DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
Calanipawan Road, Tacloban City, Leyte 6500
A.Y 2025-2026
4th Year, 1st Semester
END OF LIFE CARE
Submitted by: GROUP F
Leader:
Joy Abegail D. Pelpinosas
Assistant Leader:
Xyz Ani Gaia N. Olaya
Samantha J. Nicolas
Kent Jay Edward Y. Ong
Princess Charmaine O. Ong
Katrina Elizabeth L. Pace
Benedict Brian A. Pacheco
Abbie S. Pasaquian
Marianne Patrisha R. Petilla
Kygel Emmanuel S. Picson
Rose Anne M. Abello
Submitted to:
Mrs. Evelyn U. Rances, RN
August 26, 2025
1. Discuss ethical consideration in end of life care
Ethical considerations in end-of-life (EOL) care revolve around principles that guide nurses and
other healthcare professionals in making decisions that respect the patient’s dignity, rights, and quality of life
while addressing complex medical, emotional, cultural, and spiritual issues.
1. Autonomy and Informed Decision-Making
● Respect for patient autonomy means honoring the patient’s right to make decisions
about their own care, including whether to continue or withdraw life-sustaining treatment.
● Informed consent is essential: patients (or legally authorized representatives) should
receive clear, truthful information about prognosis, treatment options, risks, and benefits.
● Advance directives and Do-Not-Resuscitate (DNR) orders should be respected when
documented and verified.
2. Beneficence and Non-Maleficence
● Beneficence requires acting in the patient’s best interest to relieve suffering and provide
comfort, often through palliative care and pain management.
● Non-maleficence means avoiding unnecessary harm, such as performing aggressive
interventions with little chance of benefit (futile treatment).
● Ethical use of opioids and palliative sedation is allowed when the intention is symptom
relief, even if there’s a secondary risk of shortening life (“principle of double effect”).
3. Justice
● Fair allocation of resources (e.g., ICU beds, ventilators) becomes relevant in critical care
settings.
● Equal treatment without discrimination based on age, economic status, or diagnosis.
4. Veracity and Fidelity
● Truth-telling (veracity) is essential for trust: provide honest information about prognosis
and options while remaining compassionate.
● Fidelity involves loyalty to the patient’s expressed values, wishes, and best interests,
even when family opinions differ.
5. Cultural and Spiritual Sensitivity
● Recognize and respect cultural beliefs and religious practices related to death and dying.
● Include spiritual support and family involvement in care planning.
6. Withholding and Withdrawing Life-Sustaining Treatment
● Ethically, withholding (not starting) and withdrawing (stopping) treatment are considered
equivalent when guided by the patient’s goals of care.
● Decisions should involve the healthcare team, patient, and family, with clear
documentation and ethical consultation if conflicts arise.
7. Professional Codes and Legal Considerations
● The Code of Ethics for Nurses (e.g., PRC-BON in the Philippines) obligates nurses to
preserve life when possible, alleviate suffering, and assist towards a dignified death.
● Nurses must comply with institutional policies, laws (such as those regarding DNR
orders), and patient rights legislation.
8. Communication and Advocacy
● Open, empathetic dialogue with patients and families is key.
● Nurses advocate for the patient’s wishes, ensure ethical standards are followed, and
seek ethics consultations when dilemmas occur.
2. Discuss legal consideration in end of life care
End-of-life care involves complex legal, ethical, and clinical issues that require careful attention to
ensure that the patient's rights and wishes are respected. Nurses play a crucial role in advocating for and
ensuring the legal rights of patients in these circumstances. The following legal considerations are essential
components in providing ethical and legally sound end-of-life care.
● Advance Directives
○ Legal documents such as a living will or durable power of attorney for health care specify
a patient’s treatment preferences or designate a decision-maker. Nurses must ensure
these directives are recognized and followed in the plan of care.
○ Living Wills: A document specifying which medical treatments a patient does or does
not want at the end of life.
○ Durable Power of Attorney for Health Care: A legal designation of an individual
authorized to make medical decisions on behalf of the patient if they become
incapacitated.
■ Nurses are responsible for ensuring that advance directives are properly
executed, recognized, and followed in the plan of care. They must verify that
these documents are up-to-date and clearly communicated to the healthcare
team.
● Informed Consent
○ Any decision to start, continue, or withdraw treatment requires informed consent.
Patients or their legal representatives must be provided with complete information, and
nurses must verify understanding, voluntariness, and proper documentation.
○ Informed consent is required for any treatment, and it must be obtained voluntarily from
patients or their legal representatives. Nurses must ensure that patients are provided
with all necessary information regarding treatment options, understand the potential risks
and benefits, and consent without coercion. In cases of incapacitation, consent should
come from a legally authorized representative.
● Right to Refuse Treatment
○ Competent patients have the legal right to decline treatments such as mechanical
ventilation, dialysis, or chemotherapy, even if refusal may hasten death. Nurses must
respect this choice, explain consequences, and document refusal accurately.
● Patient’s Bill of Rights
○ The Patient’s Bill of Rights guarantees every patient humane care, privacy, and
participation in medical decision-making.
○ The law upholds every patient’s right to humane care, privacy, and participation in
decision-making. Nurses must protect these rights by ensuring dignity, respect, and the
patient’s freedom to choose or refuse care at the end of life.
● Family Involvement in Decision-Making
○ When a patient is no longer able to decide, the closest family members are recognized
as legal surrogates– usually family members—are responsible for making decisions on
their behalf. Nurses must balance the patient’s prior wishes with family input and help
resolve conflicts in decision-making.
● Legal Capacity and Competence
○ Only competent patients can make valid end-of-life choices. If capacity is lost, a legal
guardian or next of kin becomes the decision-maker. Nurses must ensure that consent or
refusal comes from the proper legal authority.
● PNPA (Philippine Nursing Practice Act, R.A. 9173)
○ The Philippine Nursing Practice Act (R.A. 9173) delineates the professional, ethical,
and legal responsibilities of nurses within the scope of nursing practice, particularly in the
context of palliative and end-of-life care. The law establishes the nurse's accountability
in promoting health, delivering palliative interventions, and safeguarding the rights of
patients throughout the continuum of care. Specifically, the Act mandates that nurses:
■ Provide Safe and Competent Care: Nurses are required to deliver care that
adheres to the highest standards of safety, ensuring that interventions,
particularly in end-of-life scenarios, are evidence-based and aligned with both
national and international best practices.
■ Uphold Ethical Standards: Nurses must demonstrate professional integrity by
adhering to ethical principles, such as autonomy, beneficence, and
non-maleficence, while delivering end-of-life care. This includes respecting the
patient’s autonomy in decision-making and ensuring informed consent is
obtained for all treatment decisions.
■ Ensure Legal Compliance: Nurses are bound to operate within the legal
parameters set forth by the Act, ensuring that their practice complies with laws
governing patient rights, documentation, and informed consent, among other
aspects.
■ Promote Holistic and Palliative Care: The Act emphasizes the nurse's role in
providing palliative care, with a focus on alleviating suffering, managing
symptoms, and enhancing quality of life for patients nearing the end of life.
Nurses must be competent in assessing and addressing physical, emotional,
spiritual, and psychosocial needs within this context.
■ Protect Patient Rights: Nurses must advocate for and uphold the rights of the
patient, including the right to make autonomous decisions about their care,
including refusal of life-sustaining treatment. The Act underscores the nurse’s
responsibility in ensuring that patient choices are respected and integrated into
the care plan.
Failure to comply with these responsibilities exposes nurses to legal liabilities and ethical
violations. The Act mandates that nurses engage in continuous professional development to
remain proficient in delivering safe, effective, and ethical care, particularly in high-stakes
end-of-life situations.
● Pain Management and Palliative Care Law (R.A. 10918)
○ Opioids and other controlled substances for pain relief are strictly regulated. Nurses
must comply with legal requirements for storage, counting, and documentation while
ensuring patients receive adequate comfort and symptom control.
● Legal Determination of Death
○ Death is legally defined as the irreversible loss of circulatory and respiratory function, or
complete cessation of brain function including the brainstem. Nurses must follow
institutional and national protocols in recognizing and documenting death.
■ Clinical Criteria for Brain Death: Verification of brain death requires
comprehensive neurological assessments, including the absence of cranial nerve
reflexes (e.g., no pupillary response to light, no corneal reflex), apnea tests, and
confirmation of no spontaneous respiratory effort despite elevated carbon dioxide
levels. Documentation of these findings must be signed by two physicians
independent of the patient's treatment team.
■ Cardiopulmonary Death: In cases where brain death is not applicable, death is
determined based on irreversible cessation of circulatory and respiratory
functions. This may require confirming the absence of a pulse, respiration, and
blood pressure for a specified period (e.g., 5–10 minutes) before declaring death.
■ Institutional Protocols: Institutions often have specific guidelines, such as
required waiting periods for confirmation of death and documentation steps
that include nursing and physician sign-offs. These protocols ensure compliance
with legal standards and proper communication to family members.
● Confidentiality and Privacy
A patient’s medical information remains legally protected even after death. Nurses are required
to maintain confidentiality and release information only to authorized individuals.
● Documentation
Accurate, complete, and timely charting of interventions, patient responses, and family
communications is a legal safeguard. Proper documentation provides evidence of care and
protects the nurse from liability.
● Hospital and Institutional Policies
Nurses must comply with institutional protocols on withdrawal of treatment, resuscitation, and
post-mortem care. Following these policies ensures legal compliance and protects the
healthcare team from liability.
3. Explain Advance Health Directives:
● Do Not Resuscitate
● Euthanasia, aid in dying
● Organ Donation
Advance Health Directives are legal and ethical documents that allow patients to express their wishes
regarding medical treatment and care, especially when they are no longer able to communicate. In critical care
settings, these directives guide nurses and healthcare teams in making decisions that respect the patient’s
autonomy, dignity, and quality of life.
Do Not Resuscitate (DNR) Order
A Do Not Resuscitate (DNR) order is a medical directive that instructs healthcare providers not to
perform cardiopulmonary resuscitation (CPR) if a patient’s heart stops beating or if they stop breathing. It does
not mean that all treatments are withheld, as patients under a DNR order may still receive medications, oxygen
therapy, pain management, and other comfort measures to ensure quality of life. The main purpose of a DNR
order is to prevent unnecessary suffering, particularly when CPR is unlikely to restore meaningful life, such as
in cases of terminal illness or severe debilitation. In critical care nursing, the nurse’s role involves ensuring that
the DNR order is clearly documented, advocating for the patient’s expressed wishes, and providing
compassionate communication and support to both the patient and their family.
Euthanasia and Aid in Dying
Euthanasia is the intentional act of ending a patient’s life to relieve suffering, usually carried out by a
healthcare provider through the administration of lethal medication. In contrast, Aid in Dying, also known as
Physician-Assisted Dying or Death with Dignity, involves a physician providing the means, such as a
prescription for lethal drugs, but the patient self-administers it. Although these practices remain illegal in many
countries, including the Philippines, they are explored in critical care nursing as part of discussions on ethical
dilemmas in end-of-life care. Such issues often revolve around the conflict between respecting patient
autonomy and preserving the sanctity of life, as well as considering professional values, and religious or
cultural beliefs. While nurses do not participate in euthanasia, their role is crucial in delivering palliative and
comfort care, ensuring effective pain management, and offering emotional support to both patients and their
families.
Organ Donation
Organ donation is the process of giving one’s organs or tissues, either after death or in some cases
while alive, to help save or improve another person’s life. Advance directives may include a patient’s decision
to donate specific organs or tissues. In critical care settings, organ donation is considered when a patient has
been declared brain-dead or when death is imminent, and the family is counseled about the patient’s wishes.
The nurse’s role involves: ensuring that the patient’s documented wishes regarding donation are honored,
facilitating timely referral to organ procurement organizations, maintaining the physiologic stability of potential
donors to preserve organ viability, and providing compassionate support to families during decision-making.
Organ donation reflects respect for patient autonomy, promotes altruism, and can bring meaning to end-of-life
care by allowing patients to extend life to others.
4. Responsibilities of the nurse in End of life care and organ donation.
END-OF-LIFE CARE:
A. Clinical Responsibilities
● Recognize symptoms and provide interventions for pain, dyspnea, nausea, constipation,
and other distressing symptoms.
● Ensure primary palliative care skills are applied to improve patient and family
experience.
● Collaborate with interdisciplinary teams (palliative care, ethics, legal, risk management).
● Support advance care planning such as discussing advance directives, DNR.
B. Ethical Responsibilities
● Respect patient autonomy, dignity, and self-determination.
● Support decision-making based on clinical realities.
● Be knowledgeable about state laws and institutional policies regarding end-of-life care.
● Avoid actions intended to deliberately end life.
C. Communication and Advocacy
● Provide honest, compassionate communication to patients, families, and surrogates.
● Guide families through difficult decisions
● Advocate for patient preferences, even if these conflict with family wishes.
● Initiate and support anticipatory counseling about death, dying, and care goals.
D. Family and Holistic Support
● Address psychological, interpersonal, and spiritual dimensions of care.
● Include children/adolescents in age-appropriate discussions when relevant.
● Provide bereavement support before and after death.
● Recognize and manage nurses’ own moral distress when caring for dying patients.
E. Professional Development
● Pursue continuing education in palliative and end-of-life care.
● Advocate for system-level support for palliative care services.
● Contribute to research and best practices in end-of-life nursing.
ORGAN DONATION:
1. Early Identification and Referral
○ Recognize potential organ donors (e.g., brain death, imminent death).
○ Notify the organ procurement organization (OPO) as per hospital policy.
2. Provide Accurate Information
○ Educate family members about organ donation options in a clear and compassionate way.
○ Avoid pressuring families; respect their decisions.
3. Support Family Decision-Making
○ Provide emotional support to grieving families during consent discussions.
○ Respect cultural and religious beliefs about donation.
4. Maintain Donor Viability
○ Ensure the physiological stability of potential donors (maintain circulation, oxygenation).
○ Administer medications and monitor vital signs as ordered.
5. Legal and Ethical Responsibilities
○ Adhere to legal requirements (consent, documentation).
○ Respect confidentiality and ethical principles of beneficence and non-maleficence.
6. Collaboration with the Transplant Team
○ Coordinate with physicians, transplant coordinators, and other healthcare members.
○ Assist in preparing the body for organ retrieval.
7. Post-Donation Care
○ Support the family after donation (grief counseling, follow-up support).
○ Provide dignified care to the donor’s body after organ retrieval.
REFERENCES:
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.
Morton, P. G., Fontaine, D. K., Hudak, C. M., & Gallo, B. M. (2018). Critical care nursing: A holistic approach
(11th ed.). Wolters Kluwer.
Nurses’ roles and responsibilities in providing care and support at the end of life. (2018, June
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nurses-roles-and-responsibilities-in-providing-care-and-support-at-the-end-of-life/
Republic Act No. 9173. (2002). Philippine Nursing Act of 2002. Official Gazette of the Republic of the
Philippines. https://www.officialgazette.gov.ph/2002/10/21/republic-act-no-9173/
Republic Act No. 10918. (2016). Philippine Pharmacy Law. Official Gazette of the Republic of the Philippines.
https://www.officialgazette.gov.ph/2016/07/21/republic-act-no-10918
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