Phil is a 63-year-old man who is admitted to the inpatient oncology unit for severe pain resulting from metastatic small cell lung cancer. His wife and two daughters are at his bedside. Earlier in the day, the medical oncologist discussed additional treatment options or hospice care. Phil decided on comfort care with the hope of getting his pain managed and going home on hospice.

Jenni is the oncology nurse assigned to care for Phil and his family. The family becomes emotionally distraught as Phil’s condition begins to deteriorate and asks Jenni what can be done to help relieve his suffering. One of the daughters angrily says, “Doesn’t anyone here know how to care for someone who is dying?”

What Would You Do?

When a patient is actively dying, nurses’ attention may also acutely focus on the family’s emotional needs. Oncology nurses can help family members understand the difference between actual suffering and what is a natural part of the dying process. For example, a patient’s family may be concerned that the patient is not getting enough fluids. The nurse can explain how hydration by mouth or IV can lead to fluid overload and make it more difficult for the patient to breathe. By providing the family with methods for keeping the mouth moist, the nurse empowers them to aid in the care of their loved one.

CARES, an acronym-organized tool, can help nurses identify and address some of the most common needs patients have as they approach death: comfort, airway, restlessness, emotional support, and self-care. The evidence-based CARES tool explains the physiologic changes associated with dying, details specific interventions to address patients’ needs, and presents self-care strategies for managing grief.

Using the CARES Tool

Jenni uses the CARES acronym to detail how Phil’s needs will be addressed and gives the family some simple methods for providing comfort care. She explains how pain medications work and how they will be given to provide comfort. She tells the family to watch for any twitching in Phil’s arms or legs, an indication that pain medications may need to be changed. She actively involves them in his care. Jenni also teaches the family how to moisten Phil’s mouth and explains the decreased need for hydration and food as the body begins to shut down.

The CARES tool helps Jenni further educate the family on what to expect during the dying process, what the nurses will do to address Phil’s needs, and, importantly, what the family can do to provide comfort for their loved one and for themselves.

Resources, including the CARES tool, can be downloaded from the City of Hope website. The CARES tool has three versions: healthcare providers, supportive care staff, and family and friends of the dying. The Final Journey booklet can be given to a family to help guide them in understanding the unique needs of the dying and how they can help promote a peaceful experience for their loved and themselves.

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