Ethical Considerations at the End of Life Nursing CE Course

pain relief and symptom management, allowing the patient to rest. Patients and families often fear that opioids hasten death, especially morphine sulfate. However, multiple research studies have concluded that morphine sulfate does not hasten death at the end of life when prescribed and administered appropriately to manage patient symptoms (Fink et al., 2019; NIA, 2022; Paice, 2019; WHO, 2020; Young et al., 2021). 

Skin irritation and fragility are highly prevalent among terminal patients. This irritation can be very uncomfortable and painful. Decreased nutritional intake and immobility can increase a patient's risk of pressure injuries. Due to inadequate caloric intake, treating these pressure injuries may be difficult or impossible in some cases. Consequently, offloading high-pressure areas and repositioning on a frequent schedule is essential for prevention. Dry mucous membranes and the use of oxygen can leave the patient's nose and lips dry and cracked. The higher the liter flow of oxygen, the more susceptible the patient is to this. To relieve these symptoms, a mouth moisturizer, ice chips (if the patient is conscious), or cotton swabs can keep the patient's lips and mouth from drying out, and a balm can be used in the nostrils to prevent cracking and bleeding. It is important to educate families and caregivers that petroleum jelly is contraindicated for patients treated with oxygen due to its explosive properties. Pressure injuries can present at the end of life and are sometimes referred to as Kennedy ulcers or Kennedy terminal ulcers. These skin lesions begin as an oval- or butterfly-shaped discoloration that appears suddenly and progresses rapidly (HPNA, 2022; NIA, 2022). 

Mental and Emotional Needs 

Managing mental and emotional needs is another core responsibility when caring for those nearing the end of life. Although it is critical to manage physical pain, treating emotional distress and mental anguish is equally important. Alert patients may experience fear, anxiety, depression, sadness, regret, or remorse when nearing the end of life. Many patients bear an overabundance of emotions and may cycle through emotional ups and downs as time passes. Some may have specific fears or concerns, such as being alone as they actively die or leaving family members behind, whereas others may fear the unknown. Encouraging conversations about feelings may be beneficial, but when symptoms of depression, anxiety, or panic are severe, pharmacological agents may become necessary. Loved ones, friends, and family members grieve in unique ways and may experience varying stages of grief during the dying process. If loved ones are unaware of how to help or what to say, they may visit the patient less or withdraw. This withdrawal can be particularly challenging for patients who may feel isolated, abandoned, and lonely. Simple gestures of physical contact, such as holding hands, offering a light touch, or administering a gentle massage, can help promote feelings of connection and soothe the patient. Being present in the patient's room or home is often enough to help alleviate mental anguish and fears of dying alone (Coyne et al., 2024; NIA, 2022; Xu et al., 2024). 

Spiritual Needs 

Spiritual needs at the end of life can vary greatly. They may include searching for ultimate meaning or purpose in one's life and finding peace by ending disagreements or resolving unsettled issues with others. Many patients can find solace in their faith or religion during the dying process and openly welcome visits from a spiritual care coordinator or their chosen religious leader. Some patients continue to struggle with their spiritual beliefs and religion at the end of life, and interventions must be tailored to meet their needs. Sharing positive memories and engaging in a life review are strategies that may help patients come to peace before death, as they promote connectedness and comfort. Members of the care team must take great care not to impose their personal spiritual beliefs or rituals on a patient. The spiritual aspect of care should be approached with dignity and respect for the views of the patient and their family members. Additionally, certain religions have specific guidelines and protocols that are initiated once the patient is actively dying or upon the patient's death. The care team should attempt to facilitate and honor these rituals in the plan of care (NIA, 2022; Tarberg et al., 2020). 

Practical Tasks 

The practical tasks that must be performed during the EOL process should not be overlooked, because they may be a tremendous source of stress and worry for patients and caregivers. Everyday tasks are crucial, such as taking care of a patient's pet, keeping up with household bills and chores, or finalizing personal affairs. Patients may worry or become anxious about who will care for their spouse, children, or beloved pet in the future, so making proper arrangements that the patient supports can alleviate fear and induce peace and comfort (NIA, 2022). 

Ethical Principles 

Ethics is a discipline studied in nearly all professions. It encompasses standards outlining what is right or wrong and what is good or bad. Ethics are general rules of conduct delineating behavior as guided by ethical principles. Ethics are not based on emotions or feelings and are not laws or legally binding. Instead, they are standards of conduct that define the essentials of honorable behavior. Issues in medical ethics often involve life and death, and various disciplines offer ethical standards applicable to different groups of HCPs. While the ethical principles underlying medical ethics at the end of life have universal definitions, as outlined in Table 1, the interpretation of each principle when applied to EOL care can uncover variations as determined by the governing body (Akdeniz et al., 2021; ANA, 2015; Varkey, 2021). 

Table 1 

Ethical Principles Underlying Medical Ethics at the End of Life

Autonomy	The patient's inherent worth and right to self-determination
Beneficence	Doing what is good or beneficial for the patient
Nonmaleficence	Avoidance of infliction of intentional harm to the patient
Justice	Fair and equitable delivery of health care

  (Akdeniz et al., 2021; Varkey, 2021)

  

 The American Medical Association (AMA, n.d.-b) Code of Medical Ethics has articulated the values to which providers commit themselves as members of the medical profession. The medical profession has long subscribed to a body of ethical statements developed primarily for each patient's benefit, with the first edition of standards written in 1847. Formalized ethics in nursing date back to the 1800s, when Florence Nightingale developed a pledge to practice faithfully, engage in purity, and elevate the nursing profession's standards by committing oneself to the welfare of patients. This became the basis for the ANA's current Code of Nursing Ethics developed in 2001 (refer to Table 2). It consists of nine provisions that govern how nurses should behave. The code has undergone revision several times through expert committee review but is still considered the gold standard for ethical nursing practice. In addition, the ANA has devised a position statement outlining nurses' roles and responsibilities in providing care and support at the end of life. Nurses' roles and responsibilities when providing care at the end of life are grounded in the fundamentals of practice and clinical ethics (ANA, 2015, 2024). 

Table 2 

American Nurses Association Code of Ethics 

Provision	Application to EOL Care
1. The nurse practices with compassion and respect for every person's inherent dignity, worth, and unique attributes.	The nurse must respect human dignity and provide comprehensive and compassionate EOL care to patients and their families. Respect for patient autonomy is an essential dimension of clinical decision-making at the end of life.
2. The nurse's primary commitment is to the patient and their support system, whether an individual, family, group, community, or population.	Nurses are responsible for establishing decision-making processes that reflect physiological realities, patient preferences, and clinical possibilities. Establishing goals of care for an individual patient may provide a framework for discussing what care should be provided and what level of care is appropriate. The nurse must understand the patient's values, goals, and wishes, discuss the goals of care, and advocate for the patient to ensure their preferences are upheld. The nurse must also recognize that family members are whomever the patient determines.
3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.	Nurses must protect the patient's rights and safety above all else and maintain privacy and confidentiality through death. Have discussions about death and collaborate with interprofessional care teams to ensure patients and families have current and accurate information about the possibility or probability of impending death.
4. The nurse has authority, accountability, and responsibility for nursing practice to make decisions and take action consistent with the obligation to promote health and provide optimal care.	Nurses must provide evidence-based nursing care to patients during the end of life, demonstrating basic skills in recognizing and managing symptoms common during the dying process. The nurse will remain accountable for all actions.
5. The nurse owes the same duties to themselves as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.	Nurses must act with integrity and examine internal biases and feelings on death, dying, and EOL care. Consider ethical dilemmas and address personal feelings to remain objective when caring for patients. Promote self-respect, professional growth, and competence to deliver high-quality care consistently.
6. Through individual and collective efforts, the nurse establishes, maintains, and improves the ethical environment of their work setting and conditions of employment to promote safe, quality health care.	Nurses must maintain, improve, and promote work environments where the standards for excellent care extend through the patient's death and into postdeath bereavement care for families. Remedy any workplace issues that are not optimal for providing high-quality care.
7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.	Nurses can advance the profession by identifying areas for improvement in EOL care. Strive to attain a standard of primary palliative care so all HCPs have basic knowledge of palliative nursing to improve the care of patients and families. Increase the integration of evidence-based care across the dimensions of the disease continuum and develop best practices to measure the quality and effectiveness of the interprofessional care patients and families receive during EOL decision-making and treatments.
8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.	Nurses must collaborate with other health care team members to ensure optimal symptom management and support the patient and their family members. This includes working closely with providers, social workers, case managers, and other professionals to meet patient needs optimally. Collaboration may occur within the employing institution, public, or community. The IDT must work toward a standard of care where palliative medicine is available to all patients and families from diagnosis of a severe illness or an injury until death.
9. Nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.	Nurses must behave professionally, perform civic duties, and uphold the integrity of the nursing field amidst ethical dilemmas or complex issues that arise at the end of life. Act in a way that brings honor to the profession and does not sacrifice the needs of each patient.

(ANA, 2015, 2024) 

Certified case managers (CCMs) often confront ethical dilemmas. They must abide by the Code of Conduct and the Professional Code of Ethics for their specific profession, which offer guidance and support in resolving these conflicts. Although nurses are primarily responsible for the medical care of patients at the end of life, case managers are often called upon to help during these times. The Code of Professional Conduct from the CCMC (2023) provides a framework for ethical, high-quality care governed by eight principles of professional conduct. These principles and their application to EOL care are outlined in Table 3. 

Table 3 

CCMC Principles of Professional Conduct for Case Managers

Principle	Potential Application to EOL Care
1. CCMs will always place the public interest above their own.	Assess the patient's current functioning and individual needs. Take the lead to help patients, family members, and caregivers have earlier and more positive conversations about palliative care and EOL care as a means of advocacy.
2. CCMs will respect all the rights and inherent dignity of all patients.	Respect the patient's right to self-determination and autonomy at the end of life. Preserve the patient's dignity throughout the dying process.
3. CCMs will always maintain objectivity in their relationships with patients.	Examine and recognize internal biases or conflicts to remain objective in viewpoints on dying and ethical dilemmas at the end of life.
4. CCMs will act with integrity and fidelity with patients and others.	Uphold the principles of beneficence and compassion. Desire to do good and help ease the transition to EOL care for patients and their loved ones.
5. CCMs will maintain their competency at a level that ensures patients receive the highest quality of care.	Maintain awareness of the ethical principles, standards of practice, and laws at the local, state, and federal levels that help resolve EOL issues. The CCM will remain knowledgeable about the laws and regulations regarding death and be skilled with care coordination and resources to refer families for early bereavement services.
6. CCMs will honor the integrity of the CCM designation and adhere to the requirements for its use.	The Code of Conduct provides a foundation, and each CCM is responsible for honoring and adhering to the requirements. The CCMs follow the integrity of the Code of Conduct and are role models for nurses and other staff regarding EOL care.
7. CCMs will obey all laws and regulations.	Maintain current knowledge of all laws and regulations and promote compliance. CCMs should remain current with statutes to take an active role in the policies supporting optimal EOL care.
8. CCMs will help maintain the integrity of the Code of Conduct by responding to requests for public comments to review and revise the code, thus helping ensure its consistency with current practice.	The Code of Conduct sets a baseline expectation for the public. It also allows for feedback and revisions of the code, thus ensuring its consistency with current practice. CCMs should encourage comments and feedback to help improve the code and practice guidelines relating to the EOL process.

 (CCMC, 2023) 

Advance Care Planning 

Confronting the reality of a patient's declining condition and impending death is difficult for patients and families. Choices about the most appropriate health care interventions at the end of life address whether specific treatments are ultimately likely to benefit the patient and if they are congruent with the patient's wishes. All individuals have the right to an assessment and discussion regarding their wishes about treatment preferences if they become acutely or chronically ill. Ideally, this conversation should occur when the patient is emotionally, physically, and cognitively well enough to make these decisions and preserve their autonomy. Advance directives should be the start of the conversation, not the end. Decision-making for the end of life should occur over the years rather than just in the days or minutes before imminent death (ANA, 2024). 

Advance care planning (ACP) involves a discussion between the patient and their care providers, irrespective of profession, concerning the patient's wishes, values, goals, and preferences for care or treatment in the future. Advance directives are the expression of the patient's preferences for medical care that become relevant when the patient cannot speak for themselves or is no longer cognitively competent to make decisions. ACP preparation may also include the identification of a health care proxy or someone who will represent and uphold the patient's preferences in decisions about treatment and interventions. The Federal Patient Self-Determination Act of 1990 mandates that all Medicaid and Medicare providers inform adult patients of their right to participate in and direct their own health care decisions, accept or refuse treatment, prepare advance directives (living will, durable power of attorney for health care), and be informed of health care facilities' policies on these rights. The individual's right to decide on the use of advanced treatments and EOL care based on disease progression and prognosis must be respected ethically (Akdeniz et al., 2021; AMA, n.d.-a; NIA, 2022; Tarberg et al., 2020). 

The most common types of advance directives include a living will, a durable power of attorney for health care (or medical power of attorney), do-not-resuscitate/do-not-attempt-resuscitation (DNR) prescriptions, and medical/physician prescriptions for life-sustaining therapy. The AMA's (n.d.-b) Code of Medical Ethics states that providers and care teams have a responsibility to help patients define their goals of care. They must also respect patients' preferences, support self-determination, facilitate decision-making, and promote better care at the end of life. The AMA views ACP as valuable for everyone, regardless of age or health status. However, they strongly encourage ACP to be undertaken in anticipation of a deterioration in the patient's condition. Planning for decisions about care in the event of a life-threatening illness or injury gives individuals the opportunity to reflect on and express the values they want governing their care, articulate the factors that are important to them to maintain a certain QOL, and clarify any preferences they have concerning specific interventions. This may include mechanical ventilation, the creation of a tracheostomy for extended respiratory support, or the insertion of a percutaneous endoscopic gastrostomy tube for artificial nutrition. Ultimately, ACP strives to safeguard care at the end of life and ensure it is congruent with the patient's wishes and values. Case managers are excellent resources for ACP, as they are well positioned and professionally equipped to engage in meaningful ACP discussions to enhance understanding and help guide decision-making. Notably, these discussions allow the patient to identify which person(s) they would want to make decisions on their behalf if they do not have decision-making capacity. The patient must choose an individual who supports their wishes for EOL care and treatment (AMA, n.d.-a, n.d.-b; ANA, 2024; CCMC, 2019; HPNA, 2022). 

Preparing for the end of life and making decisions about treatments and preferences can be challenging and distressing for many patients and their families. However, failing to plan for these events can be even more stressful and devastating. According to the National Cancer Institute, those without predetermined and documented plans on how they would want to transition to the end of life often endure increased psychological distress and are routinely subjected to medical treatments that are incongruent with their personal preferences. In addition, families and caregivers experience heightened emotional distress accompanying the decision-making process and endure a more difficult bereavement period, along with greater costs of care and use of burdensome and expensive health care services and resources offering minimal therapeutic benefit. Each state has unique definitions and practices regarding how individual rights to determine health care treatment are guaranteed (National Cancer Institute, 2025). 

Medical Futility 

Medical futility remains a clinically relevant and controversial ethical debate surrounding EOL care. While the main controversy centers on a lack of consensus regarding a universal definition of medical futility, it is broadly used to describe clinical interventions unlikely to benefit the patient. Medical futility concerning EOL care occurs when (a) the likelihood that an intervention will help the patient is exceedingly poor, and (b) there has been a failure to achieve the goals of prolonging life and improving QOL. There is often an associated disproportionate harm-to-benefit ratio, and clinical interventions are viewed as imposing high costs or inflicting harm. While most HCPs believe ineffective treatments should not be provided during the end of life, the definition of futility is not static when applied to complex patient situations. Instead, the concept must be defined based on each patient's unique condition. In most cases, the patient should participate in the decision-making process regarding whether a particular treatment is futile (Akdeniz et al., 2021; Miller-Smith et al., 2023). 

The AMA (n.d.-b) has indicated that providers have no obligation to offer treatments that do not benefit patients. However, determining which interventions are beneficial to a patient can be difficult, especially in cases where the patient or their family or guardian considers an intervention beneficial even when the provider does not. Although the ethical requirement to respect patient autonomy entitles a patient to choose among medically acceptable treatment options (or reject all treatment options), it does not authorize patients to receive any treatment they request. Therefore, the obligations of physicians and other licensed medical providers should be limited to offering treatments that are consistent with professional standards of care and are projected to bestow clinically significant benefit to the patient at the end of life (AMA, n.d.-b; Miller-Smith et al., 2023). 

Withdrawing or Withholding Medical Interventions 

According to the AMA (n.d.-b), a competent patient with decision-making capacity has the right to decline any medical intervention or request that an intervention be stopped, even when that decision is expected to lead to death. This decision is a prime example of a patient exercising their right to autonomy. The ANA (2017) position statement on nutrition and hydration at the end of life identifies comparable views in regard to accepting or refusing clinically appropriate food and fluids delivered by either oral or artificial means. Patient (or surrogate) decisions must be respected, provided the decision is based on accurate information and represents patient preferences. If a patient lacks the cognitive ability to make care decisions, the patient's surrogate may decline an intervention or ask to stop an intervention on the patient's behalf. When an intervention is no longer helpful in achieving the patient's goals of care or desired QOL, it is ethically appropriate for providers to withdraw that care. The AMA (n.d.-b) and the ANA (2024) have mutually agreed that there is no ethical, moral, or legal difference between withholding care (i.e., never starting it) or withdrawing care (i.e., stopping it). Furthermore, decisions about accepting or foregoing nutrition and hydration should be honored, including those decisions about artificially delivered nutrition and the decision to stop eating and drinking to hasten death voluntarily. The ANA urges providers to avoid initiating a therapy they are unwilling to discontinue. As noted earlier, the patient's care team must collaborate to elicit goals of care and preferences regarding life-sustaining interventions early in the disease process to avoid complex ethical dilemmas at the end of life (AMA, n.d.-b; ANA, 2017, 2024). 

Medical Aid in Dying 

As more states pass laws legalizing medical aid in dying, media reports have often confused the topic with suicide, euthanasia, or physician-assisted suicide, but there are distinctions. Physician-assisted suicide and euthanasia are acts in which the patient dies at the hand of a physician or another medical provider: The physician performs the act at the patient's request. The American Association of Suicidology distinguishes medical aid in dying from suicide because the terminal patient wants to live but suffers from a life-ending illness. Medical aid in dying allows terminally ill adults to request and receive prescriptions for a combination of medications that they may choose to administer themselves to bring about a peaceful death. There are specific qualifications that the patient must meet, including being mentally capable of making health care decisions and being willing and able to self-administer the medication. The patient must also have a prognosis that makes them eligible for hospice care, including an average life expectancy of no more than 6 months. Currently, 11 jurisdictions in the US authorize medical aid in dying: California, Colorado, Montana, New Mexico, Oregon, Vermont, Washington, Hawaii, New Jersey, Maine, and the District of Columbia (ANA, 2019; Compassion & Choices, 2025). 

Due to the heightened media attention, the ANA (2019) put forth a position statement to guide nurses on ethical decision-making in response to a patient's request for medical aid in dying. Legally and ethically, nurses may not administer any medication with the intention of inducing a patient's death. Therefore, the ANA urges nurses to ensure their actions align with the ethical commitment to support patients in clarifying their goals of care and making fully informed decisions. However, the position statement also reminds nurses never to "abandon or refuse to provide comfort and safety measures to the patient" who has chosen medical aid in dying (ANA, 2019). The patient may request a nurse to be present when they self-administer the medications used in this process. This is often the case for hospice patients who have established a trusting relationship with their case manager and other members of the IDT. Although nurses cannot actively participate in procuring or administering the medications used to elicit patient death, they can provide compassionate care and promote patient comfort through symptom management. Before agreeing to be present, the nurse must evaluate their beliefs on the topic. The nurse must be able to support the patient's decision but does not have to share the patient's beliefs (ANA, 2019). 

Moral Distress in Nursing 

Nurses are frequently asked to guide patients and families while confronting difficult decisions and accepting death. The hallmark of high-quality EOL care is respect for patient self-determination through advocacy and the provision of nonjudgmental support for their EOL preferences and values. Nurses are obligated to provide care that promotes comfort while preventing and alleviating pain and other distressing symptoms. The ANA (2024) requires nurses to make every effort to ensure aggressive symptom management at the end of life; the Code of Ethics also indicates it is never ethically permissible for a nurse to act by omission or administer medication with the intention of ending a patient's life. This can provoke moral distress among nurses who, for example, administer the last dose of morphine sulfate to a dying patient who subsequently stops breathing. The Code of Ethics attempts to remedy the nurse's harbored emotional distress by highlighting the action as an aggressive step in pain control for the dying patient. The intention of the medication administration was not to end the patient's life. However, many nurses may experience conflicting emotions about their roles and actions. Sometimes, the family's preferences contrast with those of the patient's preferences. In these cases, the nurse's primary responsibility is to provide care and support to the patient and to respect the patient's autonomy while continuing to support the family as they struggle to adjust to the impending reality of the patient's death (ANA, 2015, 2024). 

Implications for Practice 

Despite strong evidence that patients benefit from an early integration of EOL discussions and consistent evidence that they want to talk about it, the topic is not routinely addressed. It is too often still the elephant in the room. Each prognosis affects a patient's choices about CPR, mechanical ventilation, and additional life-sustaining measures at the end of life. Informed decisions cannot be made when patients and family members are not adequately educated about the diagnosis, treatments, and EOL options. EOL discussions do not cause emotional harm to patients and their families. In fact, when the end of life and options for future care are discussed, bereaved families report higher satisfaction with communication from the care team and increased comfort for their loved ones. They also report a better understanding of what to expect as their family member dies. Patients who have EOL discussions with their provider and care team are more likely to accept their diagnosis as terminal, have advance directives in place, complete a DNR prescription, and prefer medical treatment focused on relieving pain versus extending life with futile interventions. They are more likely to choose hospice care and die at home. Prepared patients are less likely to receive mechanical ventilation, have a feeding tube, undergo resuscitation efforts, or be admitted to an intensive care unit. At the end of life, the QOL decreases with additional aggressive interventions, whereas the QOL increases with hospice care. Choosing hospice is consistently linked to improved QOL at the end of life, greater symptom control, increased emotional support, and more comfort through the dying process. Hospice is also associated with a decreased incidence of major depression in bereaved caregivers. Caregivers of patients who received aggressive care in the last weeks of life were more likely to develop major depressive disorder, experience regret, feel unprepared for the patient's death, and report poorer QOL. Patient barriers to access to palliative care include the presence of a noncancer diagnosis, a low symptom burden, nonacceptance of a terminal illness, misleading communication, conflicting care preferences, negative perceptions of palliative care, and lack of resources. A lack of expertise, poor care coordination, emotional discomfort, and poor prognostication were provider-related barriers (Hughes et al., 2019; Pitzer et al., 2024; Wachterman & Sommers, 2020). 

As HCPs communicate with patients towards the end of their lives, themes regarding hope have emerged. HCPs should first identify the patient's beliefs about hope to instill hope as it functions for that patient. As an essential component of life, hope is a promise for the future. Hope can enhance the QOL and improve connection with others. While hope requires active work from the patient, it can be fueled externally. While truth-telling is paramount, patients describe disease progression, pain and suffering, uncertainty, off-hand information delivery, and avoidance of important conversations as barriers to hope. Despite the HCP's need to offer hope for a cure, sufficient hope is often provided by adequate symptom control and the prospect of being well cared for. Information and dialogue are key between HCPs and patients and their families, especially early in the palliative pathway. HCPs should provide education to patients and their families regarding expectations, creating a "space for dying" and accepting the inevitability of death as it becomes near (Tarberg et al., 2020; Velić et al., 2023).

End-of-Life Specialty Certifications and Organizations 

Nurses often seek certification in their area of expertise, and EOL care is no different. While all nurses are expected to deliver safe, effective, and competent care to patients at the end of life, there are higher-level certifications for those wishing to demonstrate expertise in this specialty. Being certified in EOL care allows nurses to offer patients a higher level of care and additional training and experience in handling the various ethical implications of EOL care. Currently, the Hospice and Palliative Credentialing Center (HPCC) is the only nationally recognized certifying body for hospice and palliative care nurses and advanced practice registered nurses (APRNs). HPCC currently offers four different certifications in addition to their social work and nursing assistant options. 

• The Advanced Certified Hospice and Palliative Nurse certification is designed for experienced hospice and palliative care APRNs. 
• The Certified Hospice and Palliative Nurse certification is designed for experienced hospice and palliative care RNs. 
• The Certified Hospice and Palliative Pediatric Nurse is designed for experienced hospice and palliative pediatric RNs. 
• The Certified Hospice and Palliative Licensed Nurse is designed for experienced hospice and palliative licensed practical or vocational nurses (HPCC; n.d.). 

Key Points 

• The goal of EOL care is to manage symptoms and control pain to ensure the patient is as comfortable as possible throughout the dying process. 
• Best practices in ACP include having EOL discussions early in the disease progress and enhancing communication to assist patients in completing advance directives when they are psychologically, emotionally, and physically competent to make these decisions. 
• Ethics are standards of conduct that help guide complex decision-making and moral dilemmas that present during the end of life. 
• Communicating and collaborating with professional colleagues significantly improves the experiences and outcomes for patients and families at the end of life. 

References 

Akdeniz, M., Yardımcı, B., & Kavukcu, E. (2021). Ethical considerations at the end-of-life care. SAGE Open Medicine, 9. https://doi.org/10.1177/20503121211000918 

American Medical Association. (n.d.-a). Code of medical ethics: Advance directives. Retrieved February 4, 2025, from https://www.ama-assn.org/delivering-care/ethics/advance-directives 

American Medical Association. (n.d.-b). Code of medical ethics: Caring for patients at the end of life. Retrieved February 4, 2025, from https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-caring-patients-end-life 

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only 

American Nurses Association. (2017). Nutrition and hydration at the end of life. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nutrition-and-hydration-at-the-end-of-life 

American Nurses Association. (2019). The nurse's role when a patient requests medical aid in dying. https://www.nursingworld.org/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/social-causes-and-health-care/the-nurses-role-when-a-patient-requests-medical-aid-in-dying-web-format.pdf 

American Nurses Association. (2024). Nurses' role and responsibilities in providing care and support at the end of life. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/nurses-roles-and-responsibilities-in-providing-care-and-support-at-the-end-of-life 

Berger, A. M., & O'Neill, J. F. (2022). Principles and practice of palliative care and supportive oncology (5th ed.). Wolters Kluwer. 

Centers for Medicare & Medicaid Services. (2024). Medicare payment systems: Hospice payment system and coverage. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/html/medicare-payment-systems.html#Hospice 

Commission for Case Manager Certification. (2019). When everything is rarely enough: Palliative care and the power of asking the right questions. https://ccmcertification.org/workforce-development/issue-briefs/when-everything-rarely-enough-palliative-care-and-power-asking 

Commission for Case Manager Certification. (2023). Code of Professional Conduct for case managers with standards, rules, procedures, and penalties. https://ccmcertification.org/sites/ccmc/files/docs/2023/Code%20of%20Professional%20Conduct%20for%20Case%20Managers%20FINAL%202023.pdf 

Compassion & Choices. (2025). Medical aid in dying: A policy to improve care and expand options at life's end. https://compassionandchoices.org/wp-content/uploads/2024/02/medical-aid-in-dying-policy-book-2025.pdf 

Coyne, P., Lowry, S., Mulvenon, C., & Paice, J. A. (2024). American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain management at the end of life. Pain Management Nursing, 25(4), 327–329. https://doi.org/10.1016/j.pmn.2024.03.020 

Fink, R. M., Gates, R. A., & Jeffers, K. D. (2019). Pain assessment. In B. R. Ferrell & J. A. Paice (Eds.). Oxford textbook of palliative nursing (5th ed.). Oxford University Press. 

Hospice and Palliative Credentialing Center. (n.d.). Certification. Retrieved February 5, 2025, from https://www.advancingexpertcare.org/hpcc 

Hospice & Palliative Nurses Association. (2022). Core curriculum for the hospice and palliative registered nurse (5th ed.). Kendall Hunt. 

Hughes, N. M., Noyes, J., Eckley, L., & Pritchard, T. (2019). What do patients and family-caregivers value from hospice care? A systematic mixed studies review. BMC Palliative Care, 18(18), 1–13. https://doi.org/10.1186/s12904-019-0401-1 

Miller-Smith, L., Lantos, J. D., & Pope, T. M. (2023). Palliative care: Medically futile and potentially inappropriate therapies of questionable benefit. UpToDate. Retrieved February 5, 2025, from https://www.uptodate.com/contents/palliative-care-medically-futile-and-potentially-inappropriate-therapies-of-questionable-benefit 

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