Chapter 42 - Death and Loss

Masked Grief

Occurs when the behaviors of the survivor interfere with normal functioning, but that person is not aware that these behaviors are concealing the actual grieving process.

Exaggerated Grief

Occurs when the survivor is overwhelmed by grief and cannot function in daily life. May have self-destructive behaviors and potential suicidal thoughts.

Complicated Loss

Occurs with a sudden death, a violent or traumatic death, multiple deaths, loss that is related to a social stigma, and with death of a young person.

Rigor Mortis

Stiffening of the joints of the body.

Delayed Grief

Suppression of the grief reaction while the grieving person consciously or unconsciously avoids the pain that has occurred with the loss.

Shroud

A cloth, sheet, or bag, for transportation to the morgue or the funeral home.

Hospice

A program that provides comfort and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician or other community agency.

Complicated Grief

AKA: Unresolved Grief Occurs when the affected person is not able to progress through the normal stages of grieving.

Loss

The absence of something to which the affected person has formed an attachment and can involve people, places, or things.

The nurse is caring for a young patient whose mother has only a few weeks to live. The patient has been misbehaving at school recently and is suspended after picking fights with other students and defying teachers. Which stage of grieving is the patient experiencing? a. Denial b. Anger c. Bargaining d. Depression

ANS: B The patient is angry over the impending death of his mother and is acting out this anger at school by picking fights and defying his teachers.

The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. Which goal is most appropriate for this patient? a. The patient will be referred to medical social services for evaluation and counseling. b. The patient will be encouraged to describe previous stressors and coping mechanisms. c. Nursing staff support patient's coping attempts and encourage verbalization of feelings. d. The patient will use effective coping strategies with no alcohol consumption.

ANS: D Goals are met by the patient rather than nursing or medical staff. The patient's use of effective coping strategies without drinking alcohol is an appropriate goal. Referring the patient for counseling and encouraging the patient to verbalize stressors are interventions rather than goals.

The nurse is caring for an emergency room patient who died as a result of a mishap with a loaded gun. The patient's body will be transported to the coroner's office for an autopsy. Which items will the nursing staff remove from the body before it leaves the hospital? a. Endotracheal tube b. Foley catheter and IV line c. Dentures d. Necklace and watch

ANS: D Medical devices and tubes are not removed from the body if an autopsy is to be performed. The patient's necklace and watch may be removed and given to the patient's family members before the body is transported to the coroner's office for autopsy. Dentures should be left in the patient's mouth.

The nurse is caring for a female patient who died a few minutes previously. The patient's family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse at this time? a. Inform the patient's family that the body must be transported to the morgue. b. Instruct the patient's family that hospital staff will provide post-mortem care. c. Obtain needed signatures for organ donation and autopsy. d. Offer to provide any needed supplies and provide privacy for the family.

ANS: D The most appropriate action of the nurse at this time is to allow the family to wash the patient's body in accordance with their wishes and cultural values. Signatures may be obtained from the next of kin when washing is complete. The patient's body may be transported to the morgue or funeral home after washing is completed.

The nurse is caring for a patient who died a few minutes ago. The patient's family is at the bedside and very demonstrative in their grief, weeping loudly and holding on to the patient's body. What is the most appropriate action of the nurse? a. Inform the family that the patient's body must be taken to the morgue shortly. b. Ask the family members to step outside while postmortem care is provided. c. Obtain required signatures for the body to be taken to the funeral home. d. Provide privacy and allow the patient's family to grieve over the body.

ANS: D The nurse should allow the patient's family to grieve in private over the loss of their loved one. Some cultures favor free expression of emotions after death, and the nurse should respect this. Signatures can be obtained, postmortem care can be provided, and the body brought to the morgue after an appropriate time of grieving has been provided to the family.

Anticipatory Grief

The cognitive, affective, cultural, and social reactions to an expected death.

Grief

The emotional response to a loss.

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

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

Palliative Care

Improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychological support from diagnosis to the end of life and bereavement.

Chronic Grief

Characterized by grief reactions that do not diminish over time and continue for an indefinite period or very long period of time.

Livor Mortis

Eyes may remain open, the jaw will drop as the mouth appears to be open, and the color of the skin becomes pale and then bluish as blood settles.

Mourning

The outward, social expression of loss.

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

Answer: a Nearing death awareness has been described as a state manifested by a special communication of the dying that may occur in patients who are approaching death or are imminently dying. People experiencing this "nearing death awareness" may appear confused, but they may actually be making the transition from life to death. All of the other options are questions that dying people may ask, but they do not represent nearing death awareness.

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

Answer: c Each stage of the grieving process has associated tasks that allow successful grieving to occur on an individualized basis. Theories that describe the grieving process are simply guides to understanding the process of grief, and there is no specific timeline regarding when people "should be" in a certain stage, "should" move from one stage to the next, or follow a stepwise progression. Essentially there is no timetable for the process of grief and bereavement. Nurses need to understand these stages, and the feelings as well as emotions that are common in each stage, so that nursing interventions can then be focused on the individual stage that a person is experiencing, or the task that the person is attempting to complete related to the process of grief.

Disenfranchised Grief

Any loss that is not validated or recognized.

Algor Mortis

Cooling after death.

Bereavement

Includes both grief and mourning, and can be described as the inner feelings and outward expressions that people experiencing loss are demonstrating.

The nurse is caring for a terminally ill patient who is actively dying and refuses to eat anything other than a few bites of ice cream. The patient's family member approaches the nurse and requests that a feeding tube be inserted so that her loved one will not starve to death. What is the best response of the nurse? a. "Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea." b. "I will contact the physician to obtain an order to insert the tube and start tube feedings." c. "Intravenous fluids would be more comfortable for the patient than a tube feeding. I will call the doctor to get the order." d. "I will listen to the patient's abdomen to make sure that bowel sounds are present and try encouraging oral fluids."

ANS: A Loss of appetite and decreased oral intake is expected during the last stages before death as the gastrointestinal tract shuts down. Encouraging oral intake will lead to increased secretions and congestion as well as possible aspiration of fluids. Intravenous fluids will increase congestion and edema. Tube feedings will cause discomfort as the tube is inserted and nausea as the GI tract is given food that it cannot handle.

The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient's family arrives to see the patient's body? a. Gently wash the body and provide perineal care. b. Remove the patient's dentures and jewelry. c. Ensure that the death certificate has been signed. d. Determine which funeral home will pick up the body.

ANS: A Release of bowel and bladder contents often occur at the time of death, and the perineal care is a priority before the family arrives. The body should be gently cleaned to remove blood and debris from the accident. The patient's dentures and jewelry should not be removed from the body. The death certificate does not need to be signed before the family arrives. The family can decide which funeral home will be used and notify the nurse after their arrival.

The nurse is caring for a patient who is having difficulty coping after being in a motor vehicle accident in which her brother was killed. The patient was driving the car and blames herself for the accident. What is the priority nursing intervention of the nurse? a. Check to make sure that the patient does not want to hurt or kill herself. b. Educate the patient about available support systems for grief resolution. c. Enhance the patient's coping skills to alleviate depression and anxiety. d. Encourage the patient to meet with a spiritual leader for guidance.

ANS: A The highest priority for the nurse is to ensure the safety of the patient, so assessment of potential suicidal tendencies is paramount. The other interventions can take place once the nurse is confident that the patient will not try to hurt or kill herself.

The nurse is caring for a patient who lost her husband 1 year ago. The patient and her husband had been married for 55 years. The patient no longer takes care of herself or cooks and rarely eats, stating she has no appetite. The nurse determines that the nursing diagnosis of Complicated grieving applies to the patient. Which is the priority goal for the patient at this time? a. The patient will shower every other day and eat at least two meals a day. b. The patient will identify personal strengths that will increase coping ability. c. The patient will discuss the meaning of her loss with a family member or close friend. d. The patient will be provided with phone numbers for local community resources.

ANS: A The highest priority goal of this patient is self-care including showering and eating in order to protect her health and safety. The other goals are lower priority after the patient's necessary activities of daily living are addressed.

The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. Which term best describes the activity of the patient's children? a. Anticipatory grieving b. Bereavement c. Caregiver role strain d. Death anxiety

ANS: A The patient and her children are experiencing anticipatory grief as they prepare for the expected death of the patient. The patient and her children are preparing themselves for what is to come.

The nurse is caring for a patient who suffered a miscarriage at 24 weeks of pregnancy. The patient is devastated by the loss but her husband minimizes her grief by stating, "Quit crying. It's not like you lost a real baby." What term best describes the anguish felt by the patient? a. Disenfranchised grief b. Ineffective denial c. Moral distress d. Interrupted family processes

ANS: A The patient is experiencing disenfranchised grief because she cannot share the pain of her loss with her husband. The husband is not willing to support his wife as she mourns the loss of her pregnancy or recognize the grief that she is going through

The hospice nurse is caring for a terminally ill patient who will probably die within the next hour or two. The patient's daughter is keeping a vigil by the bedside and asks what she can do to help her father at this time. What is the appropriate response of the nurse? a. "Just let him know you are here, talk to him, and let him know that you love him." b. "You can try to feed him a few bites of ice cream to keep his mouth from getting dry." c. "You can take this time to ensure that arrangements are set with the funeral home." d. "You should let me know when your father's breathing pattern changes."

ANS: A The patient's daughter should be encouraged to spend the last moments of her father's life with him, reassuring him with her presence. The daughter should be encouraged to continue talking with him because the patient may still hear her even if his eyes are closed and he does not speak. The nurse is responsible for monitoring the patient for breathing changes. Oral intake will lead to nausea and/or aspiration. This is not the time to make arrangements with the funeral home.

The nurse is caring for a patient who is terminally ill with metastatic bone cancer. The patient tells the nurse that he is not afraid of death but does not want to be in pain and suffer before he dies. Which intervention will be most appropriate to meet this patient's wishes? a. Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain. b. Assist the patient to reminisce and review his life, spending as much time as possible with loved ones. c. Use therapeutic touch, guided imagery, and soft music to put the patient at ease and relieve anxiety. d. Encourage the patient to participate in prayer and meditation along with preferred religious practices.

ANS: A The patient's primary wish is to die without pain, and the best intervention to meet this goal is administration of pain medication around the clock with extra doses for breakthrough pain. The other interventions may make the patient more comfortable but will not address his primary desire for adequate pain management.

The nurse is caring for a patient who just died after a lengthy illness. Which portions of postmortem care may be delegated to the nursing assistant? (Select all that apply.) a. Gently washing the body and closing the patient's eyes b. Offering support and empathy to the patient's family members c. Documenting the patient's time of death in the medical record d. Notifying all of the patient's consulting physicians of the patient's death e. Removing the patient's hospital ID band, IV lines, and urinary catheter f. Gathering the patient's belongings so they may be taken home by the family

ANS: A, F The nurse assistant can gently wash the patient's body, close the patient's eyes, and gather the patient's belongings. Offering support and empathy to the patient's family members should be done by the nurse along with documenting the time of death in the chart and notifying all of the patient's physicians. The nurse assistant can remove the patient's IV lines and urinary catheter, but the hospital ID band should be left in place.

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

ANS: B Complicated grief is characterized by distressing symptoms lasting at least six months following the death of a significant loved one and occurs with a sudden, unexpected death. Symptoms of complicated grief include intense longing for the deceased, denial of the death or sense of disbelief, imagining that the loss has not occurred, searching for the person in familiar places, extreme anger or bitterness over the loss, and avoiding things that remind them of the loss. Daily life routines are not able to be maintained, and a person's emotional as well as physical health becomes threatened. Anticipatory grief occurs prior to a loss, delayed grief occurs when the grief response is suppressed, and disenfranchised grief occurs when a loss is not recognized by society.

The nurse is caring for a patient who has just died. Which assessment findings by the physician and nurse are used to confirm that death has occurred? (Select all that apply.) a. The patient was incontinent of bowel and bladder. b. The patient's pupils are fixed and dilated. c. The physician does not hear a heartbeat. d. The patient's extremities are cool and mottled. e. The patient has no palpable peripheral pulses. f. The patient's face is relaxed and the mouth is open.

ANS: B, C, E Assessment findings that confirm death has occurred include lack of pulse/heartbeat and fixed dilated pupils. Cool, mottled extremities, relaxed muscles, and incontinence are common assessment findings in patients who are dying.

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

ANS: B Dysfunctional grieving includes more focused questions that help the nurse to identify potential patterns of coping that are not healthy for the individual experiencing grief and include: worsening grief, dysfunctional or unhealthy coping strategies, and an inability to function in activities of daily living. General nursing assessment parameters pertinent to nursing for a grieving individual include: current coping strategies, available support systems, health status (physical as well as emotional), and religious or spiritual beliefs.

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

ANS: B Hospice care is provided to any patient who has a terminal diagnosis of six months or less to live and needs care to meet symptom control needs and quality-of-life concerns. Hospice is not for patients who are acutely ill and need specialized treatment, or for patients with chronic illnesses who are not in the terminal stage. Palliative care is provided to those patients who have a longer life expectancy and need assistance with symptom control measures and family support.

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

ANS: B The most common symptoms at the end of life include pain and shortness of breath. While edema, anemia, and peripheral neuropathy are symptoms that may need to be addressed during care provided at the end of life, dyspnea is most commonly found in the last several weeks of life as physiologic changes occur that cause shortness of breath

The nurse is caring for a male Islamic patient who has just died. Which action is the priority for the nurse to take when postmortem care is provided? a. Arranging for embalming to preserve the body until burial b. Arranging for male staff to gently wash the patient's body c. Arranging for transportation of the body to the crematorium d. Preparing the room so that the family can say the rosary at the bedside

ANS: B According to the Islamic religion, washing of the body should be performed by a person of the same gender. Burial should be done as soon as possible after death, so cremation and embalming will not be needed. The rosary is prayed by Christians usually of Hispanic/Latino American descent.

Which statement by the patient indicates that it may be an appropriate time to consider hospice care rather than further aggressive measures to treat his terminal illness? a. "I am praying every day that this last round of chemotherapy will work." b. "I want to spend what time I have left at home with my grandchildren." c. "I need to meet with my financial planner to make sure my life insurance is all set." d. "I am concerned that my wife won't be able to live on her own after my death."

ANS: B Hospice care is provided to patients who are terminally ill and wish to have no further aggressive treatment in attempt to cure the disease. The patient's statement that she just wants to be home with her grandchildren indicates a readiness for hospice care.

The nurse is caring for a terminally ill patient who appears to be calmly having a conversation with someone even though there is nobody else in the room. The patient reaches out and appears to take something out of thin air and hold it close. Which is the appropriate action of the nurse? a. Reorient the patient and reassure that nobody else is in the room. b. Be present but quiet and let the patient continue the conversation. c. Carefully assess the patient's mental status and level of attention. d. Obtain a set of vital signs and check the patient's pulse oximetry.

ANS: B Patients who are near death sometimes have a special communication with loved ones who have already died. As long as the patient is calm and content, the best action of the nurse is to be present but let the patient continue the conversation undisturbed.

The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse? a. "The insurance company will not pay for chemotherapy at this stage." b. "The focus right now needs to be on keeping your loved one comfortable." c. "I will call the physician and let him know that you would like to restart chemotherapy." d. "The patient needs to get stronger first before chemotherapy can be administered."

ANS: B The nurse must function as the patient's advocate and encourage what is in the best interest of the patient. Chemotherapy will not extend the patient's life when death is expected within the next few days and will only make the patient suffer needlessly when it is administered. The patient will not get stronger over the next few days, and this criterion for chemotherapy will never be met.

The hospice nurse is caring for a patient who is terminally ill. The patient's wife is the primary caregiver, providing constant care and spending all of her time meeting his needs. The nurse applies the diagnosis of caregiver role strain to the patient's situation. After implementing appropriate interventions, which assessment finding by the nurse indicates that the primary goal for this diagnosis has been met? a. The patient's wife was encouraged to talk about her feelings and fears with the hospice nurse. b. A hospice aide stays with the patient through the night and his wife is able to get adequate sleep. c. The patient's wife verbalized understanding of techniques for management of nausea, pain, and constipation. d. Information about caregivers' support group meetings was provided to the patient's wife.

ANS: B The primary goal of the caregiver role strain nursing diagnosis is that the patient's wife will be able to maintain her own health while caring for her husband. Getting sufficient sleep is an important step toward keeping her health intact, and the patient's wife feels supported sufficiently by the hospice aide in order to sleep through the night.

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

ANS: C A major role of the nurse, in any setting, especially when a patient is dying is to advocate for his or her wishes related to end-of-life care. It is not the role of the nurse to diagnose or treat medical conditions, but it is the role of the nurse to advocate for the patient and implement appropriately identified independent nursing interventions.

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

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

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

ANS: C The goal of hospice care is to provide comfort and support to terminally ill patients and their families. Control of symptoms and quality of life issues are a priority when providing care.

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

ANS: C To effectively care for the dying, nurses need to explore their personal feelings regarding death. Self-exploration and reflection through personal death awareness exercises and discussion of beliefs and life and death with friends, peers, co-workers, and pastoral care workers may promote an understanding and acceptance of death as a part of life. Emotional distancing from patients and families is not an effective way for nurses to learn about themselves and their response to death and loss. Nurses also do not provide ongoing bereavement support to families, although they may provide information about ongoing bereavement services in the community. It is important to discuss feelings of loss with others, but it should be done with peers, co-workers, pastoral care workers, or other members of the health care team who have also experienced loss related to death in the work setting.

The hospice nurse is caring for a several adult children shortly after the death of their mother. They have various reactions as they deal with their loss. Which reactions are considered to be in the cognitive domain? a. They let the house get filthy because they can't be bothered to clean it. b. They are tossing and turning all night and are unable to get a good night's sleep. c. They are easily distracted and often lose train of thought during conversation. d. They have lost their appetites and have no desire to eat anything.

ANS: C Cognitive deficits include the inability to concentrate and follow a conversation. Letting the house get filthy is a sign of apathy, which is in the behavioral domain. Insomnia falls within the behavioral and physical domains. Loss of appetite is within the physical domain.

The hospice nurse is caring for a father and his children following the death of their mother. The father is having difficulty taking on the responsibilities and duties that were previously done by his wife, especially relating to and communicating with his teenage daughters. Which nursing diagnosis best describes the family's situation at this time? a. Impaired parenting r/t inappropriate child care arrangements b. Ineffective denial r/t new and unpleasant reality of single parenting c. Interrupted family processes r/t father's caregiving role changes d. Disturbed thought processes r/t father's feelings of grief over loss of wife

ANS: C The best diagnosis for this family is Interrupted family processes r/t father's caregiving role changes, as evidenced by the father's difficulties in taking over the responsibilities and duties previously done by his wife. This situation exemplifies the diagnosis in the change of family functioning that has occurred as a result of the death of the children's mother.

The hospice nurse is caring for a terminally ill patient. The patient's son is distraught because the patient will probably die within the next few days and there is nothing he can do about it. What is the most appropriate nursing diagnosis for the patient's son at this time? a. Chronic sorrow r/t impending death of mother b. Impaired religiosity r/t difficulty adhering to religious beliefs c. Powerlessness r/t progression of mother's terminal illness d. Complicated grieving r/t desired avoidance of mourning`

ANS: C The patient's son is experiencing powerlessness because he is unable to change the outcome of his mother's imminent death. The son makes no mention of religious beliefs, so impaired religiosity is not appropriate. Complicated grieving is applicable to individuals who have recently experienced a loss.

The nurse is caring for a terminally ill patient who will probably die within the next 2 weeks. What is the priority nursing intervention? a. Encouraging the patient to limit fluid intake to minimize congestion b. Limiting the use of pain medications so that the patient can visit with family c. Helping the patient to identify and complete desired tasks and activities d. Completing funeral arrangements with the patient's next of kin

ANS: C The priority intervention for the nurse at this time is to help the patient identify and complete desired tasks and activities while the patient is still able to do so. Pain management is a high priority at this time, so analgesics should never be limited unless requested by the patient. The patient can drink as much or as little fluid as desired.

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

ANS: D Advance directives are legal documents that allow people to communicate their wishes about what type of medical care they would like to receive at the end of life. It is a nursing responsibility to be aware of types of advance directives available and to discuss the options with patients and families. A copy of the patient's advance directives should be part of the medical records. Hospice is a program that provides comfort and supportive care for terminally ill patients. A will authorizes someone to make decisions about property after a person is deceased. Palliative care is a program that provides comfort and supportive care for terminally ill patients and their families.

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

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

The home care nurse is caring for a terminally ill patient who states that he wants to set up a scholarship in his name at the local university before he dies. What is the best action of the nurse? a. Suggest that the patient think it over and wait a few days before contacting the school. b. Direct the patient to ask his family about the possibility of starting a scholarship. c. Assess the patient's mental status to ensure that he is competent to make the decision. d. Assist the patient to find the necessary information about endowed scholarships.

ANS: D As the patient's advocate, the nurse should help provide the necessary information for the patient to set up a scholarship if that is his decision. The patient does not need to discuss the subject with his family first, and assessment of the patient's mental status is not needed. The patient may not have the time to wait a few days before contacting the university.

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

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

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

Answer: b Hospice care is provided in a variety of settings, including home care, freestanding inpatient units, hospitals, long-term care facilities, and prisons, as well as to the homeless, for patients with any disease or illness that has been determined to be life-limiting (prognosis of 6-month survival). Any patient who is experiencing symptoms—physical, psychological, or spiritual—benefits from hospice support and symptom control at the end of life.

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

Answer: b Many family members would like to be involved in the care of their loved one while the person is dying. It is the responsibility of the nurse to assess the level of involvement in which the family would like to participate related to patient care. Teaching about care measures is a nursing intervention that can be implemented to assist family members during the process of anticipatory grief. Family members should not be expected to meet all of the patient's needs but should not be excluded from caring for their loved one.

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

Answer: c Advance directives go into effect when a person has a terminal illness and is unable or incapable of making decisions for themselves. Advance directives are completed by people who are competent and have decision-making capacity. Advance directives should be discussed by the nurse with family members, and the written documents should be given to family, health care providers, and those at institutions where health care is provided. It is the responsibility of the nurse to discuss advance directives with patients and their families; their benefits and limitations, how to complete an advance directive, and how advance directives can assist in decision making at the end of life.

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

Answer: c Caregivers should be encouraged to openly and honestly answer any questions the child may have as they are evaluating the child's responses to the loss while determining whether the child should attend the funeral of a family member. If young children are going to attend the funeral, they should be prepared for what they will see, who will be there, what they may feel, how they may see other people grieving, and what they will be doing during the time that they are at the funeral. It is essential to explain to the child what the body will look like, and the fact that the deceased will not talk, move or breathe. Children should be allowed to attend funerals based on their own abilities to understand the loss, but they should not be forced to attend if they are fearful or have a strong negative reaction to the loss. The nurse should not give her opinion about the children attending or not attending without the mother's or nurse's first evaluating the children's level of understanding and their responses to the loss.

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

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

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

Answer: d Demonstrating respect for the deceased maintains the dignity of that person and also can help the family in the grieving process. Proper positioning of the body and covering the body appropriately will promote a peaceful impression of the deceased for the family. It is not the responsibility of the nurse to notify all family members and team members of the death immediately as the nurse will need to provide care to the family and determine what type of assistance they need in notifying family members. Family often will request time with the deceased, and it is not necessary to place a time frame of 1 hour of the arrival of the body at the morgue.