End-of-Life Care for CNAs

Palliative care and hospice care share the same goal of comfort, but they apply at different points in an illness. Palliative care is comfort-focused care that can be provided at any stage of a serious illness, even while the resident is still receiving curative treatments such as chemotherapy, dialysis, or surgery. It addresses pain, nausea, fatigue, anxiety, and spiritual distress. A resident can receive palliative care for years and continue trying to recover from their underlying disease.

Hospice care is a specific type of palliative care reserved for residents whose physician has certified a prognosis of six months or less if the illness runs its normal course, and who have chosen to stop pursuing curative treatment. The focus is entirely on quality of life, symptom control, and emotional and spiritual support for the resident and the family. Hospice can be delivered in the home, a nursing facility, an assisted-living community, or an inpatient hospice unit.

The Medicare hospice benefit covers nursing visits, aide visits, medications related to the terminal illness, durable medical equipment, counseling, and bereavement services for the family for up to a year after the death. It is structured as two 90-day benefit periods followed by an unlimited number of 60-day periods, with the physician recertifying eligibility before each one. If a resident lives longer than expected, hospice does not end as long as the terminal prognosis remains.

In her 1969 book On Death and Dying, Dr. Elisabeth Kübler-Ross described five emotional responses commonly seen in people facing death and in those grieving a loss. The stages are denial, anger, bargaining, depression, and acceptance, often remembered by the abbreviation DABDA. The model is widely used to help caregivers understand what a resident or family member might be feeling, and the NNAAP exam frequently tests your ability to recognize each stage.

It is critical to remember that these stages are not a fixed timeline. A person may skip stages, revisit them, or experience two or three at the same time. The resident may be in acceptance while their adult daughter is still in anger. A spouse may move from bargaining to depression and then circle back to denial after a bad night. Your job is never to push someone toward the 'next' stage; grief is not a checklist.

The CNA's role across all five stages is simple but powerful: be present, listen without judgment, and resist the urge to fix what you are hearing. If a resident says, 'I'm not really dying, the doctors made a mistake,' you do not argue. If a family member snaps at you over a wrinkled sheet, you do not take it personally. Sit with them, acknowledge their feelings, and report meaningful emotional changes to the nurse or social worker.

The body shuts down gradually, and the changes you observe in the final days and hours follow a recognizable pattern. Recognizing these signs allows you to provide better comfort care, prepare the family, and avoid unnecessary interventions. Families are often frightened by what they see, and a calm, knowledgeable CNA who can quietly say 'this is a normal part of the process' provides enormous reassurance. Always report new changes to the nurse so the care plan can be updated and the family kept informed.

Early signs include decreased appetite and thirst, increased sleeping, withdrawal from conversation, and disinterest in television, food, or visitors the resident once enjoyed. As death approaches, breathing patterns change. Cheyne-Stokes respirations are cycles of deep, rapid breaths followed by long pauses (apnea) of 10 to 30 seconds. You may also hear a gurgling or rattling sound called the 'death rattle,' caused by saliva and secretions pooling in the throat because the resident can no longer swallow or cough effectively.

Circulation slows in the final hours. The skin may become mottled, with purplish, blotchy patterns appearing first on the knees, feet, and hands. The extremities feel cool, the nail beds may look bluish, and urine output drops dramatically and becomes dark. Some residents experience terminal restlessness, picking at the sheets, moaning, or seeming agitated. Hearing is believed to be the last sense to fade, so continue to talk to the resident in a soft, reassuring voice even when they no longer respond.

Comfort is the entire goal of end-of-life care, and small acts matter enormously. Repositioning is still important to prevent pressure injuries, but as the resident becomes actively dying, the standard 'every two hours' rule is balanced against the burden of disturbing someone who is finally settled. Follow the nurse's guidance and the resident's response. If turning causes grimacing, moaning, or agitation, less frequent, gentler repositioning with pillows for support may be more appropriate than rigid scheduling.

Dry mouth is one of the most common sources of discomfort at the end of life. Provide frequent oral care with a soft swab, moisten the lips with lip balm or a damp cloth, and offer ice chips or sips of water only if the resident can still swallow safely. Glycerin or commercial mouth-moistening swabs can be used per facility policy. Keep the eyes moist with artificial tears if ordered, since residents who sleep with their eyes partly open are prone to dryness.

Pain control is a nursing responsibility, but you are the eyes and ears that make it possible. Watch for nonverbal signs such as grimacing, guarding, restlessness, moaning, rapid breathing, or a furrowed brow, and report them immediately. Never withhold a pain medication the nurse has scheduled because you are afraid it will 'speed things up.' Properly ordered pain control is ethical, legal, and humane. Keep the room quiet, the lighting soft, and continue speaking gently to the resident throughout your care.

When you believe a resident has died, do not panic and do not announce it to the family. Step out, find the nurse, and report your observations: 'I do not feel a pulse, I do not see breathing, the resident is not responsive.' The nurse, not the CNA, pronounces death and notifies the physician, the family, and the funeral home or coroner. While you wait for the nurse, stay calm, dim the lights, and offer the family privacy. Document the time you noticed the change and what you observed.

Once death is pronounced, postmortem care begins. Tubes, IVs, and catheters are usually removed by the nurse unless the death is being investigated or the body is being donated. Position the body supine with the head slightly elevated on a pillow to prevent discoloration of the face. Close the eyes gently, replace dentures if appropriate, and place a small rolled towel under the chin if needed to keep the mouth closed. Bathe the body, comb the hair, and dress it in a clean gown or per facility policy.

Apply identification tags as required by your facility, usually one on the wrist and one on the ankle or the shroud. Gather the resident's personal belongings, place them in a labeled bag, and give them to the family. Allow the family as much time at the bedside as they need before the body is transported to the morgue or funeral home. Speak quietly, move gently, and treat the body with the same respect and dignity you showed the living resident.

Every culture and faith tradition has its own beliefs about death, the body, and grief. You are not expected to memorize the rituals of every religion in the world. You are expected to ask, listen, and accommodate respectfully. A simple question like 'Are there any traditions or practices we should know about for your family?' opens the door. Document the family's wishes in the care plan and share them at shift change so the entire team can honor them.

Some examples you may encounter on the job and the NNAAP exam: Jewish tradition often requires that the body not be left alone after death, prohibits embalming, and calls for burial as soon as possible, sometimes within 24 hours. Islamic tradition typically requires the body to be washed by a family member of the same gender and wrapped in a plain white cloth. Catholic residents may want a priest to perform the Anointing of the Sick (formerly called Last Rites) and may wish to hold a rosary or crucifix.

Buddhist families may request quiet meditation at the bedside and ask that the body not be moved for a period after death to allow the consciousness to depart peacefully. Hindu families may light a lamp, place sacred basil or water in the mouth, and prefer that family members care for the body. Many Native American traditions involve smudging with sage, specific songs, and avoiding disturbing the body. When in doubt, pause, ask, and follow the family's lead. Cultural humility is part of competent, compassionate care.