The prevailing paradigm promotes the proposition that a properly informed terminal patient will refuse "futile" medical treatment in favor of a "Good death" surrounded by family, in the comfort of their own bed. This may accurately portray the preference of many Americans but it certainly does not reflect the outcome experienced by most patients. Nor does the current bias for withholding or withdrawing "futile" treatment invalidate a patient's preference for aggressive life support.

The place where Americans actually die is influenced by a number of factors including: individual preference, cultural beliefs, access to care, age, cause of death, social support, race, ethnicity, health insurance coverage and services used around the time of death. The Health, United States, 2010 indicates that there has been a shift away from prolonged in-hospital life support toward out-of-hospital death. This data indicates that at least 65% of U.S. residents are in the care of nurses at the end of their lives.

Science continues to extend lifespan. As our population ages, chronic incapacitating disease and pain management along with end of life care have become important quality of life indicators. In addition, intensive care science can regularly sustain physiologic activity for extended periods even after brain death. To acknowledge the patient's right to self determination even in the event of incapacitation, every state has devised some form of advanced directive. Advance directives are legally recognized orders which give voice to a patients' health care preferences in the event that they are unable to communicate.

End of life treatment choices are among the most difficult decisions a patient and family must make. Nursing is in an ideal position to assist the patient/family to navigate the challenges of end of life care. Respecting and supporting a patient/family's informed end of life preference is a core principle of patient advocacy. Healthcare workers must be knowledgeable about end of life options and sensitive to patient/family preferences if they are to facilitate the “Good death” that everyone hopes for.

This course will examine the shift from curative to palliative treatment and professional advocacy for the right of patient autonomy in the health care setting. Emotional, psychosocial, spiritual and family issues will be followed by pain management, ethical and legal issues and options for care. Problems and prospects for the future, as well as specific state laws will conclude the offerings in this course.

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From 1989 to 2007 the number of U.S. hospital inpatient decedants over the age of 65 declined by 14%.


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