What are the primary nursing diagnoses for an elderly adult in the terminal phase of a life‑limiting illness (e.g., advanced cancer, end‑stage organ failure, severe neurodegenerative disease) receiving end‑of‑life comfort care?

Primary Nursing Diagnoses for End-of-Life Comfort Care

The primary nursing diagnoses for elderly adults in the terminal phase focus on comfort, symptom management, and preservation of dignity, with the overarching goal of preventing distressing symptoms rather than prolonging life. 1

Core Nursing Diagnoses

Acute/Chronic Pain

• Pain assessment and management is the foundational nursing diagnosis, particularly in patients who cannot verbally communicate discomfort 2
• Use behavioral pain scales for non-verbal patients and treat with opioids as needed to achieve comfort 2
• Pain control should be aggressive and prioritized over concerns about respiratory depression when comfort is the primary goal 1

Impaired Comfort

• Overall comfort and prevention of distressing symptoms are the primary goals at end of life 1
• This encompasses physical, emotional, spiritual, and environmental comfort needs 1
• Comfort measures should be considered standard practice and the default strategy, even when formal consent cannot be obtained 1

Risk for Imbalanced Nutrition: Less Than Body Requirements

• Comfort feeding only should be provided—tube feeding does not improve outcomes in advanced disease and contradicts comfort-focused goals 2
• Decreased oral intake is part of the natural dying process and should be accepted 2
• Dietary restrictions should be eliminated to allow patient food preferences 1
• Artificial hydration is not indicated in the terminal phase 2

Ineffective Breathing Pattern/Impaired Gas Exchange

• Dyspnoea indicates poor short-term prognosis (weeks) and requires comfort-focused management 1
• Manage respiratory distress with comfort measures and medications as needed 2
• Address secretions with scopolamine, atropine, or glycopyrrolate 2

Anxiety/Fear

• Behavioral symptoms require environmental modifications first, followed by pharmacologic intervention when necessary 2
• Use lorazepam for agitation or low-dose antipsychotics for severe distress 2
• Midazolam is the preferred agent for palliative sedation due to its short half-life and rapid onset 1, 3

Deficient Knowledge (Patient/Family)

• Initiate conversations regarding goals and intensity of care before crisis situations occur 1
• Discussions should include the patient's condition, prognosis, treatment options, and shift from curative to comfort-focused goals 1, 3
• Address suffering across all domains and provide ongoing education to family caregivers 2

Decisional Conflict

• Advance care planning should be completed to ensure goal-concordant medical care 1
• Document patient preferences, designate durable power of attorney, and complete POLST forms when appropriate 1
• Patient and family wishes should be respected wherever care is provided 1

Medication Management Considerations

Simplification of Regimens

• Discontinue medications not contributing to comfort, including statins, antihypertensives, and strict glycemic control agents 1, 2
• Strict glucose and blood pressure control are not necessary and reduction of therapy is appropriate 1
• Withdrawal of statins in palliative care improves quality of life 1

Diabetes-Specific Management

• For Type 2 diabetes, discontinue all medications if there is no oral intake 1, 2
• For Type 1 diabetes, maintain a small amount of basal insulin to prevent acute hyperglycemic complications and DKA 1
• Glucose targets should prevent hypoglycemia and severe hyperglycemia only (100-180 mg/dL fasting, 110-200 mg/dL postprandial) 1
• Avoid A1C monitoring—it has no role in end-of-life care 1

Psychosocial and Spiritual Nursing Diagnoses

Spiritual Distress

• Engage chaplaincy or spiritual care services based on patient/family values 2
• Address the patient's sense of meaning, purpose, and legacy 4

Anticipatory Grieving (Family)

• Provide bereavement support resources and anticipatory grief counseling 2
• Inform family members of the patient's condition and the natural dying process 1, 3

Risk for Caregiver Role Strain

• Offer appropriate support to families and respect their preferences 1
• Ensure interdisciplinary team involvement with regular communication 2

Care Coordination Priorities

Continuity of Care

• Avoid hospitalizations for acute events unless absolutely necessary for comfort 2
• Reassess symptom burden and adjust interventions at each visit 2
• Management should be multidisciplinary with strategy discussed among all involved parties 1

Common Pitfalls to Avoid

• Do not pursue aggressive interventions that compromise comfort or quality of remaining life 3
• Do not withhold opioids or benzodiazepines due to respiratory depression concerns when comfort is the priority 1, 3
• Do not maintain dietary restrictions or pursue artificial nutrition/hydration in the terminal phase 1, 2
• Do not delay palliative sedation discussions until crisis situations when consent becomes impossible 1
• Do not continue medications for disease prevention (statins, tight glycemic control) that do not contribute to immediate comfort 1, 2