Week 12: Understanding Shock: Caring for the Dying Client

Shock
1) Ineffective cardiac pump
2) Ineffective circulatory system
3) Inadequate blood volume
o inability of circulatory system to supply adequate oxygen and nutrients to tissues
o Demand for oxygen is not met by oxygen delivery
o In early shock respiratory alkalosis is found primarily due to hyperventilation.
o In late stage of shock metabolic acidosis occurs due to accumulation of organic acids (lactic acid) from anaerobic
metabolism.

Classification of Shock
 Low Blood Flow:
o Cardiogenic shock:
 MIs
 Cardiomyopathy
 Systolic dysfunction –inability of heart to pump blood forward
 Diastolic dysfunction-inability of heart to fill during diastole
 Disrythmias / Arrhythmias
 Structural factors, valvular abnormalities
o Hypovolemic:
 Absolute: loss of blood or fluid
 Eg. V&D, DI, diuresis)
 Relative: pooling of blood or fluid
 Eg. Ascites, bowel obstruction, internal bleeding, ruptured spleen, sepsis
 Fluid moves out of vascular space into extravascular space (interstitial or intracavitary),
known as third spacing
 Maldistribution of Blood Flow:
o Neurogenic
 Spinal cord injury
 Opioid overdose
 Eg. hemodynamic consequences of injury, disease or both to spinal cord at or above T5, spinal
anesthesia, vasomotor centre depression
o Anaphylactic
 Multiple transfusions
 Severe allergic reaction
 Eg. blood/blood products, insect bites, drugs, foods, vaccines, latex, environmental agents,
anesthetic agents
o Septic
 Pancreatitis
 Infection (Sepsis)
Progression of shock
 Systemic Inflammatory Response Syndrome (SIRS)
 can be triggered by both infectious and non-infectious conditions
 nonspecific and can be caused by ischemia, inflammation, trauma, infection, or a combination of several
insults
 not always related to infection
 Infection is defined as "a microbial phenomenon characterized by an inflammatory response to the
microorganisms or the invasion of normally sterile tissue by those organisms."
 Mediator excess
 Widespread epithelial injury and dysfunction
 Vasodilation and increased capillary permeability
 Tissue edema
 Neutrophil entrapment in microcirculation
 Multiple Organ Dysfunction Syndrome (MODS)
 failure of more than one organ in an acutely ill client in which homeostasis cannot be maintained without
intervention
 CV, Lung, GI, Liver, CNS, Renal, Skin

Consequences of Reduced 02 Supply

 Cellular oxygen deprivation
 Changes to cell membranes causes fluid shifts
 Na-K pump fails

4 Stages of Shock
1) Initial
o No outward signs
o Imbalance of oxygen supply & cellular demand
o Metabolism: aerobic to anaerobic
 producing adenosine phosphate anaerobically which is then converted to lactic acid
o Lactic acid builds up
 As lactic acid builds the environment becomes acidotic and cell function ceases
 Cells begin to swell and membranes become more permeable allowing easy transference of fluid
and electrolytes both in and out of cells.
 Cell death escalades until conditions improve
o Process of removal requires oxygen
 Lactic acid must be removed by the blood and broken down by the liver, this process requires
oxygen-unavailable at cellular level

2) Compensatory
o Specific to each type of shock
 Protect the body from the consequences of anaerobic metabolism and maintain BP and volume
within normal limits
o Priority is to treat underlying disorder*
o Relies upon mechanisms of homeostasis
 Mechanisms activated are specific to underlying cause
 Important to focus on treatment at the cause *
Compensated Shock
Clinical Symptom Corresponding Cause
• Tachycardia • Release of catecholamines
• Rising diastolic BP • Systemic vasoconstriction
• Weak pulse • Reduced stroke volume
• Cool peripheries, delayed capillary refill • Systemic vasoconstriction
• ↓ urine/concentrated • Blood diverted away, reabsorption of Na & H 2O
• Increased RR • ↑ HR increases O2 demand
• Nausea • Blood diverted away
• Diaphoresis • Release of catecholamines
• Increased blood sugar • Stress response, conversion of glycogen stores
• Confusion/anxiety • Stress response & catecholamine release

3) Progressive
o Compensatory mechanisms begin to fail
o Organ perfusion grossly inadequate
 Respiratory system
i. decreased blood flow & SNS stimulation
ii. the pulmonary arterioles constrict resulting in decreased blood flow to capillaries and
ventilation-perfusion mismatch.
iii. Capillary leakage results in movement of fluid into interstitial space
(bronchoconstriction)-alveolar edema. Pt develops tachypnea, crackles & increased
work of breathing.
 Cardiovascular system
i. CO falls, BP falls, perfusion to the organs is compromised and organ failure begins.
Patient may complain of chest pain, significant hypotension & arrhythmias
 Renal system
i. Hypoperfusion: kidneys-renal tubular ischemia, necrosis leading to acute renal failure:
oliguria and increasing BUN & Cr Metabolic acidosis results from an inability to excrete
acids & reabsorption of bicarbonate
 Gastro
i. GI-development of ischemia, predisposing client to erosive ulcers, GI bleed,
translocation of bacteria, decreased ability to absorb nutrients
 Liver
i. failure to metabolize drugs waste products such as ammonia and lactate-jaundice
 Hematological system
i. DIC- consumption of platelets and clotting factors with secondary fibrinolysis.
o Aggressive intervention to prevent MODS
 Failure of one organ accelerates failure of other organs unthere is MODS

4) Decompensated or Irreversible
o Death is imminent
 Profound hypotension & hypoxia
 Failure of liver, lungs and kidneys results in accumulation of waste products (lactate, ammonia,
urea and carbon dioxide)
 Failure of one organ leads to failure of several organs and compensatory mechanisms are
overwhelmed
 Respiratory and cardiac arrest are inevitable.
 Hypovolemic Shock

o Causes: loss of fluid or blood from body, third spacing of fluid or blood
o Self-preservation: compensation through homeostatic mechanisms
o Survival mechanism: increase heart rate & systemic vasoconstriction

o Hypovolemic shock: loss of intravascular fluid volume (reduction in circulating volume)

 3 types of problems:
1. Fluid can move out of blood vessels and into body spaces (eg. femur, ruptured spleen,
hemothorax)
2. Fluid can move into interstitial spaces (e.g. burns, allergic reactions, sepsis)
3. Loss of fluid from the body (e.g. blood or plasma loss, fluid loss through diarrhea, vomiting
or excessive diuresis (DM & DI).
 Symptoms generally do not appear until loss of 1/5 (adult) or 1/3 volume (infant/child)
circulating volume, which is approximately 750 ml for an adult.
 femur= 1000ml
 pelvis= 3000ml
 Abdominal injury= 2000ml
 Absolute: fluid leaves body
 Relative: fluid moves into extravascular space- interstitial, intracavitary(third spacing)

Pathophysiology of hypovolemic shock

 circulating volume  ↓ Venous return  ↓ Stroke volume  ↓ Cardiac output  ↓ Cellular O2 supply 
↓ Tissue perfusion = Impaired cellular metabolism

Note:
- Increase in HR and systemic vasoconstriction is triggered by an increase in sympathetic activity and release of
catecholamines (adrenaline & noradrenaline).
- Further compensation by kidneys: reduced blood flow results in release of renin from juxtaglomerular
apparatus, causes the conversion of inactive angiotensin to angiotensin I.
- Angiotensin I is converted to Angiotensin II (powerful vasoconstrictor) by the angiotensin converting enzyme
(ACE) in lungs. ADH is released from the posterior pituitary gland which releases aldosterone from adrenal
glands resulting in increased sodium reabsorption and indirectly water in distal tubules which increases blood
volume. This increases blood pressure

Clinical Manifestations
o Reasonable BP with up to 15% loss
 BP can be in normal range with up to 750ml loss in some clients, it cannot be the only sign when
determining fluid loss
o Look at colour, temp (to touch), HR, general state, urine output (will diminish)
 Skin color will be pallor, cool and clammy extremities, delayed capillary refill
 Patient may be nauseated as blood moves away from GI tract, absent bowel sounds
o Increased RR to rid body of lactic acid causes respiratory alkalosis = altered mental state

Collaborative Care
o Warmed fluids
o Optimize cardiac output with meds (Adrenaline, noradrenaline, dopamine)
o Optimize oxygenation
 O2 delivery is dependant on cardiac output, available hemoglobin, arterial oxygen saturation.
Increase supply and decrease demand
o Locate and correct underlying cause
o Volume replacement
 o Treatments:
 Rapid IV infusion- insertion of 2 large bore IVs (#18 or larger), central line may be required.
 Strict In & Out- need foley catheter.
 Initially crystalloids (NaCl, dextrose, RL) are used for volume losses up to 1500ml. Used for short
periods of time. Blood loss requires blood or plasma needed. Blood can be given rapidly
depending on the extent of loss. If several units required use blood warmer to prevent
hypothermia.
 Isotonic crystalloid- RL or NS, advantage of RL is it is more consistent with the physiologic
electrolyte composition. Disadvantage of large volumes of NS is that it increases hyperchloremic
metabolic acidosis.
 Colloids (Dextran, albumin, starches, gelatins), require less volume; however, more problems
associated with infection, allergic reaction, clotting problems & reports of movement of colloids
into interstitial spaces, more expensive
 Treatment is always focused on ABCs and determining underlying cause.
 BP remains low despite fluid volume replacement, vasoconstrictors are used (adrenaline,
noradrenaline, dopamine). These drugs act on both alpha and beta receptors in the peripheral
blood vessels causing them to constrict and BP to increase.

Cardiogenic Shock

o Results from heart failure

o 80% mortality
o considered “engine malfunction”
o normal compensatory mechanisms lead to ultimate heart damage
o Most common cause is the result of a myocardial infarct; 89% will occur after admission
o Other causes: cardiomyopathies, cardiac tamponade, arrhythmias, valve disease, pericardial infection, heart
failure due to drug toxicity.
o Types of MI:
 Anterior infarction= 55% (elderly, diabetics)
 Inferior infarctions= 46%
 Posterior infarctions= 21%
 Mortality rate associated with cardiogenic shock= 50-80%

Compensatory Mechanisms
o Decreased CO
 Triggers SNS
o SNS maintains BP
 Normal homeostatic mechanisms to maintain BP and circulating volume are counterproductive for
the patient in cardiogenic shock
o Counterproductive due to cardiac workload
o Pump failure = shock and impaired cellular metabolism
 Activation of SNS= in increased HR and increased cardiac contractility (stroke volume) both of which
can cause increased ischemia
 H2O retention = increased workload on heart
 Increase in SVR increase afterload –resistance which the heart has to pump against
 There is an increased demand for O2 & nutrients from a failing heart
 Impaired cellular metabolism
Clinical Manifestations
o Falling BP
o Cold, clammy skin
o Increase Na & H20 retention, oliguria
o Dyspnea – pulmonary edema
o Anxiety, confusion, agitation
o Nausea and vomiting, decrease BS
o Chest pain
o Arrhythmias
o Increase blood glucose, increase cardiac markers, increase BUN

Collaborative Care
o Patients in cardiogenic shock often require prompt revascularization, either angioplasty or CABG often preceded
by the placement of intra aortic balloon pump as a temporary measure
o Treatment of arrhythmias
o Circulatory assist
o Improve 02 deliver, increase supply
o Re-establish blood flow
o Drug therapy:
 Dilate coronary arteries – nitrates
 Improve contractility – inotropic agents dobutamine, dopamine
 Reduce pre-load – morphine, diuretics, nitrates, ACE inhibitors
 Reduce afterload – ACE inhibitors, vasodilators
 Reduce heart rate - CCB
 Reduce contractility
o Control pain – morphine
o Management aimed at improving contractility and BP, and treatment of secondary problems such as pulmonary
edema and cardiac ischemia.
o Vasodilators reduce cardiac workload, relives pain and reduces both preload and afterload
Distribution Shock
o Skin feels warm due to vasodilation
o Loss of blood vessel tone, enlargement of the vascular compartment and displacement of the vascular volume
away from heart
o Blood Volume constant-returns insufficient
o 3 different types:

Neurogenic Anaphylactic Septic

 Rare
 commonly assoiciated to trauma
to spinal cord (at or above T5 or
closed head injury)
 factors that stimulant
parasympathetic or inhibit
sympathetic
(Injury results in massive vasodilation
without compensation due to loss of
SNS vasconstrictor tone. Massive
vasodilation leads to pooling of blood
in blood vessels. Unopposed
activation of the parasympathetic
nervous system leads to bradycardia)
 spinal anaesthesia
 vasomotor centre depression:
severe pain, drugs, hypoglycemia,
injury
 Systemic allergic reaction to antigen Most common
 Occurs on second exposure to  Bacteremia leads to chemical
allergen cascade and inflammatory
 1st exposure-produce antibodies to response
allergen  At risk: elderly, neonate,
 allergen provokes defense reaction critically ill, malnourished,
immunocompromised
(Allergic reaction:  Majority gram negative (e.g.
Anaphylactic reaction: via invasive catheter;
Body produces IgE antibodies specific to abdominal surgery) & gram
an antigen. With subsequent exposure positive bacteria
the IgE binds to mast cells and basophils
resulting in a cascade of events.
• Vasodilation
• Increased vascular permeability
• Bronchoconstriction
• Increased mucous production
• Increase inflammatory mediators
are recruited to sites of antigen
interaction

Clinical Manifestations
• Bradycardia Cardio: Early Signs:
• Hypotension  chest pain, 3rd spacing  Massive vasodilation
• Poikilothermia-hypothermia Pulmonary:  Pink, warm flushed skin
• Cool or warm, dry skin  Swelling of lips and tongue  Tachycardia, bounding
• Flaccid paralysis below level of  SOB, wheezing, rhinitis, stridor pulse
lesion  Edema of larynx and epiglottis  Tachypnea
• Loss of reflex activity, bowel & Skin:  Decreased SVR
bladder function  Flushing  Elevated CO
• ↑ ICP (V, H, changed in  Puritis  crackles
behavior, progressive  Uticaria
decreased consciousness,  Angioedema Late Signs:
lethargy, neurologic deficits, Neuro:  Vasoconstriction
seizures)  Anxiety, impending doom,  Skin pale & cool
confusion  Tachycardia
 Decrease LOC, metallic taste  Hypotension
Gastro:  Changes in LOC
 Abdominal pain  Increased SVR
 Cramping  Decreased CO
 N&V  Changes in clotting
 Diarrhea dysfunction
  Metabolic & respiratory
acidosis

Collaborative Care
• Treat underlying cause
• Careful neurologic
observations (GCS)
• Monitor temp (vasodilation)
• Watch for DVT from blood
pooling
• Watch for increased ICP
 Fluid resus
 Maintain airway (intubation and
beyond)
 Withdraw antigen immediately!!
 Optimize ventilation and
oxygenation
 Drug therapy: epi, bronchodilator,
antihistamine, corticosteroids)
 Epinephrine: 1:10,000, 0.5mL
SQ/IV every5-20 minutes
depending on severity
 High flow oxygen via non-
rebreather
 Administer Diphenhydramine IM
or IV
 Education should focus on
prevention of exposure and use of
“epi-pen”. Often source of
reaction can not be determined,
referral to allergist may be
appropriate. May consider pre-
medication with prior history of
sensitivity, such as contrast dye
 (+/-) inotropes-
noradrenaline: often
requires inotropic therapy
due to ineffectiveness of
simple fluid resuscitation.
Need vasoconstrictive effect
(noradrenaline)
 correct acidosis
(If not corrected- may progress
to late septic shock with >
mortality rate (inadequate CO,
BP falls, anuria, tachycardia, pt
cold and clammy, decreased RR
and LOC)
 strict universal precautions
 identify causative organism
 early oxygenation increase
supply / decrease demand
 treating with appropriate
antibiotic
 administer IV fluid


Key Points
 Shock leads to MABP inadequate to meet demands of the tissues
 Early symptoms of shock may be subtle
 All clients at risk of deteriation-require collaborative care
 Good understanding of the pathophysiology of the different shock types
 Psychosocial support-frightening experience

Dialogue about death

 Challenges of Care
o Personal anxieties
o Uncertainty
o Lack of experience
o Death is failure/enemy
o Socialization of death- cultural differences
o Not having the answers
o Family responses
 Dying with dignity
o Experiencing dying is a mutual suffering experience
o What should I say?
o What can I do?
o What are my values and beliefs regarding death?
 Preparing for Death
 o Parse’s: persons live out their experiences on the basis of value choices
o Choices involve continuous change processes
o No standards of normality
o Nursing focus- quality of life
 End-of-life care
o Provide comfort & supportive care during the dying process
o Improve the quality of remaining life
o Help ensure a dignified death
o Full code
 Do not resuscitate (DNR)
 Order instructing health care providers not to attempt CPR
 Often requested by family
 Does not preclude the use of other forms of treatment or care
 Allow natural death (AND)
 Withholding or withdrawing treatments
 Needs a health care provider order
 Medical Assistance in Dying (MAID)
 February 6, 2015
 Supreme Court of Canada, in its landmark decision in Carter v. Canada (Attorney
General), unanimously struck down the Criminal Code prohibitions against assisted
dying under certain specific circumstances
 College of Nurses of Ontario, Guidance on Nurses’ Roles in Medical Assistance in Dying

Good Death
 Avoiding prolonged death
 Strengthening relationships with loved ones
 Relieving the burden for their loved ones
 Receiving adequate pain and symptom management
 Achieving a sense of control
o Advanced directives
 Power of Attorney for Personal Care, Expressed wishes, Advance Directives and Living Wills,
Levels of Care Forms
o Palliative Sedation
 To intentionally produce sedation to relieve intractable symptoms in last days of a client’s life
 Principle of double effect justifies use of medications that cause sedation as a adverse effect, an
unintended harm, as its primary role is to relieve suffering and not intended to hasten death
 Opioid use at end of life is often misunderstood
 Many clients do not receive adequate medication, which may lead to physical and emotional
suffering from uncontrolled pain and symptoms
 Terminally ill clients should not be concerned with physical dependence when the goal of
treatment is comfort until death

Death
o Defined as: irreversible cessation of circulatory and respiratory function
Or
o irreversible cessation of all functions of the entire brain, including the brainstem
Physical Manifestations of Approaching Death
As death approaches there is a declining oxygenation and circulation to the brain, which alters interpretation of sensory
input. There are also metabolic changes:
o Sensory:
 Hearing-last sense to disappear
 Touch-↓ sensation, ↓ perception of pain & touch
 Taste & smell- decreased
 Vision- blurring of vision, sinking & glazing of eyes, absent blink reflex, eyelids remain ½ open
o Integumentary:
 Mottling on hands, feet, arms & legs
 Cold, clammy skin
 Cyanosis-nose, nail beds & knees
 Wax-like skin very near to death
o Respiratory system:
 Increased respiratory rate
 Cheyne-stokes respirations (periods of apnea)
 Inability to cough & clear secretions (death rattle)
 Irregular breathing, gradually slowing to terminal gasps
o Urinary system:
 Gradual decrease
 Incontinence
 Unable to urinate
o Gastrointestinal:
 Slowing of digestive tract & possibility of cessation
 Accumulation of gas
 Distension & nausea
 Loss of sphincter control-incontinence
 Bowel movement may occur when death is imminent or at time of death
o Musculoskeletal system:
 Gradual loss of ability to move
 Sagging of jaw due to loss of facial muscle tone
 Difficulty speaking, swallowing
 Difficulty maintaining body posture & alignment
 Loss of gag reflex
 Myoclonus-jerking in seen in clients on large amounts of opioids
o Cardiovascular system:
 Increased heart rate, with later slowing & weak
 Irregular rhythm
 Decreased blood pressure
 Delayed absorption of drugs given IM or SC

Psychosocial Manifestations
 Altered decision making  Helplessness
 Anxiety about unfinished business  Life review
 Decreased socialization  Peacefulness
 Fear of loneliness  Restlessness
 Fear of meaningless  Saying goodbye
 Fear of pain  Unusual communication
  Vision-like experiences  Withdrawal

Physical Care (Nursing Assessment and care)

o Neurological
 assess LOC, presence of reflexes, pupil responses
o Circulation
 vital signs, skin color, and temperature
o Respiratory
 character & pattern of respirations, characteristics of breath sounds (wet)
o Gastrointestinal
 nutritional & fluid intake, bowel functioning
o Renal
 urinary output
o Skin
 skin becomes fragile and breaks down easily
o Pain:
 can be acute or chronic, physical & emotional irritations may exacerbate, Source of fear
 TX: assessment, minimize irritations, regular schedule, do not delay, alternative therapies, reassess
effectiveness
o Delirium:
 State characterized by confusion, restlessness, clouding of consciousness, incoherence, fear, anxiety,
often hallucinations. Causes: opioids, corticosteroids, underlying disease process, generally considered
reversible. May be misidentified as depression, psychosis, anger or anxiety
 TX: reversible causes (pain, constipation, urinary retention), quiet, well lit room, reorient client
frequently, reassure, touch, family presence, use of benzodiazepines, sedatives, & antipsychotics
o Pooling of secretions
 gentle oropharyngeal suctioning, side-lying, semi-prone, anticholinergic medications (scopolamine)
o Weakness & fatigue
 timing of nsg interventions, assist as needed & complete valued or desired activities, support aids for
positioning, frequent rest periods
o Myoclonus
 if distressing may need to modify drug plan, changes in opioids may decrease myoclonus
o Skin breakdown
 assess frequently, perform wound care diligently, pressure-relieving mattresses, prevent shearing
effects (proper transfer techniques), preventative strategies for skin irritations from bowel & bladder
incontinence
o Bowel patterns
 assess, monitor for fecal impaction, encourage mobility as tolerated, high fibre diet, fluids & use of
enemas, suppositories, & laxatives as required
o Urinary incontinence
 use absorbent pads, in-dwelling catheter or external catheter should be considered, appropriate
routine for incontinence care
o Anorexia, nausea & vomiting
 assess for complaints and source of stimulus, have family bring favourite meals or culturally appropriate
diets, smaller more frequent meals, consider drug modifications, administer anti-emetics as required
and before meals, frequent mouth care
Psychological Care
o Anxiety and depression
 common manifestation during EOL stage caused by a source that is not easily identified (fear, pain,
altered physiological states, drugs used in high doses)
 Encouragement, support and education may help alleviate anxiety.
 Use of both pharmalogical and non-pharmalogical methods (guided imagery, massage)
o Fear:
 associated from 3 sources:
i. Pain
 assumption of pain associated with death, pain relieving meds should be given
promptly and routinely and side effects managed, most clients want to be pain free but
have the ability to interact with others.
ii. Loneliness & abandonment-
 most want presence of a loved one or caregiver, often no words are required, just
physical presence (holding hands, touching & listening)
iii. Meaninglessness
 examining actions & regrets, life review helps to recognize value-look at positive aspects
of one’s life
o Communication
 therapeutic communication is an important nsg. Intervention, empathy & active listening. Silence allows
time to gather thoughts & organize overwhelming feelings- listening to the silence sends the message of
acceptance & comfort.
o Grief
 goals for grief resolution include client expression of feelings related to grief, acknowledgment of
impending loss, & demonstration of behaviours that reflect progress in grief resolution
 Expression of grief without guilt or judgement, know reactions are normal, respect for privacy, honesty
in providing answers, encouraging families and clients to maintain control and some aspects of normal
life
 Anger is normal response- cannot force acceptance of loss, nurses are sometimes target of anger & it
cannot be taken personally
 Feelings of hopelessness & powerlessness are usual & need to encourage realistic hopes & allow family
and client to have control over what they can control- client identified goals helps restore some sense of
power.
o As death approaches: strategies for family & nurse
o Withdrawal of client from physical environment- converse with client as if alert, using soft voice & gentle touch
o Unusual communication (restlessness, unresolved issues)- giving permission to let go
o Vision-like experiences
 affirm to the dying person, part of transition from this life
o Saying good-bye
 encourage verbalization of feelings of sadness, loss, forgiveness- touch, hugs and tears

Culturally Congruent Care

o Defined by personal and cultural values
o Acknowledgement of friends and family
o Spiritual/religious practices & rituals
o Influences decisions regarding autopsy & organ donation
 o Funeral rites- divine obligation, not merely a social function
o Gadow
o participation with the patient in determining the unique meaning which the experience of health,
illness, suffering or dying is to have for that individual
o Leininger’s theory of cultural care
o recognition and preserving of cultural rituals is necessary in providing beneficial and meaningful care.
Understanding cultural values is one step to advocacy.
Family Care: What families want
o Treat the patient & family/friends with care, dignity & compassion
o Demonstrate caring attitudes & behaviours
o Information and education
o Communication-active listening and explaining client’s condition
o Attending to spiritual & religious needs (Curtis et al, 2002)
o 5 themes reflected family caregivers description of outstanding care:
i. Non-abandonment
ii. Respect of the client
iii. Care of the family
iv. Facilitation of family process
v. Follow up of the family after death
o Symptom management
o Emotional support- including spiritual & religious support
o Provider responsiveness & consistency of care