Chapter 35 - Loss, Death, and Palliative Care

Which intervention is an example of countercoping for a client who has recently received a terminal diagnosis of cancer? (Select all that apply.) a.) Answering the client's questions regarding the trajectory of his or her illness b.) Offering to pray with the client and family c.) Scheduling a meeting with the client and family to identify alternative end-of-life plans d.) Assessing the client frequently for depression and risk of self-harm e.) Being available to just listen to the client talk about dying

a, c, d, e a.) Answering the client's questions regarding the trajectory of his or her illness c.) Scheduling a meeting with the client and family to identify alternative end-of-life plans d.) Assessing the client frequently for depression and risk of self-harm e.) Being available to just listen to the client talk about dying One of the strategies of countercoping includes clarification and control. The nurse helps cope with loss and dying by helping individuals confront the loss by getting or receiving information, considering alternatives, and finding a way to make the grief manageable. The nurse helps persons resume control by encouraging them to avoid acting on impulse. It is not an acceptable practice to initiate such an intervention as asking the client to pray.

The daughter of a patient who has a chronic illness that has reached the terminal phase talks about the palliative care referral that the primary care provider made for her mother. Which of the following statements indicate that the daughter needs additional education about palliative care? (Select all that apply.) a.) "I know that palliative care is only available to people who have 6 months or less to live. That is really hard to cope with." b.) "My mom still can be actively treated while receiving palliative care." c.) "I understand that the palliative care team is made up of health care professionals of all different disciplines, not just doctors and nurses." d.) "The goal of palliative care is to prevent or to minimize suffering" e.) "My mom will have to be transferred to a special unit in the hospital in order to receive palliative care."

a, e a.) "I know that palliative care is only available to people who have 6 months or less to live. That is really hard to cope with." e.) "My mom will have to be transferred to a special unit in the hospital in order to receive palliative care." While many individuals are not referred to palliative care until they are at the end of life, ideally, the earlier they are referred, the better. There is no time frame for referral regarding the point that they are in their illness. Palliative care is offered simultaneously with life- prolonging or stabilizing care for those living with chronic conditions. Palliative care uses an interprofessional model of care. Palliative care can be offered in any setting across the continuum of care and on any unit; it is a philosophy of care.

Which of the following characteristics are associated with acute grief? (Select all that apply.) a. Preoccupation with the loss of a loved one b. Waves of grief or distressing emotion c. Prolonged inability to sleep after a loss d. Exacerbations of grief on specific dates e. Change in attitude toward the future loss f. Inability to perform simple self-care tasks

a. Preoccupation with the loss of a loved one b. Waves of grief or distressing emotion f. Inability to perform simple self-care tasks

An older patient who has end-stage pulmonary disease decides to accept care from the palliative care nurse. This older adult will most likely benefit from the palliative care nurse in which patient needs of Weismans six needs for the dying? a. Closure b. Control c. Composure d. Cohesiveness

b. Control

A woman is terminally ill. Although it has never been discussed in the family or stated outright by her physician, she is growing to believe that she will die because of her illness. Upon which concept will the nurse base therapeutic intervention on? a.) Closed awareness b.) Suspected awareness c.) Mutual pretense d.) Open awareness

b.) Suspected awareness In suspected awareness, the patient suspects that she is dying; however, it is never openly discussed. With closed awareness, the patient does not know that she is dying; it is kept secret. With mutual pretense, there is a "let's pretend" atmosphere, where real feelings are kept hidden. Open awareness acknowledges the reality of the approaching death.

When working with a bereaved individual, the goal of nursing interventions is to: a.) assist the individual to go through the stages of grief work in the optimal order. b.) assist the individual to attain a healthy adjustment to the loss experience. c.) encourage the individual to talk about his or her feelings about the deceased individual. d.) offer support and advice about how to successfully achieve grief work.

b.) assist the individual to attain a healthy adjustment to the loss experience. The goal of nursing interventions when working with bereaved individuals is to help them adjust in a healthy manner. There is no optimal order in which to experience grief. Not all individuals are able to talk about their feelings, nor is it helpful for everyone. The role of nursing is to offer support, but not advice.

While awaiting the imminent death of her sister, an older woman makes arrangements to bury her sister in the survivors home state because she cannot reach the other family members. Which step should the nurse implement? a. Ask questions, including questions about the location of her sisters family. b. Instruct this woman that this is not her decision to make. c. Try to contact the family to inform them of the decision. d. Question her about holding behaviors that she will want.

a. Ask questions, including questions about the location of her sisters family.

The nurse suspects that the spouse of a terminally ill client is experiencing anticipatory grief when he : a.) dramatically reduces the time he spends attending to the client. b.) refuses to leave the client's bedside regardless of the reason. c.) sobs inconsolably whenever he visits. d.) spends hours recalling details of their life together.

a.) dramatically reduces the time he spends attending to the client. Anticipatory grief is the response to a real or perceived loss such as in anticipation of the death of a loved one. Behaviors that may signal anticipatory grief include a sudden change in attitude toward the thing or person to be lost. The other options are characteristics of normal grieving.

A patient tells a nurse that she has prepared a living will (LW). The nurse understands that a living will: (Select all that apply.) a.) is an advanced directive that is used in the situation of a person who is unable to speak for herself or himself. b.) is a legally binding document in all states and territories of the United States. c.) appoints a proxy to uphold the patient's wishes. d.) includes the provision that the patient's next of kin have more authority than the appointed proxy. e.) can be revoked by the patient at any time in either writing or verbally.

a.) is an advanced directive that is used in the situation of a person who is unable to speak for herself or himself. c.) appoints a proxy to uphold the patient's wishes. e.) can be revoked by the patient at any time in either writing or verbally. The Patient Self-Determination Act (PSDA) recognized a Living Will (LW) as an advanced directive that is specifically related to a situation in which a person is facing a terminal illness and unable to speak for herself/himself. It is a morally and, in some jurisdictions, legally binding document in which adults could express their wishes regarding end-of-life decisions for some future time when they were unable to do so for themselves. The exact requirements for a living will and the associated laws around it vary from state to state. The patient appoints a proxy to uphold his or her wishes when he or she is no longer able to do so. As the proxy is selected by the individual, the legal assumption is that a designated person has more authority than the next-of-kin. The patient can revoke an LW verbally or in writing at any time for any reason.

A nurse is caring for a patient in Portland, Oregon, who has a terminal illness. The patient tells the nurse that she has made a decision "to end it all," that she has suffered enough and is considering asking her physician to prescribe medications to help her die. The nurse knows that the regulations for physician-assisted suicide include which of the following? (Select all that apply.) a.) A nurse or physician must be the one to administer the medications. b.) The patient must have a prognosis of 6 months or less to live. c.) The patient must be informed of all treatments and alternatives. d.) The family of the patient must agree in writing to the patient's decision. e.) The patient must have received counseling to ensure that she is fully informed of the risks.

b, c b.) The patient must have a prognosis of 6 months or less to live. c.) The patient must be informed of all treatments and alternatives. The physician-assisted suicide laws in the states of Oregon and Washington have the following requirements: The individual must be a competent adult who is free of depression and who has a prognosis of less than 6 months to live. The patient must make two requests, both verbal and in writing, repeated in 15 days, and there must be two witnesses to the request; one must not be an heir, related, or employed by the health care facility caring for the patient. The patient must have been informed of alternatives and have received counseling to ensure that the person is fully informed regarding the risks of such actions. Neither physicians nor nurses are permitted to administer the product used.

Which of the following indicate a person is effectively coping? (Select all that apply.) a. Avoids avoidance b. Confronts realities c. Focuses on solutions d. Redefines problems

b. Confronts realities c. Focuses on solutions d. Redefines problems

A patient loses her husband because of a sudden myocardial infarction, and she blames herself for not recognizing the warning signs. Which patient outcome associated with her loss should the nurse use to plan care? a. Meets her daily responsibilities b. Expresses feelings of guilt, fear, anger, or sadness c. Assesses the causes of the dysfunctional grieving processes d. Identifies problems connected to anticipatory grief

b. Expresses feelings of guilt, fear, anger, or sadness

The health care provider believes an older woman has approximately 6 weeks to live. After 2 months, the family remains at the bedside but, in the last few days, are becoming increasingly impatient and irritable. This pattern is least indicative of which of the following statements? a. Family is experiencing anticipatory grief for the older adult. b. Family desires that the patient be relieved of her misery. c. Anticipatory grieving can fail to attenuate acute grief upon death. d. Grievers deal more easily with known losses at known times.

b. Family desires that the patient be relieved of her misery.

After the loss and burial of a beloved pet, an older man loses weight because he eats very little. Three months later, he starts to paint pictures of the pet and his appetite slowly improves. Describe this individuals mourning for his pet. a. Weight loss from inadequate intake b. Pets burial and painting pictures of the pet c. Loss of his appetite resulting in weight loss d. Increased food intake after painting begins

b. Pets burial and painting pictures of the pet

The primary difference between the Loss Response Model (LRM) and the Worden model of grief is which of the following? a. In the Worden model, those grieving pass through stages in order. b. The LRM uses a systems approach that acts to uphold stability. c. In the Worden model, the system helps maintain equilibrium. d. In the LRM model, those who are grieving transition through several stages.

b. The LRM uses a systems approach that acts to uphold stability.

Which of the following statements is true about end-of-life care? a. The physician is the ultimate authority in the decision to use or not to use life-sustaining medical treatment. b. The proxy appointed in a living will cannot speak for the testator in health care matters other than terminal illness. c. A patient with dementia cannot be capable of making personal wishes known about life-sustaining treatment. d. The American Nurses Association encourages nurses to participate in assisted suicide.

b. The proxy appointed in a living will cannot speak for the testator in health care matters other than terminal illness.

A 78-year-old patient who is dying of colon cancer with metastases to the liver is refusing to eat or drink. He is alert and oriented, and states that he has no desire to eat, which is causing the family great distress. In order to best address the client and family, the nurse should: a.) explain the family's concern to the client. b.) educate the family that this is normal behavior in this situation. c.) contact the physician for an order for enteral feeding. d.) contact the dietitian for feeding supplements.

b.) educate the family that this is normal behavior in this situation The nurse should educate the family that this is a normal part of the dying process and should not pressure the client, contact the physician for enteral feeding, or contact the dietitian for feeding supplements. Because the patient is expressing a desire not to eat, his wishes should be honored. Essential to the facilitation of self-esteem is the premise that the values of the patient must figure significantly in the decisions that will affect the course of dying. Whenever possible, the nurse can have the person decide when to groom, eat, wake, sleep, and so on.

After the older adult dies, the brother who has a history of alcohol abuse upsets the family by going on a drinking binge instead of attending the funeral. Which of the following is the best description of the brothers behavior? a. Personality disorder b. Disrespectful attitude c. Disenfranchised grief d. Chronic grief

c. Disenfranchised grief

The son of an older adult couple ends his life suddenly and violently. The husband proceeds with living as usual. After 1 year, the wife remains in seclusion and is hospitalized for dehydration. Which steps should the nurse implement to help improve the wifes mental health and wellness? a. Encourage additional fluids and social activity. b. Instruct the husband to display empathy for her. c. Establish a trusting, caring relationship with her. d. Ask social services for a survivors support group.

c. Establish a trusting, caring relationship with her.

Those who cope less effectively may exhibit which of the following? (Select all that apply.) a. Avoids avoidance b. Confronts reality c. Is demanding d. Is rigid

c. Is demanding d. Is rigid

When the older woman who is close to death asks the family to leave after short visits and acts withdrawn in their presence, the family becomes distraught. Which of the following does the nurse include in family teaching to explain the patients behavior? a. She is preoccupied with her own death. b. She must have unresolved family issues. c. She can be experiencing anticipatory grief. d. Her body prepares for death in this manner.

c. She can be experiencing anticipatory grief.

Which of the following statements is true about loss in older adulthood? a. A person experiences each stage of grief once, and then grieving is resolved. b. Antianxiety agents are frequently recommended for reducing the pain of grief. c. The loss response model is concerned with the effect of loss on an individual. d. Referring to the deceased in the past tense can acknowledge the deaths reality.

d. Referring to the deceased in the past tense can acknowledge the deaths reality.

Which of the following is a true statement about loss, dying, and death for older adults? a. Men and women tend to respond similarly to the loss of a spouse. b. Visions on the part of a person who has lost a spouse are not normal grief reactions and should be regarded as signs of underlying defects. c. The grieving process is not rigidly structured. d. Bereaved persons regain their normal capability approximately 6 months after loss, and regressive behavior after that time should be discouraged.

c. The grieving process is not rigidly structured.

Which principle regarding grief crisis intervention is the basis for intervention planning? a.) The acute phase is the most intense period of the grieving process. b.) The intensity of the grief is in proportion to the expected death trajectory. c.) Grief work is most effective when addressed during the acute phase of grief. d.) Anticipatory grief is an expected barrier to grief work.

c.) Grief work is most effective when addressed during the acute phase of grief. The acute phase is usually the peak time of stress and anxiety as the life and future of the individual and the family are thrown into disequilibrium. Crisis intervention is most effective here because the individual, family, and caregivers are struggling to come to terms with the knowledge. While the other options are true, they are not as directly related to intervention planning.

Which truism will the nurse base spousal grief counseling upon? a.) Men are less likely to grieve the loss of a spouse. b.) Women carry deeper attachments to their spouses than men do. c.) Women are generally more likely to outlive their spouses. d.) The male response to grief has been thoroughly studied and documented.

c.) Women are generally more likely to outlive their spouses. Three out of four women will be widowed at some point because women tend to live longer than men and frequently marry older men. There is no evidence that men grieve less than women; men and women grieve in different manners. It has not been found to be true that women carry attachments to their spouses that are less deep than men's attachments. Male response to grief has not been studied as thoroughly as that of women; the abundance of literature on this topic deals with women.

The actions of the family members of an older adult who just died are chaotic, and they are unable to decide on a funeral home. Which recommendation should the nurse implement? a. Help them make a list of the problems. b. Provide a list of preferred funeral homes. c. Allow them privacy to work it out alone. d. Suggest they call someone who can help.

d. Suggest they call someone who can help.

Which of the following interventions is recommended for an older adult in the final stages of dying? a. Apply an electric blanket to keep the patient warm. b. Lower the head of the bed, and turn the head to the side. c. Decrease the number of visitors. d. Support the preservation of energy.

d. Support the preservation of energy.

Which behavior is characteristic of grief by a disenfranchised adult child in response to a parent's death following a lengthy, painful illness? a.) Crying out loudly while invoking "God's help" to go on with life b.) Announcing to family members, "I've already grieved the loss." c.) Having difficulty even deciding what to wear to the funeral d.) Going on a drinking binge instead of attending the funeral

d.) Going on a drinking binge instead of attending the funeral The individual is exhibiting disenfranchised grief since situations have distanced him or her from the family, making grieving openly impossible. Pathological grief begins with a normal grieving process, but obstacles interfere with a normal evolution toward adjustment, causing reactions to be exaggerated. Anticipatory grief is a response to a real or perceived loss before the loss occurs. Acute grief is a crisis; it is a syndrome of physical and psychological symptoms of distress, often accompanied by functional disruption.

The nurse sits at the bedside of a comatose, terminally ill older client reading the wishes expressed in the numerous cards the client has received. Which concept of grief work is the nurse addressing with this intervention? a.) Everyone needs social interaction. b.) The nurse needs to "attend to the patient." c.) Hearing is believed to be the last sense to be lost. d.) The individual is living until he or she is dead.

d.) The individual is living until he or she is dead. An individual is living until he or she has died; the nurse works with the older adult and significant others to maintain as high a quality of life as possible before, during, and after the loss or death. While the other options are true they are not directly involved in grief work.