Chapter 08: Concepts of Care for Patients at End of Life

After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates that the client correctly understands the teaching? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."

"An advance directive will specify what I want done when I can no longer make decisions about health care." An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want to be taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's residence or financial matters.

A nurse plans care for a client who is nearing end of life. Which question will the nurse ask when developing this client's plan of care? a. "Is your advance directive up to date and notarized?" b. "Do you want to be at home at the end of your life?" c. "Would you like a physical therapist to assist you with range-of-motion activities?" d. "Have your children discussed resuscitation with your primary health care provider?"

"Do you want to be at home at the end of your life?" When developing a plan of care for a dying client, consideration would be given for where the client wants to die. Different states have different laws regarding legal requirements for advance directives, but this would not take priority over establishing client preferences. A physical therapist would not be involved in end-of-life care. The client would discuss resuscitation with the primary health care provider and children; do-not-resuscitate status would be the client's decision, not the family's decision.

A nurse teaches a client who is considering being admitted to hospice. Which statement does the nurse include in this client's teaching? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is not designed to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

"Hospice care focuses on a holistic approach to health care. It is not designed to hasten death, but rather to relieve symptoms." As both a philosophy and a system of care, hospice care uses an interprofessional approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire an around-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."

"I have some of her favorite hymns on a CD that I could bring for music therapy." Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client's inner restlessness. Hiring an around-the-clock sitter does not demonstrate that the client's family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.

An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How will the nurse respond? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the primary health care provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

"I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." The nurse validates the family's concerns and provides accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about their purpose. If the client's family asks for specific information about euthanasia, legal, or religious issues, the nurse would provide unbiased information about these topics.

A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How would the nurse respond? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your spouse comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your spouse onto the side."

"I will have another nurse assist me to turn your spouse onto the side." The choking sound or "death rattle" is common in dying clients. The nurse acknowledges the spouse's concerns and provides interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. The nurse would not minimize the spouse's concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client and may cause agitation.

A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How does the nurse respond? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."

"Let him know that food is available if he wants it, but do not insist that he eat." Anorexia often causes distress in family members. When family members understand that the client is not suffering from hunger and is not "starving to death," they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family and contributes to client discomfort.

A nurse discusses palliative care with a client and the client's family. A family member expresses concern that the loved one will receive only custodial care. How will the nurse respond? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."

"The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." Palliative care provides an increased level of personal care designed to manage symptom distress. It does not specifically relieve the family's burden of caring for a client at home. It is not a place where only pain medications are given. The client is involved in this discussion so the nurse would not state he or she is unaware of surroundings. The goal of palliative care is to improve the quality of life for the patient and the family.

A nurse is caring for a dying client whose adult child confides frequent crying episodes to the nurse. How does the nurse respond? a. "It's normal. Most people move on within a few months." b. "Whenever you start to cry, distract yourself with pleasant thoughts of your parent." c. "You should try not to cry. Your parent will be in a better place soon." d. "Your feelings are completely normal and may continue for a long time."

"Your feelings are completely normal and may continue for a long time." Everyone grieves and mourns differently. The nurse would offer support to the client and family during this time. By telling the adult child that the feelings are normal and may continue, the nurse is providing support to whatever the person is feeling. The other statements all show lack of compassion and respect to the family member's feelings.

A nurse cares for a dying client. Which manifestation of dying does the nurse treat first? a. Anorexia b. Pain c. Nausea d. Hair loss

Pain Only symptoms that cause distress for a dying client would be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client's comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they would be treated only if the client is distressed by their presence. The nurse would treat the client's pain first.

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action will the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure the primary health care provider completed the death certificate. d. Request family members to prepare the client's body for the funeral home.

Ask family members if they would like to spend time alone with the client. Before moving the client's body to the funeral home, the nurse asks family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first would ask family members if they would like to be alone with the client. The client's family would not be expected to prepare the body for the funeral home but they could be asked if they wish to provide some care such as brushing the hair.

A nurse admits an older adult client to the hospital. Which criteria does the nurse use to determine if the client can make his or her own medical decisions? (Select all that apply.) a. Can communicate treatment preferences. b. Is able to read and write at an eighth-grade level. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information. e. Has completed an advance directive. f. The family states the client can make decisions.

Can communicate treatment preferences. Is oriented enough to understand information provided. Can evaluate and deliberate information. To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented × 4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client's level so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to. The family may or may not be correct in stating the client is capable, but the nurse would listen openly to their statements.

A nurse teaches a client's family members about signs and symptoms of approaching death. Which of the following does the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities b. Long periods of insomnia c. Increased respiratory rate d. Decreased appetite e. Congestion and gurgling f. Incontinence

Decreased appetite Congestion and gurgling Incontinence Common physical signs and symptoms of approaching death include coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion? a. Roman Catholic—autopsies are not allowed except under special circumstances. b. Christian—upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth. c. Judaism—a person who is extremely ill and dying should not be left alone. d. Islam—an ill or a dying person should receive the Sacrament of the Sick.

Judaism—a person who is extremely ill and dying should not be left alone. According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest usually performs the Sacrament of the Sick for ill or dying people.

A nurse is caring for a client who has lung cancer and is dying. Which prescription does the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol metered dose inhaler every 4 hours PRN for wheezes c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate enema once a day PRN for impacted stool

Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 Pain medications would be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The dying client should not have to request medications for serious pain. The other medications are appropriate for this client.

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this clients pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the clients feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine.

Play music that the client enjoys. Rub lavender lotion on the clients feet. Complementary therapies for pain management include massage therapy, music therapy, therapeutic touch, guided imagery, and aromatherapy. Nurses would not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.

A nurse assesses a client who is dying. Which sign or symptoms does the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0-10 scale

Respiratory rate Although all of these assessments would be performed during the dying process, periods of apnea and Cheyne-Stokes respirations indicate that death is near. As peripheral circulation decreases, the client's level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, the nurse would continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

A hospice nurse is caring for a dying client and family members. Which interventions does the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent. f. Allow the client and family to voice concerns and fears.

Teach family members about physical signs of impending death. Encourage the management of adverse symptoms. Encourage reminiscence by both client and family members. Allow the client and family to voice concerns and fears. The nurse would teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family's loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether the client's religion is the same. The nurse shows presence by allowing the client and family members to voice their fears and concerns openly.