Chapter 15: Planning for the End of Life GROWTH & DEVELOPMENT NCLEX

The _________________ ___________________ Act of 1990 is a federal law stating that acute care or long-term care facilities must provide written information to patients concerning their rights to accept or refuse treatment and make advance directives.

Omnibus Reconciliation The Omnibus Reconciliation Act of 1990 and the Patient Self-Determination Act mandates that all patients, at the time of admission, should be given written information relative to their right to refuse treatment and should be encouraged to make advance directives. DIF: Cognitive Level: Comprehension REF: p. 235

The health-care worker can support grieving families at the time of death by: a. allowing the family time to stay with the loved one after the death. b. calling the funeral home to collect the body. c. uttering consoling phrases such as "I know how you feel." d. emphasizing that the painful grieving should last less than a year.

A One of the roles of the health-care worker at the time of death is to provide support to grieving families. Providing privacy and time with the loved one after death allows family members an opportunity to see and touch the deceased, often for the last time. DIF: Cognitive Level: Application REF: p. 238

The school-age siblings of a dying child should be: a. involved in the plan of care for their sibling. b. allowed to remember the dying child as he or she was before death. c. allowed to contact their sibling only by phone. d. protected from death rituals and end-of-life care.

A Siblings should be included as much as possible in the plan of care for the dying child, so they do not feel abandoned or punished or develop a sense of sibling rivalry and, later, guilt feelings. DIF: Cognitive Level: Application REF: p. 238

The primary goal of end-of-life care is: a. comfort and care to promote death with dignity. b. protecting the dying person from needless grieving. c. implementing measures to maintain physiological functioning. d. facilitating the patient's progress through all stages of grieving.

A When modern technology and pharmacology can no longer keep someone alive, the dying person's bill of rights states that he or she has the right to die in comfort and with peace and dignity. DIF: Cognitive Level: Application REF: p. 234

The health-care worker clarifies to the family of a dying patient that palliative care includes: (Select all that apply.) a. patient-centered care b. analgesics c. oxygen therapy d. curative therapy e. laxatives

A, B, C, E Palliative care is an active total care of patients whose disorder does not respond to curative therapy, and aggressive curative efforts are not pursued. The patients are provided with comfort measures such as pain and anxiety relief, oxygen therapy, laxatives, and antinausea drugs. DIF: Cognitive Level: Application REF: p. 235

When parents ask if their school-age child should attend the funeral of their grandmother, the health-care worker would base a response on the understanding that attendance will: a. provide an closure for the child. b. be a frightening experience. c. be a deeply religious experience. d. be parents' responsibility is to protect the child from distressing events.

A

A young Cambodian man has just arrived at the hospital from the airport to find that his father has already died. His family members are all praying at the bedside. The culturally competent health-care worker would offer the young man a(n): a. white hospital gown to wear. b. small basin with soap so that he may wash his hands before praying. c. surgical cap so he may cover his head. d. opportunity to pray with the hospital chaplain.

A Cambodians wear white during their grief rituals. DIF: Cognitive Level: Comprehension REF: p. 232, Table 15-3

The best practice in promoting quality of life for a terminally ill 10-year-old child would be: a. focused on the child's chronological age. b. allowing the child to return to his or her regular classroom. c. having the child cared for only by health-care providers, who are more objective than families. d. placing the child in a health-care facility for treatment and care.

B An important understanding about quality of life for a child with a terminal illness is that they can participate in age-appropriate activities as normal, healthy children do. Attending school, even if it must be part time, helps the child and family cope with the illness. DIF: Cognitive Level: Analysis REF: p. 239, Table 15-4

Denial is a common reaction to the diagnosis of a terminal illness, because the use of this defense mechanism: a. is a maladaptive response. b. is helpful to adaptation. c. prevents a sense of hope. d. prevents the development of problem-solving behavior.

B Denial may allow the patient to function adaptively and productively through the grief process. It is helpful for gradual adaptation and does not interfere with problem-solving behavior. DIF: Cognitive Level: Comprehension REF: p. 230

A 90-year-old West Indian man is dying, and 20 family members fill the hall as they try to crowd into the room. The culturally competent health-care worker will: a. inform the family that only 3 or 4 at a time should try to be at the bedside. b. move out unnecessary furniture to make room for the family. c. direct the family to the waiting room so they will have more space. d. call the chaplain to pray with the family.

B Making room for the family at bedside is comforting to West Indian families as they prefer to be at bedside at time of death to pray for their loved one. DIF: Cognitive Level: Application REF: p. 233, Table 15-3

A psychological death occurs begins when the: a. dying person begins to discuss end-of-life rituals. b. person is informed of a terminal illness. c. terminally ill person gives up hope. d. person loses confidence in his curative protocols.

B The phenomenon of psychological death begins when the person is informed of his terminal illness and the body processes decline in function. DIF: Cognitive Level: Application REF: p. 228

The health-care worker enters the room of a patient who has just been diagnosed with a terminal illness. The son is highly agitated and tearfully screams, "I am taking my dad out of this place and take him somewhere where people actually care what happens to him!" The most helpful response would be: a. "Why don't you tell me what is really wrong?" b. "I can understand your angry feelings." c. "I'll be back when you calm down." d. "Yelling at me will not change the diagnosis."

B Therapeutic communication involves not only accepting a patient's anger and emotional outbursts but those of the family as well. DIF: Cognitive Level: Application REF: p. 229, Table 15-1

MULTIPLE CHOICE 1. The sensitive health-care worker can demonstrate therapeutic presence by: a. keeping family informed about patient's condition every hour. b. remaining near the patient and family. c. calling the chaplain to administer to the family. d. giving pain medication every 4 hours.

B Therapeutic presence can be accomplished by simply being near the patient and available. DIF: Cognitive Level: Knowledge REF: p. 228

When the treatment for a 12-year-old child with terminal cancer needs to shift from cure to palliation, the health-care worker reminds the family it is important that they should: a. tell the child that he will not have to take any more treatments. b. explain this new approach in age-appropriate terms. c. the family must understand that palliative care takes place at home. d. withhold this information from the child as it will contribute to a sense of hopelessness.

B Truthfulness and explanations in age-appropriate terms will help the child to better communicate his needs and feelings. DIF: Cognitive Level: Application REF: p. 237

MULTIPLE RESPONSE 31. The impending signs of death include: (Select all that apply.) a. thirst. b. anorexia. c. pulmonary congestion. d. flushed face. e. mottled extremities.

B, C, E Among the signs of impending death are weakness, weight loss, decreased appetite (anorexia), sweating, pulmonary congestion, altered breathing patterns, decreased urine output slowed pulse, relaxed jaw, and mottled, cold extremities. DIF: Cognitive Level: Application REF: p. 229, Box 15-1

A terminally ill person has elected to stop receiving curative treatment and has requested no cardiopulmonary resuscitation. The family is very upset by this decision and wants to override the patient's decision. The best response to the family is: a. "I will discuss your concerns with the doctor and ask her to reinstitute treatment." b. "I will discuss your concerns with your family member and try to get him to change his mind." c. "According to the dying person's bill of rights, your relative has the right to make this decision." d. "I will get the chaplain to help you accept this decision."

C According to the dying person's bill of rights, the patient has the right to participate in decisions concerning care and the right to not be judged for his or her decisions, which may be contrary to the wishes or beliefs of others. DIF: Cognitive Level: Application REF: p. 234 , Box 15-2

Patients and families progress through various stages of reactions when a diagnosis of a terminal illness is made. After the helplessness phase, a period of adjustment usually follows. This phase is characterized by: a. social reintegration. b. denial. c. guilt. d. acceptance.

C Although some patients and families never progress beyond the shock and denial stage, most go through stages of the grieving process. Anger and guilt usually follow denial, and some patients will regress to anger from time to time even though they may have reached a level of acceptance of the diagnosis. DIF: Cognitive Level: Comprehension REF: p. 230

A terminally ill patient is unresponsive and having periods of apnea. The patient's family is arguing at the bedside about where the funeral should be held. The health-care worker should: a. remind the family that this should be the patient's decision. b. ask the family members to leave the room. c. take the family members aside and explain that the patient may be able to hear them. d. tell the family members that such decisions are premature.

C Although the dying person may appear to be in a coma, hearing is the last sense to be lost. Asking the family to leave the room without an explanation is inappropriate. DIF: Cognitive Level: Application REF: p. 229, Box 15-1

When a terminally ill patient says, "I feel that death is just around the corner," the most appropriate response would be: a. "Don't talk like that. You sound as if you are giving up hope." b. "We are all going to die. No one knows when." c. "Is this feeling something you would like to talk about?" d. "Let's not talk about dying. Let's talk about living. "

C Health-care professionals need to provide an atmosphere in which the patient is able to freely verbalize feelings about death. DIF: Cognitive Level: Application REF: p. 231, Table 15-2

A terminally ill patient in hospice care says that she plans to attend her grandson's college graduation 5 months from now. This patient: a. is in denial about her condition. b. has unrealistic expectations about the length of time she has left. c. will probably live to attend the graduation. d. is only offering her family false hope and should stop planning an event so far in the future.

C Patients with a strong desire to be present at an important family event often prolong their lives until that event, then die soon afterwards. DIF: Cognitive Level: Application REF: p. 229, Table 15-1

The grieving mother whose adolescent son died last week tells the home health-care worker that her 5-year-old has begun to wet the bed. The health-care worker's most helpful response would be: a. "Your preschooler should probably be evaluated by a urologist." b. "Your son is showing a rather severe grief reaction." c. "Regression to less mature forms of behavior are not unusual after a death." d. "Don't worry about it. Bedwetting is no big deal."

C Regression is to be expected in the preschooler after a traumatic event such as death. DIF: Cognitive Level: Application REF: p. 239, Table 15-4

The document naming the person or persons who should make health-care decisions if a patient cannot make informed decisions for him- or herself is the: a. personal will. b. living will. c. durable power of attorney. d. do not resuscitate (DNR) order.

C The durable power of attorney for health care names the person who is to make medical decisions for the patient if the patient is unable to do so. DIF: Cognitive Level: Knowledge REF: p. 238

The health-care worker assesses a normal response in a dying 8-year-old boy who says: a. "I am too young to die. God is being cruel to make me die!" b. "I cry because my mom cries a lot." c. "I will miss my mom and dad, but my grandmother in heaven will take care of me." d. "After I am dead, I can come back and be with my mom and dad again."

C The school-age child may fear separation from family but envision continuation of life in another form. DIF: Cognitive Level: Comprehension REF: p. 239, Table 15-4

When caring for a terminally ill patient, health-care workers are permitted to provide interventions that: a. present the family with the means to end the dying person's life. b. actively aim to end a suffering person's life. c. relieve symptoms only if there is low risk for hastening death. d. offer pain relief to the dying person even if there is a risk death will occur.

D Analgesics, particularly opioids, should be administered around the clock to prevent pain, with dosage and schedule adjustments made as needed to maintain maximum comfort. This often requires very large doses of medication given at more frequent intervals, in accordance with the patient's wishes. DIF: Cognitive Level: Analysis REF: p. 236

A school-age child is diagnosed with a terminal illness. The parents want to protect their child from knowing the seriousness of the illness. The health-care worker should explain that: a. denial will help the child cope more effectively. b. this attitude is helpful in order to give the parents more time to cope. c. terminally ill children usually do not wish to discuss the seriousness of their illness. d. truthfulness in understandable terms is the most supportive approach.

D Children who have a terminal illness are often more aware of their condition than parents realize. Therefore, truthfulness, explained in age-appropriate terms in a supportive manner, is the best approach when providing care to a terminally ill child. DIF: Cognitive Level: Application REF: p. 237

The family of a terminally ill Hindu patient requests that all life support equipment be removed, as per the wishes of the patient, and the loved one discharged to their care at home. The health-care worker points out that: a. "This is an unrealistic request. Your family member is in no shape to go home." b. "I'm sorry, that request is against hospital policy." c. "The grief counselor can speak to you about this decision." d. "I know that you and your loved one will be more comfortable at home; I will do what I can to expedite the process."

D Hindus prefer death to occur in the privacy of their own home, where family and friends can conduct religious ceremonies without interruption. Health-care providers must demonstrate cultural competence when providing end-of-life care. DIF: Cognitive Level: Analysis REF: p. 232, Table 15-3

The health-care worker caring for a dying 78-year-old Hispanic woman understands that in Hispanic families when death is near, the family will: a. seek the spouse's advice on medical decisions. b. confirm the DNR order. c. call for the shaman to perform religious rites. d. prohibit pregnant women and children from the bedside.

D In the Hispanic culture, pregnant women and children are prohibited to be in contact with the dying person. The shaman is the holy man revered by the Native Americans. Hispanics feel DNR orders are not acceptable, and the eldest child is usually responsible for health-care decisions. DIF: Cognitive Level: Application REF: p. 233, Table 15-3

A dying patient becomes withdrawn and verbally uncommunicative. Relatives try to cheer him up, which is most indicative of: a. hopefulness. b. anticipatory grief. c. very strong support toward the patient's feelings. d. failure to recognize the patient's need to openly express his grief.

D Most dying persons are aware of the reality of their conditions. Open acknowledgment and open communication provide support during this difficult time not only to the patient, but to family, friends, and caregivers. DIF: Cognitive Level: Application REF: p. 231

As a Native American elder is dying, a young health-care worker complains to her supervisor that the eldest son is not at his father's bedside and is nowhere to be found. The culturally competent health-care worker responds: a. "He is probably making arrangements with the funeral home." b. "Because he believes it is dishonorable to watch a person die, he is not here." c. "He has gone to get the ceremonial robes for his father to wear after death." d. "He is observing his own private grieving away from his dying father."

D Native Americans avoid contact with the dying person and grieve in private, away from the person who is dying. DIF: Cognitive Level: Application REF: p. 232, Table 15-3

An 8-year-old child with a terminal illness is returning to school after having received treatment that has caused hair and weight loss. The most appropriate action by the school nurse would be to: a. recommend that the child's parents attend school at first to prevent teasing. b. refer the child to a home school program. c. discuss with the child and the parents that the child's classmates will not accept him or her as before. d. prepare the child's classmates and teachers for changes they can expect.

D Peer contact and regular school attendance should be encouraged to promote quality of life for the child with terminal illness. Classmates and teachers can be very supportive when they understand the changes they will see in the child. DIF: Cognitive Level: Application REF: p. 239, Table 15-4

The statement that best depicts the preschooler's understanding of death is: a. "My brother is in a better place now and isn't sick now." b. "It will seem funny not to play with my brother anymore." c. "My mom and dad won't have two children since my brother died." d. "I know that my brother got taken because I had a fight with him."

D Preschoolers engage in magical thinking and think that death is reversible. They frequently believe their own behavior caused the illness or death of a sibling. DIF: Cognitive Level: Analysis REF: p. 238

A terminally ill man tells the health-care worker, "I have never believed in God or in an afterlife, but now it really doesn't seem so bad." The health-care worker assesses that this man has reached the dying state of: a. denial. b. bargaining. c. depression. d. acceptance.

D The Kübler-Ross stages of dying describe acceptance as a sense of "My time has come." DIF: Cognitive Level: Comprehension REF: p. 229, Table 15-1

The best description of therapeutic communication related to terminally ill patients and their families would be that it is a(n): a. goal-directed interaction that brings about the patient's insight. b. purposeful interaction that is highly structured. c. interaction guided by the needs of the patient and the health-care worker. d. interaction that involves accepting the patient's emotional responses.

D Therapeutic communication with terminally ill patients and families involves acceptance of emotional outbursts and expressions of anger and encourages venting and verbalization. DIF: Cognitive Level: Comprehension REF: p. 228

COMPLETION 33. The health-care worker recommends the services of _____________, a community health-care organization specializing in the care of dying patients and their families.

hospice Hospice services are provided to patients and families through the death and bereavement process. The service addresses the physical, psychological, spiritual, and social needs of the dying patient. This service is available to patients in the hospital, nursing home, and in their own home. DIF: Cognitive Level: Comprehension REF: p. 239