Chapter 37- The Experience of Loss, Grief, and Death

Mr. Jones' young daughter died in a tragic car accident one year ago. Mr. Jones states that he still looks for his daughter when he drives by the playground of her former school and that he often misses work because of lack of sleep and intense feelings of grief. As a nurse, you understand that the type of grief Mr. Jones is experiencing is identified as a. anticipatory grief. b. complicated grief. c. delayed grief. d. disenfranchised grief.

ANS: B Complicated grief is characterized by distressing symptoms lasting at least six months following the death of a significant loved one and occurs with a sudden, unexpected death.

While working with patients in a hospice setting, the nurse is aware that certain symptoms are particularly common among patients near the end of life. Which of the following health problems should the nurse anticipate among dying patients? a. Peripheral edema b. Dyspnea c. Anemia d. Peripheral neuropathy

ANS: B The most common symptoms at the end of life include pain and shortness of breath.

In which scenario is hospice care provided? a. Only in the homes of the terminally ill b. For any terminal illness that requires symptom control c. For cancer patients only in their last weeks of life d. In hospital settings based on the seriousness of the illness

ANS: b Hospice care is provided in a variety of settings, including home care, freestanding inpatient units, hospitals, long-term care facilities, and prisons, as well as to the homeless, for patients with any disease or illness that has been determined to be life-limiting (prognosis of 6-month survival).

A nurse's role when communicating with a physician caring for a dying patient is a. to make him or her see the situation correctly. b. to carry out his or her orders. c. to advocate for the patient's wishes. d. to suggest an appropriate course of action.

ANS: C A major role of the nurse, in any setting, especially when a patient is dying is to advocate for his or her wishes related to end-of-life care.

A nurse is caring for a patient in the acute care setting who has a do-not-resuscitate order in place. The family approaches the nurse as he or she is walking down the hall and says, "I think my mother has died." To facilitate acceptance of the death by the family, an important nursing intervention is to a. notify the physician that death has occurred while in the room with the family. b. ask another nurse to come into the room to confirm that death has occurred. c. assess the patient for pulse, respirations, or blood pressure with the family present. d. check that the cardiac monitor that was in place still has the appropriate leads attached.

ANS: C Experienced nurses will intuitively know when death has occurred, but the act of placing the stethoscope on a patient's chest and listening for heart sounds while assessing for any respiratory effort can act to confirm, thus facilitate the acceptance of death by family members who may have been present at the time of death.

Rather than simply providing physical care to patients, hospice was designed to a. reduce hospital bills for families. b. provide better psychosocial care. c. improve a patient's quality of life. d. allow families control over the decision making for alert elders.

ANS: C The goal of hospice care is to provide comfort and support to terminally ill patients and their families.

Advanced directives a. provide relief from pain and other distressing symptoms, affirm life and regard dying as a normal process, and intend to neither hasten nor postpone death. b. authorize someone to make decisions about property after the person is deceased. c. are programs that provide comfort and supportive care for terminally ill patients and their families. d. are legal documents that allow people to communicate their wishes about what type of medical care they would like to receive at the end of life

ANS: D Advance directives are legal documents that allow people to communicate their wishes about what type of medical care they would like to receive at the end of life.

What is the palliative care team's primary obligation for the patient with severe pain? a. Providing postmortem care. b. Teaching about grief stages. c. Enhancing the patient's quality of life. d. Supporting the family after the death.

Enhancing the patient's quality of life.

To best assist a patient in the grieving process, which of the following is most helpful to determine? a. Previous experiences with grief and loss b. Religious affiliation and denomination c. Ethnic background and cultural practices d. Current financial status.

a. Previous experiences with grief and loss

On entering a room the nurse sees the patient crying softly. What is the most therapeutic response? a. Using silence b. Asking, "Why are you crying today?" c. Using therapeutic touch d. Stating, "I see that you're crying."

d. Stating, "I see that you're crying."

When planning care for the dying patient, which interventions promote the patient's dignity? Select all that apply. a. Providing respect b. Viewing patients as a whole c. Providing symptom management d. Showing interest e. Being present f. Using a preferred name

a. Providing respect b. Viewing patients as a whole d. Showing interest e. Being present f. Using a preferred name

Which factors influence a person's approach to death? Select all that apply. a. Culture b. Age c. Spirituality d. Personal beliefs e. Previous experiences with death f. Gender g. Level of education h. Degree of social support

a. Culture c. Spirituality d. Personal beliefs e. Previous experiences with death

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. Which type of grief is she experiencing? a. Normal b. Complicated c. Chronic d. Disenfranchised

a. Normal

A nurse has the responsibility of managing a deceased patient's postmortem care. Which of the following is the proper order for postmortem care? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed. a. 9, 1, 2, 4, 3, 5, 7, 8, 6 b. 6, 9, 2, 5, 7, 3, 1, 4, 8 c. 8, 4, 1, 3, 5, 2, 6, 7, 9 d. 2, 1, 5, 3, 7, 9, 4, 8, 6

b. 6, 9, 2, 5, 7, 3, 1, 4, 8

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? a. Use therapeutic techniques when communicating with the patient. b. Allow the patient to determine timing and scheduling of interventions. c. Encourage family to only visit for short periods of time. d. Provide the patient with a private room close to the nurse's station.

b. Allow the patient to determine timing and scheduling of interventions.

A family member of a dying patient talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? a. Denial b. Anticipatory grief c. Yearning and searching d. Dysfunctional grief

b. Anticipatory grief

Which comment to a patient by a new nurse regarding palliative care needs to be corrected? a. "Even though you're continuing treatment, palliative care is something we might want to talk about." b. "Palliative care is appropriate for people with any diagnosis." c. "Only people who are dying can receive palliative care." d. "Children are able to receive palliative care."

c. "Only people who are dying can receive palliative care."

A young mother is dying of breast cancer with bone metastasis and tells the nurse, "My body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis for this patient? a. Spiritual Distress related to questioning God b. Hopelessness related to terminal diagnosis c. Pain related to disease process d. Anticipatory Grief related to impending death

c. Pain related to disease process

Mr. S. has recently lost his wife of 56 years after she had been diagnosed with terminal pancreatic cancer. Which of the following focused assessment questions is appropriate to ask when you suspect that Mr. S. may be experiencing dysfunctional grief? a. "How would you describe your feelings about the loss of your wife?" b. "Do you feel that your sense of loss has gotten worse over the last year?" c. "Do you have any religious or spiritual beliefs that have helped you during this time of loss?" d. "What types of support do you have during this time?"

ANS: B Dysfunctional grieving includes more focused questions that help the nurse to identify potential patterns of coping that are not healthy for the individual experiencing grief and include: worsening grief, dysfunctional or unhealthy coping strategies, and an inability to function in activities of daily living.

The nurse recognizes the value of hospice care in promoting quality of life at the end of life. Which of the following older adult patients reflects an eligible requirement for hospice care? a. A patient who is immobilized due to injuries and unable to afford specialized nursing care b. A patient who experienced a stroke and has been given 3 months to live c. A patient with cancer who is living with uncontrolled persistent pain d. A patient with acquired immunodeficiency syndrome (AIDS) who lacks family support to provide needed care

ANS: B Hospice care is provided to any patient who has a terminal diagnosis of six months or less to live and needs care to meet symptom control needs and quality-of-life concerns.

The best way for a new nurse to cope with his or her own feelings related to death, loss, and grief while caring for patients is to a. emotionally distance him or herself from dying patients and their families immediately after death has occurred. b. provide ongoing bereavement support to families of patients who have died. c. develop a beginning awareness of his or her own fears, feelings, responses, and reactions to death and dying. d. discuss feelings of loss with family members and friends as a way to cope with loss in the workplace.

ANS: C To effectively care for the dying, nurses need to explore their personal feelings regarding death.

A newly graduated nurse is assigned to his first dying patient. The nurse is best prepared to care for this client if he: a. Completed a course dealing with death and dying b. Is able to control his own emotions about death c. Experiences the death of a loved one d. Has developed a personal understanding of his own feelings about death

ANS: d d. When caring for clients experiencing grief, it is important for the nurse to assess his own emotional well-being and to understand his own feelings about death. The nurse who is aware of his own feelings will be less likely to place personal situations and values before those of the client.

A grieving patient complains of confusion, inability to concentrate, and insomnia. What do these symptoms indicate? a. These are normal symptoms of grief. b. There is a need for pharmacological support for insomnia. c. The patient is experiencing complicated grief. d. These are common complaints of the admitted patient.

a. These are normal symptoms of grief.

What are the physical changes that occur as death approaches? Select all that apply. a. Unresponsiveness b. Erythema c. Mottling d. Restlessness e. Increased urine output f. Weakness g. Incontinence

a. Unresponsiveness c. Mottling d. Restlessness e. Increased urine output f. Weakness

When providing postmortem care, which action is a priority for the nurse? a. Locating the patient's clothing b. Providing culturally and religiously sensitive care in body preparation c. Transporting the body to the morgue as soon as possible d. Providing postmortem care to protect the family of the deceased from having to view the body

b. Providing culturally and religiously sensitive care in body preparation

As a nurse, you evaluate how an individual is progressing through the process of grief, loss, and mourning and understand that a grieving individual is functioning effectively if he or she is a. using distraction as a coping mechanism while avoiding contact with former friends who have not experienced a loss. b. dealing with conflict by avoiding those family members who appear to be coping effectively. c. able to express his or her feelings of loss and grief to close friends only when in social situations. d. able to accept assistance and support of friends and family as needed during the time of loss and grief.

ANS: D Outcomes identified for the process of loss and grief include: talking about the loss and the meaning of the loss, expressing feelings appropriate to the loss, identifying factors that may affect the grieving process, which include healthy coping strategies and support systems, and accepting assistance from friends, family, and significant others during the process of grief and bereavement.

The nurse is using Bowlby's phases of mourning as a framework for assessing the client's response to the traumatic loss of her leg. During the "yearning and searching" phase, the nurse anticipates that the client may respond by: a. Crying off and on b. Becoming angry at the nurse c. Acting stunned by the loss d. Discussing the change in role that will occur

ANS: a a. During the "yearning and searching" phase of Bowlby's phases of mourning, the nurse anticipates that the client may have outbursts of tearful sobbing and acute distress.

Hospice nursing care has a different focus for client. The nurse is aware that client care provided through a hospice is: a. Designed to meet the client's individual wishes, as much as possible b. Usually aimed at offering curative treatment for the client c. Involved in teaching families to provide postmortem care d. Offered primarily for hospitalized clients

ANS: a a. The nurse's role in hospice is to meet the primary wishes of the dying client and to be open to individual desires of each client. The nurse supports a client's choice in maintaining comfort and dignity.

The nurse is orienting new staff to a clinical unit that provides palliative care. A new employee asks what "grief" is exactly. Which statement indicates that the nurse has correctly defined grief? a. The emotional response to a loss b. The outward, social expression of a loss c. The depression felt after a loss d. The loss of a possession or loved one

ANS: a Grief is the emotional response to a loss that is an individualized and deeply personal feeling related to a real or perceived loss. The outward, social expression of a loss is bereavement. Depression is not a normal response to loss, although there are many emotional feelings that occur related to a loss. The loss of a possession or a loved one is considered an actual loss.

The nurse caring for a dying patient understands that "nearing death awareness" is occurring when the patient asks which question? a. "Where are my shoes? I need to get ready for the trip." b. "Is my daughter from California going to come and visit before I die?" c. "When do you think that I am going to die?" d. "How much longer can I live without food or water?"

ANS: a Nearing death awareness has been described as a state manifested by a special communication of the dying that may occur in patients who are approaching death or are imminently dying.

While caring for a female patient with advanced multiple sclerosis, the nurse is discussing the difference between hospice and palliative care. Which statement by the patient indicates understanding of the difference between hospice care and palliative care? a. "I will need to get hospice care if I want my symptoms controlled." b. "I can get palliative care right now—even though I am not going to die anytime soon." c. "My doctor has to make the decision if I have hospice care." d. "I can't get any other treatments, even if they are experimental if I choose palliative care."

ANS: b Hospice care and palliative care are focused on the management of symptoms. Hospice care is provided to those who have a prognosis of less than six months to live. Palliative care is provided to any person who needs assistance with management of symptoms. Physicians delineate the prognosis, but the patient and family ultimately make the decision if they want care provided by hospice.

A client has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the client states, "I wonder why this happened to me?" According to Kübler-Ross, the nurse identifies that this stage is associated with: a. Anxiety b. Denial c. Confrontation d. Depression

ANS: b b. According to Kübler-Ross, the client is in the denial stage of dying. The client may act as though nothing has happened, may refuse to believe or understand that a loss has occurred and may seem stunned, as though it is "unreal" or difficult to believe.

A nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client is to: a. Limit fluids b. Position the client upright c. Reduce narcotic analgesic use d. Administer bronchodilators

ANS: b b. Positioning the client upright is an independent nursing intervention for the promotion of respiratory function in a terminally ill client.

To promote comfort for the terminally ill client specific to nausea and vomiting, the nurse should: a. Provide prompt mouth care b. Offer high-protein foods c. Increase the fluid intake d. Offer a high-residue diet

ANS: b b. To promote comfort for the terminally ill client specific to nausea and vomiting, the nurse should administer antiemetics, provide oral care at least every 2 to 4 hours, offer clear liquid diet and ice chips, avoid liquids that increase stomach acidity such as coffee, milk, and citrus acid juices, and offer high-protein foods in smaller portions and of a bland nature.

In caring for a dying patient, what is an appropriate nursing action to increase family involvement? a. Insisting that all bedside care be performed by the family b. Asking family members what they would like to do for their loved one and allowing them to participate c. Expecting the family to be able to perform the patient's daily needs and to meet them consistently d. Refusing all assistance from the family, to decrease family stress

ANS: b Many family members would like to be involved in the care of their loved one while the person is dying. It is the responsibility of the nurse to assess the level of involvement in which the family would like to participate related to patient care.

An identified outcome for the family of the client with a terminal illness is that they will be able to provide psychological support to the dying client. To assist the family to meet this outcome, the nurse plans to include in the teaching plan: a. Demonstration of bathing techniques b. Application of oxygen devices c. Recognition of client needs and fears d. Information on when to contact the hospice nurse

ANS: c c. A dying client's family is better prepared to provide psychological support if the nurse discusses with them ways to support the dying person and listen to needs and fears.

The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. The nurse should: a. Have the client first discuss the subject with the family b. Suggest the client delay making a decision at this time c. Assist the client to obtain the necessary information to make this decision d. Contact the physician so consent can be obtained from the family

ANS: c c. No topic that a dying client wishes to discuss should be avoided. The nurse should respond to questions openly and honestly. As client advocate, the nurse should assist the client to obtain the necessary information to make this decision.

A client who is Chinese American has just died on the unit. The nurse is prepared to provide after death care to the client and anticipates that the probable preferences of a family from this cultural background will include: a. Pastoral care b. Preparation for organ donation c. Time for the family to bathe the client d. Preparation for quick removal from the hospital

ANS: c c. Some families of Chinese Americans will prefer to bathe the client themselves. They often believe the body should remain intact; organ donation and autopsy are uncommon.

The nurse is working with a client on an inpatient hospice unit. To maintain the client's sense of self-worth during the end of life, the nurse should: a. Leave the client alone to deal with final affairs b. Call on the client's spiritual advisor to take over care c. Plan regular visits throughout the day d. Have a grief counselor visit

ANS: c c. Spending time to let clients share their life experiences, particularly what has been meaningful, enables the nurse to know clients better. Knowing clients then facilitates choice of therapies that promote client decision-making and autonomy. Planning regular visits also helps the client maintain a sense of self-worth, because it demonstrates that he or she is worthy of the nurse's time and attention.

Which statement is true regarding advance directives? a. Advance directives apply only when the person has a chronic illness. b. Advance directives should be drawn up by family members of people who are incompetent. c. Discussion of advance directives is a nursing responsibility. d. Advance directives should be kept in a safety deposit box until the person dies.

ANS: c Advance directives go into effect when a person has a terminal illness and is unable or incapable of making decisions for themselves.

The mother of two children, 8 and 10 years of age, has just experienced the death of her mother, the children's grandmother. The mother is concerned about the emotional impact attending the funeral may have on her children. She asks the nurse what she should do in relation to her children attending the funeral. What is the nurse's best response? a. "Take them to the funeral—they need closure, and seeing their grandma in the casket will assist them in knowing that she has died and will not return. Many children attend funerals in today's society." b. "Do not take them to the funeral—they are too young to be exposed to the emotions that are demonstrated at funerals. Many children who attend funerals have adverse psychological reactions." c. "Talk to your children about how they feel about attending the funeral and encourage them to ask questions and talk about their concerns. If they want to go, they will need to be prepared for what will happen at the funeral." d. "Talk to your children about what your mother meant to you and how much she cared for them as her grandchildren and then see if they really want to attend the funeral. If they want to go it is okay to take them."

ANS: c Caregivers should be encouraged to openly and honestly answer any questions the child may have as they are evaluating the child's responses to the loss while determining whether the child should attend the funeral of a family member.

The nurse has been caring for a 65-year-old male patient who has just died. In planning for follow-up bereavement care, the nurse knows that which person is at risk for disenfranchised grief? a. A daughter who lives in a different state b. The son who was with the client when he died c. An estranged ex-wife of the patient who lives nearby d. The 16-year-old grandchild of the patient

ANS: c Disenfranchised grief, a term coined by Kenneth Doka, may occur with any loss that is not validated or recognized. This type of grief is encountered when a loss is experienced that cannot be openly acknowledged or publicly shared by the grieving person. An ex-wife who has been estranged from the deceased may not be able to openly express the grief that she may feel over the loss of someone who once played a significant part in her life. Other family members, such as a daughter who lives in another state, a son who has been active in the patient's care, or a grandchild, are able to openly express their grief and are viewed by society as having an acceptable grief response.

Several theorists have identified stages of the grieving process. The nurse understands these stages and knows that people progress through them in an individualized manner. Which statement is true regarding the steps of the grieving process? a. There is a definite "timetable" or period of time specific to each stage of the grieving process. b. Nursing interventions are generalized across all stages of the grieving process. c. Tasks to be achieved at each stage have been identified by each theorist. d. There is a common stepwise progression through each stage of the grieving process.

ANS: c Each stage of the grieving process has associated tasks that allow successful grieving to occur on an individualized basis.

The nurse is discussing future treatments with a client who has a terminal illness. The nurse notes that the client has not been eating and responds to the nurse's information by saying, "What does it matter?" The most appropriate nursing diagnosis for this client is: a. Social isolation b. Spiritual distress c. Denial d. Hopelessness

ANS: d d. A defining characteristic for the nursing diagnosis of hopelessness may include the client stating, "What does it matter?" when offered choices or information concerning him or her. The client's behavior of not eating also is an indicator of hopelessness.

A nursing intervention to assist the client with a nursing diagnosis of Sleep pattern disturbance related to the loss of spouse and fear of nightmares should be to: a. Administer sleeping medication per order b. Refer the client to a psychologist or psychotherapist c. Have the client complete a detailed sleep-pattern assessment d. Sit with the client and encourage verbalization of feelings

ANS: d d. A nursing intervention to facilitate grief work is to offer the client encouragement to explore and verbalize feelings of grief. This encouragement refocuses the client on current needs and minimizes dysfunctional adaptation behaviors (e.g., not sleeping) by facilitating resolution of grief through problem-solving skills.

The nurse recognizes that anticipatory grieving can be most beneficial to a client or family because it can: a. Be done in private b. Be discussed with others c. Promote separation of the ill client from the family d. Help a person progress to a healthier emotional state

ANS: d d. The benefit of anticipatory grief is that it allows time for the process of grief (i.e., to say good-bye and complete life affairs). Anticipatory grief allows time to grieve in private, to discuss the anticipated loss with others, and to "let go" of the loved one. Anticipatory grief can help a person progress to a healthier emotional state of acceptance and dealing with loss.

Which of the following is the primary concern of the nurse for providing care to a dying client? The nurse should: a. Promote optimism in the client and be a source of encouragement b. Intervene in the client's activities of daily living and promote as near normal functions as possible c. Allow the client to be alone and expect isolation on the part of the dying person d. Promote dignity and self-esteem in as many interventions as possible

ANS: d d. The focus in planning nursing care is to support the client physically, emotionally, developmentally, and spiritually in the expression of grief. When caring for the dying client, it is important to devise a plan that helps a client to die with dignity and offers family members the assurance that their loved one is cared for with care and compassion.

The nurse is preparing to assist the client in the end stage of her life. To provide comfort for the client in response to anticipated symptom development, the nurse plans to: a. Decrease the client's fluid intake b. Limit the use of analgesics c. Provide larger meals with more seasoning d. Determine valued activities and schedule rest periods

ANS: d d. To promote comfort in the terminally ill client, the nurse should help the client to identify values or desired tasks and then help the client to conserve energy for those tasks.

The nurse has been caring for a patient who has just died. What is the preferred outcome in caring for the body after death? a. Make sure the body is sent to the morgue within an hour after death. b. Have the family members participate in the bathing and dressing of the deceased. c. Notify in person or by phone all family and team members immediately after the patient's death. d. Demonstrate respect for the body and provide a clean, peaceful impression of the deceased for the family.

ANS: d Demonstrating respect for the deceased maintains the dignity of that person and also can help the family in the grieving process.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks if the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? Select all that apply. a. Palliative care and hospice are the same thing. b. Palliative care is for any patient, any time, any disease, in any setting. c. Palliative care strategies are primarily designed to treat the patient's illness. d. Palliative care relieves the symptoms of illness and treatment. e. Palliative care selects home health care services.

b. Palliative care is for any patient, any time, any disease, in any setting. d. Palliative care relieves the symptoms of illness and treatment.