Chapter 16: End of Life Care
durable power of attorney for health care A durable power of attorney (DPOA) for health care or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want to be implemented, avoided, or withdrawn and offers reassurance that others will carry out their wishes. Power of attorney is a legal term used in a different context. A living will is a written or printed statement describing a person's wishes concerning medical care and life-sustaining treatments that are wanted or unwanted in the event that a person is unable to personally make those decisions. Although a living will describes a person's wishes, it does not designate decision-making power to another person in the same was as a DPOA. Designated signer is not a term used in healthcare.
A 90-year-old home care client's son has been designated to make decisions regarding the client's medical care when the client is no longer able to do so. As the client nears the end of life, the son is consulted on an ever-increasing basis. What legal instrument activates the son's decision-making designation? designated signer power of attorney durable power of attorney for health care living will
Coach to use pursed lip breathing. Explanation: Dyspnea is one of the most prevalent symptoms at the end of life and is considered a highly subjective symptom. To determine the intensity of dyspnea, the client can be asked to report the severity on a scale from 0 to 10, similar to using a pain rating scale. Interventions to reduce the subjective feeling of dyspnea includes the use of purse-lipped breathing. The head of the bed should be elevated or help the client assume a forward-learning posture. Oral fluids should not be restricted as this will help keep pulmonary secretions thin. The air temperature in the room should be cool as this helps facilitate breathing.
A client approaching end-of-life reports dyspnea as being 7 on a scale from 0 to 10. Which action will the nurse take to assist this client? Restrict the intake of oral fluids. Increase the air temperature in the room. Lower the head of the bed. Coach to use pursed lip breathing.
Durable power of attorney for health care A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.
A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? Durable power of attorney for health care End-of-life treatment directive Living will declaration Medical directive by proxy
Respect the client's and family members' choices. In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.
A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? Abide by the dying client's wishes. Share emotional pain. Ask the family members about spiritual care. Respect the client's and family members' choices.
Encourage loved ones to express their feelings. The nurse can encourage the client and loved ones to express their feelings. The nurse should listen in a nonjudgmental manner and avoid delivering criticism or advice. To help with this, the nurse should assess the client's family or other companions in terms of characteristics such as roles, cohesion, flexibility, and communication. Spending time alone with the client does not facilitate the grieving process for the client and loved ones. Disengaging is also not an effective intervention, as the grieving individuals often value the nurse's teaching about what to expect during the process of dying. Providing palliative care is often done during this time, but it does not address the grieving process.
A client is dying, and the client and loved ones are in the grieving period. The nurse wants to support them in the grieving process. Which is the best intervention the nurse could perform? Provide palliative care to the client. Spend time alone with the client. Disengage to give the grieving individuals privacy. Encourage loved ones to express their feelings.
Anger Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? Acceptance Anger Denial Bargaining
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Tis, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? Can't assess tumor or regional lymph nodes and no evidence of metastasis Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
Anger Anger includes feelings of rage or resentment. Denial includes feelings of isolation. Bargaining occurs when a client and/or family pleads for more time to reach an important goal. Depression includes sadness, grief, and mourning for an impending loss.
A client with a terminal illness has feelings of rage toward the nurse. According to Kubler-Ross, the client is in which stage of dying? Depression Bargaining Denial Anger
Palliative sedation Effective control of symptoms can be achieved under most conditions; however, some clients may experience distressing, intractable symptoms and other clients may be incapacitated. Although palliative sedation remains controversial, it is offered in some settings to clients who are close to death or who have symptoms that do not respond to conventional pharmacologic and nonpharmacologic approaches, resulting in unrelieved suffering. Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Proportionate palliative sedation uses the minimum drug necessary to relieve the symptom while preserving consciousness, whereas palliative sedation induces unconsciousness, which is more controversial. Barbiturate coma is a technique used to induce a coma in clients with specific conditions. Conscious sedation is used for some diagnostic tests and procedures. Clients who are incapacitated are not likely candidates for patient-controlled analgesia.
A client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client? Palliative sedation Conscious sedation Barbiturate coma Patient-controlled analgesia
"Let's take this one day at a time; remember you have your daughter's dance recital next week." Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism.
A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client? "I believe that you will fight hard to beat this and see your babies grow up." "Let's take this one day at a time; remember you have your daughter's dance recital next week." "You should seek a second medical opinion about your diagnosis." "I know another client with the same diagnosis who has been in remission for 10 years."
Participating in assisted suicide violates the Code of Ethics for Nurses. The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. Proponents of physician-assisted suicide argue that terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives and the timing and circumstances of their deaths. However, this is not the case at the present time. Two states have enacted legislation for physician-assisted suicide. These laws provide access to physician-assisted suicide by terminally ill clients under very controlled circumstances.
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? Most states have enacted laws that allow for physician-assisted suicide. A client has the right to make independent decisions about the timing of his or her death. Nurses may administer medications prescribed by physicians to hasten end of life. Participating in assisted suicide violates the Code of Ethics for Nurses.
Faith and belief The question about what gives life meaning provides information about the client's faith and belief. Importance and influence are addressed by questions focusing on the role faith plays in the client's life and how his or her beliefs affect the way the client cares for self and illness. Community is addressed by questions focusing on the client's participation in a spiritual or religious community and the support obtained from it. Address in care focuses on how the nurse would integrate the issues involving spirituality in the client's care.
A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following?
weight loss and inadequate food intake The nurse should report weight loss and inadequate food intake so that the team can consider adding appetite stimulants and the nutritionist can alter the meal plan to give more satisfying meals as a comfort measure. The nurse knows that changes of gastrointestinal function such as irregular eating or bowel changes occur as part of the dying process and are not relevant to the desired intervention. Deteriorating vital signs are part of the dying process so that these signs are not relevant to the desired intervention.
A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? altered gastrointestinal function drop in blood pressure and rapid heart rate irregular eating habits weight loss and inadequate food intake
Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.
A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. Comfort the client by saying it will all be over soon. Encourage the client to explain his or her wishes. Control the client's pain with prescribed medication. Recommend that the client consider physician-assisted suicide. Advise the client's health care provider of the client's condition.
"When your stay reaches 6 months, you will be recertified for a continued stay." Federal rules for hospices require that eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged, provided that their physician and the hospice medical director continue to certify that they are terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course).
A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse? "When your stay reaches 6 months, you will be recertified for a continued stay." "You will be able to stay only for approximately 1 month and then you will be discharged." "You will be able to stay for 2 months before being discharged." "There is no time limit for your stay. You can stay until you die."
"It will enable the patient to remain home if that is what is desired." The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means.
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will enable the patient to remain home if that is what is desired." "It will prolong life in a dignified manner." "It will use artificial means of life support if the patient requests it." "It will hasten the death of the patient."
seizure. A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with seizures, abnormal reflexes, papilledema, coma, and death. Anorexia, weight gain, and myalgia are associated with serum sodium concentrations lower than 120 mEq/L.
A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with myalgia. anorexia. weight gain. seizure.
20 According to federal guidelines, hospices may provide no more than 20% of the aggregate annual patient-days at the inpatient level. The other numerical values are incorrect.
According to federal guidelines, hospices may provide no more than what percentage of the aggregate annual patient-days at the inpatient level? 20 10 30 40
no evidence of primary tumor. T0 means that there is no evidence of primary tumor. N0 means that there is no regional lymph node metastasis. M0 means that there is no distant metastasis. M1 means that there is distant metastasis.
According to the TNM classification system, T0 means there is no distant metastasis. no regional lymph node metastasis. distant metastasis. no evidence of primary tumor.
Clients and families view hospice care as giving up Clients often equate hospice with giving up and are reluctant to accept hospice care. Lack of fully credentialed and trained hospice nurses is not a barrier to hospice care. Lack of Medicare funding and lack of certification for hospice service providers have not been documented as barriers to access of hospice services.
Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services? Lack of fully credentialed and trained hospice nurses Lack of Medicare/Medicaid funding for hospice Clients and families view hospice care as giving up Difficulty obtaining Medicare certification for hospice services
Encourage the family members to express their feelings and listen to them in their frank communication Family members usually find it difficult to communicate frankly with a dying person. When a nurse encourages family members to express their feelings and listens to them as they frankly communicate, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members express their feelings.
The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? Encourage the client's family members to spend time with the client. Encourage conversations about the impending death of the client. Encourage the family members to express their feelings and listen to them in their frank communication. Be a silent observer and allow the client to communicate with the family members.
Palliative care Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.
The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? Inpatient respite care Continuous care General inpatient care Palliative care
Advice for the family to have fruit juices readily available at the client's bedside. To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.
The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care? Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Arrangements for the client to eat meals while others are out of the home. Suggestions that the family offer the client foods that are hot.
Side effects must be treated. The nurse who is administering narcotics at the end of life still must realize that there are side effects from the narcotics which must be addressed. Depending on the status of the client, death may be days or weeks away, not imminent. Pain medications are liberally given at the end of life to ensure that the client is comfortable. Typically, pain medications relax the client as the pain level is eased. The client is not sedated.
The nurse is caring for a client at the end of life. The client is ordered a regular dosage of narcotics and short-acting narcotics for breakthrough pain. When administering the narcotics, the nurse is correct to realize which of the following? Side effects must be treated. Client may become sedated. Dosages are restricted. Death is imminent.
"The hair loss is usually temporary." Alopecia associated with chemotherapy is usually temporary and will return after the therapy is completed. New hair growth may return unchanged, but there is no guarantee and color, texture, and quality of hair may be changed. There is no correlation between chemotherapy and delay in greying of hair. Use of wigs, scarves, and head coverings can be used by clients at any time during treatment plan.
The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia? "Wigs can be used after the chemotherapy is completed." "New hair growth will return without any change to color or texture." "The hair loss is usually temporary." "Clients with alopecia will have delay in grey hair."
The principle of autonomy By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.
The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? The principle of autonomy The principle of fidelity The principle of justice The principle of nonmaleficence
Social Physical Spiritual Psychological The voluntary stopping of eating and drinking is an option of last resort and may be considered when a client cannot imagine prolonged dying and suffering from a life-limiting illness. Aggressive palliative treatments for all types of suffering to include social, physical, spiritual, and psychological measures should be explored and offered before supporting voluntarily stopping of eating and drinking. Grieving is specific to family loss, not something that the nurse would assess in the client.
The nurse is caring for a client with Huntington chorea who has decided to refuse all food and beverages. For which type of suffering will the nurse assess the client before supporting the client's decision? Select all that apply. Physical Grieving Social Spiritual Psychological
Explore own feelings on mortality and death and dying. To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.
The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following?
Irregular pulse Mottled extremities Apnea lasting 45 seconds Symptoms indicating that a client is hours before dying, or is in the actively dying phase, include an irregular pulse and mottled extremities. The client may also have periods of apnea that last longer than 40 seconds. A blood pressure of 60 mm Hg without a diastolic reading indicates slowing of the cardiovascular system. Verbalizing with coherency is unlikely in the hours before dying, whereas verbalizing incoherent phrases indicates delirium that would occur weeks before death.
The nurse is visiting the home of a client who has refused all medical treatment for a terminal illness. Which assessment findings indicate to the nurse that the client will die within a few hours? Select all that apply. Irregular pulse Apnea lasting 45 seconds Mottled extremities Verbalizing incoherent phrases Systolic blood pressure of 80 mm Hg with no diastolic reading
Add haloperidol to the client's treatment plan. Haloperidol may reduce hallucinations. Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Biopsy is used to analyze the lymph nodes or to destroy the tissues surrounding the tumor.
The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? Obtain a biopsy to analyze the lymph nodes. Add haloperidol to the client's treatment plan. Perform surgery to remove the tumor from the brain. Begin radiation therapy to prevent cellular growth.
care that will reduce the client's physical discomfort and manage clinical symptoms. Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.
The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms. an alternative therapy that uses massage and progressive relaxation for pain relief. care that is provided at the very end of an illness to ease the dying process. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care.
Using a soft toothbrush to vigorously clean the mouth Secretions are often more distressing to the family than their presence is to the client. Gentle mouth care with a moistened swab or very soft toothbrush helps maintain the integrity of the client's mucous membranes. Other helpful measures include positioning the client on the side with the head supported with pillows to allow secretions to drain freely from the mouth, gently suctioning the oral cavity, and administering prescribed anticholinergic agents sublingually or transdermally. Deeper suctioning may cause significant discomfort to the dying client and rarely is of benefit because secretions tend to reaccumulate quickly.
When assessing a terminally ill client, the nurse notices that the client has copious secretions at the back of the throat and in the mouth. The nurse is preparing a teaching plan for the family about caring for these secretions. Which of the following would be least appropriate to include? Administering a prescribed anticholinergic agent Using a soft toothbrush to vigorously clean the mouth Performing gentle suctioning of the mouth Positioning the client on the side with the head supported with a pillow
Mutual pretense awareness In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to openly acknowledge that reality.
Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? Open awareness Closed awareness Mutual pretense awareness Suspected awareness
Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."
Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice
Clients have a life expectancy of 6 months or less. A criterion of hospice care is that the client has a life expectancy of 6 months or less, due to a terminal illness. It is not focused on a cure and it does not seek to encourage prolongation of life through artificial means.
Which is a true statement regarding hospice care? Clients have a life expectancy of 6 months or less. Patients have an acute illness. It encourages the prolongation of life through artificial means. It is cure-focused.
They gain access to the blood and lymphatic channels. By gaining access to blood and lymphatic channels, a tumor can metastasize to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rates of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.
Which statement is true about malignant tumors? They usually grow slowly. They grow by expansion. They gain access to the blood and lymphatic channels. They demonstrate cells that are well differentiated.
"Tell me some more about what is on your mind." When responding to the client, the nurse needs to acknowledge the client's fears. Having the client tell the nurse what's on his or her mind acknowledges the client's feelings and opens the way for more discussion. Asking the client about what makes him or her think he or she is dying is probing and does not address the client's feelings or needs. Telling the client that he or she will be fine gives the client false reassurance and does not address his or her fears. Asking about what the physician has told the client redirects the conversation away from the client's feelings and is inappropriate.
While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate? "What has your physician told you about your condition?" "Tell me some more about what is on your mind." "What makes you think that you might be dying?" "You're just having a bit of a set-back. You'll be fine."
