please create a nursing care plan for terminal ill case who is planning dying in place in OAH, the nursing care plan should include :Diagnosis, assessment, planning, intervention, evaulation

Below is a nursing care plan for a terminally ill patient choosing to die in place at home in Oʻahu, Hawaiʻi. It follows the nursing process: Nursing Diagnosis, Assessment, Planning, Interventions, and Evaluation. It assumes the patient is receiving hospice or hospice-coordinated end-of-life care at home, and that the plan is individualized to the patient’s goals and preferences .

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Nursing Care Plan: Terminal Illness — Dying in Place (Home, Oʻahu)

Nursing Diagnoses: Top 3 Priorities

1. Risk for Ineffective Breathing Pattern related to terminal disease process, dyspnea, or retained secretions .
2. Chronic Pain / Acute Pain related to disease progression and end-of-life symptom burden .
3. Grieving, Anticipatory — patient and family related to terminal prognosis and impending loss .

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Assessment: Subjective & Objective Data

Domain	Assessment Findings to Collect
Physical	Pain level using a numeric or behavioral scale, respiratory effort, breath sounds, cough or secretions, bowel and bladder function, skin integrity, edema, nausea, appetite, hydration status, and other comfort-related symptoms .
Psychosocial	Patient’s stated goals for dying at home, family caregiver availability and stress level, emotional concerns, preparedness for death, and cultural or spiritual preferences .
Environmental / Safety	Home layout, bathroom accessibility, hospital bed or equipment needs, caregiver coverage, emergency plan, medication storage, and whether needed documents such as DNAR or comfort-focused orders are visible in the home .
Hawaiʻi-specific	Confirm hospice involvement and clarify that the hospice provider retains professional management responsibility for services related to the terminal illness . Assess whether the patient has questions about Hawaiʻi’s medical aid-in-dying option, which is available to eligible Hawaiʻi residents with a terminal illness and six months or less to live .

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Planning: SMART Goals

Goal	Target
Comfort	Patient reports pain at an acceptable level, such as ≤ 3/10 if consistent with the patient’s goal, and comfort improves within 48 hours of medication or care-plan adjustments .
Breathing	Patient and family report that breathing appears comfortable, with dyspnea managed according to comfort-focused goals rather than cure-focused targets .
Psychospiritual	Patient and family verbalize understanding of the expected dying process and express emotional concerns to the nurse, social worker, chaplain, or other team member as desired .
Home Safety	Patient remains at home without unwanted or unplanned hospital transfer, when consistent with the patient’s goals and clinical needs .
Family Support	Primary caregiver demonstrates understanding of comfort medications, when to call hospice or the nurse, and how to respond to common signs of decline .

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Nursing Interventions

1. Dyspnea & Respiratory Management

• Position patient in semi-Fowler’s or side-lying with the head elevated to support comfort and ease of breathing .
• Use comfort-focused measures such as a fan, calm environment, pacing of activity, and reassurance when these align with the patient’s preferences .
• Administer hospice-prescribed medications for dyspnea or anxiety-related air hunger according to the written plan of care and agency protocol .
• Use oxygen if it has been prescribed for comfort, while recognizing that the goal at end of life is relief of distress rather than normalization of numbers .
• Provide gentle oral care and repositioning, and avoid burdensome interventions that do not improve comfort .
• Collaborate with the hospice nurse or prescriber to adjust medications for terminal secretions if noisy breathing appears distressing to the patient or family .

2. Pain & Symptom Control

• Assess pain using a validated numeric, verbal, or behavioral scale, and reassess after each intervention .
• Administer scheduled and breakthrough analgesics as prescribed, and promptly report uncontrolled pain to the hospice nurse or prescriber .
• Monitor for common end-of-life symptoms such as nausea, constipation, shortness of breath, sleeplessness, and agitation, and implement the prescribed comfort plan .
• Use non-pharmacologic comfort measures such as gentle repositioning, oral care, lip balm, warm blankets, quiet presence, massage if desired, and reduced environmental stimulation .
• Maintain skin integrity with pressure relief, moisture management, and gentle handling during turns or hygiene care .

3. Emotional & Spiritual Support

• Use therapeutic presence and active listening during each visit, allowing silence and emotional expression without rushing the patient or family .
• Encourage life review, legacy work, prayer, music, storytelling, or other personally meaningful practices if the patient desires .
• Offer chaplaincy, social work, or culturally appropriate spiritual support through the hospice or care team .
• Honor cultural preferences, including ʻohana involvement, home-based rituals, prayer, or other practices requested by the patient and family, as long as they are safe and consistent with the patient’s wishes .
• Communicate clearly and sensitively that the focus of care is comfort when death is expected soon .

4. Family Caregiver Education & Support

• Teach caregivers common signs of approaching death, such as increased sleeping, decreased intake, changes in breathing, decreased urine output, coolness, mottling, and reduced responsiveness .
• Provide the 24/7 hospice or on-call nursing number and instruct the family to call before seeking emergency transfer if the goal is to remain at home .
• Instruct caregivers on safe administration, documentation, and storage of prescribed comfort medications .
• Review when and how to give PRN medications according to the written plan of care .
• Encourage caregivers to report distress, exhaustion, uncertainty, or fear so the team can adjust support and consider respite or additional visits when available .
• Prepare the family for what to do at the time of death, including whom to call and what paperwork should be accessible .

5. Coordination with Hawaiʻi End-of-Life Resources

• Confirm that a Hawaiʻi hospice or appropriate end-of-life care provider is involved and that the written plan of care reflects the patient’s goal to remain at home .
• Clarify team roles, including nursing, prescribing clinician, social work, chaplaincy, aide services, and family caregiver responsibilities .
• If the patient asks about medical aid in dying, provide neutral information and refer to the appropriate Hawaiʻi resources and prescribing clinicians, because Hawaiʻi residents who meet eligibility criteria may voluntarily request medical aid-in-dying medication .
• Ensure advance care planning documents, DNAR orders, and comfort-focused instructions are completed, signed when required, and placed where emergency responders and caregivers can find them .
• Coordinate equipment, medications, and after-hours support early so the home environment can support the patient’s preference to die in place .

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Evaluation: Ongoing, Each Visit

Outcome Criteria	Met?	Notes
Pain controlled at the patient’s stated acceptable level	☐ Yes ☐ No	Titrate or report to hospice prescriber if comfort goal is not met.
Dyspnea not causing distress; patient or family reports breathing is comfortable	☐ Yes ☐ No	Consider additional prescribed medication, positioning, fan, or calming measures.
Patient remains at home according to stated goals	☐ Yes ☐ No	Review emergency plan and reinforce hospice or nurse phone triage.
Family can verbalize at least three signs of approaching death and demonstrate one PRN medication process	☐ Yes ☐ No	Re-teach as needed and involve social work if anxiety is a barrier.
Patient and family report feeling heard and supported	☐ Yes ☐ No	Increase chaplain, nursing, social work, or other supportive visits as needed.

Revisions: Update the care plan whenever the patient’s condition, goals, symptoms, or family caregiving capacity changes, and coordinate changes through the hospice or interdisciplinary care team .

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Key Hawaiʻi-specific notes: Hawaiʻi hospice rules state that the hospice provider retains professional management responsibility for services related to the terminal illness . Hawaiʻi’s medical aid-in-dying law has been effective since January 1, 2019, for eligible adult Hawaiʻi residents with a terminal illness and six months or less to live who meet the law’s requirements . The care plan should remain comfort-focused, culturally respectful, and aligned with the patient’s preference to die at home whenever safely possible .