Chapter 7 End-of-Life Care & PHIL END-OF-LIFE CARE & ETHICAL DILEMMAS

A patient receiving nursing care in a home hospice program can expect which kind of care? a. The use of high-technology equipment such as ventilators until time of death. b. Around-the-clock skilled direct nursing patient care until time of death. c. Pain and symptom management that will achieve the best quality of life. d. Complete relief of only distressing physical symptoms.

C

The terminally ill patient has an advance directive living will, which states that she does not want heroic measures such as cardiopulmonary resuscitation (CPR) and intubation. She also has a do not resuscitate order in her chart written by the provider. As the patient nears death, her daughter tells the hospice nurse that she wants everything possible done to save her mother's life. What is the nurse's best action? a. Call a code and bring the crash cart to the patient's bedside. b. Inform the health care provider of this change in the plan of care. c. Respect the patient's wishes and ask the chaplain to stay with the daughter. d. Inform the daughter that further interventions are futile.

C

Which phrase correctly describes palliative care? a. Care for patients with a prognosis of 6 months or less b. Diagnoses and treatment for patients with a life-threatening illness c. Patient care with a focus on treatment of symptoms d. Patient education about relevant treatment alternatives

C

Which symptom is most distressing and feared by terminally ill patients? a. Difficulty breathing b. Confusion c. Pain d Loss of consciousness

C

While caring for a patient of the orthodox Jewish faith who is dying, what cultural concept should the nurse keep in mind? a. Traditionally, Jewish cultures are male-dominated. b. Expression of grief is open, especially among women. c. An autopsy after death will not be permitted. d. Family members are likely to avoid visiting the terminally ill family member.

C

Which statements about pain management in a patient who is dying are true? (select all that apply) a. The patient's pain may come from many areas. b. Patients who are dying should discontinue long-acting opioids. c. Alternative therapies have been shown to be useful when integrated into a pain management plan of care. d. When using massage for patients with cancer, deep pressure is the preferred method. e. Aromatherapy, massage, music therapy, and therapeutic touch are a few alternative therapies that have been whown to be useful.

Ace

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 should 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."

A Rationale: 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.

A hospice nurse is caring for a dying client and her family members. Which interventions should 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.

A,B,D Rationale: The nurse should 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.

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this client's 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 client's feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine.

A,C Rationale: Complementary therapies for pain management include massage therapy, music therapy, Therapeutic Touch, and aromatherapy. Nurses should not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.

A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.) a. Can communicate his 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

A,C,D Rationale: 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.

What does the Roman Catholic Church say about euthanasia? A.It can be used if a person is in extreme pain B.It is the individual's free choice C.It is morally unacceptable in all circumstances D.It could be seen as an act of compassion

C.It is morally unacceptable in all circumstances

A nurse is conducting an initial screening of wellness for a patient diagnosed with autism. What can the nurse do to provide a better environment? A. Nurse should lower the exam room lights B. Nurse should only talk to the caregiver for information C. Nurse should speak very slowly and speak loudly D. Nurse should schedule additional time for the patient

A. Nurse should lower the exam room lights D. Nurse should schedule additional time for the patient

Which of these religions/faiths are against withdrawal of medical care in the event that brain death has not occurred? Select all that apply. A.Orthodox Jewish B.Catholic C.Islamic (modern) D. Islamic (traditional)

A.Orthodox Jewish D. Islamic (traditional)

The terminally ill patient who is near death has loud, wet respirations that are disturbing to the family. Which interventions by the nurse are appropriate at this time? (select all that apply) a. Position the patient on her side. b. Place a small towel under her mouth. c. Use oropharyngeal suctioning to remove the secretions. d. Administer an ordered anticholinergic drug to dry up the secretions. e. Teach family members how to use the suctioning device whenever needed.

Abd

Which end-of-life interventions must the nurse be prepared to perform for a dying patient and his or her family? (select all that apply) a. Allow the family to verbalize fears and concerns about the impending loss of their loved one. b. Listen and acknowledge the legitimacy of the family's pain. c. Minimize the family's loss by using statements such as "Don't be upset" d. Assist the patient and family with reminiscence or storytelling. e. Work to determine the patient's and family's spiritual needs.

Abde

Which statements about caring for a patient with dyspnea are true? (select all that apply) a. Pharmacologic interventions should begin early in the course of dyspnea. b. Nonpharmacologic, alternative treatments may be used successfully in place of pharmacologic interventions. c. Dyspnea may be caused by the primary diagnosis or its treatments. d. Diagnostic testing must be used to determine the cause of dyspnea before beginning treatment. e. Oropharyngeal suctioning is appropriate for patients with loud, wet respirations nearing death.

Ac

Which items are relevant to the concept of hospice? (select all that apply) a. Unit of care is the patient and family. b. Preferred location is the hospital setting. c. Interdisciplinary team approach is used. d. Focus is on alleviating pain and suffering. e. Hospice care does not hasten death.

Acde

Which characteristics apply to the concept of palliative care? (select all that apply) a. Patient must have less than a year to live. b. Care time is not limited to specific periods of time. c. Care focus is curative or may prolong life. d. Care is provided when curative treatments have been stopped. e. Patient can be in any stage of serious illness.

Bce

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

B Rationale: Only symptoms that cause distress for a dying client should 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 should be treated only if the client is distressed by their presence. The nurse should treat the client's pain first.

What therapies are included in Withdrawal of support? (select all that apply) A.Speech therapy B.Chemotherapy C.Hydration D.Mechanical Ventilation E. Physical therapy

B.Chemotherapy C.Hydration D.Mechanical Ventilation

Adolescent pregnancy are at increased risk for neonatal complications such as: (Select all that apply) A.Fetal macrosomia B.Intrauterine Growth Retardation C.Neonatal mortality D.Prematurity

B.Intrauterine Growth Retardation C.Neonatal mortality D.Prematurity

What are the requirements for a patient to execute the Death with Dignity in Washington State? (Select all that apply) A.Being Oregon resident B.Minimum age of 18 C.Mentally competent D.Terminal illness with less than one year to live E.Require two physicians' independent diagnoses

B.Minimum age of 18 C.Mentally competent E.Require two physicians' independent diagnoses

The nurse is caring for a patient who has a terminal condition but is expected to live several years. For which type of care would the nurse advocate? A.Hospice care B.Palliative care C.Rehabilitation care D.Pastoral/clergy care

B.Palliative care

The hospice nurse is caring for a patient who is actively dying. When the patient's respirations become loud and wet, the caregiver expresses fear that the patient is in respiratory distress. What is the appropriate nursing action? (Select all that apply.) A.Immediately administer oxygen B.Reposition the patient onto one side C.Administer an anticholinergic drug as ordered D.Contact 9-1-1 E.Provide the caregiver with reassurance that this is a normal finding in someone who is actively dying

B.Reposition the patient onto one side C.Administer an anticholinergic drug as ordered E.Provide the caregiver with reassurance that this is a normal finding in someone who is actively dying

Which are direct causes of death? (select all that apply) a. GI bleeding b. Heart failure c. Respiratory failure d. Shock e. Kidney failure

Bcd

Which interventions after a patient's death are appropriate to perform? (select all that apply) a. Remove the body to the morgue or funeral home immediately after death. b. Follow agency policies to remove all tubes and lines from the body. c. Make sure that they physician has completed and signed the death certificate. d. Provide privacy for the family and significant others with the deceased. e. Allow family and/or significant other to perform religious and cultural customs.

Bcde

To qualify for hospice benefits, a criterion for admission is that the patient's prognosis must be limited to what amount of time? a. 2 weeks or less b. 3 months or less c. 6 months or less d. 1 year or less

C

A new RN graduate is taking care of a patient recently diagnosed with cancer. The patient is discussing his concerns about his medical bills and transportation. The nurse learns that the employer fired the patient because the "cancer would slow down the work flow". What American Disability Act (ADA) title would the nurse inform the patient about? A. Title IV: Telecommunications B. Title II: Public Entities and Public Transportation C. Title I: Employment D. Tile III: Public Accommodations

C. Title I: Employment

Which of the following statements about Values clarification tools would indicate need for further education? A.Value clarification tools are helpful in analyzing underlying biases that may impact thoughts about and behavior toward others. B. As nurses, they can be used to identify how our values and beliefs may impact patient care when faced with situations that may present ethical dilemmas. C.A patient assessment tool used upon admission to emergency care. D.Exercises developed by the National Abortion Federation to clarify values related to abortion, views about the role of health care providers, as well as case studies used to identify and examine potential biases.

C.A patient assessment tool used upon admission to emergency care.

Which statements about the assessment of a terminally ill patient are true? (select all that apply) a. Assess only the patient; do not include the family's perception of the patient's symptoms. b. When the patient is unable to communicate, there is no need to assess symptoms of distress any longer. c. Assess patients who are unable to communicate distress by observing for objective signs of discomfort. d. Assess the patient for dyspnea, agitation, nausea, and vomiting only. e. Identify alternative methods to assess for symptoms of distress. f. The family can help identify patient habits and preferences, which may aid in the overall assessment.

Cef

A nurse teaches a client's family members about signs and symptoms of approaching death. Which manifestations should 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

D,E Rationale: Common physical signs and symptoms of approaching death including coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.

What is the nurse's role in a patient that chooses death with dignity? A.Provide information about the pros and cons of death with dignity B.Influence the patient decision C.Being a witness D.Advocate for the patient's wishes and continue to perform unbiased care

D.Advocate for the patient's wishes and continue to perform unbiased care

All of the following are NOT authorized in the state of Washington, except: A.Lethal injections B.Active euthanasia C.Mercy killings D.Assisted suicide

D.Assisted suicide

The most common treatment of pain in a terminally ill patient is administration of which kind of therapy? a. Opioids b. Steroids c. Nonsteroidal antiinflammatory agents d. Radiation treatments

A

The terminally ill patient is nearing death. His wife expresses concern that he has no appetite and eats very little. What is the nurse's best response to this concern? a. Teach the patient's wife about the risk of aspiration and explain that loss of appetite is normal when a patient nears death. b. Encourage the patient's wife to feed the patient as much as he will take to maintain adequate nutrition. c. Request that the health care provider order a dietary nutrition consult to include foods that the patient prefers. d. Keep fluids and finger foods at the bedside for easy access whenever the patient is hungry or thirsty. e. Spark a dubie and break out some funions. That'll get the ****er to eat.

A

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol (Proventil) 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 (Fleet) enema once a day PRN for impacted stool

A Rationale: Pain medications should be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The other medications are appropriate for this client.

A nurse discusses inpatient hospice with a client and the client's family. A family member expresses concern that her loved one will receive only custodial care. How should 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."

A Rationale: Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.

A hospice patient is deteriorating and the family is concerned about his restlessness and agitation. Which intervention is the nurse prepared to perform? a. Notify the primary health care provider and request orders for transfer to the hospital. b. Determine if the patient is in pain, provide, analgesics, and make the patient as comfortable as possible. c. Initiate IV hydration to provide the patient with necessary fluids. d. Encourage the family to assist the patient to eat in order to gain energy.

B

A nurse assesses a client who is dying. Which manifestation of a dying client should 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-to-10 scale

B Rationale: Although all of these assessments should be performed during the dying process, periods of apnea and Cheyne-Strokes respirations indicate 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 should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

A nurse teaches a client who is considering being admitted to hospice. Which statement should 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 designed not 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."

B Rationale: As both a philosophy and a system of care, hospice care uses an interdisciplinary 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."

B Rationale: 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.

A nurse plans care for a client who is nearing end of life. Which question should 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 health care provider?"

B Rationale: When developing a plan of care for a dying client, consideration should be given for where the client wants to die. Advance directives do not need to be notarized. A physical therapist would not be involved in end-of-life care. The client should discuss resuscitation with the health care provider and children; do-not-resuscitate status should be the client's decision, not the family's decision.

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 should 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 that a death certificate has been completed by the physician. d. Request family members to prepare the client's body for the funeral home.

B Rationale: Before moving the client's body to the funeral home, the nurse should ask 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 should ask family members if they would like to be alone with the client. The client's family should not be expected to prepare the body for the funeral home.

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 dying person should receive the Sacrament of the Sick.

C Rationale: 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 performs the Sacrament of the Sick for ill or dying people.

After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates 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."

C Rationale: An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want 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.

An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How should 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 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."

C Rationale: The nurse should validate the family's concerns and provide 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 should provide unbiased information about these topics.

A competent patient who has been given three months to live expresses the desire to voluntarily stop eating and drinking. Which is the appropriate nursing response? A.Tell the patient that this is unethical. B.Disclose the patient's desire to caregivers. C.Advocate for the patient's choice. D.Refuse to care for the patient.

C.Advocate for the patient's choice.

Which action is an example of active euthanasia for a dying patient? a. Removal of a patient from a mechanical ventilator b. Discontinuing intravenous fluids c. Withdrawal of telemetry heart monitoring d. Administering a large dose of intravenous morphine

D

Which intervention should be done when performing postmortem care? a. Place the head of the bed at 30 degrees. b. Remove pillows from under the head. c. Leave a Foley (indwelling) catheter in place in the bladder. d. Place pads under the hips and around the perineum.

D

Which statement regarding the approach to hospice/end-of-life care is correct? a. Hospice programs only include provision of care in the home? b. Admission to hospice is involuntary and directed by a health care provider's order. c. The focus is on facilitating quality of life just for the dying patient. d. An interdisciplinary team approach is used for the care of the patient and family.

D

A client tells the nurse that, even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. How should the nurse respond? a. "Most people move on within a few months. You should see a grief counselor." b. "Whenever you start to cry, distract yourself from thoughts of your sister." c. "You should try not to cry. I'm sure your sister is in a better place now." d. "Your feelings are completely normal and may continue for a long time."

D Rationale: Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client's response.

A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How should 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 husband 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 husband on his side."

D Rationale: The choking sound or "death rattle" is common in dying clients. The nurse should acknowledge the spouse's concerns and provide 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 should 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.