
  • Establish a steering committee composed of key stakeholders and interdisciplinary members who are committed to leading the change initiative. Identify short- and long-term goals. Keep a work plan to track activities, responsibilities and timelines.
  • Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision.
  • Program design should include:
    • Target population
    • Goals and objectives
    • Outcome measures
    • Required resources (human resources, facilities, equipment)
    • Evaluation activities
  • Design educational sessions and ongoing support for implementation. The education sessions may consist of presentations, facilitator's guide, handouts, and case studies. Binders, posters and pocket cards may be used as ongoing reminders of the training. Plan education sessions that are interactive, include problem-solving, address issues of immediate concern and offer opportunities to practice new skills.
  • Provide organizational support such as having the structures in place to facilitate the implementation. For example, hiring replacement staff so participants will not be distracted by concerns about work and having an organizational philosophy that reflects the value of best practices through policies and procedures. Develop new assessment and documentation tools.
  • Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done.
  • Organizations implementing this guideline should adopt a range of self-learning, group learning, mentorship and reinforcement strategies that will over time, build the knowledge and confidence of nurses in implementing this guideline.
  • Beyond skilled nurses, the infrastructure required to implement this guideline includes access to equipment and treatment materials. Orientation of the staff to the use of products and technologies must be provided and regular refresher training planned.
  • Teamwork, collaborative assessment and treatment planning with the client and family and interdisciplinary team are beneficial in implementing guidelines successfully. Referral should be made as necessary to services or resources in the community or within the organization.

In addition to the strategies mentioned above, the RNAO has developed resources that are available at its website (www.rnao.org External Web Site Policy). A toolkit for implementing guidelines can be helpful, when used appropriately. A brief description of the toolkit can be found in Appendix M in the original guideline document. A full version of the document in PDF format is also available at the RNAO website, www.rnao.org/bestpractices External Web Site Policy (see also the "Availability of Companion Documents" field).

Implementation Tools

Audit Criteria/Indicators

Chart Documentation/Checklists/Forms

Mobile Device Resources

Patient Resources

Resources

Slide Presentation

Tool Kits

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

End of Life Care

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Registered Nurses' Association of Ontario (RNAO). End-of-life care during the last days and hours. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2011 Sep. 119 p. [229 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2011 Sep

Guideline Developer(s)

Registered Nurses' Association of Ontario - Professional Association

Source(s) of Funding

Funding was provided by the Ontario Ministry of Health and Long-Term Care.

Guideline Committee

Guideline Development Panel

Composition of Group That Authored the Guideline

Christine McPherson RN, BScN (Hons), MSc, PhD
Chair
Associate Professor
School of Nursing, Faculty of Health Sciences
University of Ottawa
Ottawa, Ontario

Debora Cowie RPN
Grief and Bereavement Educator
Staff Nurse
Ontario Shores Centre for Mental Health Sciences
Whitby, Ontario

Beverley Cross RN, BScN, CHPCN(C)
Program Development Educator
Palliative Care Services
Regina Qu'Appelle Health Region
Regina, Saskatchewan

Beverly Ann Faubert RN, BScN
Long Term Care Best Practice Coordinator
Registered Nurses' Association of Ontario
Toronto, Ontario

Debbie Gravelle RN, BScN, MHS
Manager/Advanced Practice Nurse
Regional Palliative Care Community
Élisabeth Bruyére Hospital
Ottawa, Ontario

Julia Johnston RN(EC), BScN, MN, NP Adult, CHPCN(C)
Advanced Practice Nurse
Palliative Care Program
Trillium Health Centre
Mississauga, Ontario

Lynn Kachuik RN, BA, MS, CON(C), CHPCN(C)
Advanced Practice Nurse
Palliative Care
The Ottawa Hospital
Ottawa, Ontario

Patricia Lafantaisie RN, BScN
Case Manager
North-East Community Care Access Centre
Sudbury, Ontario

Mary Ann Murray RN, MScN, PhD, CON(C), GNC(C), CHPCN(C)
Advanced Practice Nurse
Home Dialysis Unit
The Ottawa Hospital
Ottawa, Ontario

Marg Poling RN, BScN
Palliative Pain and Symptom Management Consultation/Client Service Manager
North West Community Care Access Centre
Thunder Bay, Ontario

Carol Sloan RN, CHPCN(C)
Manager/Palliative Care Consultant
Palliative Care Consultation Program
Oakville, Ontario

Loretta Ward RN, CHPCN(C)
Program Manager
Good Shepherd Centres – Emmanuel House
Hamilton, Ontario

Sandy White RN, BScN, MN, CHPCN(C)
Trent/Fleming School of Nursing
Trent University
Peterborough, Ontario

Frederick Go RN, BSc, BScN, MN
Program Manager
International Affairs and Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Glynis Vales BA
Program Assistant
International Affairs and Best Practice Guidelines Program
Registered Nurses' Association of Ontario
Toronto, Ontario

Shirley Alvares RN, BScN, MN/Ed
Research Assistant
Registered Nurses' Association of Ontario
Toronto, Ontario

Abida Dhukai RN(EC), BScN, MN
Research Assistant
Registered Nurses' Association of Ontario
Toronto, Ontario

Kelly Kilgour BScN, MScN, CHPCN(C)
Research Assistant
Registered Nurses' Association of Ontario
Toronto, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses' Association of Ontario.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses' Association of Ontario (RNAO) Web site External Web Site Policy.

Print copies: Available from Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Availability of Companion Documents

The following are available:

  • Toolkit: implementation of clinical practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2002 Mar. 88 p. Electronic copies: Available in Portable Document Format (PDF) from the Registered Nurses' Association of Ontario (RNAO) Web site External Web Site Policy. See the related QualityTool summary on the Health Care Innovations Exchange Web site External Web Site Policy.
  • Sustainability of best practice guideline implementation. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2006. 24 p. Electronic copies: Available in PDF and as a Power Point presentation from the RNAO Web site External Web Site Policy.
  • Educator's resource: integration of best practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2005 Jun. 123 p. Electronic copies: Available in PDF from the RNAO Web site External Web Site Policy.

Assessment tools for end-of-life care are available in the appendices to the original guideline document External Web Site Policy. A table in the original guideline document, based on the framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines, illustrates some suggested indicators for monitoring and evaluation.

Print copies: Available from the Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Mobile versions of RNAO guidelines are available from the RNAO Web site External Web Site Policy.

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on February 6, 2012. The information was verified by the guideline developer on February 14, 2012.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses' Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario (2011). End-of-Life Care During the Last Days and Hours. Toronto, Canada: Registered Nurses' Association of Ontario.

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