Chapter 43: Loss, Grief, and Dying

The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family regarding terminal weaning?

"All efforts will be taken to make sure your loved one is comfortable and out of pain." A common and valid concern of families during terminal weaning is to make sure the client is not suffering. As such, the nurse's role is to educate the family regarding comfort measures, such as pain medication and additional sedation. It is inaccurate to tell the family that the client will no longer be able to breathe once the tube is removed. The client may continue breathing for several hours to days. When a decision is made to terminate mechanical ventilation, it should be clear that reintubation is no longer an option and death is inevitable. The nurse must be honest with the family, as the client may be aware of loved ones in the room and talking to the client is encouraged.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

"Can you tell me about why you've made this decision?" Having the client explain his decision-making process is open-ended and allows exploration of the client's feelings. A competent client is not required to continue with treatment that has been initiated. The other options are closed-ended and stop any further conversation.

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

"In hospice care, the nurses make most of the care decisions for the clients." The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life.

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?

"Sometimes a person returns to a previous stage." Kübler-Ross (1969) studied the responses to death and dying. Her findings are as follows: Sometimes a person returns to a previous stage; the stages of dying may overlap; the duration of any stage may range from as little as a few hours to as long as months; the process varies from person to person.

The nurse is caring for a woman with terminal breast cancer. Which statement made by the client reflects the bargaining stage of grief?

"Please, let me live long enough to see my grandchild." Bargaining occurs as a client seeks to delay a dreaded event. For example, the client bargains with a higher power for enough time to see the grandchild. The statement, "Why is this happening now? I will never see my grandchild" indicates frustration and anger. Depression is evident in the statement, "I do not care about anything. Just let me sleep." Acceptance occurs when the client comes to terms with the loss and begins to detach from supportive people. As such, the statement, "I may not see my grandchild here on Earth, but I will in the afterlife" shows acceptance.

The new hospice nurse is reviewing the concepts of loss and grief with the preceptor. Which statement leads the preceptor to believe that the nurse has an understanding of grief and loss?

"The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." Normal expressions of grief may be physical, emotional, social (feeling detached from others and isolating oneself from social contact), and spiritual. Grief is an internal emotional reaction to loss and occurs with loss caused by separation (e.g., divorce) or by death. Clients lamenting their loss of youth are demonstrating a type of perceived loss, which is intangible to others. Situational losses are experienced as a result of unpredictable events; a child going to college would be a maturational loss for the parent.

The nurse visits a client in the home who is at the end stage of life from stage IV colon cancer and observes that the client is in obvious pain. The nurse asks the spouse when the client last had medication for pain and the spouse reports withholding the pain medication, fearing the client will become addicted. How should the nurse respond to the spouse?

"The fear of addiction should not prevent the client from obtaining adequate pain relief so let us discuss the schedule of medication." The fear of addiction is a very real issue, not only for family members but also for health care providers. The fear of addiction should not interfere with the client's ability to obtain adequate pain relief, and the family member should be educated or re-educated regarding this philosophy. The nurse should work with the spouse to form a schedule for administration so that there is not a period of time when the client is suffering from pain. Admonishing the spouse is nontherapeutic and will cause feelings of guilt. The spouse does not have the intention of creating suffering for the client but is uninformed. Stating that it makes no difference because the client is dying is a callous and insensitive comment as well as non-therapeutic. When the nurse discusses a parent, the comment deflects from the actual issue with the client and does not create an educational climate.

A client comes to the hospital because of complications related to newly diagnosed terminal cancer. The client is concerned about how his wife is coping with the diagnosis. Which information is important for the nurse to obtain to assess factors that may affect the family member's grief? Select all that apply.

- Financial concerns - Cultural practices - Social support - Religious beliefs Many factors, including socioeconomic position, cultural and religious influences, and social support affect a person's reaction to, and expression of, grief. The socioeconomic position is the financial elements and how it affects treatment. Cultural and religious influences may impact the client and client's wife ability to belong to a larger entity and have empathy with others. Social support also provides empathy for the client and client's wife. Like the stages of grief reaction, these factors vary from person to person. Previous relationships may be a part of healing and working through the stages of grief but it is not important for the assessment.

Applying Engel's models of grief, place the phases below in the order in which they would occur from first to last

- Shock and disbelief - Developing awareness - Restitution - Resolving the loss - Idealization - Outcome Engel (1964), one of the first to study grief, proposed six phases of grief: (a) shock and disbelief, (b) developing awareness, (c) restitution, (d) resolving the loss, (e) idealization, and (f) outcome.

A nurse is explaining the preparation of a death certificate to a student nurse. Which statements accurately describe this process? (Select all that apply.)

- U.S. law requires that a death certificate be prepared for each person who dies. - A physician's signature is required on a death certificate. - It is the nurse's responsibility to ensure that the physician has signed a death certificate. - A death certificate is signed by the pathologist, the coroner, and others in special cases. Death certificates are required in all deaths in the U.S., must be signed by a physician, and the pathologist or coroner. The nurse must ensure that death certificates are signed. Death certificates are sent to local health departments. The mortician handles and files death certificates.

Which statement regarding perceptions of death by children is accurate?

At about age 9, the child perceives death as irreversible. At about 9 years of age, the child's concept of death matures, and the child perceives death realistically as irreversible, universal, inevitable, and natural.

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing?

Denial By making this statement, the client denies the seriousness of the malignant tumor diagnosis. Denial is often the first emotion the client will experience, as initially it helps in coping with the reality of impending death. There is nothing in the client's statement to indicate anger or acceptance. Bargaining would be indicated by the client negotiating with a higher power to extend life or delay the inevitable.

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief?

Depression Depression is a commonly accepted form of grief and it represents the emptiness when the client realizes the person or situation is gone or over. Signs and symptoms may be withdrawn, sadness, crying, and flat affect. Denial is the stage where client may disregard that the news of diagnosis or death is not true. Anger is the stage where the client may think "why me?" and "life's not fair!" Bargaining is the stage of false hope. The client might falsely make themselves believe that they can avoid the grief through a type of negotiation. The stages are denial, anger, bargaining, depression, and acceptance.

The hospice nurse is visiting the wife of a client who died 10 months ago. The wife states, "My life is meaningless since my husband died." The nurse recognizes that the client is in which stage of grief?

Disorganization In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of deceased, be comfortable when remembering the deceased, and return to previous level of ability.

The husband of a client with terminal cancer is afraid of hurting his wife during sexual intercourse. Which action by the nurse is likely to be most helpful in reducing this client's fears?

Encourage discussion between the husband and wife regarding their intimacy needs Partners of terminally ill clients may wish to be physically intimate with the dying person but are afraid of "hurting" him or her and may also be afraid that an open expression of sexuality is somehow "inappropriate" when someone is dying. Encourage discussion and suggest ways to be physically intimate that will meet the needs of both partners, such as a foot massage or embrace, and not just watching TV. Telling the client that he cannot have relations based on the fatigue of the client's spouse is not appropriate. Reassuring the client that he will not cause pain is incorrect.

A client is being discharged from the hospital with terminal brain cancer and a life expectancy of 1 month. When planning this client's discharge, it is most important for the nurse to include a referral to which agency?

Hospice Hospice is care provided for people with limited life expectancy, often in the home. A support group would be appropriate, but not as high in priority as hospice. Home health and outpatient rehab would not be appropriate for this client, as both of these facilities promote care toward independence.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness. Hospice programs, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a life expectancy of 6 months or less, and their families. Palliative care, on the other hand, may be given at any time during a client's illness, from diagnosis to end of life. Hospice and palliative care programs provide care that focuses on quality rather than length of life. Both hospice and palliative care share a similar foundation. Hospice and palliative care provide physical, social, psychological, and spiritual support through a team of health care professionals and lay volunteers.

After the death of a terminally ill spouse, a client reports frequent headaches and loss of appetite. The client states, "How am I going to live without him?" What type of grief is the client experiencing?

Inhibited grief With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Abbreviated grief is not a common classification of grief. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period.

A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

Inpatient pain management for hospice patients is covered by Medicare. Inpatient pain management is covered by Medicare as are any other Medicare-covered services needed to manage pain and other symptoms as recommended by the hospice team. Medicare will cover pain control in the home as well, but for extreme pain, hospitalization may be required. Telling a client not to worry about payment does not educate about what services are available.

A nurse caring for a client with a terminal illness understands which statement to be true?

Recovery is not expected. A terminal illness is a condition from which recovery is not expected. Clients with terminal illness do not recover from the illness; they may be treated symptomatically and be provided care and comfort. Recovery cannot be based on a time frame such as 3 months. Recovery is not dependent on the selected treatment as it is not expected.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation. The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes. Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia. The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

The client's breathing becomes noisy. Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch (not warm) because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

Unresolved grief In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited grief occurs when a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating oneself from social contact), and spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life, and the meaning of death).

The nurse is caring for several clients in the home care setting. Which client, when found deceased, will the nurse report as a case for the medical examiner?

a client found with an empty bottle for a newly-prescribed opioid by the bedside A death that is reportable to the medical examiner would include one that is suspicious for suicide (in this instance, as demonstrated by an empty prescription bottle for an opioid). The deaths of the other clients described are not suspicious. The client with end-stage kidney disease is under the regular care of a health care provider since receiving dialysis at home. A client with cancer is not suspicious. Even with the refusal of hospice care, the client has been diagnosed with an end-stage disease, thus not qualifying for a medical examiner case. A client who was recently discharged after a myocardial infarction who had also been receiving care from a primary care provider is not considered suspicious. Other indications for reporting to a medical examiner include a death that occurs when a client is otherwise in good health and not under the care of a provider, a client who was involved in a violent crime such as a homicide, a client who dies while in police custody or in prison, a client who has had a criminal abortion, or if the deceased poses a potential threat to public health (such as a client who had an infectious disease).

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model?

bargaining Bargaining is a psychological mechanism for delaying the inevitable, usually by negotiating with a higher power. All other choices are incorrect.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed.

A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an):

durable power of attorney. A durable power of attorney allows clients to designate another person to make decisions if they become incapacitated and cannot make decisions independently. Advanced estate planning typically involves estate tax reduction, Medicaid planning and/or special needs trust planning is for a client with a large estate. Exemplary representative and significant power are not related to health care.

Which manifestation of grief by the client who lost his wife 3 years earlier is considered abnormal?

leaving the wife's room and belongings intact Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief, but considered most of the manifestations to be abnormal if they continue beyond 3 years.

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to:

specify the treatment measures that the client wants and does not want. Living wills provide instructions about the kinds of health care that should be used or rejected under specific circumstances. The management of an individual's estate is specified in a will, not a living will. It is not legal for a living will to make provisions for active euthanasia. A living will may or may not include reference to organ donation, but normally this is addressed in a separate, specific consent card or document.

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care?

to improve the client's and family's quality of life The goal of palliative care is to improve the client's and the family's quality of life. The support should include the client's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. A separate plan of care developed by the client with each discipline of the health care team is not the goal of palliative care.

Palliative care is a structured system for care delivery. What is its aim?

to prevent and relieve suffering Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to "...prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies." Palliative care goes beyond giving traditional medical care. Palliative care is considered a "bridge" not exclusively limited to hospice care. "Hope" is something clients and families have even while the client is actively dying.

Following surgery, the surgeon informed the client's spouse that invasive cancer was found during the procedure and the client may only have days to live. The client's spouse has told the physician and the nurse that they do not want the client to know the severity of the diagnosis. How will the nurse respond?

understanding that this directive would violate the client's rights The Dying Person's Bill of Rights includes the right to not be deceived and to receive truthful answers regarding prognosis and care. The nurse will be honest with the client. Impending worry will likely occur, but the client has a right to know their prognosis and the client's spouse does not have the right to direct care.